Understanding Urinary Incontinence After Gender-Affirming Surgery

Undergoing gender-affirming surgery is a life-changing decision for those seeking to align their physical bodies with their gender identity.

This surgery can be a milestone in an individual’s journey towards self-acceptance, and while the positive outcomes of gender-affirming surgery are widely recognized health care community, it’s crucial to address the physical and emotional challenges that can arise after surgery is performed.

In this article, we’ll talk about the types of gender-affirming surgeries and the side effects they can have on your urinary system and mental health, as well as treatments that are available for those with urinary incontinence.

In many cases, quality of life has been shown to improve after undergoing gender-affirming surgery. One recent report that combined 27 studies of 2,718 cases of gender-affirming surgery showed that transwomen and transmen reported more satisfaction with their bodies, as well as a higher quality of life after the surgery was completed. However, it was also reported that mental health issues and mortality remained higher than cisgender individuals (people whose bodies align with their gender identity).

Transgender men have several options when it comes to surgically affirm their gender identity. Two of the procedures, often referred to as “bottom surgeries,” are metoidioplasty and phalloplasty.

• Masculinizing 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
• Facial reconstructive surgery: (Facial feminization surgery or facial masculinization surgery) Makes facial features more masculine or feminine.

When making the decision to undergo a gender-affirming surgical procedure, transgender women may elect to undergo a procedure that shortens their urethra. These procedures include vaginoplasty, top surgery, and thyrochondroplasty.

• Feminizing vaginoplasty: Sometimes called "bottom surgery" or genital surgery, creates female genitalia, such as the clitoris, labia, and vagina.
• Chest surgery: Also called “top surgery,” breast augmentation, or chest reconstruction, removes or resizes breast tissue to create more masculine or feminine chest features.
• Reduction thyrochondroplasty: Reduces the size of the adam’s apple for more feminine features.
• Facial reconstructive surgery: (Facial feminization surgery or facial masculinization surgery) Makes facial features more masculine or feminine.

Other therapies that can be given to transgender persons are hormone therapy and voice therapy.

Urinary incontinence (UI) is the loss of bladder control that results in an involuntary loss of urine. UI can occur in any person of any age and develops for many different reasons, including surgical treatment.

Stress incontinence: Stress urinary incontinence results in leaking urine when running, jumping, laughing, sneezing, coughing, or lifting.

Overactive bladder (OAB) / Urge incontinence: Voiding the bladder more than 8 times in a 24-hour period, or feeling the intense and sudden urge to urinate, resulting in leakage.

Overflow incontinence: Frequent or constant dribbling of urine due to the inability to empty the bladder completely.

Functional incontinence: Urine leaks due to limited mobility or neurological disorders, such as Parkinson’s disease.

Mixed incontinence: Experiencing 2 or more types of UI symptoms at once, such as stress incontinence and OAB.

UI, though not experienced by all people, can impact both physical and emotional well-being after gender-affirming surgery is performed. The symptoms experienced can range from occasional to severe leakage that may require treatment.

Both MTF and FTM procedures can result in UI. It’s highly common for urinary complications to arise after gender-affirming surgeries. Some of the most common procedures that cause UI symptoms are vaginoplasty and metoidioplasty.

After undergoing a FTM metoidioplasty, which lengthens the urethra and lengthens the clitoris, some patients report experiencing UI symptoms such as

While these types of surgeries can cause urinary complications, they have been shown to increase the quality of life for transgender people. Following gender-affirming surgery, it’s reported that between 80% of people are satisfied with their sexual function, and 77% are satisfied with the aesthetic outcome of their procedures.

It can be difficult to feel that a surgery that’s supposed to help you feel more comfortable results in a challenge like UI. This is especially true for transgender individuals who undergo gender-confirmation surgery and develop UI because it can further impact their mental health when they are already at risk for mental health complications. One study showed that 32% to 50% of transgender people have attempted suicide, while another study showed 31% have major depressive disorder and 12% have general anxiety disorder.

A stand-to-pee (STP) device can help align your preferred technique of toileting with your 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 may also cause a hypertonicity of the pelvic floor muscles. This can lead to:

 However, a pelvic floor therapist can assist with these issues as they arise. And remember that sitting to urinate is okay, especially if it will improve voiding function and prevent discomfort.

2. Incontinence Products

Developing UI symptoms can make you feel as if you can’t enjoy all the activities you once did, but with the help of high-quality bladder control products, you can!

These discreet products are breathable and comfortable for daytime or nighttime wear. Their highly-absorbent cores soak up any leaks and keep you dry while maintaining skin health. Some products also come in male and female designs to look and feel like regular underwear. After undergoing gender-affirming surgery, we recommend the following products to protect yourself against leaks:

If you’ve been diagnosed with UI by a healthcare provider, you may qualify to get your bladder care products 100% free through insurance. See if you qualify!

