Terms to use for transgender and other LGBTQ+ patients, from Campbell's
Follow up after starting testosterone, from Campbell's
Follow up after starting estrogen, from Campbell's
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"
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%)
References
AUA Core Curriculum
Elsamra, S. "Evaluation of the Urologic Patient: History and Physical Examination." Campbell-Walsh Urology 12 (2020).
Kocjancic, E., V. Iacoveilli, and O. Acar. "Sexual Function and Dysfunction in the Female." Campbell-Walsh Urology 12 (2020).
Lumen, N., A. Spinoit, and P. Hoebeke. "Special Urologic Considerations in Transgender Patients." Campbell-Walsh Urology 12 (2020).