The Transgender Dictionary

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Rectosigmoid

(also: bottom surgery, bowel vaginoplasty, colon vaginoplasty, colovaginoplasty, intestinal vaginoplasty, lower surgery, rectosigmoid vaginoplasty, sigmoid (colon) vaginoplasty)

Table of Contents

Introduction

Many transgender women, and some transfeminine nonbinary people, experience gender dysphoria regarding the lack of a vulva and/or vaginal canal. Having a vulva and/or vaginal canal procured through surgical means can be a great source of gender euphoria. This page will be discussing the technique known as "rectosigmoid vagnioplasty." For general information on vaginoplasty that may not be included on this page, click on the underlined word to go to the general vaginoplasty page, or navigate to it using the alphabet menu at the top of this page.

This method of vaginoplasty was first described in 1974.

This method of vaginoplasty is most commonly performed in Thailand and Eastern Europe. This surgery is rarely performed in The United States. Unlike other methods of vaginoplasty, this one does not require electrolysis prior to surgery.

General Information

This technique results in a self-lubricating, durable, natural-feeling neovagina that has less of a need for dilation compared to other types of vaginoplasty, and a lower risk of losing vaginal depth. Average vaginal depth for colovaginoplasty averages 14-19cm (5-7inches) - though some surgeons are able to achieve depths of 25cm (10inches) for patients. This depth is greater than that of other techniques (such as penile inversion) and results in a lower risk of vaginal stenosis (narrowing).

This surgery is best for women with limited penile or scrotal tissue, scarring from prior surgeries, no major bowel disorders (such as Crohn’s disease or previous bowel surgery), are comfortable with abdominal surgery (and the risks that come alongside it), and prefer to have a self-lubricating vagina. Colon vaginoplasty is typically used in the case of a failed penile inversion vaginoplasty, in the case of a prior penectomy, or if the patient otherwise needs a revisionist surgery. This surgery may be performed a few months after vulvoplasty as a "stage two" surgery.

Limited penile skin or scrotal tissue can be caused by having undergone circumcision, trauma, or long term GAHT. Note that patients are to pause GAHT approximately 4 weeks prior to surgery to reduce the risk of blood clots.

Rectosigmoid vaginoplasty has a 99% satisfaction rate (the highest satisfaction rate among vaginoplasty techniques) in terms of both functional and aesthetic results, though labiaplasty after vaginoplasty helps improve the cosmetic appearance if desired. 95% of patients are able to achieve orgasm.

Unlike other techniques that use skin grafts (which do not self-lubricate), the rectosigmoid technique uses intestinal lining, which produces mucus. Over time, the intestinal tissue intergrates well with the body, resulting in a look and feel that is more natural than skin graft techniques. This results in a self-lubricating, naturally moist neovagina. The mucosal lining of the colon closely resembles the elasticity and texture of a natal vagina.

Patients are required to do bowel preperation prior to surgery. This includes dietary adjustments, laxatives, and sometimes antibiotics to minimize infection risks.

Due to resulting in a naturally moist and flexible vagina, rectosigmoid vaginoplasty is lower maintenence than other types of vaginoplasty, and requires less frequent dilation. The thicker, elastic nature of this type of neovagina results in a lower risk of tearing during vaginal intercourse as compared to other methods.

Note that any initial odor is temporary and resolves itself within 6 months after surgery as the colon tissue adjusts. No new odor is produced as the intestinal segment is no longer a part of the digestive system, and does not produce any new odors relating to digestion.

There is a possible risk of excessive discharge, though mucus production typically decreases over time. This can be managed with daily rinsing of the neovagina, or useage of panty liners.

Many surgeons require that a patient have a BMI under 30. Patients who smoke are encouraged to quit smoking at least 6-8 weeks prior to surgery to ensure proper healing. A mental health evaluation, as well as 2 letters of recommendation confirming gender dysphoria, is generally required prior to surgery to ensure that the patient understands the impact of this surgery.

