35.1 Introduction

The pelvic floor is a complex anatomic area, important for pelvic organ support, urinary and bowel sphincteric function, and sexual function. Gender-affirming vaginoplasty dissects through the superficial and deep pelvic floor muscles to create a new pelvic space. This surgery has the potential for impacting all functions of the pelvic floor. In addition, patients will need to directly interact with their pelvic floor during receptive sexual activity as well as with regular dilation which is required to maintain the neovagina after surgery.

Gender-affirming vaginoplasty is unusual among reconstructive surgeries in that it requires active maintenance by the patient, in the form of regular dilation of the neovagina to prevent stenosis and further complications (see Chapters 16 and 34). Neovaginal stenosis can occur at the introitus or within the vaginal canal and is reported to occur in about 11% of patients after vaginoplasty [Reference Bustos, Bustos and Mascaro1]. In our experience, vaginal stenosis occurs most frequently (and severely) at the passage through the pelvic floor. To avoid stenosis, most surgeons recommend a program of regular dilation with dilators of increasing diameter and uniform length to affect the whole vaginal canal. To our knowledge, there are no scientifically validated dilation regimens, but there is consensus that dilation is necessary and important.

We have noticed many patients to be anxious about postoperative dilation, which is natural but can be compounded by experiences shared by community members who have already undergone vaginoplasty and had difficulty with dilation. Fear of pain may result in increased pelvic floor activity as a protective reaction, and the pelvic floor musculature is indirectly innervated by the limbic system and reactive to emotional stimuli [Reference Weijmar Schultz, Basson and Binik2]. If early dilation is a painful or traumatic experience, which, in our experience, usually reflects high tone pelvic floor dysfunction, patients may avoid or altogether abandon dilation.

This chapter is conceptualized to outline the improvement of pelvic floor functioning regarding the creation of a neovagina and the functional impact of pelvic floor physical therapy. Pelvic floor physical therapists should be an integral part of the team of physicians and healthcare professionals caring for people undergoing gender-affirming vaginoplasty. Other professionals may benefit from this information in understanding when pelvic physical therapists are especially helpful.

35.2 Anatomic Impact of Vaginoplasty

Dissection of the neovaginal canal divides through the connections between the urethra/corpus spongiosum and the perineal body, dividing the bulbospongiosus, superficial, and deep transverse perinei musculature. The dissection divides the rectourethralis muscle and exposes the external urinary sphincter. Dissection then passes through the ventral rectal fascia and into the potential space within the pelvis between the ventral rectal fascia and the prostate, this potential space continuing up to the peritoneal reflection. To make the neovaginal canal sufficient caliber, the levator ani muscles, specifically the puboanalis and puborectalis muscles, are partially divided.

The proximity of the dissection to the external urinary sphincter and disruption of the surrounding attachments has the potential for weakening this continence mechanism and risking urinary incontinence. While this does not seem to be a common clinical finding, urinary incontinence after vaginoplasty has been reported as 16–33% [Reference Poone, Geolani and Dugi3–Reference Hoebeke, Selvaggi and Ceulemans5] but has had little formal study. Likewise, disruption of the levator ani muscles has the potential for affecting fecal continence. This is also understudied.

As in the native vagina, the neovaginal canal passes through the pelvic floor musculature. Within 5 days to 2 weeks from surgery patients will be asked to perform dilation of the neovaginal canal several times a day when the tissue is still inflamed and tender. We believe that physical therapy involving the pelvic floor before and after surgery is important in helping patients successfully perform dilation and with receptive sexual activity.

35.3 Preoperative Physical Therapy for Gender-affirming Genital Surgery

The purposes of preoperative physical therapy (PT) are to provide education about postoperative dilation and the pelvic floor, as well as to screen for and address pelvic floor dysfunction. Primarily, this consists of teaching pelvic floor relaxation in anticipation of dilation and educating individuals about the course of recovery.

