GENERAL NOTE

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• The most common metoidioplasty includes UL, vaginectomy, scrotoplasty, perineal reconstruction, and associated procedures like a SP tube insertion. These instructions cover this most common combination of procedures. Patients who elect to omit one or more of these procedures like NO UL and NO vaginectomy will not need to worry about the catheter related instructions. 

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DEFINITIONS

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• Fever: elevated body temperature; if greater than 101°F, notify your surgeon

• Rash: new red spots that develop on the skin

• Constipation: not having regular bowel movements (example: one large bowel movement per day is expected)

• Hematuria: blood in the urine; this is expected whenever there is a catheter and increases in volume and redness when patients are moving/walking more.

• Fistula: abnormal connection between a segment of the urethra and the skin, causing urine to come out of a separate opening​

• Bladder spasms: the catheter can trigger the bladder to contract forcefully, causing a sudden desire to void which can cause pain and discomfort.

• Graft: tissue from somewhere on your body (typically lower abdomen, groin, or inner cheek) to cover another part of your body (typically the urethra).​

• Perineum: area between the scrotum and anus

• Diverticulum: outpouching of the urethra, usually near the native urethra

• Infection: surgical site that has redness that spreads beyond the incision line combined with increased pain and tissue swelling and/or pus

• DVT: deep venous thrombosis; a clot in a vein, typically in the legs. This can progress to a more serious blood clot in the lung, called a pulmonary embolism. This is potentially life threatening.

 

GENERAL INSTRUCTIONS

 

• Activity: Avoid any activity or position that puts strain or tension on your incisions.

  • Examples: sitting on your incisions; plopping into a chair; sit ups, pull ups, large strides with walking

  • Pain is the body’s way of telling you a certain movement or position may inhibit healing; listen to your body and limit those positions and movements.

  • Walking is encouraged (about 1 hour per day; example: six 10-minute walks); check the surgical sites to make sure pressure/tension isn't applied on the incisions while walking.

  • No jogging for 6-8 weeks; start slow and gradually increase to your pre-surgery cardio routine.

  • Avoid sexual activity for 6 weeks.

• Return to work: for desk dominant jobs, many can return to work when their pain is well controlled (usually 7-14 days after surgery) and the catheter is not bothersome. For jobs that are strenuous, 8 weeks off is more appropriate.

• Diet: eat normally whenever your appetite returns. Water is a good drink choice.​

• Showering: may shower daily 2 days after surgery; no baths/pools for 6 weeks; make sure to gently wash with mild soap between the skin folds (examples: sides of the scrotum, behind the scrotum, between the scrotum and the phallus). Not doing so can lead to a buildup of skin, oil, sweat and dirt that can lead to bacterial overgrowth and potentially increased risk of infection.

• Underwear: When wearing underwear, it may be more comfortable to have gauze over the incisions. Slightly loose boxer briefs tend to work well. You will typically have mesh underwear after surgery.

• Genital positioning: position the penis and scrotum in a comfortable spot; it’s different for everyone.

• Driving: Do not drive yourself until you are completely off prescription pain meds and your catheter has been removed.

 

SURGICAL SITE CARE

 

• Incisions: close observation and avoiding certain activities will help it heal. 

  • Avoid putting tension on the incisions.

  • Drainage is common and is yellow-red in character.

  • Ointment (like medi-honey, aquaphor) applied daily to twice daily on the incisions may make things more comfortable and is optional. Ointment is very helpful for wound healing when there is a separation of the incision (a wound). Use Aquaphor as a default unless directed otherwise.

  • Frequently, patients are provided mesh underwear with gauze; this can be removed a few hours later or the following day. If desired, this can be used for the first 3-7 days and combined with gauze to help keep the incisions clean and dry. Consider transitioning to boxer briefs when the incisions stop draining.

  • Gauze should be changed on average 1-2 x daily; the most frequently used gauzes are called 4x4s (4 inch x 4 inch). They do not have to be sterile but they should be clean. Ointment, gauze, then mesh underwear may help with postop drainage and pain.

• Wound care: if a wound develops, use gauze and change regularly to help catch drainage that occurs. 

  • If the gauze begins to get stuck, applying ointment like aquaphor 1-2x per day is helpful to make the wound less dry​

  • Wounds heal best when they are clean, not too dry, and not too wet

• Catheter care: if you have a catheter, know where the catheter is at all times and avoid any tugging on the catheter. It should generally be protected or covered by your underwear.

  • Putting ointment at the point where the catheter touches the skin or urethra may make it more comfortable.

  • Sometimes the catheter can get tugged and cause worse bladder spasms. This typically happens with walking or at night with shifting while asleep.

