This piece has been medically reviewed by Aleece Fosnight, MPAS, PA-C, CSC-S, CSE, NCMP, IF, Medical Advisor to Aeroflow Urology.
Embarking on the journey of transition can be a very exciting time for a transgender individual. Finally being able to match their outward appearance to their gender identity can do wonders for their mental health and confidence. Hormone therapy is a common first step in the transition process, but there is very little education on how hormone therapy can affect the urinary tract. There are things that can be done to manage the changes that will come with hormone therapy and other transitional processes, and that is what I will work to outline today.
It should be noted that although this blog specifically uses transgender language, this information also applies to non-binary individuals who are also seeking hormone therapy.
Transgender Women and Urinary Health
Transgender women are individuals who were designated male at birth. When beginning hormone therapy, they often take high levels of estradiol medications as well as anti-androgens (spironolactone and finasteride are the typical beginning medications). These medications target the lower urinary reproductive system by blocking testosterone production. This limits the growth of the prostate and can also cause the pelvic floor muscles to relax, often resulting in stress incontinence or urge incontinence. This is where a pelvic floor physical therapist can be enormously helpful. They can work with the individual to resolve or ease some of these common issues.
One of the leading side effects associated with estradiol and anti-androgen medications is issues with the prostate. Removal of the testes in addition to estrogen therapy can decrease the risk for benign prostatic hyperplasia (BPH), also known as an enlarged prostate. This form of treatment can also help minimize the potential for urinary tract symptoms that often accompany BPH, including urinary frequency or urgency, nocturia, and incomplete emptying of the bladder. It should also be noted that prostate cancer is more common among transgender women that begin hormone therapy over the age of 50.
Transgender Men and Urinary Health
Transgender men, or individuals who were assigned female at birth, often begin the transition process by taking high levels of testosterone. Testosterone medications act to block ovarian function, which in turn decreases estrogen levels. While this is an effective method to change outward appearance, there are side effects that individuals should be aware of before they begin to take hormone supplements. Side effects of testosterone therapies include vaginal dryness, urinary urgency, pelvic pain, and urinary tract infections (UTIs). While these side effects may not be eliminated completely, there are ways to help minimize them and make the individual more comfortable.
Avoid products that are highly fragranced. Personal products like bubble bath, highly perfumed soaps, lubricants, etc. can exacerbate vaginal dryness and irritation and should be avoided, if possible.
Consider natural lubricant alternatives. A few natural lubricant options are coconut oil, aloe vera, and vitamin E.
Stay hydrated. Staying hydrated raises your body’s overall moisture levels. This is key to easing vaginal dryness and decreasing your chances of frequent urinary tract infections (UTIs).
Try taking probiotics. Some individuals have found that probiotics help alleviate vaginal dryness. However, it is important to talk with your healthcare provider about the best way to introduce probiotics into your routine.
If you begin to experience pelvic pain or dysfunctional voiding, it may be helpful to seek help from a pelvic floor physical therapist. Dysfunctional voiding occurs when there is inconsistent coordination between the bladder and the urethra. Signs of voiding dysfunction include frequent urination, urinary urgency, and the inability to completely empty the bladder. Whether you are experiencing symptoms or not, regularly seeing a pelvic floor therapist can be very beneficial in resolving issues ranging from painful intercourse to incontinence issues.
Gender Confirmation Surgery
For some transgender individuals, the next step to affirming their gender identity is undergoing a gender affirmation surgery. There are multiple surgeries available to individuals who elect to surgically transition their gender. As with any surgical procedure, there are risks, and it is important to consult with your healthcare provider on any questions you have about potential complications. It should also be noted that not all transgender people choose to, or can afford to, undergo medical procedures that will be listed below, and this is perfectly fine.
Transgender men have several options when it comes to surgically affirming their gender identity. Two of the procedures, often referred to as ‘bottom surgeries,’ are a metoidioplasty and a phalloplasty. Metoidioplasties or phalloplasties are surgical procedures by which a penis is constructed.
Metoidioplasty: a procedure that involves changing the clitoris into a penis. During this procedure, the surgeon will also perform a vaginectomy, removing the vagina. This procedure is different from a phalloplasty in that it only creates a micropenis and will not enable the individual to stand while urinating.
Phalloplasty: a procedure in which grafted skin (often from the thigh or arm) is used to construct a neopenis. A lengthening of the urethra is required to allow for urination through the neopenis. Potential complications with phalloplasties are the development of urinary stenosis or fistulas, which can increase the risk for urinary tract infections (UTIs), as well as the possibility that an intermittent catheter will be required to keep the urethra intact.
Toileting Technique Options
A stand-to-pee (STP) device can help align an individual’s preferred technique of toileting with their gender, but it can become complicated when using a male restroom that may have limited private stalls. Users of STP devices are also at risk for skin irritation and infections if the device is not cleaned diligently after each use.
Standing to urinate causes a hypertonicity of the pelvic floor muscles. This can lead to pain, dysfunctional voiding, incontinence, and constipation. However, a pelvic floor therapist can assist with these issues as they arise.
Individuals should be reassured that sitting to void is okay, especially if it will improve voiding function and prevent discomfort.
Transgender women, when making the decision to undergo a gender affirming surgical procedure, may elect to undergo a procedure that shortens their urethra. This can increase the risk of urinary tract infections (UTIs), scar tissue build up, and urethral strictures. After surgery, individuals can experience neurogenic bladder symptoms, and during recovery, they may need intermittent catheterization.
In this type of procedure, the prostate is relocated, which can cause challenges with urination and complete voiding. Individuals should discuss options of new toileting techniques with their healthcare provider to find the best fit for their needs.
Knowing Your Health Care Rights
It isn’t always easy to advocate for yourself, especially if you aren’t exactly sure what your rights are. We recognize that healthcare providers can (and do) break laws due to their own personal prejudices. However, we believe that it is important to know what your healthcare rights are, so you can properly defend and advocate for yourself if the situation arises.
Overall, there are federal and state laws that prohibit most public and private health insurance plans from discriminating against you simply because you are a transgender person. Healthcare providers cannot, under federal law, refuse to treat you or admit you because you are transgender. They cannot force you to have unnecessary examinations based on the fact that you are transgender. They also cannot refuse to treat you in accordance with your gender identity. This includes providing you access to restrooms that are consistent with your gender.
There are many ways that a transgender person can advocate for themselves in making their lives more comfortable. One way we recommend is to ask your healthcare provider to provide a note that allows proper bathroom access at your workplace. This can ease anxiety and prevent the individual from waiting too long to void, causing additional urinary tract problems. While there are many other ways to advocate for yourself and your healthcare, we recommend visiting the below links for more information.
Healthcare Resources for Transgender Individuals:
Getting Your Health Care Covered: A Guide for Transgender People
Knowing Your Rights | Healthcare
A Guide to Being an Ally to Transgender and Nonbinary Youth
Out 2 Enroll: Helping Transgender People Enroll in Insurance
HealthCare.gov - Transgender Health Care