Postop Week 1-4:

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• Leakage of urine or drainage from the penis?

  • This happens on occasion with a bladder spasm, trying to empty the suprapubic tube, and/or when moving your bowels. This is expected and is ok.

• Pain at the end of emptying the bladder/suprapubic (SP) catheter?

  • This is from the bladder wall clamping around the suprapubic tube tip as the bladder empties. This is common and is usually well tolerated. If the pain is intolerable, it can be minimized by timing the unclamping of the catheter so that there is some residual urine left in the bladder on purpose so that the bladder doesn't contract completely around the suprapubic tube tip.​ Bladder spasm medication can also reduce this sensation.​

• ​New bladder spasm pain suddenly happens overnight or with activity?

  • 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.

• Blood in the urine/urethra?

  • ​​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 and movement, for as long as the catheter is in place. Hematuria is usually light red (like Koolaid) and resolves with rest and hydration with water.

  • 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 occur 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 3-6 months postop. If hematuria persists beyond 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.

• Chunks in the urine that look like mucous, or skin?​

  • Usually not a concern; this occurs regularly and will go away with time.​

When can I start urinating?​

• Patients are instructed to start urinating through their penis usually by their 3rd or 4th postop visit. They are given specific instructions on what is called a voiding trial.

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Postop Week 4 onward:

 

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 1-2 teaspoons of urine after voiding. Anatomic urethras also hold about a teaspoon of urine, which is why the post-void penis shake is frequently seen in public urinals. It is common to get some drips of urine on the underwear after voiding.

• For the neourethra, start pushing from behind the scrotum (aka the perineum), then push on the scrotum, and then "milk" the phallus from the base to the tip (in this specific order) to expel the residual urine in the lengthened urethra. 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.​

• If you notice leakage through your underwear and pants after urinating to completion, there may be a pocket connected to the urethra holding some urine that leaks out in high volume after urination. This may require repair.

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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 6-12 months after phalloplasty. This is frequently caused by swelling at the tip of the phallus. It may take 6-12 months to resolve as swelling at the tip is prolonged by gravity pulling fluid towards the glans, compressing the tip of the urethra. In most patients, this resolves by 3 months. Elevating the phallus when resting can help counteract the force of gravity. 

• On occasion, there is tissue that permanently blocks a portion of the tip of the urethra (like a thumb over a garden hose), that then leads to persistent spraying. This may require surgical removal of the obstructing tissue.

• 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 months. As long as it’s not associated with a weak urinary stream, cloudy urine, and odorous urine, then it is normal.

• Dysuria is NOT normal if there is a 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/doctor 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 may require ER management with emergent SP tube placement.

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

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