I'm considering getting bottom surgery at some point. At first, I thought I'd be fine with just top surgery, then I thought I'd be fine with just top surgery and testosterone, but now I want metoidioplasty. I think I'm gonna do a simple release with monsplasty and urethral lengthening, but we'll see what makes the most sense. My bottom dysphoria has been getting harder to ignore, and I think this will likely help a lot. Still not 100% though. I'm mostly worried about recovery, as it sounds like it's quite a bit more painful than top surgery. I'm also very nervous about the consults and follow up appointments. It's already very difficult for me to get pelvic exams bc of dysphoria and trauma, and I'm worried that this will be a barrier to treatment. My GP lets me do self-swab tests now, but surgical results need to actually be seen by a doctor. Hopefully it'll be easier if I have a lower level of dysphoria.
Ey if youre comfortable answering i wanted to ask how comfortable it is to pee standing up with fly-less underwear at a urinal. It seems strange to me cause in my case i gotta yank down the elastic so far and end up stretching them out. Then again im still relying on gravity
I don’t find it uncomfortable at all. I actually find that trying to pee through the fly of my underwear/pants is more uncomfortable for a few reasons. First, pre-erectile device especially tight underwear with narrow flys could push into the sides of my dick and make my stream a little weaker. Keep in mind that my stream was already weak because of a stricture though so not everyone would have that problem. Second, after getting my erectile implant my dick doesn’t have the same flexibility/maneuverability (ie it isn’t super flaccid) so it’s easier to just pull my underwear down a little. Last, when I pee through the fly of my underwear/pants I don’t have the same level of access to my perineum so I’m not able to clear my urethra as well. This can lead to a few drops of urine coming out in my underwear which can be extremely annoying. Nearly all of my underwear is fly-less so I don’t even think about it most of the time. I just go up to the urinal, unbutton and unzip my pants, pull my underwear down and out a little, and pull the shaft sort of to the side and over. I haven’t had any issues with the elastic wearing out over time.
Hi, I was wondering if you knew if it was possible to have meta with urethral hookup but without a vaginectomy or testicular implants?
Yes, this is an option which is available.
It is however important to understand that there is an increased risk of urethral complications such as strictures or fissures (narrowing or holes respectively) when urethral lengthening is performed without vaginectomy. Having urethral lengthening also narrows the vaginal opening, so dilation is necessary to increase the size to allow penetration.
I have a personal pet peeve with using the phrase "stand to pee" when it's used to gauge whether someone wants UL or not.
I want UL just because peeing from my dick sounds nice - standing or no.
Maybe it's just because I don't personally care much about standing. Also because I have heard lots of people who get UL can't necessarily pee standing (stream type or clearance, also fistula)
But peeing out of your dick might still be wanted? Worth it?
It could be because I have cis guy friends who sit to pee.
Do you know if theres any other tissue that can be used for urethral lengthening in meta other than that of the mouth? I have had braces for like 4 years and every time i got so much as an ulcer i would lose my mind so i dont think i could deal with having a graft taken.
They have occasionally been known to take it from “downstairs” rather than from the mouth, but it is much less common and would depend on your particular anatomy as to whether there is sufficient skin to do so.
It’s certainly worth discussing it with the lower surgery team though, as they’re generally quite accommodating when it comes to preferences, as long as it’s medically possible.
Aside from differences that might come up with strictures, fistulas, or other urethral complications it’s actually very similar to peeing pre-op. The only real differences are that I can aim the stream and when I start or stop peeing there’s a very minor delay since the urine has to travel further. I also don’t have to wipe afterwards, though for my own cleanliness I usually dab the tip with a piece of toilet paper to get any remnants. The actual mechanics of peeing, having a full bladder, etc feels the same.
Also potentially good news, since having my erectile device placed some of my urethral issues have gotten better. Dr. Chen was surprised but happy to hear this since it could mean avoiding another urethral repair in the future. Long story short, I developed another (minor) stricture after my repair in September and was having occasional pressure when peeing and a slightly weaker stream. I was originally set to have another repair this time around but opted to have my implants instead because the urethral issues weren't getting worse. My reasoning was that I could go another 6 months peeing uncomfortably but felt I couldn't go another 6 months in an in-between stage feeling like my life was on hold. Since the erectile device was placed my stream is stronger and I'm not feeling pressure as often when peeing. Dr. Chen believes this is because the erectile device and mons resection straightened out my urethra so that urine flows more naturally through it. If it lasts that's fantastic and if not we'll cross that bridge when we get there.
