EP737 - Where Is the Incontinence? Preserved Pelvic Floor Function After Gender-Affirming Vaginoplasty

Purpose/Background: Vaginoplasty patients have clinical outcomes that defy our conventional understanding of pelvic floor physiology. Our current belief is that the pelvic floor muscles maintain delicate control over fecal control by providing structural support, sustaining the anorectal angle, and coordinating contractions at different stages of defecation. Vaginoplasty for the purpose of gender affirmation involves the creation of a large defect in the pelvic floor at the level of the perineal body that reaches nearly both sides of the pelvic outlet. This involves the transection of puborectalis, pubococcygeus, and partially levator ani. Traditional wisdom would suggest major injury such as these would cause severe pelvic floor dysfunction and incontinence. Paradoxically, new onset pelvic floor dysfunction is only reported in 2.5% of patients after vaginoplasty. Therefore, we aim to determine the degree of worsening, if any, of fecal incontinence for patients who are undergoing gender-affirming vaginoplasty.

Methods/Interventions: This is a single institution prospective cohort study actively recruiting since July 2024 for patients undergoing creation of neovagina. Pelvic floor disorder symptoms and fecal incontinence were measured using the Initial Measurement of Patient-reported Pelvic Floor Complaints Tool (IMPACT) Bowel Function Short Form at three different time points: preop, one month postop, and one year postop. Demographic and operative data were also collected. Wexner score, St. Marks Fecal Incontinence (STFI) score, Colorectal-Anal Distress Inventory-8 (CRADI-8) score, Constipation Severity Instrument (CSI) score, Patient Assessment of Constipation-Symptoms (PAC-SYM) Total score, PAC-SYM Rectal score, FDA: Extent of Solid FI, and FDA: Extent of Liquid FI were calculated and analyzed.

Results/Outcomes: Ten patients were included in this study to date with no patients reporting postoperative FI. The average age was 35. Three patients underwent colon vaginoplasty, four underwent penile inversion vaginoplasty, and three underwent peritoneal flap vaginoplasty. The average length of stay after surgery was 5.2 (±0.4) days. There was one case of return to the OR for vulvar hematoma. When compared pre-operatively, there were no significant differences observed in average Wexner score (pre-op: 0.0±0.0, 1-month post-op: 0.6±1.1, 1-year post-op: 0.7±1.2), St. Marks FI score (pre-op: 1.6±2.1, 1-month post-op: 2.3±2.8, 1-year post-op: 2.0±2.0), CRADI-8 (pre-op: 8.8±6.7, 1-month post-op: 13.0±12.0, 1-year post-op: 9.4±8.3), CSI score (pre-op: 8.2±7.2, 1-month post-op: 10.9±6.1, 1-year post-op: 8.3±3.9), PAC-SYM Total score (pre-op: 4.5±5.7, 1-month post-op: 7.3±9.0, 1-year post-op: 1.7±0.6), PAC-SYM Rectal (pre-op: 0.6±1.1, 1-month post-op: 0.7±1.0, 1-year post-op: 1.7±0.6), FDA: Extend of Solid FI scale (pre-op: 100% none, 1-month post-op: 100% none, 1-year post-op: 100% none), and FDA: Extend of Liquid FI scale (pre-op: 100% none; 1-month post-op: 100% none; 1-year post-op: 67% none, 33% stain).

Conclusion/Discussion: Considering the degree of pelvic floor muscle transection during the creation of neovagina, there is shockingly little if any changes in incontinence or constipation. This observation directly challenges our conventional understanding of pelvic floor physiology. More studies need to be performed to study the effect of pelvic floor injury and underlying function of pelvic floor muscles.

Wexner score, St. Marks Fecal Incontinence (STFI) score, Colorectal-Anal Distress Inventory-8 (CRADI-8) score, Constipation Severity Instrument (CSI) score, Patient Assessment of Constipation-Symptoms (PAC-SYM) Total score, and PAC-SYM Rectal score at pre-op, 1-month post-op, and 1-year post-op among patients undergoing creation of neovagina.
Bars and error bars represent mean and standard deviation, respectively.