The medical care of the neovagina of transgender women: a review Vincent J. Cornelisse A,B,C,F , Rosemary A. Jones D , Christopher K. Fairley B,C and Sonia R. Grover E A Prahran Market Clinic, Pran Central, 325 Chapel St, Prahran, Victoria, 3183, Australia. B Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, 3800, Australia. C Melbourne Sexual Health Centre, 580 Swanston St, Carlton, Victoria, 3053, Australia. D The Adelaide Private Menopause Clinic, suite 22/183 Tynt St, North Adelaide, South Australia, 5006, Australia. E Department of Obstetrics and Gynaecology, The University of Melbourne, Victoria, 3010, Australia. F Corresponding author. Email: vcornelisse@mshc.org.au Abstract. For transgender women, genital adjustment surgery involves removal of the natal reproductive organs and creation of a neovagina, vulva and clitoris. We conducted a review of the medical literature in order to summarise the issues that can affect the health of the neovagina in the long term, and to make recommendations on how to manage these issues. Received 2 March 2017, accepted 5 July 2017, published online 25 August 2017 Language The language used in the gender diverse community has evolved in recent years. To reflect these changes, we use the term ‘trans woman’ to refer to a person who identifies as female and was assigned the male sex at birth, and we use the term ‘cis woman’ to refer to a person who identifies as female and was assigned the female sex at birth. We use the term ‘neovagina’ to refer to a vagina that was created surgically, and we use the term ‘natal vagina’ to refer to a vagina that was present at birth. We use the term ‘genital adjustment surgery’ to refer to surgical procedures in which a person’s genitals are altered to reflect their gender identity. Introduction For trans women, genital adjustment surgery involves removal of the natal reproductive organs and creation of a vagina, vulva and clitoris. The ideal surgical outcome is a vagina and external genitalia that appear as natural as possible, without scars or neuromas. The vagina should be internally hairless, moist and elastic, with adequate depth and width to allow penetrative intercourse, and have adequate sensation to make intercourse enjoyable. The clitoris should be a size the patient is happy with and should provide adequate sensory stimulation. The urethra should produce a urinary stream that points downwards when sitting on the toilet. 1 It is believed that the first neovagina was created in 1934 by Dr Brindeau using amniotic membrane to construct a vagina for a patient with Müllerian vaginal agenesis (or Mayer– Rokitansky–Kuster–Hauser syndrome). Surgical techniques since then have utilised skin grafts, perineal flaps, peritoneum, and rectosigmoid. 2,3 Currently, the most common technique used to construct a neovagina for a trans woman is to invert the skin of the penile shaft to construct the vaginal cavity, termed penile infibulation, and to construct the labia from scrotal skin. 4 This technique has a major advantage over that of using a segment of sigmoid colon to construct a neovagina, as the latter may have a higher operative complication rate, may be complicated by ongoing diversion colitis in the neovaginal segment and mucosal prolapse may occur. 3,5 Sigmoid vaginoplasty is often reserved for trans women with penoscrotal hypoplasia, 6 as may occur when the onset of puberty is prevented medically as part of the gender affirmation process. Sigmoid vaginoplasty is also used for trans women in whom primary vaginoplasty has failed. 7 The advantages of sigmoid vaginoplasty are that it usually provides ample depth, is somewhat self-lubricating, has less tendency to reduce in length or diameter over time, and hence there is less need for ongoing vaginal dilatation. 8 Neovaginal surgery options for trans women have previously been thoroughly reviewed. 4 Immediate post-operative care is usually provided by the surgeon who constructed the neovagina, and a review of immediate post-operative complications has previously been published. 9 In this paper we describe some of the issues that can affect the health of the neovagina in the longer term, to CSIRO PUBLISHING Sexual Health, 2017, 14, 442–450 https://doi.org/10.1071/SH17044 Journal compilation Ó CSIRO 2017 www.publish.csiro.au/journals/sh