Content Note: In this post I’m talking about undergoing metoidioplasty fistula repair surgery. This naturally involves 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 — I’m simply speaking from my own experience and research.
If you are assigned female at birth and you take testosterone for more than a few months, then the clitoris will naturally get bigger. Metoidioplasty surgery relies on this growth for the creation of a small phallus that the urethra can be extended underneath. For the remainder of this article I’ll be referring to the clitoris-phallus as the ‘penis’.
After having stage 2 metoidioplasty with urethral lengthening in December 2019, I was left with a fistula (leak) in my extended urethra. This meant that although I was able to pee out of the tip of my penis, which happened in a forward direction from the body, I was also still leaking a significant amount of urine through the fistula, which was in a downwards direction.
Because I was peeing in two very conflicting directions, I obviously had to continue sitting down to use the toilet. This has been messy, frustrating and disappointing, and something I felt sad about every day for over three years.
After Stage 2 Metoidioplasty
On the 16th of January 2020 — about a month after my second-stage-surgery — the clinic called and asked me to come in so Mr Christopher (my surgeon) could take a look.
When I went to the clinic, Mr C had a poke around and confirmed that I did have a leak. He advised that he’d try to fix it by stitching it up and then taking some fat from my labia and using it to pad the stitches.
This would of course require another surgery, as well as another three weeks of recovery with the double catheter situation.
He said this was something they could attempt to do several times — a few years apart — if it doesn’t work the first time around. This didn’t fill me with confidence that I was going to get a positive outcome any time soon.
Dilating After Surgery
When the new urethra is created, the opening to the vagina is affected. You can read more about this in my previous post. This is obviously only an added issue you’ll need to consider if you decide not to have a vaginectomy.
Before I left my appointment, I asked how I should start to dilate as I hadn’t received any instruction yet. Mr C suggested I source a ‘thin dildo’ from somewhere and then gradually insert it a little bit every couple of days. This didn’t really seem like an exact science and I feel like there could have been some more guidance given on this.
I had a look online and found a dilation kit that was marketed to cis women. It was around $50 for a piece of plastic, so I decided to just use appropriately-shaped items that I already had. At first, I tried to do this every day, just a little bit, but it was quite uncomfortable so I ended up doing it every two or three days.
When dilating, I always used some kind of lubricant and only did it for a few minutes at a time. I found it most comfortable to do it in the bath, and then to hold the item inside for a few minutes. It took a few months to get back to normal and I’m not excited about having to do this again.
Three Months Later
I was told that I would need to check in with the clinic three months post-op, which for me was in March 2020.
In March, I was contacted by the clinic just to say that Mr C was going to call me two weeks later. Two weeks later, Mr C called me to ask if I still had a leak, which was an obvious yes, he then said that he would be in touch again soon…
Two months later in May 2020, Mr C called again, asked again if I still had a leak, and then said that I would likely be able to come and have it fixed “in the next few months”.
By this point, the coronavirus pandemic was already raging and we were in the first lockdown. The surgeon didn’t give any indication that surgery wasn’t happening, or that there would be any further delays to waiting times. He simply said he’d likely see me in a few months.
Nine months later, in February 2021, I contacted the clinic to update my address and also to ask if it was possible to get an update on what was going on.
They wrote me back to say that they were not doing surgery at the moment and they hoped to be able to resume soon.
The delays with the service were an unfortunate combination of the pandemic and the NHS then removing the contract for this specific surgery from the current provider. However, it was later handed back to the exact same group of surgeons, albeit at a different hospital. This completely pointless chaos added about a further year to the waiting list and left a lot of people in a devastating limbo.
New Victoria Hospital & Mr Christopher
It wasn’t until November 2022, nearly three years after my unsuccessful surgery, that New Victoria Hospital (NVH) finally called me. I was offered a surgery slot for January 11th 2023 and obviously immediately said I would take it.
On November 29th, I travelled to NVH for my pre-op assessment and then on December 7th I had a consult on the phone. During this call, Mr C explained again that he would locate the fistula and stitch it up before padding the surgery site with fat taken from the labia. During this call, he told me there was around a 95% chance that this would totally resolve the problem. This was really reassuring to hear and I finally started to feel hopeful that it might all be over soon.
