Our objective is to demonstrate how morphological and functional problems related to residual spongy and cavernosal tissue after gender affirming vaginoplasty can be corrected.

A 46-year-old transgender female presented due to the inability to dilate her vagina and have penetrative vaginal intercourse. She underwent penile inversion vaginoplasty in 2008 elsewhere. Since 2015, she started having difficulty in inserting the dilator into her vagina. Afterward, she developed dyspareunia and eventually ceased to have intercourse because of intolerable genital pain. She was disturbed by the painful engorgement that she felt in and around her vagina upon arousal. Lower urinary tract symptoms were not a part of the clinical picture. Her past medical history was remarkable for thyroidectomy due to thyroid cancer and hypertension. Physical examination revealed a digitally palpable vaginal mass narrowing the vaginal inlet. Webbing of perineal skin was further obscuring the introitus. Her laboratory test (urine and blood) results were within normal limits. Based on these findings she was scheduled for a revision vaginoplasty and perineoplasty.

The procedure was conducted in lithotomy position. A 16 Fr. Foley catheter was inserted into the bladder. Then, an infra-meatal “U” – shaped incision was done. The plane between the neovaginal wall and urethra was identified and dissected. Bulb tissue, which was adherent to the urethral wall, was dissected and then completely liberated off the urethral wall. Periurethral dissection was extended laterally and superiorly towards the pubic bone. It was noted that the corpus cavernosum was incompletely excised on the left side. Whereas, the extent of corporal excision was sufficient on the right side. Left corpus cavernosum was dissected and then amputated with ligasure device. Hemostasis was secured. Hemostatic tissue (Surgicell) was placed in both periurethral grooves to minimize bleeding and prevent adhesions. Vagina was unroofed, redundant perineal skin and vaginal wall were excised. A midline perineal skin incision, extending inferiorly towards the anus, was done in order to mobilize a skin flap which will serve as a vascular tissue supply for perineoplasty. Perineal skin defects were closed in an interrupted fashion using vicryl stitches. Vagina was packed and a slightly compressive dressing was applied. Estimated blood loss amount was 20 ml. The operation lasted 90 minutes. Packing was removed on day 1 together with the dressing. She was discharged on day 2. Foley catheter was removed on day 5. Perioperative period was devoid of any complications. At 1 month follow-up; the patient was satisfied with the cosmetic outcome and she did not report any problems related to vaginal dilation.

Insufficient excision of urethral bulb and cavernosal tissue at the time of gender affirming vaginoplasty may limit the ability to do self-dilatation and prevent penetrative intercourse by obscuring the vaginal inlet. Perineal skin webbing, if present, can increase the severity of this problem. Revision surgery, addressing both conditions simultaneously, should be performed to restore vaginal morphology and sexual function.