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A colovaginoplasty is an operation that builds a vagina from a short section of a person’s own bowel, most often the sigmoid (lower) colon. The borrowed piece of bowel is moved down to form the lining of a new vaginal canal, while the rest of the bowel is rejoined so it keeps working as normal. Because bowel is a moist mucous membrane, the new vagina (neovagina) it creates is naturally self-lubricating and tends to be generously deep.1
It is used in two broad situations: to create a vagina for someone born without a functioning one, and as part of gender-affirming surgery for trans women and some non-binary people. In both, it is usually a considered, second-line surgical choice rather than the first thing anyone reaches for.
This guide walks through who it is for, how it works, and what life is like with a bowel-derived vagina. It also covers the long-term care it needs – the bits we focus on most, like discharge, odour and the neovaginal microbiome.
On this page:
- What is a colovaginoplasty?
- Who has a colovaginoplasty?
- Why bowel, and why it is rarely the first choice
- How the surgery works
- What are the advantages?
- What are the risks and complications?
- Living with a bowel neovagina
- Sex, sensation and fertility
- Recovery and emotional wellbeing
- How a bowel vagina compares to other methods
- Questions worth asking your surgical team
- Frequently asked questions
- What to do next
What is a colovaginoplasty?
Colovaginoplasty – also called sigmoid vaginoplasty, bowel vaginoplasty or intestinal vaginoplasty – is a type of reconstructive surgery that uses a segment of bowel as the lining of a new or rebuilt vagina.1
A surgeon removes roughly 10 to 15 cm of sigmoid colon, keeping its blood supply intact, and reconnects the remaining bowel ends so digestion continues unaffected. The freed segment is then brought down through the pelvis and stitched into place to form the walls of the vaginal canal. One end is opened at the vulva; the other is usually closed off and anchored to stop it slipping down later.2
The result is a canal lined with the kind of tissue that makes mucus for a living. That single fact – mucus-producing bowel rather than skin – shapes nearly everything that is good and tricky about this operation.
Who has a colovaginoplasty?
People come to this surgery from two quite different directions, but the operation itself is much the same.
Born without a working vagina
Some people are born with a vagina that is absent, very short or blind-ending. The most common reason is MRKH syndrome (Mayer-Rokitansky-Kuster-Hauser syndrome), where the uterus and most of the vagina do not form, affecting roughly one in 5,000 people assigned female at birth.2 Others have vaginal agenesis from other causes, or a difference of sexual development (DSD).
This includes some people with androgen insensitivity, where the body cannot fully respond to its own androgens; you can read more about how that works in our piece on how androgens work in female bodies. For these groups, surgery is about creating a vagina that did not develop naturally.
After the vagina is lost
A vagina can also be lost or badly narrowed later in life – for example after pelvic cancer surgery, or as a result of radiation-induced vaginal stenosis. When tissue has been removed or scarred by cancer treatments, a bowel segment can be a reliable way to rebuild a functional canal where local tissue is simply not available.
Gender-affirming surgery
For trans women and some non-binary people, the usual method of building a vagina is penile inversion, which uses existing genital skin. Colovaginoplasty tends to come in as a second-line or revision option – for instance when there is not enough genital skin to give good depth, or when an earlier vaginoplasty needs more depth or better self-lubrication.1 In a large recent series of bowel vaginoplasties for gender affirmation, almost half the operations were revisions of previous surgery rather than first-time procedures.1
In our clinic, we look after people from every one of these groups. What they share matters more than what separates them: a vagina made of bowel behaves like bowel, and the day-to-day care follows from that. If you are weighing up surgery itself, our overview of the outcomes of gender-affirming surgery is a useful companion read.
Why bowel, and why it is rarely the first choice
For people born without a vagina, the recommended first-line approach is not surgery at all. It is gradual stretching with vaginal dilators, a non-surgical method that works for most people, avoids operating risks and keeps the person in control of their own progress.3 Professional bodies recommend trying dilation first wherever it is realistic.3
Surgery is generally considered when dilation has not worked, is not suitable, or when there is no usable local tissue to work with. Among the surgical options, bowel is often chosen when good depth and natural lubrication matter most, or when skin-based methods are not available or have already been tried.1
How the surgery works
Colovaginoplasty is major abdominal surgery, carried out under general anaesthetic, and increasingly done with keyhole (laparoscopic) or robot-assisted techniques rather than one large open incision.1
In plain terms, the surgeon:
- Frees a short segment of sigmoid colon while preserving the blood vessels that keep it alive.
