Gender-Affirming Metoidioplasty

Gender-affirming metoidioplasty is a surgical procedure that creates a small penis (neophallus) from the hormonally enlarged clitoris. The goal is to achieve male genital appearance, sensation, and, in some cases, the ability to urinate while standing. It is usually performed for transmasculine and nonbinary individuals.

Types of Gender-Affirming Metoidioplasty

There are several variations of metoidioplasty, which can be combined depending on goals:
– Simple or release-only metoidioplasty: frees the enlarged clitoris from surrounding tissue to increase length and exposure.
– Full metoidioplasty: includes urethral lengthening so the patient can urinate through the neophallus
– Scrotoplasty: creates a scrotum, often with testicular implants (usually staged)
Monsplasty- excision of the pre-pubic fat pad to flatten the area and improve projection of the penis
Vaginectomy – this is optional and where desired, will be performed at the time of metoidioplasty

Who Is Eligible

Eligibility for gender-affirming metoidioplasty is based on the World Professional Association for Transgender Health (WPATH) standards. This generally includes a diagnosis of gender dysphoria or gender incongruence, being of legal adult age, and at least 12 months of masculinising hormone therapy (testosterone) to ensure clitoral growth. Patients should also be in good overall health and have realistic expectations.

Preparing for Surgery

Preparation may include:
– At least 12 months of testosterone therapy to maximise clitoral enlargement.
– Stopping smoking and optimising general health.
– Discussion of surgical goals with your team (urination ability, size, sensitivity, future phalloplasty).
– Possible hair removal in the genital region if skin grafts will be used.
– Obtaining required mental health assessments or letters of readiness.

The Surgical Procedure

Gender-affirming metoidioplasty is performed under general anaesthetic and may take several hours. The clitoris, which has been enlarged by testosterone, is freed from its attachments under the pubic bone and repositioned to project forward. If urethral lengthening is included, skin flaps from the labia or tissue grafts (from vaginal or buccal mucosa) are used to extend the urethra through the neophallus. Scrotoplasty can be done at the same time or later and may include insertion of testicular prostheses. The vagina may be partially or completely closed (vaginectomy), depending on patient goals. Finally, monsplasty ( excision of pubic fat pad) may be done to further expose the new penis and facilitate urination in the standing position.

Recovery and Aftercare

Most patients stay in hospital for 3 to 5 days. A urinary catheter is left in place for 3 weeks. Initial swelling and bruising are normal. Pain relief and antibiotics are provided. Patients should avoid strenuous activity and sexual contact for 6 weeks or as advised by their surgeon. If urethral lengthening is performed, urination through the new urethra is checked with a camera ( cystoscopy) before catheter removal.

Risks and Complications

Possible risks include bleeding, infection, wound breakdown, scarring, or narrowing (stricture) of the new urethra. Small fistulas (leaks) can occur but are often repairable. Some patients may experience less-than-expected length or projection. Loss of sensation is rare, and most patients maintain good erotic sensitivity. Revision surgery may be needed in some cases.

Long-term Care

Long-term care includes regular follow-up appointments to assess healing, urinary function, and satisfaction. Most patients continue testosterone therapy. Scrotal implants or further lengthening procedures can be performed later if desired. Sexual activity can usually resume after 2 to 3 months once healing is complete.

Questions to Ask Your Surgeon

Which type of metoidioplasty do you recommend for me?
Will I be able to urinate standing up?
What are the risks of urethral complications?
What length and appearance can I expect?
How will sensation and sexual function be affected?
What are the costs and what is covered by Medicare or insurance?

Summary

Metoidioplasty is a safe and effective option for many transmasculine and nonbinary people seeking masculinising genital surgery. It provides natural sensation, the potential for standing urination, and minimal scarring. Thorough preparation, skilled surgery, and attentive aftercare are key to successful outcomes. Contact us today to find out more.