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Transgender Patient Care

Assessment of overall health

• Steps towards transition: cross-dressing, hormonal therapy, gender-affirming surgery
• Physical exam to assess secondary sex characteristics
• Can consider topical estrogen for 1-2 weeks prior to a pelvic exam
• DO NOT perform genital exam unless otherwise indicated
• IMPORTANT: establish trust and decrease anxiety, just as for any patient

Fertility

• Treatments may have permanent effects on fertility, discuss side effects and goals prior to initiating irreversible treatments
• Sperm may need to be obtained through electroejaculation or extraction after treatments

MTF hormone therapy

• Administer estrogens (goal < 200pg/mL) with antiandrogen medications - 5ARi or spironolactone
• Aim for testosterone 30-100ng/dL
• Estrogen increases cardiac, cerebrovascular, breast cancer, and hyperlipidemia risks
• Unclear effect of hormone replacement therapy on prostate cancer, may be protective or exacerbating

FTM hormone therapy

• Can administer testosterone alone, aim for 300-100ng/dL
• Testosterone increases polycythemia, liver dysfunction, cardiac, cerebrovascular, and hypertension risks
• Testosterone does not seem to cause PCOS or affect the potential follicle reserve

Gender-Affirming Surgeries

Male to Female (usually performed by gynecology)

• Creating vaginal cavity between bladder and rectum puts nerve supply to sphincter and bladder at risk
• Prostate not removed, potential risk for prostatic pathologies, use PSA cutoff 1.0, can be assessed on neovaginal exam (instead of DRE)
• Leave urethral catheter for 10 days, then assess voiding function
• Vaginoplasty/vulvoplasty: disassemble corpora, create perineal urethrostomy, define space between bladder/rectum, create vagina from skin/intestine, perform clitoroplasty and labiaplasty
• Clitoroplasty: keep portion of glans attached to neurovascular bundle to allow for sensate neoclitoris
• Labiaplasty: use scrotal skin to create labia majora
• Vaginoplasty maintenance: lifelong dilation, lubrication, and hygiene
• Can perform vulvaplasty to provide appearance without vaginal canal
• Orchiectomy: no need for antiandrogens, allows lower estrogen dose (less side effects), easier to "tuck"
• Complications: abnormal urinary stream (33%), urethral stenosis (15%), vaginal stenosis (10%)

Female to Male (usually performed by urology)

• Potential goals: gender-congruent genital appearance, standing to void, ability to have intercourse
• Surgical goals: remove female anatomic structures, create normal male anatomic structures, and implant penile/testicular implants
• Surgery specific workup: manage LUTS, assess PVR, and renal US to rule out upper tract pathologies
• Remove complete uterus, cervix, and tip of vagina
• Vaginectomy: unclear when is best timing (staged vs all-in-one), not required for phalloplasty
• Urethroplasty: use vestibular mucosa to create "bulbar" urethra, clitoris fixed to pubic symphysis to provide continued sensation, bulbospongiosus muscles closed over urethra to prevent fistulas and postvoid dribbling
• Phalloplasty: tube-within-a-tube created from radial forearm or thigh flap
• Scrotoplasty: created from labia majora, flaps supplied by external pudendal artery
• Metoidioplasty: alternative to phalloplasty, enlarges clitoris without creating an organ adequate for penetrative intercourse, buccal mucosa graft may be necessary to create short tubular urethra
• Testicular prosthesis: implant 6mo after scrotoplasty, fix into pouch to prevent migration
• Erectile prosthesis: implant 12mo after phalloplasty if no urethral issues and sensation intact, can implant single-cylinder IPP, can fix to pubic bone periosteum, erosion/infection rate 20%, replacement rate 44%
• Catheter: place urethral and SPT, can remove urethral catheter after 12 days, remove SPT once voiding is normal
• Catheterization: use Tiemann (stiff Coude) to pass sharp urethral angle x1, otherwise use cystoscopy
• Urethral complications: overall 40%, fistula (15-70%), stricture (25-58%), postvoid dribbling common (provide perineal pressure to empty), flap loss (1%)