Vaginoplasty, a gender-affirming surgery for transgender women and some nonbinary individuals, creates a neovagina, or ‘new vagina’. While this surgery can be life-changing and affirming, it comes with its own unique considerations for care and maintenance.
Below are answers to frequently asked questions about neovaginas, focusing on health, functionality, and what to expect after surgery. Remember, the best person to talk to is your doctor or surgeon! If you have concerns or questions, talk to the person or team in charge of your care.
1. What is a neovagina, and how is it created?
A neovagina is a surgically constructed vaginal canal created during vaginoplasty. It can be made using penile inversion (turning penile and scrotal tissue inward), scrotal grafts, a segment of the sigmoid colon (bowel graft), or a combination of these methods.
The choice of technique depends on your anatomy, surgical goals, and surgeon’s expertise. Your surgeon will discuss the best approach for your needs.
2. Can a neovagina produce natural lubrication?
In some cases, yes. During sexual arousal, residual Cowper’s glands (which normally produce pre-ejaculatory fluid) may contribute some lubrication.
However, this varies greatly between individuals, and many find the amount insufficient. For most people with a neovagina, using unscented, alcohol-free, water-based lubricants is essential for comfortable sexual activity.
3. Why do I need to dilate my neovagina, and how often should I do it?
Dilation is a critical part of postoperative care. After surgery, the neovagina is essentially a wound that the body may try to close. Regular dilation with medical dilators helps maintain the depth and width of the vaginal canal.
Initially, you’ll need to dilate several times a day, but this frequency decreases over time. Eventually, once-a-week dilations may suffice. Skipping dilations can result in the narrowing or closure of the canal, requiring corrective procedures.
4. Can I get infections in my neovagina?
Yes, infections such as vaginitis are possible, as the neovagina is prone to inflammation due to bacterial imbalance, hygiene issues, or insufficient lubrication.
The bacterial environment of a neovagina often includes species commonly found on the skin, in the mouth, or the gut (if a sigmoid graft is used). Maintaining good hygiene and using appropriate products as instructed by your healthcare team can help prevent infections.
5. What does good neovaginal hygiene involve?
Good hygiene involves gentle cleaning of the external vulva and the neovaginal cavity. Use warm water and unscented, pH-balanced cleansers for the external area.
For the internal canal, your surgeon may recommend irrigation with saline or other solutions to flush out debris or bacteria. Avoid douching with harsh products, as this can disrupt the microbiome and lead to irritation or infection.
6. Will I need gynaecological examinations after vaginoplasty?
Yes, annual gynaecological check-ups are recommended to monitor the health of your neovagina. These visits may involve a speculum exam to assess the inner walls of the neovagina for signs of scarring, inflammation, or other issues.
However, Pap smears are not necessary, as neovaginas are lined with skin or bowel tissue, which are not at risk for cervical cancer.
7. Can I still develop prostate issues after vaginoplasty?
Yes, the prostate is not removed during vaginoplasty. Regular prostate exams, as advised by your doctor, remain important, especially if you have a family history of prostate cancer or other risk factors.
Discuss this with your primary care provider to ensure it remains part of your routine health care.
8. Will I experience natural sensations in my neovagina?
Sensations in the neovagina vary based on the surgical technique and your unique anatomy. The clitoris, reconstructed from penile tissue, often retains sensitivity and is a primary source of sexual pleasure.
While the neovaginal canal itself may have limited sensation, many individuals report being able to experience intimacy and pleasure with their new anatomy over time.
9. Can hair grow inside the neovagina?
If penile or scrotal skin is used for the neovaginal lining and hair removal isn’t performed before surgery, hair can grow inside the neovagina. This may cause irritation, infections, or discomfort during dilation or sexual activity.
If hair regrowth becomes an issue, treatments like laser removal or surgical cauterisation may be necessary. Discuss hair removal options with your surgeon prior to surgery to minimise this risk.
10. Is it possible for my neovagina to tear?
The neovagina is designed to withstand regular activities and penetration once healed. However, since the tissue may lack some of the natural elasticity found in natal vaginas, improper dilation or forceful sexual activity could lead to microtears.
Using adequate lubrication and being gentle during penetration can minimise this risk. If pain or tearing occurs, consult your healthcare provider promptly.
11. How does the microbiome of a neovagina differ from that of a cisgender woman’s vagina?
The neovaginal microbiome is distinct from that of a natal vagina. Instead of being dominated by Lactobacillus (a protective bacteria in cisgender women), neovaginas often have a diverse range of bacteria, including skin, oral, or gut microbes.
While diversity is beneficial in the gut, it can lead to inflammation or bacterial vaginosis-like conditions in the neovagina. Maintaining hygiene, using recommended products, and monitoring for symptoms of imbalance are essential.
12. What should I do if I experience inflammation or irritation in my neovagina?
If you notice signs of inflammation, such as redness, swelling, pain, unusual discharge, or a strong odour, consult your healthcare provider. These could indicate an infection or imbalance in the neovaginal microbiome.
Treatment may involve antibiotics, antifungal medications, or changes to your hygiene routine. Ignoring these symptoms can lead to more severe complications, so early intervention is key.
13. Does estrogen impact neovaginal health?
Estrogen plays an indirect role in maintaining the health of your neovagina, especially if penile and scrotal tissue is used. Without adequate estrogen, the skin may
have reduced keratinization and barrier function, leading to increased vulnerability to irritation or tearing. Discussing hormone therapy with your endocrinologist can help ensure optimal support for your neovaginal tissue.
14. Can I engage in sexual activity after vaginoplasty?
Sexual activity, including penetrative sex, is generally safe about 12 weeks after surgery, once healing is complete. However, it’s crucial to use adequate lubrication and proceed gently to avoid discomfort.
It’s also recommended to wait at least eight weeks before exploring clitoral stimulation, as nerve endings need time to recover. Take your time to rediscover your body and communicate openly with your partner about what feels comfortable.
15. What should I know about long-term care for my neovagina?
Long-term care involves regular dilation, proper hygiene, and annual medical check-ups. Pay attention to your body’s signals and address any discomfort or unusual symptoms promptly.
Staying proactive about your health ensures that your neovagina remains functional and comfortable, allowing you to enjoy the benefits of this life-affirming surgery for years to come.
References1–4
- 1.van der Sluis WB, de Haseth KB, Elfering L, et al. Neovaginal discharge in transgender women after vaginoplasty: A diagnostic and treatment algorithm. International Journal of Transgender Health. Published online February 13, 2020:367-372. doi:10.1080/26895269.2020.1725710
- 2.Horbach SER, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG. Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques. The Journal of Sexual Medicine. Published online June 1, 2015:1499-1512. doi:10.1111/jsm.12868
- 3.Dietrich JE. Review of Surgical Neovagina Techniques and Management of Vaginal Stricture. Journal of Pediatric and Adolescent Gynecology. Published online April 2022:121-126. doi:10.1016/j.jpag.2021.10.001
- 4.Stoehr JR, Moss C, A HJ. The microbiome of the neovagina: a systematic review and comparison of surgical techniques. International Journal of Transgender Health. Published online July 27, 2023:623-633. doi:10.1080/26895269.2023.2237014
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