GENERAL CONCERNS

 

I’m having pain from surgery. Is this normal?

• Pain is very common and should stay about the same for a few days and gradually improve thereafter. It is NOT normal if the pain progressively worsens without any activity (that is, pain not brought on by any particular movement or position). Notify your surgeon and/or the office.

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I’m not having daily bowel movements. Is this normal?

• Constipation is not normal. Constipation (generally defined as not having at least one large bowel movement per day) is, however, very common after surgery. It is especially common when taking pain meds regularly. It is normal though to not have a bowel movement for about the first week after metoidioplasty since patients often do a bowel prep the day prior to surgery. After 1 week postop, the goal should be one bowel movement per day.

• Make sure to take miralax or other stool softener while you are on pain meds to avoid constipation. Constipation may cause pain, nausea, vomiting, and negatively affect your ability to urinate since the colon and bladder share a similar nerve supply.

• The goal is one large bowel movement per day.

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When can I drive?

• Driving is safe when you are catheter free and off pain meds.

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How much should I walk?

• Walking is important and the general recommendation is about 1 hour total per day (six 10 minute walks, four 15 minute walks, etc). Stairs are also okay, but take it one step at a time and take it slow.

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When can I shower?

• It is generally okay to shower after 48 hrs.

• There are new skin crevices after metoidioplasty that require regular hygiene. Clean between the skin folds of the scrotum, penis, and perineum with mild soap and water.

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WOUND CONCERNS

 

Is my wound infected?

• Infection symptoms typically include a combination of redness spreading beyond the incision, combined with worsening swelling and pain, and sometimes fever (defined as higher than 101°F). Notify your surgeon immediately. If you notice chest pain or lightheadedness with these symptoms, go to the ER and/or call 911. Infections may also lead to wound openings; open wounds with redness and drainage of pus require medical attention.

 

I’m bleeding from my wounds. Does this require emergent evaluation?

• Bleeding: rarely does this require emergency room management. Most times, the bleeding is small volume oozing and may occur for several weeks after surgery. If the drainage is bright red and dripping, this requires holding pressure over the bleeding site (usually a skin edge around the ridge) for about 5 minutes at a time. It should stop. If it doesn’t, it may require an additional 5 minutes.

• If the above does not stop the bleeding, if you notice brisk bleeding, and/or notice lightheadedness, headaches, weakness, chest pain, and/or shortness of breath, notify your surgeon and go to the ER and/or call 911.

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I have an open wound. How do I manage this?

• Most open wounds are shallow and narrow; use ointment like vaseline, medi-honey, or aquaphor on the open wound and apply it 1-2 x per day until it heals (can take 2-4 weeks). Antibiotic ointment use is acceptable for a few days but not necessary. Prolonged antibiotic ointment use may lead to an allergic reaction and/or a fungal infection.

• Avoid activities that put tension or pressure on the wounds.

• Eat a healthy diet (minimize processed foods); avoid smoking/second-hand smoke.

• Wound separation requires emergent evaluation if it is a large, open and deep wound with surrounding redness, pus drainage, and fever over 101°F.

 

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URINARY CONCERNS

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Urinary leakage: Is this normal?

• Once patients are urinating through the longer urethra, it is normal to have urinary leakage after voiding. This is from the lengthened urethra holding about 1 teaspoon of urine after voiding. It is common to get some drips of urine on the underwear after voiding.

• For the neourethra, start pushing from behind the scrotum (the perineum), then push on the scrotum, and then compress the penis from the base to the tip to expel the residual urine. This may be repeated to decrease the amount of leakage.

• Urinary leakage that is not normal: If you see urine leaking from another site (examples: scrotum, perineum, phallus but not the tip), this is a fistula. Fistulas may come and go; if they persist beyond 3 months after phalloplasty, repair may be required.

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Urinary Spraying: Is this normal? How long will this persist?

• Urinary spraying is common in the postop period and may continue for 3-6 months after metoidioplasty. This is frequently caused by swelling of the penis (picture gently stepping on a garden hose). In most patients, this resolves by 1-3 months. 

• Spraying is not normal if it is associated with a progressively worsening/weakening urinary stream. These are symptoms of a stricture.

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Burning/Pain with Urination: is this normal?

• Burning/pain with urination (dysuria) when you first start urinating is common and may last a few days to a few weeks. As long as it’s not associated with a consistently weak urinary stream, cloudy urine, and odorous urine, then it is normal.