- Rejoins the two cut ends of the remaining bowel so normal digestion continues.
- Creates a space (a tunnel) in the pelvis between the bladder and the rectum.
- Brings the bowel segment down into that space and stitches its lower end to the vulva to form the vaginal opening.
- Closes and anchors the top end, often to a ligament near the tailbone, to reduce the risk of the new vagina slipping down later.2
A hospital stay of several days is normal, partly because the bowel needs time to wake up and work again after being handled. Most people are taught how to look after the new vagina before they go home, and follow-up continues for months.
What are the advantages?
The appeal of a bowel-derived vagina comes down to a few practical strengths.
It is self-lubricating. Because the lining is mucous membrane, it produces its own moisture, so many people need little or no added lubricant for comfortable sex.1
It tends to be deep. Bowel gives generous length, which can be hard to achieve with skin-based methods. In one trial in people with MRKH, the average usable depth went from under 3 cm before surgery to around 17 cm afterwards.2
It often needs less ongoing dilation than skin-lined methods once it has fully healed, because the segment is less prone to shrinking back.1 Reported sexual satisfaction after healing is generally good across both reconstructive and gender-affirming groups.1,2
What are the risks and complications?
This is real surgery on the bowel and the pelvis, so the risks are not trivial and deserve honest attention. In a recent series of 119 bowel vaginoplasties, short-term complications affected about 18 per cent of people and longer-term complications about 24 per cent, with a minority needing a further operation.1
Narrowing and prolapse
The two most common longer-term problems are narrowing of the entrance (introital stenosis) and the lining bulging or sliding down (mucosal prolapse).1 Both can often be managed, but sometimes need revision surgery. Anchoring the top of the segment during the first operation helps reduce prolapse.2
Diversion neovaginitis
Because the bowel segment no longer has waste passing through it, it can develop a specific kind of inflammation called diversion neovaginitis – the neovaginal version of what is known as diversion colitis. It happens when the diverted bowel lining is starved of the nutrients it normally gets from its contents.4
It can show up as pain, mucus discharge, an unpleasant smell, or bleeding, and inflammation can be seen in most sigmoid neovaginas if you go looking with a camera.4 The good news is that it is treatable – typically with locally applied anti-inflammatory medicines or short-chain fatty acid preparations that feed the starved lining – and this is something a knowledgeable clinician can manage rather than something you have to simply live with.4
Heavy or smelly discharge
Bowel makes mucus, so some ongoing discharge is normal and expected with this kind of vagina. For some people it is more than they would like, and malodour is one of the most commonly reported concerns after vaginoplasty in general.6 Discharge that suddenly changes, smells strongly or comes with pain is worth getting checked, because it can signal inflammation or infection rather than just everyday mucus.4
Rare but serious: cancer in the segment
Very rarely, a cancer can develop in the bowel tissue used to build the vagina, sometimes many years or even decades after surgery.7
It is uncommon, but because the segment is still bowel – and bowel can develop bowel cancers – specialists increasingly suggest long-term monitoring, especially for anyone with a personal or genetic higher risk of cancer.7
A persistent lump, unexplained bleeding or a sore that will not heal should always be examined.7
Surgical complications
As with any major abdominal operation, there can be early problems. These include the bowel being slow to restart (ileus), wound breakdown, leakage where the bowel was rejoined, or, rarely, a fistula (an abnormal connection between the vagina and the bowel or bladder).1
A perforation of the neovagina is a rare but serious complication that needs prompt treatment.2
Living with a bowel neovagina
Aftercare is where this kind of vagina asks the most of you, and where good information makes the biggest difference. Our detailed neovagina aftercare guide covers the practical routine in depth; here is the shape of it.