3. Collagen Injections

This procedure consists of injecting collagen around the urethra and bladder neck to treat stress incontinence. There have been a small number of studies that show the advantages of periurethral collagen injections for people who experience UI after gender-affirming surgery; one study reported that both FTM and MFT individuals saw improvements in their UI symptoms after treatment.

4. Pelvic Floor Physical Therapy

Pelvic floor physical therapy (PFPT) can be beneficial if you’ve undergone gender-confirmation surgery. PFPT works by assessing your symptoms with a licensed pelvic floor physical therapist who specializes in the pelvic floor and pelvic floor disorders. After diagnosing your symptoms, your therapist will recommend certain treatments, such as:

• Biofeedback therapy.
• Pelvic floor exercises, such as kegel exercises (for men and women).
• Lifestyle modifications (diet, exercise, weight management, etc.).

5. Dietary Changes

Certain foods can irritate your bladder and cause irritation. It’s best to avoid these if you’ve had gender-affirming surgery and are experiencing UI symptoms to lessen leakage and urinary frequency. Foods to avoid include:

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 transgender people 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.

Since the topic of urinary incontinence after gender affirming surgery is relatively unexplored, it’s crucial to shed light on this issue and provide much-needed information, resources, and support for those who may be affected.

By openly discussing UI within the context of gender affirming surgery, we hope to empower individuals to seek appropriate care, reduce the stigma surrounding both gender-confirmation health services and UI, and form a sense of community among those navigating similar challenges.

It’s our goal to promote education, understanding, and compassion, and to contribute to a more inclusive and supportive environment for all who embark on the path of gender affirmation.

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

References

Cleveland Clinic. (2021, May 3). Gender Affirmation Surgery: What Happens, Risks & Benefits. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/21526-gender-affirmation-confirmation-or-sex-reassignment-surgery 

‌NHS. (2017, October 23). Gender dysphoria. Nhs.uk. https://www.nhs.uk/conditions/gender-dysphoria/#:~:text=Gender%20dysphoria%20is%20a%20term 

‌Meier, A. C., & Papadopulos, N. (2021). [Quality of life after gender reassignment surgery: an overview]. Handchirurgie, Mikrochirurgie, Plastische Chirurgie: Organ Der Deutschsprachigen Arbeitsgemeinschaft Fur Handchirurgie: Organ Der Deutschsprachigen Arbeitsgemeinschaft Fur Mikrochirurgie Der Peripheren Nerven Und Gefasse: Organ Der V..., 53(6), 556–563.  https://doi.org/10.1055/a-1487-6415 

‌The Impacts of SRS on Urinary Habits. (2022, March 22). ActivKare. https://activkare.com/blogs/news/the-impacts-of-srs-on-urinary-habits‌ 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10073518/ 

Metoidioplasty Risks and Complications: Is Metoidioplasty Really Worth It? (n.d.). Metoidioplasty.net. Retrieved May 25, 2023, from https://www.metoidioplasty.net/risks-complications/ 

‌Hamidian Jahromi, A., Spellman, A. M., Horen, S., Cherullo, E. E., Dorafshar, A. H., & Schechter, L. S. (2022). A narrative review of outcomes following metoidioplasty: complications and satisfaction. Plastic and Aesthetic Research, 9(6), 41. https://doi.org/10.20517/2347-9264.2021.111 

‌Nassiri, N., Maas, M., Basin, M., Cacciamani, G. E., & Doumanian, L. R. (2021). Urethral complications after gender reassignment surgery: a systematic review. International Journal of Impotence Research, 33(8), 793–800. https://doi.org/10.1038/s41443-020-0304-y 

‌Virupaksha, H., Muralidhar, D., & Ramakrishna, J. (2016). Suicide and suicidal behavior among transgender persons. Indian Journal of Psychological Medicine, 38(6), 505. https://doi.org/10.4103/0253-7176.194908 

‌Wanta, J. W., Niforatos, J. D., Durbak, E., Viguera, A., & Altinay, M. (2019). Mental Health Diagnoses Among Transgender Patients in the Clinical Setting: An All-Payer Electronic Health Record Study. Transgender Health, 4(1), 313–315. https://doi.org/10.1089/trgh.2019.0029 

‌Disclaimer

Information provided on the Aeroflow Urology blog is not intended as a substitute for medical advice or care from a healthcare professional. Aeroflow recommends consulting your healthcare provider if you are experiencing medical issues relating to incontinence.