Stage 1 date: April 25th, 2016
Repair date: September 27th, 2016
Surgeon: Dr. Chen in San Francisco, CA
It’s been nearly a month since my stricture repair and I thought I’d make a post talking what strictures are, why I needed the operation, what the day of surgery looked like, what the recovery looked like, the catheter removal, and where I am now.
To give some background information, a urethral stricture is a narrowing of the urethra often caused by inflammation or scar tissue. The risk of developing a stricture after urethral lengthening varies depending on factors such as the technique your surgeon uses or your health history but in general UL carries about a 10-20% complication rate if a vaginectomy is also performed. If a vaginectomy is not performed then the complication rate rises to at least 25%. While that complication rate seems significant it’s important to also mention that the grand majority of urethral complications (about 90% of them) heal on their own with no need for surgical intervention. The 10% of cases that require further surgery are most often fistulas (holes) that aren’t able to close on their own or strictures caused by excess scar tissue that needs to be removed. Frustrating as it may seem, these repairs typically aren’t performed until about 6 months after the initial operation so the scar tissue has time to soften, the inflammation and swelling of the tissue has gone down, and the vascularity of the phallus is well-established. The composition of a urethra after UL (for phalloplasty) will also depend on your surgeons technique but in many cases your natal urethra is partially extended using labia minor tissue and then this is extended to the tip of the penis using skin from the donor site. If urethral lengthening is performed in this way there are 3 main points where strictures can form - where the natal urethra meets the l. minora tissue, where the l. minora tissue meets the tissue from the donor site, and the opening of the urethra at the tip of the penis. Strictures can range from mild to severe - a mild stricture might cause a weakened urine stream or discomfort when peeing whereas a severe stricture could block the urethra completely.
Why I needed a repair:
Around 3 months post-op I noticed a very slight change in the strength of my stream when peeing. The stream didn’t seem to have as much force as it used to and when I ‘pushed’ to make it go faster it stayed the same speed. I took a mental note of this and carefully watched for other changes as time went on. Luckily I was set to meet with Dr. Chen a few weeks later so I preemptively sent him an email explaining what I was noticing. Dr. Chen was extremely glad I emailed him as soon as I started noticing changes rather than waiting until the stricture progressed because waiting could’ve resulted in the need for an emergency surgery later on. When we met in person he performed a quick physical exam in his hotel room and then took me out for breakfast to discuss what the repair would entail as well as some other unrelated things. During the exam he said that the urethral opening at the tip of my penis had narrowed and that that was a good indication that there was probably a narrowing inside as well. We talked about some other symptoms I was having, like an uncomfortable and at times painful pressure when I peed, and collectively everything pointed to me more than likely having a stricture. The uncomfortable pressure I felt was the urethral area right before the stricture bulging slightly whenever I peed because the urine wasn’t able to go through my urethra as quickly. Some scheduling mishaps happened and I had to get both Dr. Chen and Ursula involved to figure it out but I ended up with a surgery date on September 27th at the Bon Air Surgical Center which is attached to Dr. Chen’s office. They use the surgical center rather than CPMC for less extensive/outpatient operations. Also, during my pre-op phone call I mentioned to Dr. Chen that the post-op instructions I was sent were pretty minimal and that I didn’t have a clear idea of what to expect, what to bring, when I could do basic activities, etc. Dr. Chen sincerely apologized for that, obviously very surprised, and less than 12 hours later he sent me an email with much more in-depth aftercare instructions that he also made available on their website.