Dilation and healing
Even though a bowel vagina needs less long-term dilation than skin-lined types, regular dilation is still important in the early healing phase to keep depth and width while everything settles.2 Your surgical team will set a schedule, and sticking to it in the first weeks and months really matters.
The neovaginal microbiome
A bowel-derived vagina does not host the protective, lactobacilli-dominated community that a typical natal vagina relies on. Across surgical techniques, the neovagina tends to carry a mixed range of bacteria with very few protective lactobacilli, which means it cannot rely on the same acid-based self-defence.5 We dig into this in detail in our article on the neovaginal microbiome.
This matters practically: standard vaginal swabs and scoring systems were designed for a natal vagina and can be misleading here, so results often need interpreting by someone who understands neovaginal tissue rather than taken at face value.6
In our clinic, we treat the person and their whole picture – tissue type, symptoms, history and what the test can and cannot tell us.
Infections, irritation and odour
Because the protective acid environment is missing, a bowel neovagina can be prone to overgrowth, irritation, inflammation and odour, and discharge patterns can take time to settle.5,6 Yeast can also be part of the picture in any moist environment; our guide to stubborn candida may help if that is what you are dealing with. The aim is steady, informed management rather than panic at every change.
When to seek help
See a clinician who understands neovaginal tissue if you notice new or worsening pain, bleeding that is not expected, a strong or changing smell, a lump, or discharge that suddenly looks or feels different.4,7 These are usually manageable, but they are worth proper attention rather than guesswork.
Sex, sensation and fertility
A bowel-derived vagina is built for penetrative sex to be comfortable, and its self-lubrication and depth are a large part of why people choose it. Reported sexual satisfaction after full healing is generally good in both reconstructive and gender-affirming groups.1,2
Sensation depends a great deal on the surgical technique and on what other structures are created or preserved. In gender-affirming surgery, for example, erotic sensation usually comes from a clitoris built from sensitive genital tissue rather than from the bowel lining itself. Bowel tissue has its own kind of sensitivity, but it is not the same as natal vaginal tissue.
Fertility is a separate question that surgery does not change. For someone with MRKH, a colovaginoplasty creates a vagina but does not create a uterus, so it does not make pregnancy possible. People who want to explore parenthood have other routes to consider, and that conversation is well worth having early and separately from the surgery itself.
Recovery and emotional wellbeing
Recovery from colovaginoplasty takes time, and it is both physical and emotional. The first stretch is dominated by the bowel: it needs to wake up and start working again, which is why the hospital stay is longer than for some other vaginoplasty methods and why early eating is managed carefully.1
Over the following weeks, energy returns, the dilation routine becomes part of normal life, and discharge patterns gradually settle. Healing is rarely a straight line, and a setback or two does not mean something has gone wrong.
The emotional side matters just as much. For people born without a vagina, this surgery can sit alongside years of feeling different or unseen; for trans women, it can be a long-awaited step. Good psychological support, realistic expectations and a care team you trust all make the recovery smoother.
How a bowel vagina compares to other methods
Bowel is one of several ways to build a vagina, and each has trade-offs.
Penile inversion uses genital skin and is the usual first choice in gender-affirming surgery. It avoids abdominal bowel surgery, but the lining is skin, so it is not self-lubricating and generally needs lifelong dilation.1
Peritoneal techniques (including the Davydov approach) line the canal with the smooth membrane from inside the abdomen, and can add useful depth with some natural moisture. Skin-graft methods such as the McIndoe procedure use a graft from elsewhere on the body, but share skin’s lack of self-lubrication.
Bowel stands out for depth and self-lubrication, at the cost of being bigger surgery with bowel-specific upkeep.1 There is no single best option – the right one depends on anatomy, what tissue is available, prior surgery and personal priorities.
If you are deciding between procedures, our pieces on the vulvoplasty procedure and why some trans women choose vulvoplasty over vaginoplasty are worth reading, and clinicians may appreciate our practitioner perspectives on gender-affirming surgery.
Questions worth asking your surgical team
If you are considering a colovaginoplasty, the consultation is the place to get specifics for your body and situation rather than generalities. A few questions that tend to be genuinely useful:
- Why are you recommending bowel for me specifically, rather than penile inversion, a peritoneal method or dilation?
