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A journal club style critical review of current publications in evidence-based transgender medical care.

Thursday, October 27, 2011

Microflora of the Penile Skin-Lined Neovagina of Transsexual Women

     In a study of the penile-inversion neovaginal microbiome of 50 transsexual women,  vaginal irritation and discharge was not correlated with the presence or absence of leukocytes or specific organisms on gram stain.  No cases of candidal colonization were identified, and only one woman had lactobacilli. (1)

     Transsexual women often present with a variety of vaginal symptoms after penile-inversion vaginoplasty.  The authors aimed to identify colonizing flora of the neovagina, and determine if any correlation existed between vaginal cleansing habits, specific flora or the presence of leukocytes and symptoms of irritation or discharge.  They also aimed to evaluate any correlation between sexual orientation (i.e. presence or absence of receptive penetrative sex with a penis) and presence of particular microbiologic species.

     50 post-vaginoplasty transsexual women (mean time since surgery: 6.3 yrs) were studied through a combination of pelvic examination, gram stain and culture/PCR, and self-report survey.  Almost all were on estrogen HRT (94%),  44% were heterosexual, 22% homosexual, 28% bisexual and 6% asexual.  Regular episodes of vaginal irritation occurred in 22% of the women and 18% experienced frequent dysuria.  Only 34 women answered questions about foul smelling discharge;  Of these, 23.5% had frequent foul smelling discharge.   No correlation was found between vaginal rinsing habits and vaginal pH or vaginal discharge, and no correlation was found between vaginal pH and complaints of irritation or malodorous discharge.  No correlation was found between the presence of leukocytes and reported malodorous discharge. 

     Mean vaginal pH was found to be 5.88.  On exam, clinicians reported a foul smelling discharge in “most patients”.  Microbiological studies revealed a mixed vaginal flora with typical skin and intestinal organisms.   Lactobacilli were found in only one woman, and candida were notably absent from all women.  Notably, colonization with E. faecalis was correlated with both heterosexual orientation and regular receptive coitus with a male partner.  Mobiluncus (a genus typically resistant to metronidazole) was found in higher numbers than in natal vaginal flora.  All participants were negative for Chlamydia and gonorrhea.  Twelve novel, untypable species were identified.  No strong correlation was found for any specific flora species and symptoms.

     The authors conclude that they are unable to explain the high rates of vaginal discharge and irritation in transsexual women through microbiologic analysis or analysis of vaginal rinsing habits. 


     This article highlights the fact that postoperative symptoms of irritation, odor, discharge, and dysuria are common complaints in transsexual women, even years after surgery.  It also reminds providers to take a different approach to penile-inversion neovaginas than they would for natal vaginas in the setting of vaginal complaints.  Also of interest is that the neovagina is colonized (not surprisingly) with a variety of skin and intestinal flora, and in heterosexual transsexual women active in receptive coitus is more likely to be colonized with the UTI-causing coliform E. faecalis. 

     No correlations with symptoms were found between symptoms and cleansing habits, pH, a particular microbial species, or the presence of leukocytes.  Only one woman was colonized with lactobacilli, and no candida was found.  Hopefully this will help lay to rest the notions that neovaginas are (or should become) colonized with a usual vaginal microbiome, that lactobacilli are important for neovaginal health, that neovaginal candidiasis is a common entity, and that pH effects microbial outcomes in neovaginal health. 

     The authors are unable to draw any conclusions on neovaginal symptomatology from a microbial perspective; It is likely that while colonization occurs, most neovaginal symptoms are not infectious in nature and instead relate to the constant production of sebum, sweat, and cellular and keratin debris that occurs in a skin-lined vagina.  Also likely to contribute is the presence of semen, lubricating gels and other foreign substances and the constant “skin-on-skin” irritation which may occur.  Treating neovaginal symptoms with antimicrobials is likely only treating colonization.  It is curious that cleansing habits did not improve or worsen symptoms.  More outcome-based research is needed to explore risk factors and curative interventions for neovaginal symptomatology.

Several additional points of interest in this paper:
- The range of reported sexualities in the study population supports the notion of diversity of sexual orientations among transsexual women

- A metronidazole-resistant microorganism was commonly found in neovaginas, suggesting that clindamycin should be used if one does decide to treat with antibiotics

- Heterosexual transsexual women are at higher risk of E. faecalis colonization.  Weather specific recommendations for preventive measures against UTI should be given to tramssexual women, and what measures should be taken are areas for future study.

- The fact that none of the 50 women were positive for gonorrhea or Chlamydia suggests that the neovagina itself is resistant to infection with these organisms;  Providers may consider obtaining swabs for these organisms from the urethral meatus for a higher yield.  It also may simply suggest that there are populations of transsexual women who have a low incidence of these (and perhaps other) STI’s.


1) Weyers S, Verstraelen H, Gerris J, Monstrey S, Santiago G dos SL, Saerens B, et al. Microflora of the penile skin-lined neovagina of transsexual women. BMC Microbiol. 2009;9:102. 


  1. The sample used is very different than what you would find in STI/HIV related studies. They don't go into much detail about the demographic characteristics but the lack of STI's wasn't that surprising.

    Sexual orientation doesn't really tell us anything. Recent sexual activity 9partner and activity) would have been more informative.


  2. Emilia,

    Thanks for your comments. Could elaborate more on your points?

  3. My thinking is that the women in this sample had better access to resources (i.e. social privilege) than the women in studies examining HIV and STI's among trans populations because of their access to genital surgery. They would not have the same risks.

    I'm also wondering if recent sexual activity would impact bacterial flora. Specifically would those who are penetrated by a penis or sex toy have different flora than those who did not.


  4. Interesting about the potential increased risk for UTI. In my practice this does not bare out clinically. Just from experience, it seems neo-vaginal women have less UTIs than natalvaginal women. Anyone else have a sense of this in their practice?

    -Christine McGinn