Metoidioplasty: Stage One

Content Note: In this article on metoidioplasty I’m talking about genitals – my own and in a general sense. I’m going to use words that some transgender people might not use for their own genitals and therefore might find uncomfortable to read.

Disclaimer: I am not a medical expert and am simply speaking from my own experience and research on the topic.

Choosing Metoidioplasty

Choosing between phalloplasty, metoidioplasty, and not having lower surgery at all was mostly a simple decision for me.

Almost five years ago, when I was preparing to have top surgery, several cis-people asked me,

‘When are you getting the full op’?

A not so subtle reference to phalloplasty; a surgery that many cis-people think is a guaranteed choice when you transition from identifying as female to identifying as male.

Phalloplasty wasn’t a surgery I had any interest in at the time, and that largely hasn’t changed much over these last five years.

A lot of trans-masculine people speak very publicly about the dysphoria they experience in relation to their genitals, and this hasn’t ever really been something that I’ve struggled with. However, the one thing that has stressed me out a whole lot about the genitals I was born with is not being able to stand to pee.

Five years ago when I was adamantly telling anyone who asked that I was never going to have any more transition related operations after my top surgery, I didn’t know that metoidioplasty was a thing. However, as soon as I discovered that it was, I instantly knew it was something I wanted to know more about, and probably do.

Below I’m going to talk about what metoidioplasty is, and you can also read on for my personal experience of undergoing this surgery.

What is Metoidioplasty?

If you are assigned female at birth and you take testosterone for more than a few months, then the clitoris will naturally get bigger. In order to be eligible for metoidioplasty surgery, it is generally required that you have been taking testosterone for between one and two years, so that you have an ample amount of growth to work with.

For the remainder of this article I will be referring to the clitoris as the ‘new penis’.

Metoidioplasty Simple Release Surgery

The first stage of metoidioplasty is the simple release. This is where the tissue surrounding the new penis is cut away so that it comes forward to be more visible, and therefore appears to be bigger.

Buccal Mucosa Skin Graft

Some people opt to only have the simple release surgery. If you are going to go on to have stage two, then a skin graft will also be taken during the first surgery and surgically attached beneath the new penis. This skin is usually taken from inside one of the cheeks and is known as a buccal mucosa skin graft.

This skin graft will later be used to extend the urethra up underneath the new penis so that the patient is able to urinate through it whilst standing up.

Second-Stage Metoidioplasty

During the second stage, the surgeon may also perform a procedure known as mons resection, during which some skin and fatty tissue from the pubic mound is removed. Remaining skin in the area can then be pulled up to further enhance visibility, and therefore the size, of the new penis.

Hysterectomy & Vaginectomy

A hysterectomy and a vaginectomy can also be performed during the second stage of this surgery, or later on in a separate operation. However, it is not required or necessary that either of these surgeries take place in order for metoidioplasty to be complete.

Hysterectomy – Removal (full or partial) of the womb.

Vaginectomy – Removal of the vagina and closure of the vaginal canal.

Scrotoplasty

The patient may choose to undergo a third surgery, during which testicular implants can be added. It is possible to have the testicular implants even if you choose only to have the simple release, and forego the ‘skin graft – urethral extension’ stage.

Successful & Healed Surgery

Upon successful completion of metoidioplasty surgery (if the second stage has been included) the new penis will generally be between 3 and 8 centimetres in length. As well as being able to urinate through the new penis, it can also become erect (but probably not enough for penetrative sex).

All of these surgeries will be performed under general anesthesia, and will usually take place between six months and one year apart from each other.

As with any surgery, it is possible that complications may occur. The most common complication with this surgery seems to be the potential for a fistula to develop. This is when a hole presents in the urethra, which will result in urine leaking. Further surgery may be required to fix a fistula, although it may sometimes correct itself.

For those who opt to have the third stage of testicular implants, a potential complication is that the body rejects the implants, in which instance further surgery will be required.

My Surgery

I opted to just have stages one and two, with a full hysterectomy to happen at the same time as the second stage. Depending on the outcome of the second surgery, this could mean that I would be able to stand to pee at a public urinal (my goal) without the use of prosthetics.

Here’s how it went!

Day One – August 8th 2018

On August 8th I went with my friend Debbie to the hospital in St John’s Wood to have the first stage with Mr Christopher.

I was the first on the list for surgery that day and by the early afternoon I was awake and taking semi-naked hospital selfies for Instagram.

I don’t remember the pain being too intense when I woke up, but there was definitely a lot of discomfort. I do remember thinking that the swelling looked disgusting and snapping a pic of my junk to send to a doctor friend, half for the gross points and half for reassurance.

The swelling in my face was a much bigger concern at this point than whatever was going on with my junk. My graft was taken from my left cheek. This side of my face felt huge, and was very noticeably swollen on the outside. The inside of the cheek looked and felt like a huge hole, and I was unable to place any food in the left side of my mouth for several weeks.

Sidenote: I feel like my surgeon didn’t prepare me at all for how painful the skin graft site was going to be, and ten months later (today) my cheek still doesn’t feel as though it’s back to normal. To me, it still feels swollen on the inside, and sometimes I think that it’s visible on the outside too. I also still catch the inner left cheek with my teeth when I’m eating and still often prefer to chew on the right side of my mouth.

Day Two – August 9th 2018

The following morning I was discharged from the hospital with a packet of paracetamol, some ibuprofen, and a huge bottle of some magical laxative juice.