- How many of these do you do each year, and what are your own complication and revision rates?
- What depth and width can I realistically expect, and what dilation will I need afterwards?
- How will discharge, odour and infections be managed long term, and who do I see for that?
- What is your plan for long-term monitoring of the bowel segment, including for the rare cancer risk?
- What does recovery look like week by week, and what counts as a warning sign I should call about?
A good team will welcome these. The answers also tell you something important about how closely a service thinks about the years after surgery, not just the operation itself.
Frequently asked questions
Not exactly. Gender-affirming vaginoplasty is most often done by penile inversion. Colovaginoplasty is a specific method using bowel, and in gender-affirming care it is usually a second-line or revision option.1
Yes – that is one of its main strengths. Because the lining is mucous membrane, it produces its own moisture, and many people need little or no added lubricant.1
The lining is bowel, and bowel makes mucus. Some discharge is normal and expected. It is worth getting checked when it changes suddenly, smells strongly or comes with pain or bleeding.4,6
Usually less than with skin-lined methods, but regular dilation is still important in the early healing phase to protect depth and width.2
It can. A bowel neovagina lacks the protective lactobacilli and acidity of a natal vagina, so it can be prone to irritation, overgrowth and odour, which is why informed long-term care matters.5,6
The risk is low, but because the lining is still bowel tissue, cancers can rarely develop in it, sometimes years later. Long-term monitoring is increasingly recommended, particularly for those at higher risk.7
Bowel generally allows good depth. In one MRKH trial the average usable depth was around 17 cm after surgery.2 Individual results vary with anatomy and healing.
For most, yes, as a first step. Non-surgical dilation is the recommended first-line approach because it is effective and avoids surgical risks; surgery is considered when dilation is unsuitable or has not worked.3
What to do next
If you are considering or recovering from a colovaginoplasty, the most useful next step is good, tissue-specific information and a clinician who genuinely understands neovaginal anatomy.
For day-to-day questions you can ask Aunt Vadge’s Assistant, the chat widget in the bottom left of your screen, any time. If you would like tailored help with discharge, irritation, odour or microbiome questions, our practitioners work with neovaginal tissue and can guide you through it.
If you want to know what is actually growing in your neovagina rather than guessing, a thorough PCR or NGS microbiome test gives a far clearer picture than a standard swab. That kind of swab was never designed for this tissue.
This article is general information, not a substitute for personalised medical advice. Surgical decisions and any new or worsening symptoms should always be discussed with a qualified clinician who knows your history.
- Lava CX, Ferdousian S, Li KR, et al. Outcomes of gender-affirming sigmoid colon vaginoplasty: A retrospective study of 119 patients. J Plast Reconstr Aesthet Surg. 2025;106:310–318.
- Delshad S, Delshad B, Mogheimi P. Postoperative outcomes of sigmoid colon vaginoplasty for vaginal agenesis: A randomized controlled trial. Ann Med Surg (Lond). 2022;78:103833.
- Committee on Adolescent Health Care. ACOG Committee Opinion No. 728: Mullerian Agenesis: Diagnosis, Management, and Treatment. Obstet Gynecol. 2018;131(1):e35–e42.
- van der Sluis WB, Bouman MB, Meijerink WJHJ, et al. Diversion neovaginitis after sigmoid vaginoplasty: endoscopic and clinical characteristics. Fertil Steril. 2016;105(3):834–839.
- Hamidian Jahromi A, et al. The microbiome of the neovagina: a systematic review and comparison of surgical techniques. Int J Transgend Health. 2024;25(4):623–633.
- Hallarn J, Bauer GR, Potter E, et al. Gynecological concerns and vaginal practices and exposures among transfeminine individuals who have undergone vaginoplasty. J Sex Med. 2023;20(11):1344–1352.
- van der Sluis WB, de Boer NKH, Buncamper ME, et al. Neovaginal cancer after sigmoid vaginoplasty: Implications for postoperative cancer surveillance. JPRAS Open. 2024.
