GENERAL NOTE

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• The most common phalloplasty 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 or the equivalent is expected)

• Hematuria: blood in the urine. This is expected whenever there is a catheter. Hematuria may increase in volume and redness whenever 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 be painful and uncomfortable.

• 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 with or without 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. Smaller steps are usually required the first few weeks after surgery.

  • Stairs are ok as long as you take one step at a time.

  • No jogging for 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). For jobs that are strenuous, 8-12 weeks off may be more appropriate.

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

• Showering: may shower in 7 days; no baths/pools for 8 weeks and sometimes longer if wounds have not healed by 8 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.

  • Note: it is ok to let the penis hang for the duration of a short shower (5-10 minutes) to free up your hands for washing.​

    • Make sure to cover the donor site arm or thigh when showering.​

  • Sometimes it is hard to keep the thigh dressing dry. Some patients have used saran wrap, but this is not necessary and it is generally okay to get the thigh dressing (graft harvest site) wet. It is essentially a large scab. Allow it to air dry or fan dry it based on your comfort level. 

• 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.

• Phallus positioning: Gently supporting the penis is ideal and this can be achieved with mesh underwear or slightly loose boxer briefs or a similar type of underwear. Don’t smash the phallus but avoid prolonged dangling of the phallus. Keeping the phallus in the 45-degree angle away from the plane of the body with a washcloth and/or gauze can help with healing faster and better. This keeps pressure off the incision between the penis and the scrotum.

  • Important note: NEVER position the phallus upward and toward the side of the groin incision (where the vascular pedicle is); this can kink your blood vessels and compromise blood flow to the penis.

  • Avoid folding or bending the penis excessively as it can cause a permanent crease. 

• Scrotum positioning: avoid sitting or smashing the scrotum. A wider walking stance and smaller strides may help. Paying attention when sitting may also help avoid smashing the scrotum. There will be frequent conscious crotch adjustments the first 4 weeks until things become second nature.

• Driving: Do not drive yourself until you are completely off prescription pain meds and all catheters have 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. 

  • Swelling of the phallus and scrotum is common and usually takes a few weeks to months to resolve. It is expected and considered normal postoperatively. Swelling is not normal if it is worsening over time and combined with increased redness, pain, and fever.

  • 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. The combination of ointment, gauze, and mesh underwear may help with postop drainage and pain.

• Catheter care: 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.

  • Hematuria is common with a catheter and usually resolves several weeks and rarely several months 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

    • urethral leakage: very common and often looks dark red and sometimes brown; allow it to drain. If the drainage is blocked by a scab, it is ok to remove the scab in the shower if easy to allow continued drainage. Your surgeons could also remove the scab at one of your postop visits.​

• Putting ointment at the tip of the penis where the catheter is visible may make it more comfortable.

• Donor Site: radial forearm and anterolateral thigh donor sites are managed similarly the first month after surgery

  • The mepitel silicone dressing stays on for about 3 weeks; it will be removed at your 3rd or 4th postop appointment.​

  • If the wrap around the mepitel is clean, you do not need to change it; we'll change it at your postop appointment. If the wrap is dirty, it is ok to remove and place another wrap around the donor site and mepitel.

  • You can wash your arm/thigh donor site around week 3; specific instructions will be provided. Generally, it's avoid direct water pressure on the donor site and use mild soap and water. 

  • Around 4 weeks postop, the skin graft on the donor site is healed. Ointment like aquaphor should be applied daily. Only a thin layer is required. Mild lotions with minimal chemicals are also acceptable if there are no open wounds.​

  • Around 6 weeks postop, silicone sheets can be obtained over the counter and placed over the scar.

  • Using lotion that has minimal dyes/fragrances and an SPF of 30 or greater when skin is at risk of sun exposure is recommended on the donor site.

 

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 surgeons. If you need immediate attention, call 911 or go to the ER.​

• Infection: redness spreading beyond the incision combined with worsening swelling and pain, and sometimes fever (defined as a temperature 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.

  • Keeping tension off your catheter (make sure it doesn't look like it's being tugged) will help minimize spasms.​

• 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.​

  • Most wounds are wet in the beginning and using gauze alone is appropriate--changing the gauze 1-4x daily as needed depending on the drainage amount.

  • Once the gauze starts to stick to the wound, this means the wound is getting dry and may benefit from regular ointment application (usually 1-2 x per day). Aquaphor is usually best. 

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

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

• Fistula: these usually heal on their own. On occasion, leaving the SP tube in an extra 1-2 weeks may help with fistula healing. However, the pain/discomfort and increased risk of leaving the SP tube in longer must be considered.

  • Treatment: several options:

    • Delay urinating x 1-2 weeks and keep the catheter in longer

    • Take the catheter out regardless and keep the fistula site clean; it may help to put ointment at the fistula site. 

    • Many fistulas will heal with or without a catheter

• Post urination leakage: Once the catheter is removed, post void dribbling can happen in the longer urethra. Putting some pressure behind the scrotum (the perineum) and on top of the scrotum, followed by gently milking the phallus from base to tip can help compress the residual urine out of your newly lengthened urethral. This will likely minimize the leakage after urination.

• Constipation: very common after surgery especially when needing to take pain meds regularly. Make sure to take miralax or other stool softeners 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​

• Aspirin: 81mg by mouth daily, for 4 weeks

  • Side effects*: bleeding, rash, abdominal pain, heartburn, headache

• May not be prescribed from Hospital due to confusion on when to take: Bactrim (trimethoprim/sulfamethoxazole): DS by mouth, twice per day, for 7 days (take only when prescribed or directed)

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

  • If allergic to this or sulfa drugs, may substitute 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.