Pelvic Floor Pre- and Rehabilitation for Masculinizing Gender Affirming Surgery

Objectives: Pelvic floor physical therapy (PFPT) has been used to improve postoperative pelvic floor dysfunction (PFD) after masculinizing genital gender-affirming surgery (mgGAS). However, preoperative PFPT has not yet been evaluated. This study investigates preoperative and postoperative pelvic floor disorders in patients undergoing mgGAS who receive either preoperative or postoperative PFPT or both.

Methods: A retrospective chart review was performed. All mgGAS patients were included over a 20-month period. PFPT is offered routinely to all patients undergoing mgGAS at our institution. PFD symptoms were recorded. Symptoms were excluded if not related to PFD (for example, incontinence from urethrocutaneous fistula).

Results: Twenty-two consecutive patients were included (Table 1). Patients had one (n=10), two (n=6), or three (n=6) procedures. Mean follow-up after the index surgery was 11.8 months (range 3 days – 23.3 months).

Seven (31.8%) patients engaged in a single session of PFPT prior to their index operation within the study period, at an average of 147 days (range 2 to 362 days) preoperatively. Preoperative PFD history was reported by 11 patients. Urinary dysfunction symptoms included urinary hesitancy (n=2), urgency (n=1), and stress incontinence (n=1). All four patients noted improvement or resolution of preoperative symptoms. Anorgasmia was reported by 1. Preoperative bowel symptoms and pelvic pain were not endorsed by any patients.

Thirteen (59.1%) of patients elected to engage in PFPT after their index (59.1%, n=13), secondary (33.3%, n=4), and/or tertiary (50%, n=3) operations. Patients underwent between 1 and 12 sessions, starting at 3 days after surgery (range 9-76 days).

After the index procedure, urinary dysfunction was found in 22.7% of patients (n=5 of 22). Symptoms improved or resolved in all five patients. Of these five, three had engaged in preoperative PFPT, but only one reported preoperative urinary PFD (urinary hesitancy). Of the four patients with preoperative urinary PFD, only one had postoperative urinary symptoms.

Post-operative bowel symptoms were expressed by one patient. The symptom was decreased fecal urgency, which improved with PFPT. Pelvic pain was reported by 2 patients after their index surgery, which improved after massage and pelvic floor muscle downtraining. After their planned secondary and tertiary surgeries, no PFD symptoms were expressed by these two patients.

Conclusions: Urinary symptoms were the most common PFD preoperatively and postoperatively, and improved or resolved after PFPT. The majority of patients with preoperative urinary symptoms who underwent pre-operative PFPT did not report postoperative urinary PFD. PFPT is an important perioperative consideration to address and alleviate existing and/or de novo PFDs for those undergoing mgGAS.

Table 1 Legend: PFD: pelvic floor dysfunction; PFPT: pelvic floor physical therapy; '-': no data available; TI: testicular implant; Meta: metoidioplasty; +UL: with urethral lengthening; EP: erectile prosthesis; NR: not recorded; SUI: stress urinary incontinence