Again, at this point I don’t remember the pain in my pants being too severe but I had been taking painkillers throughout the night and in the morning. The discomfort and inability to walk with ease were my biggest problems.

My friend Leo picked me up in their car and drove me to East Croydon where I managed to cautiously shuffle my way onto a train back to Brighton.

I had been given a flip-flo catheter that I also had the option to connect to a bag. Dealing with the catheter was a new experience for me and it’s not something I ever got comfortable with.

My buddy Taylor picked me up at the train station in Brighton, and we drove to the house of another friend, where I was to stay for the next few weeks.

By the evening of the second day the pain was pretty intense and paracetamol wasn’t doing it. Fortunately I was quickly able to source some codeine and that helped a bunch.

Day Three – August 10th 2018

On day three I was almost certain I was going to die of constipation.

I hadn’t been able to sleep well because of the pain and the discomfort. I usually sleep on my side curled in a ball and rolling around throughout the night, so trying to sleep flat on my back whilst hooked up to a catheter wasn’t a good time for me. If I tried to move onto my side then the pressure on my junk became unbearably painful.

My appetite wasn’t as huge as it normally is during these first three days but I still managed to eat a few small meals very slowly.

Luckily on this day someone brought me some sleeping pills and I was able to start resting better.

Sidenote: In addition to the pain medication, I was also taking antibiotics and some kind of intense mouthwash to keep the skin graft site clean. I ran out of this mouthwash after one week and had to go on a mission to the pharmacy to find more. So if you’re having this surgery then it’s worth stocking up because the hospital likely won’t give you enough!

Day Four – August 11th 2018

The fear of certain death from constipation was lifted when my doctor friend came round to visit and informed me that this definitely isn’t a thing you can die from. They also showed me how to safely overdose on my laxatives for maximum effect.

The swelling was starting to look a little better by this point and there was less blood and gunk involved.

Day Five – August 12th 2018

On day five I finally managed to go to the toilet, much to the relief of myself and everyone I’d been complaining about it endlessly to.

The next few days were mostly spent staring at the cows outside of the window, trying to get used to catheter living, and trying to stay awake long enough to get back on top of my work.

Not the same cows, but look how cute they are.

Day Ten – August 17th 2018

On the tenth day I had to be in London to have the catheter out at the Andrology Clinic. I decided to go the night before so I could sleep in London and break up the trip.

I still wasn’t walking very well and had to shuffle onto the train. I took my catheter bag with me in a cereal box, which I held by my side with the tube quite obviously coming out of the box and into my pants.

It was still very uncomfortable to walk at this point. I had to take stairs one step at a time and still very much had to take it slowly as I was walking around. I was very conscious during this trip that someone might bump into me and used my catheter cereal box as a defence in front of my pants.

As soon as the catheter was snipped out, I felt a lot of relief and was able to walk relatively normally again.

The nurse asked me to urinate before I left to make sure everything was okay. I was very concerned that this was going to hurt, but it was actually totally fine.

Getting back to Brighton was so much easier than getting to London the previous day had been.

2.5 Weeks Post-Op

By 2.5 weeks post op I was feeling totally fine and was already back in the gym (doing upper body exercises only and no cardio at all).

The swelling had totally eased and the size of my junk at this point was pretty much how it has stayed ever since.

The discomfort in my mouth was still really noticeable though and it was still taking me a long time to eat solid food.

3 Months Post-Op

3 months after my surgery I went to see Mr Christopher for a check up. He said everything was totally fine with the surgery and the graft was healing really well.

He asked me to puff my cheeks out, which I realised I can no longer do on my left side, and he also asked me to purse my lips in a kissing motion, which I can also no longer do in the way I could before. Mr Christopher told me he could snip the scar tissue in my mouth during another surgery if the tightness felt like too much. I opted not to pursue this at the time because I still felt like it might heal by itself, but it’s something I’ll raise with him when I go back for the second stage.

What I Wish I Knew

When I had my consultation with Mr Christopher the only thing he told me about the skin graft from the cheek was that it would look like I ‘had been punched in the face’ for a week or so. I wasn’t prepared at all for the ongoing pain and swelling, and the trouble that I still sometimes have with eating normally.

During my initial consultation I was told that the surgeries would happen six months apart, and it didn’t become clear until five-ish months post-op that this wasn’t going to happen. My estimated surgery date for stage two + hysto is in August or September this year, which will mean there’s at least 12 months between surgeries. That is unless I get offered an earlier slot due to a cancellation.

The longer wait between the two surgeries isn’t really a huge problem, but it would have been helpful for me to be aware of this initially just so I could manage my own expectations.

Before surgery I was told that I should avoid sex, exercise, or any serious physical activity for approximately 10 weeks. Feeling like I couldn’t go to the gym for 10 weeks was the most difficult thing for me, and actually I felt totally able to do so at 2.5 weeks. If I had known that I’d be feeling up to this then I’d definitely have been less stressed out about how long the recovery process was likely to be.

Finally, if I knew how painful it was going to be and that I wasn’t going to be given ample pain medication, then I would have requested some from my GP in advance, and I’ll definitely be doing this for stage two.

Update: On December 14th 2019 I had the second stage of this surgery. I’ve written about my experience of Stage Two Metoidioplasty – click here to read it.

If you have any questions about metoidioplasty surgery or you’re thinking about getting it and want to talk it out, then feel free to shoot me a message anytime!