Surgery day:
My operation was set for 8 AM which meant I had to check-in at the surgical center at 7. When I arrived I filled out some basic paperwork with the nurse at the front desk, used the restroom, and then waited. Around 7:10 they took me back to get prepped. The nurse at the front desk gestured for me to go into the bathroom and it took a minute for me to realize there were lockers in the bathroom, not that she was trying to make me pee again. I changed into a gown, hair net, and leg warmers and then they took me to the prep area. For some reason all of the beds in this surgical center are extremely high up, so they brought out of step stool for me to get into the bed. A lovely nurse named either Ilene or Irene was in charge of my surgical prep and she instantly made me feel more at ease as we traded stories about where we’ve traveled and why we work in the professions that we do. Around 7:45 Dr. Chen come around to answer any last minute questions I had. I still wasn’t clear about what exactly was going to happen with this surgery, so he had me lift the gown and he showed me where the incisions would be. I was under the impression that it would be a horizontal incision along the underside of the base of my penis but it was actually a vertical incision, 2-4 cm depending on how large the stricture was, running from the base down the middle of my scrotum. In August we also discussed slightly opening my urethral opening because it had narrowed but after further examination Dr. Chen said he didn’t think this would be necessary. If the stricture were long he also mentioned he might need to use buccal tissue - something he hadn’t mentioned before. I was nervous going into this surgery because there were a lot of unknowns. I didn’t know how large the incision would be, if they would need to increase my urethral opening (and if so by how much), and I didn’t know if they’d have to use buccal tissue, all of which were dependent upon how long and how narrow the stricture was. I’d wake up with 1, 2, or 3 incisions.
I was in a state of pretty high anxiety and was set to go under at 8 o’clock. Eight rolled around and the really lovely nurse I’d been talking to apologized for the delay since the anesthesiologist wasn’t there yet. I laid back and closed my eyes for about half an hour, steadily relaxing and accepting what was to come. Honestly I was very thankful for the delay since it gave me a lot of time to calm down. By the time the anesthesiologist arrived, about 8:45, I was completely relaxed and ready. Apparently a truck had caught on fire on a bridge leading into Marin, so he had to get through that. Shortly after meeting with the anesthesiologist the nurse came over to help me use the bathroom one last time before walking to the OR. I’d never walked into an OR before so that was a new experience. It was a relatively small team - about 2 nurses, the anesthesiologist, and Dr. Chen (who wasn’t in the room yet). I climbed up on the table and the nurse helped me scoot my butt into the right place. The anesthesiologist put Fetanyl in my IV (which hit me in less than 10 seconds) and about 5 minutes later I went under.
I woke up around 11 AM to Dr. Chen giving me a basic summary of what happened in the OR. I vaguely recall responding to what he said but mentally I just wasn’t there yet. About 5 minutes later, when I was fully coherent, I asked the nurse if Dr. Chen had actually talked to me or if it had been a dream. I asked if she could have him cover over again and tell me how the operation went. Dr. Chen said that everything has gone very well but the stricture was actually much longer than they expected. They’re usually 1-2cm but mine was 3cm. On the plus side, based on how he described it with his hands, my stricture was only about half as narrow as they usually are. This would explain why I never felt much pain when I urinated; just pressure. Because of the length of the stricture Dr. Chen almost had to use buccal tissue but thankfully the urethral tissue was pliable enough that he didn’t need to. He also didn’t need to extend my urethral opening since the narrowing was at the very very tip and the scope fit fine. During the repair he excised the scar tissue in my urethra, turned each end of the urethra into a spoon-like shape, and connected the now oval ends together. The idea behind this technique is that if the scar tissue were to grow back there would be a lower possibility of it causing an issue because the scar tissue is more spread out. I woke up with a foley catheter in my penis (which would be there for 3 weeks), mesh underwear, gauze behind my scrotum, and gauze between my scrotum and shaft. I was surprisingly pain-free when I woke up and aside from being a little dizzy and having to walk kind of funny everything was fine. Sitting on the ride home was uncomfortable because I had to lean back on my tailbone (you can’t have your feet on the floor and you need to keep pressure off your scrotum) but once I was home I laid in bed for the rest of the day. I occasionally got up to walk around or empty my bladder through the catheter but I mostly rested.