Preoperative physical therapy is commonly utilized before many types of surgeries and has been shown to improve patient outcomes. In abdominal and cardiac surgeries, preoperative education and physical therapy reduces complication rates and length of hospital stay [Reference Valkenet and Dronkers6]. Physical therapy reduces pain and improves mobility prior to hip and knee replacements and improves function in the early post-op period [Reference Wallis and Taylor7], and also pelvic floor muscle training is effective in reducing urinary incontinence in those undergoing prostatectomy [Reference Saliyan and Ozbas8,Reference Tienforti, Sacco and Marangi9]. In two studies of ciswomen undergoing surgery for urinary incontinence and/or pelvic organ prolapse, pre- and postoperative pelvic floor physical therapy improved outcomes and quality of life [Reference Jarvis, Hallam, Lujic, Abbott and Vancaillie10,Reference Nauman, Stolzle, Owens, Frilot and Gomelsky11]. Currently there is limited research to show the benefit of perioperative physical therapy in gender-affirming care. However, these surgeries have a significant impact on the musculoskeletal system and therefore preoperative physical therapy should be considered for all patients, especially in complex cases.

One study of 40 individuals undergoing gender-affirming vaginoplasty found that pre- and postoperative physical therapy significantly reduced pelvic floor dysfunction and improved quality of life [Reference Manrique, Adabi and Huang12]. In our center, a study of 77 patients undergoing gender-affirming vaginoplasty, 94% attended pelvic floor PT at least once. Of those who presented to PT with pelvic floor dysfunction preoperatively (primarily inability to relax the pelvic floor muscles), 69–73% demonstrated resolution by the first postoperative visit. Individuals who attended both preoperative and postoperative PT had significantly lower rates of pelvic floor dysfunction than those who attended only postoperatively [Reference Jiang, Gallagher, Burchill, Berli and Dugi13].

Pelvic floor muscle dysfunction (PFMD) in a person without neurological disease can be categorized as decreased tone or increased tone [Reference Frawley, Shelly and Morin14]. Tone is referring to the baseline function of the contractile elements of the muscle tissue. Though problems of decreased tone such as urinary and bowel leakage are important, it is the increased tone PFDM in the context of vaginoplasty that can create a challenge for postoperative successful dilating and sexual functioning.

Increased tone PFMD can be further divided into transient and persistent. People with transient PFMD can decrease the pelvic muscle tone with verbal cues, reassurance, or gentle pressure. For persistent increased tone, or spasm, the contraction of muscle cannot be easily reduced voluntarily. Persistent spasms can lead to increased viscoelastic stiffness and shortening in the muscular and connective tissues. A pelvic physical therapist through the examination techniques outlined below can determine the presence of normal, decreased, or increased tone. Treatments include breathing exercises, lumbopelvic stretches such as child’s pose, electromyographic (EMG) biofeedback, and appropriate manual stretching.

To avoid a sense of gatekeeping, which is a lived experience for many transgender people, we advise to not make participating in physical therapy a requirement for surgery. Buy-in from the surgical team and explaining that the goal is to maximize their comfort and success with dilation and address unique individual needs can be very helpful. We have had very high rates of participation from our patients when it was explained this way.

35.4 Duration and Timing of Preoperative Physical Therapy

Patients without pelvic floor muscle dysfunction, limitations, or impairments likely need only one to two visits, one to two months before surgery. Patients with pelvic floor muscle dysfunction, limitations, or impairments or significant musculoskeletal impairments of hips, lumbopelvic region, or use of their arms for holding the dilator could need more visits (as many as 4–8 visits), starting 3–4 months before surgery.

35.5 Counseling and Preparation

A trauma-informed approach to care (see also Chapter 23) [15] is especially important in this patient population, considering a long history of trauma and mistreatment from the medical establishment [Reference James, Herman and Rankin16].

We advise preparing the patient mentally for questions on pelvic floor function. Questions on physical pain, bowel, bladder, and sexual function may make a patient uncomfortable or appear invasive. By informing the patient at the start of the visit why these questions are important and by asking for permission to discuss these topics, the physical therapist helps create a safe environment.

The physical therapist may assess the patient’s current physical activity level to determine if they need a preoperative exercise routine to prepare for days to weeks in advance of postoperative bed rest and activity limitation. Exercising preoperatively reduces complications in multiple surgeries [Reference Pouwels, Hageman and Gommans17]. Some examples including colorectal oncology surgeries, show that preoperative physical activity levels and overall physical fitness are good predictors of postoperative recovery [Reference Dronkers, Chorus, Meeteren and Hopman‐Rock18], and that pre-rehabilitation is effective in improving functional capacity [Reference Mayo, Feldman and Scott19]. Also, the postoperative 6-minute walk test performance improves with preoperative exercise [Reference Gillis, Li and Lee20]. Detailed questions about pre-existing pain assist with determining if the pain will impact the individual’s postoperative recovery, tolerance to bed rest and postoperative activity limitations, and tolerance of positions for dilation.

