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

Friday, December 2, 2011

Vaginal Prolapse, Pelvic Floor Function, and Related Symptoms 16 Years After Sex Reassignment Surgery in Transsexuals

     Cross sectional study of 52 MTF patients assessing for prolapse and related bladder, bowel and sexual problems found 3.8% of patients having prolapse warranting surgical repair, 47% with voiding difficulties, and 75% reporting that sexual complaints in some way interfered with their enjoyment of life.  (1)

     Pelvic organ prolapse affects 50% of non-transsexual parous women over age 50, though not all women with clinical signs of prolapse are symptomatic.  The authors aimed to assess the prevalence of pelvic organ prolapse in a cross sectional study of post-vaginoplasty MTF transsexual patients with a median age of 57 (range 39-69 years) under care at a single Swiss tertiary referral gynecology & endocrinology service.  The medial postoperative time was 16 years (range 13-29 years).  49 patients had undergone scrotal inversion and 3 patients had undergone sigmoideocolpoplasty at 14 different surgical centers distributed between Switzerland, the UK, France, the US and Thailand.  Objective measurement by a single examiner using the International Continence Society - Pelvic Organ Prolapse scoring (ICS-POP) and subjective symptom survey using the Sheffield Pelvic Organ Prolapse Quality-of-Life Questionnaire (SPS-Q) were conducted.

     7.5% of patients were found on exam to have an ICS-POP score greater than 2, with 3.8% of patients requiring surgical repair.  47% of patients reported voiding difficulties, 24.6% reported urgency, 17% urge incontinence, and 23% stress incontinence.  With respect to sexual satisfaction, 22.6% reported "never" and 26.4% reported "occasionally".  The paper includes a discussion of various anatomical considerations in pelvic surgery on transsexuals and also looked at outcomes in 3 FTM patients.


     This paper is useful in reminding us that vaginoplasty is not a risk-free procedure, and that a non-trivial percentage of patients will experience bothersome urinary and sexual symptoms that can impact quality of life.  Primary care providers and surgeons should discuss known and unknown risks and percentages during the informed consent process prior to surgery.  These data are also useful in the ongoing development of government policies which allow changing legal documents to reflect the affirmed gender without requiring surgical intervention;  As more data emerge showing that surgery can be associated with substantial morbidity, the justification of surgery as a requirement for changing documents becomes weaker.

     The paper has several strengths and several weaknesses.  Using a single examiner eliminates inter-examiner reliability issues with respect to ICS-POP scoring.  At the same time, decision to perform pelvic surgical repair in cases of prolapse is more often guided by patient symptomatology and response to conservative treatment.  The study sample was rather large, but skewed towards an older population with an average age of 57.  The study population also represented an all-comer population from surgeons in a range of countries, but individual outcomes by surgeon or country were not reported.  Being a tertiary referral center, referral bias may have caused a higher prevalence of pathology in the study population.  The ICS-POP and SPS-Q scales have not been validated in transsexuals, and given the discussed anatomical differences may not be applicable or clinically relevant.  Comparisons are made to the prevalence of pelvic symptoms in parous non-transsexual women;  Weather or not this comparison is applicable vs. comparisons between groups of transsexual women by age or surgical technique, or comparison with pre- or non-op transsexual women are subjects to ponder.


1) Kuhn A, Santi A, Birkhäuser M. Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals. Fertil. Steril. 2011 Jun;95(7):2379–82.