The recovery:
I didn’t fill my pain medication prescription right away and by the next day I was regretting that. As the night went on the pain medication from surgery worked its way out of my system and my scrotum started to ache. The difficult thing about this particular recovery is that there’s no way to keep pressure off of the incision sites entirely. Your shaft sits right on top of the incision, so once the medication wore off this constant pressure on the incision made moving very painful. There was a constant low level (3/10) pain and then particular movements (like sitting down) momentarily spiked that up to around a 7/10. I filled my prescriptions later that day but in the meantime found that ibuprofen took away almost all of my pain. The day after my surgery I had a bit of a scare when I noticed a lot of blood and possible urine coming out around the catheter at the tip of my penis. I texted Ursula, Dr. Chen’s head nurse, about it and she had me come in so she could examine it in person. This was around 4:50 and their office closes at 5 but she and a few other nurses waited for me to get there. I wasn’t able to drive and no one else was home so I took an Uber. Ursula took a look at everything while Courtney and another nurse stood by. Ursula drained and flushed the catheter to see if there was a blockage but didn’t find one. She said everything looked fine but scheduled to have Dr. Chen see me the next day just in case. When I saw Dr. Chen the next day he did the same thing, examined all of the surgical incisions, and explained that the blood was from the catheter keeping the narrowed part of my urethral opening stretched open. Typically having blood come out around the catheter is a bad sign but in my case it was completely fine. Having the catheter keep my urethral opening stretched out was a good thing. Thankfully in the end nothing was wrong and on the plus side Dr. Chen also saw the very beginnings of a skin infection during the exam and started me on antibiotics before it could progress to anything serious. Aside from that slight hiccup everything was extremely smooth with my recovery. I saw Dr. Chen for a post-op appointment one week later and I was cleared to go home the next day.
Though I could walk immediately after my surgery I tired out very easily and it wasn’t comfortable. Stairs were also challenging to go up since I couldn’t lift my legs very high without worrying about the catheter or friction or what have you. I could go up stairs, I just had to take it very slowly and eventually found out that going up them backwards was a lot easier. Sitting down ranged from uncomfortable to downright painful depending on how I sat and I could only sit for a few minutes at a time. Bending, squatting, or otherwise trying to reach something lower than my mid-calf was difficult until I removed my catheter. For about 3 weeks I kept a few pieces of gauze at the tip of my penis, gauze between my shaft and scrotum, gauze behind my scrotum to keep it elevated and away from my legs, and I kept an ABD pad folded around the tip/shaft to catch any extra blood. During that time I only wore mesh underwear because it kept everything securely in place. The downside to needing all of this gauze was that it also bulked everything up in my underwear and looked downright obscene most of the time. Eventually I was able to use less gauze/bandaging as the bleeding from my tip reduced but in the first 2 weeks I didn’t leave the house much because I tired easily, walking was a little difficult, and I didn’t want to make anyone uncomfortable. I could try to obscure how it looked by wearing long t-shirts, jackets, or oversized shorts I otherwise don’t wear. It was most obvious whenever I sat down:
The worst part of the recovery were the bladder spasms. A bladder spasm is a sudden, involuntary contraction of the bladder and they’re extremely common with catheters. Some people have them right away, some people never experience them. Based on my experience with this recovery and the recovery from my first stage it seems like my bladder spasms start around the 2nd week of having a catheter in place. Prior to that I was hardly ever aware of the catheter unless I was sitting (which put pressure on it). You know how painful and urgent it feels when your bladder is extremely full and you’re trying to hold it in? A bladder spasms feels like that but about 3x as painful, lasting about 20 seconds each time, and they can happen multiple times a day with no warning. Mine started when I was in the middle of making dinner one day. One moment I was dicing sweet potatoes and the next moment I was clutching onto the counter, almost doubled over in pain, and felt like I was a nanosecond away from peeing myself. For me it’s a hot, searing pain. Like everything else the feeling and intensity of a bladder spasm will vary from person to person. I went from not having any to having about 3 an hour in one day. Part of the reason spasms are so common with catheters is that the catheter is held in place by a balloon inside of your bladder that can cause irritation. When a spasms happens the bladder contracts around the balloon and essentially attempts to push it out. During particularly strong spasms, or if the bladder is full, this can also lead to some urine being expelled around the catheter. I only had this happen once - I was on my way to the bathroom when an extremely strong spasms happened and I ended up peeing a little bit. It happens. It’s no big deal. It can be embarrassing because of the stigma and shame surrounding incontinence but seriously this is just a thing that can happen and that is okay. I originally requested 2 weeks off of work but once the bladder spasms started I extended it to 3 weeks so I could return once the catheter was removed. Once the catheter was removed my spasms immediately stopped.