As a patient, it is very important to discuss your options with your surgeon ahead of time, and your personal goals regarding surgery. It is a good idea to research your surgeon ahead of time, and look for reviews and images from real people (not just the photos from the surgeon's personal website). Have consultations with more than one surgeon surgeon if possible, to make sure that you have the outcome and surgical team that is right for you.

How It's Done

This surgery typically takes 5-7 hours to perform by a team of gynecological, urological, and colorectal surgeons while the patient is under general anestheseia. This is an inpatient procedure, where the patient typically stays in the hospital for 7-10 days while being monitored during the healing process, and potential complications are addressed if they arise. There are two key stages during this surgery; creating a vaginal space & grafting the sigmoid colon section.

An abdominal incision (similar to that of a C-section) is made to access the sigmoid colon. A section of the sigmoid colon (typically around 15-20 cm or 5-8inches) is carefully removed while preserving its blood supply. The remaining parts of the colon are reconnected to ensure normal bowel function (intestinal anastomosis).

A space is created between the rectum and the bladder for the vaginal canal. This step is critical for ensuring proper width and depth. During this step, the surgical team checks for any surrounding tissue or structures that could interfere with healing.

The harvested colon segment is moved down through the abdominal cavity and attatched to the perineal opening. The segment is secured with absorbable sutures, ensuring adequate blood flow. If needed, labiaplasty, orchiectomy, and clitoroplasty (the creation of a clitoris) are performed using donor or scrotal tissue to create a natural-looking vulva. The urethra is shortened & repositioned and a catheter is inserted to help drain urine (and prevent urinary retention) as the patient recovers. The abdominal incision is closed with dissolvable sutures.

A vaginal mold is inserted to help keep the new vaginal canal from losing its shape and narrowing during this early phase of healing.

Note that a laparoscope is typically used for this surgery.

Recovery

During the first week of this inpatient procedure, the patient remains in the hospital. For the first 3 days, the patient is under strict bed rest with IV fluids and pain managment. From days 3-5, the patient is able to drink fluids and eat soft foods as the bowels slowly regain function. From days 5-7, the vaginal mold is removed and the patient performs her first dilation session while under supervision by a doctor. Around the 7-10 day mark, the patient is discharged (if healing is stable) with a urinary catheter (which remains for 10-14 days).

During weeks 2-4 post-op, the patient must dilate daily to maintain vaginal length. The patient prohibited from straining, lifting, or sexual activity to prevent complications. There may be mild swelling and discomfort at the surgical site, which gradually improves as the patient heals.

At around 1-3 months post op, the patient has regular follow-up appointments with her surgeon to monitor the healing process and address any potential complications. Patients may resume light work and low-impact activities. Dilation schedules for most patients' dilation schedules reduce in frequency to once or twice per day during this timeframe.

Most swelling is fully resolved by the 3-6 month mark as the neovagina takes on its final shape and texture. Depending on healing, most surgeons will approve sexual activity around this time. Dilations reduce in frequency to only once per day or every other day. Mucus production typically decreases during this time.

After 6 months, patients are functionally stable in both daily life and sexual activity. Dilation is reduced to 1-2 times per week, depending on individual needs. Dilation may be subsituted with regular vaginal intercourse (once intercourse has been approved).

Annual medical checkups and proper care/hygine are necessary for long-term recovery. The colon may need occasional monitoring for signs of intestinal issues.

Risks & Complications

86% of patients do not complications, and when complications do arise, 97.4% of complications are minor.

Potential risks/complications/unwanted effects that have not been previously mentioned include; tissue necrosis, vaginal prolapse (this risk is minimized through proper surgical technique and post-op monitoring), fistulas (abnormal connections between the vagina and nearby organs that are correctable with surgery), and infection (preventable with proper hygine and antibiotics). Minor bleeding is to be expected after surgery, but it is important for a patient to contact her surgeon if she experiences major bleeding.

This surgery comes with the associated risks of intestinal surgery, and a large scar.