• Dysuria is NOT normal if there is a consistently weak stream (stricture or narrowing of the urethra can cause stretching of the urethra upstream to the stricture, causing pain) or if there is cloudy/odorous urine (UTIs can cause dysuria).

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Weak Stream: Is this normal?

• Yes, if it occurs on occasion and is not consistent.

• A consistently weak/slow stream that is progressively worsening is NOT normal and is indicative of a stricture. If the office/surgeon is not notified in a timely fashion, some patients have ended up in acute urinary retention (the inability to urinate with severe lower abdominal pain from a full bladder). This requires ER management with possible emergent SP tube placement.

• Weak stream and stricture may be associated with dysuria, and sometimes UTIs.

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Blood in the urine/urethra: Is this normal?

• ​​Blood in the urine is medically referred to as hematuria. This is normal whenever patients still have a catheter in place, and it will occur off and on, especially with walking. Hematuria is usually light red (like gatorade) and resolves with rest.

• Hematuria may also be seen whenever patients get UTIs and this is expected.

• Blood may leak around the catheter and through the penis. If it is red wine like in appearance, it is likely old blood within the urethra that has liquefied. This will be off and on until you are urinating regularly through the penis. It is not normal if it is bright red and high volume.

• Intermittent hematuria may persist for about 3 months postop. If hematuria persists beyond 3-6 months, a cystoscopy (camera evaluation of the urethra) may be required.

• Hematuria is not normal if it is high volume (example: soaked wash cloth with bright red blood) and ketchup-like. This requires contacting your surgeon and potential ER management.

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CATHETER CONCERNS: ​

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• Know where your catheter is at all times and make sure it is not getting tugged​

  • A tugged SP tube or catheter often looks straight coming out of the abdomen and is often associated with intense bladder spasms.

    • Loosening the tension by repositioning the tubing can help​

    • Sometimes, putting ointment where the catheter touches the skin and pushing the catheter in 1-2cm will help reposition the internal parts of the catheter to decrease the spasming.

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PENIS CONCERNS

 

Penis positioning: how should it be positioned?

• For the first 2 months after metoidioplasty, it is generally helpful to support the phallus and scrotum with a washcloth and/or gauze (helps create a “bean bag” for the genitals). 

• When sleeping, do your best to avoid putting undue pressure on the penis and scrotum. 

• When walking, it’s helpful to have a washcloth and/or gauze in slightly loose boxer briefs or hospital underwear to achieve the ideal positioning of the genitals.

 

Swollen penis: is this concerning?

• A swollen penis occurs commonly and frequently improves with time. Ice off and on (about 15-20 min at a time) may also help with swelling and pain. 

• If swelling is worsening and redness develops, this is not normal and may be an infection; start antibiotics and notify the surgeon/office. 

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SCROTAL CONCERNS

 

How should I position my scrotum?

• Avoid putting tension on the scrotal incisions. The scrotum should be positioned comfortably between the inner thighs without undue tension or compression; this can be achieved with the thighs slightly apart and with careful walking.

 

Bleeding: what do I do?

• Drainage of small amounts of blood mixed with yellow fluid (serosanguinous fluid) is common and will occur for 3-6 weeks until the incisions mature.

• If bleeding is bright red, holding pressure for about 5 minutes at the site of bleeding should help; repeat if needed; if no improvement, call your surgeon.

 

There is an opening behind my scrotum. What do I do?

• The most common open wound is behind the scrotum, at the junction with the perineum (flat area between anus and back of scrotum; aka vaginectomy site). It is typically small and shallow and will heal with wound care, nutrition, and daily to twice daily ointment.

 

My scrotum is swollen and uneven. Is this normal?

• Yes, as long as it’s not enlarging rapidly (a sign of bleeding inside the scrotum).

• Swelling can take 1-3 months to resolve; occasionally longer.

 

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PERINEUM CONCERNS

 

I have an open wound just above my anus. What do I need to know?

• The second most common open wound in the perineum is in front of the anus. It is typically small and shallow and will usually resolve and close with wound care, nutrition, and daily to twice daily ointment. If it doesn’t heal with skin, and granulation tissue (pink tissue that bleeds easily) develops instead, silver nitrate topical treatment (done in the office) may be required.

• This wound can open up with tension (hard bowel movements, not gently sitting from a standing position, etc). Avoid tension to prevent the wound from getting bigger and use stool softeners regularly; miralax is the preferred stool softener.