Catheter removal:
My foley catheter was in place for 3 weeks. I had the choice of either having the catheter removed by a local urologist or removing it myself at home. I discussed this with the nurse in the hospital, Dr. Chen, and Ursula and from the beginning I was pretty comfortable removing it myself. At my post-op appointment Dr. Chen went over how to remove the catheter myself and gave me the supplies I’d need. I watched him remove my suprapubic catheter after my first stage and I watched a few videos about removing one the night before my post-op appointment, so I asked a few clarifying questions about it based on what I already knew. For example, in the videos I watched the often said to twist the catheter while removing it and Dr. Chen said that wasn’t necessary. The end of the catheter has two openings - a urine drainage port where you attach either a drainage bag or a cap (you remove the cap to pee) and a balloon port. When removing the catheter you’ll attached a syringe to the balloon port and push up on the plunger slightly. The syringe should fill up with the saline from the balloon inside of your bladder.
Dr. Chen usually uses about 10ml of saline but advised me to completely fill the 10ml syringe, empty it, and try to fill it again just in case there was more. For good measure you can also cut the balloon port off to ensure it’s empty. Once the balloon is empty you pull on the end of the catheter gently but firmly, going roughly the speed that you would naturally move your arms when walking, and that’s it. It’s a very simple process but it can be very nerve-wracking doing it by yourself. Dr. Chen also advised me to remove the catheter on a weekday so that if something went wrong I wouldn’t be scrambling to find a urologist who could help. Thankfully I didn’t encounter any issues during the removal process. It wasn’t painful but it was very uncomfortable being able to feel every bit of the tubing as it was removed. I remember thinking to myself, “Is there seriously more??”. In the picture below you can see how long the tubing is. The gradual change in color around the 10-11 inch mark is roughly where it went from being internal to external.
The results:
It’s been about a week since I removed the catheter and the difference between peeing pre-repair and post-repair is enormous. I didn’t realize how bad the problem was until it was fixed. Before the repair I felt an uncomfortable pressure about 80% of the time I peed, my urine stream was very weak, it took at least a full minute to clear my bladder, it cleared slowly enough that I hardly felt the sensation of my bladder emptying, and I had a lot of issues with not being able to fully clear my urethra after peeing. In some of my monthly phalloplasty updates I talked about the frustration of not being able to do this and not being able to find the right spot to push to clear the remaining urine from my urethra and Dr. Chen said the stricture was completely to blame. My stricture was at the point where the l. minora tissue meets the skin tissue from the donor site, so no matter where I pushed along my perineum or scrotum trying to clear those last drops it just couldn’t go through the narrowing. Post-repair I feel very minor pressure when I pee (likely attributed to the healing tissue), my urine stream is very strong, I pee in under 15 seconds, I can feel my bladder emptying, and I don’t have issues with residual urine in my urethra. I have to wait until I’m 6 weeks post-op to resume ‘milking’ the phallus, a technique used to get all of those drops out, but even though I can’t do that I’m not having any issues. It’s downright incredible! Recovery-wise, I also can’t do any straddling activities (biking, motorcycle), sexual activities (including masturbation), or running/jogging until I’m at least 6 weeks post-op (which funny enough falls on Election Day).
So far everything looks great but there’s a 20% chance the stricture could come back and require an additional repair. If that were the case I would have a second repair done instead of my second stage in March and my second stage would be delayed a few months. If another repair were necessary Dr. Chen would use buccal tissue from my inner cheek. Failing that, another option would be lingual tissue from the side of my tongue. A 20% recurrence rate seems scary at times but it helps to shift the perspective and say that there’s an 80% chance everything will be completely fine. And you know what? I can live with those odds. If these operations have taught me anything it’s to take everything a day at a time and to recognize my own strength. If the stricture never comes back then that’s great! If it does then I have faith in Dr. Chen’s surgical expertise, I have the contact information for urologists who specialize in complex urological care and recurring strictures who could work with Dr. Chen, and I know what needs to be done.