    • A tugged catheter can cause very uncomfortable spasms that require catheter repositioning. ​

    • Repositioning a catheter can be done by putting ointment where the catheter touches the skin or urethra, and pushing it in 1-2cm (1/2 an inch).

  • Hematuria is common with a catheter and usually resolves several weeks after the catheter is removed. Hydrate regularly with water to help with this.

  • Plugging: plugging the end of the catheter (where the drainage bag tubing is attached) is ok when you are walking more.

  • There will be leakage of bloody or cloudy fluid around the catheter; this is seen frequently and is expected. It will resolve when the catheter is finally removed and patients are urinating more regularly

 

POSTOPERATIVE CONCERNS

 

• Bleeding: a small amount of bleeding from the incisions (estimate is about a 4x4 gauze sized area of redness) is expected; sometimes holding pressure over the incision for 5 minutes (like holding pressure on a paper cut) is required. If there is any concern or the bleeding does not stop, contact your surgeon.​

• Infection: redness spreading beyond the incision combined with worsening swelling and pain, and sometimes fever (defined as higher than 101°F) are consistent with infection; notify your surgeon immediately. If you notice chest pain or lightheadedness with these symptoms, call 911 immediately or go to the Emergency Room.

• UTI: Urinary Tract Infection. This is seen when the urine is consistently cloudy and more smelly than usual. Start the antibiotic provided and contact the office to let them know.

• Swelling: this is common and should worsen the first day, stay about the same for the next 3-7 days, and then slowly improve thereafter. If the swelling progressively worsens, combined with increased pain and redness around the incision, this is an infection. Bruising is common and is not a sign of infection.

• Pain: this 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 activity).

• Bladder spasms: with a foreign body (the catheter) in your bladder, some patients get bladder spasms. Oxybutynin (aka Ditropan) can help decrease this pain/discomfort, as can catheter repositioning

• Wounds: occur commonly, especially behind the scrotum and the junction between the base of the penis and scrotum.

  • These are managed by keeping the wounds clean, good nutrition, and ointment use if the wound is dry.​

• Drainage: it is expected/normal if it is a small amount of slightly blood-tinged yellow fluid. It is not normal if it is bright red blood or cloudy and cream colored, or if there is a large volume of drainage with no improvement.

• Leg pain: if there is leg pain combined with swelling, especially with one leg moreso than the other, there is a chance you have a DVT. Go to the ER as soon as this is seen to get evaluated. 

• Constipation: very common after surgery especially when needing to take pain meds regularly; make sure to take miralax or other stool softener while you are on pain meds.

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POSTOPERATIVE MEDICATIONS

 

• Take over the counter Tylenol 1000 mg every 6-8 hrs for baseline pain control. This will likely be needed for 3-7 days.

• Tramadol 50mg tablet: pain medication; take 1-2 tablets every 6-8 hrs as needed for breakthrough pain.

  • Over the counter ibuprofen 200-400mg is acceptable for further pain control if needed.

    • Take it with meals. Ibuprofen may be taken at the same time as Tramadol and Tylenol since they are not in the same class.

  • Side effects*: itchiness, constipation, diarrhea, nausea, sweating, insomnia; liver problems (when acetaminophen is included)

• Miralax: stool softener to be taken while on pain medication; 17g by mouth daily (mix powder with liquid of your choice)

  • Side effects*: nausea, gas, drowsiness, stomach ache, loss of appetite

• Ditropan (oxybutynin): take 1 tab (5mg) every 8 hrs as needed for bladder spasms

  • Side effects*: dry mouth, headache, constipation in 5-10% of patients​

• Bactrim (trimethoprim/sulfamethoxazole): DS by mouth, twice per day, for 7 days (take only as directed)

  • Side effects*: itching, rash, diarrhea, nausea, headache

  • If allergic to this or sulfa drugs, we will substitute this with another antibiotic like Augmentin, Clindamycin, or Ciprofloxacin

 

*This is not a complete list of all the side effects that may occur with these medications. Getting side effects are infrequent; the side effects named are the more common ones for those who do experience side effects. Please call the office if you have any questions about your medications. Definitely notify us if you notice a rash that started soon after starting a new medication. If you notice shortness of breath or difficulty breathing after taking a new medication, call 911 and/or go to the nearest emergency room. You may be having a serious allergic reaction to the medication.

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Call office or your surgeon for fevers, chills, redness and pus from the incision, or pain not controlled with pain medication. If after hours, call the office phone number and leave a message; urgent messages will be relayed to the surgeons. If you feel it is a medical emergency and need immediate help, call 911 and/or go to the closest Emergency Room.