Pelvic floor dysfunction is common in patients undergoing gender-affirming vaginoplasty. In our center, physical therapists identified 42% of patients had pelvic floor dysfunction and 37% had bowel dysfunction [Reference Jiang, Gallagher, Burchill, Berli and Dugi21], most commonly constipation. Pelvic physical therapists are practiced and comfortable screening for urinary and bowel dysfunction. This can be particularly helpful in identifying patients with fecal incontinence (which could increase the risk of postoperative wound infection) or urinary incontinence (which may be addressed preoperatively and/or help with counseling about postoperative expectations).

For all patients in whom a pelvic floor muscle exam is being proposed, it is important to screen for a history of past trauma or abuse. Patients with a history of childhood victimization or post-traumatic stress disorder [Reference Raphael and Widom22], or depression [Reference Mazi, Kaddour and Al-Badr23], have been found to have higher rates of hypertonic pelvic floor musculature. Among patients undergoing gender-affirming vaginoplasty, 91% of those who reported a history of abuse had pelvic floor muscle dysfunction preoperatively, compared to 31% of those who did not report a history of abuse [Reference Jiang, Gallagher, Burchill, Berli and Dugi21].

To avoid re-traumatizing a patient through specific questions about trauma, physical therapists may consider saying “Because we are working with your pelvis and pelvic floor, a private part of your body, is there anything you’ve experienced that might make you more concerned, or nervous about an exam?”

While survey instruments validated in this population are currently lacking [Reference Dy, Nolan, Hotaling and Myers24], some outcome measures that are pelvic-floor-specific include the Pelvic Floor Dysfunction Index and ICIQ-UI Short Form (with a modification to remove “male/female question”).

35.6 Physical Examination

Helping a patient preoperatively prepare for successful dilation postoperatively may include assessment of their ability to physically perform the actions of dilation, as well as an assessment of their ability to relax their pelvic floor muscles. While the idea of passing a vaginal dilator through the perineum may not sound challenging, we have treated patients who struggled to perform dilation because of physical mobility problems. Therapists should assess functional strength and range of motion of the hands, shoulders, lumbar and thoracic spine, and hips. For instance, weak hip muscles might limit patient tolerance to leg positions used during dilation. Loss of hip, spine, or upper extremity range of motion could limit perineal care, catheter care or dilator training, and these should be addressed preoperatively. In addition, patients with abdominal/truncal obesity may struggle to reach the perineum with a dilator or have trouble successfully inserting the dilator because of the challenge of reaching around the abdomen; it is helpful to prepare patients for these challenges preoperatively.

Assessment of a patient’s pelvic floor function can be very useful in identifying preoperative dysfunction and providing education. The goals of pelvic floor muscle testing are to assess for pain, strength, coordination, ability to isolate, and ability to relax. The patient should be provided with multiple exam options, and the therapist should gain consent at every step of the exam. No exam should always be an option and an acceptable choice.

One option in examination is external visualization only (no touch); looking at skin integrity, the presence of hemorrhoids, skin tags, anal fissures. Therapists may visually assess pelvic floor muscle contraction and bearing down, including muscle isolation, relaxation, and breathing patterns.

External palpation is another option. This can be performed over light clothing or directly on skin. With this option the therapist can assess sensation and pain response, and to a limited extent muscle tension, reflexes, and coordination of pelvic floor contraction and relaxation.

Electromyographic biofeedback exam can be done if equipment is available. The option of a channel placed on the gluteus maximus muscle helps evaluate the ability to isolate the pelvic floor muscles from the gluteal muscles. Since the patient’s perineum is only exposed during the placement of the external electrodes this could be a good option. EMG is measuring the activity of the contractile elements of the pelvic floor muscles. The therapist can measure resting activity of the pelvic floor and detailed information on pelvic floor contraction, including isolation, recruitment, and decruitment.

A digital anorectal examination, while invasive, can provide more definitive information about the pelvic floor. Multiple muscles and muscle groups may be assessed, including the external anal sphincter, puborectalis, and levator ani muscles. If the person consents to such an exam, the therapist can assess sensation and pain response, muscle tension at rest, coordination of pelvic floor contraction, and relaxation with bearing down. The power of the pelvic floor muscle contraction using the modified Oxford scale [Reference Laycock, Schussler, Laycock, Norton and Stanton25,Reference Chevalier, Fernandez-Lao and Cuesta-Vargas26] can be noted, as well as the duration and number of contractions.