A few days after my phone consult with the surgeon, a nurse from NVH called me to say that an infection had been detected during my pre-op assessment. I was prescribed a course of antibiotics to complete at least one week before my surgery, and I was assured that it could still all go ahead.
Surgery Day – Metoidioplasty Fistula Repair
I took a train to NVH, which is in Raynes Park in London, on the morning of January 11th. I had to check in at 11:30 although I hadn’t been told what time my surgery would be.
When I arrived at the hospital, I had to do a few basic admin things before being shown to my room. Here I was asked to give a urine sample, change into the surgery gown and select which meals I would like during my stay. I was then left alone for an hour to wait.
Around 12:30 another nurse came in to take my blood pressure and heart rate. She asked me a few basic questions about my health and told me I was first on the surgery list, meaning I’d be going within the hour. Shortly after she left, the anaesthetist came into the room to ask me more questions about my health and to explain her role in the procedure. Once she left, Mr Christopher came to see me and explained how he’d be repairing my fistula again. He explained that the width of the vagina would again be affected by the surgery, meaning I’d have to go through the process of dilating again, but that he’d “leave it as open as he could”.
Shortly after he left, the nurse returned and asked me to follow her to to operating theatre.
The surgery only took around an hour and by 4pm I was back in my room awake. I felt incredibly nauseous when I woke up so I was given some anti-sickness medication and a bowl to throw up in, just in case. A nurse came once every hour to take my blood pressure and temperature but I was more or less left alone to sleep.
I was given a mix of ibuprofen and codeine, along with bladder spasm medication and antibiotics. I felt exhausted and a bit confused for the rest of the night, and I was in and out of sleep until the morning.
The bladder spasm medication was a surprise but something I was very grateful for. During the second surgery, I hadn’t been warned about this and ended up in A&E on Christmas Eve with the pain, which was easily resolvable with the right medication.
At some point, Mr C came to visit me to explain that there had actually been two holes in the urethra. He said he’d cut between them to create one bigger hole and then stitched everything together. As planned, the stitches were then padded with the fat that he’d snipped out.
He seemed positive that this had all gone well. However, it wouldn’t be possible to know if the surgery was successful until three weeks post-op when I would attempt to pee through the urethra.
Day 2 – 12/01/2023
I wasn’t in much pain in the morning and was able to comfortably lie in bed and eat breakfast. After a few checks, I was discharged with my medication and catheter supplies around 10:30.
Before I was discharged, I was advised that I should try to organise having both catheters removed locally, so as to avoid a trip back to London. I reached out to my local GP to ask if this was possible and spent some time thinking of alternative plans in case they weren’t able to do it.
My friend Jack came to pick me up and the hour-long drive home wasn’t too uncomfortable. I was able to get in and out of his van with a little bit of assistance, and his tiny dog Finn sat on my lap without causing any pain or discomfort.
Managing the catheters has been my least favourite part of going through these procedures. Again, I had a stent catheter in my urethra and a suprapubic (SP) catheter coming through my lower stomach directly from the bladder. The SP catheter was connected to a leg bag, which I was able to drain at the bottom whenever it got full. I was also given night bags to connect to the leg bag while I’m sleeping so that I don’t have to get up to empty the bag in the night.
The stent catheter was to be removed after seven days and the SP one was to stay until I could successfully pee through the urethra.
Jack and Finn stayed to cook lunch and then I got into bed to rest for the rest of the day.
Day 3 – 13/01/2023
I was given a course of antibiotics as well as a three-week supply of solifenacin (bladder spasm prevention), which I only needed to take once a day. I also had a stash of ibuprofen, paracetamol and codeine.
My boyfriend Rowan (who at this point was six weeks post-op from their top surgery) came in the evening to take care of me for the weekend. I was feeling pretty sleepy and gross but it was really comforting to have them around.
Day 4 – 14/01/2023
My surgery site felt quite sore today and I took as much pain medication as I was allowed. I already had the feeling that the surgery wasn’t going to have worked and I was mentally preparing myself for it to fail.
Rowan helped me to take a shower, which was my first shower since surgery. I was advised to gently wash the area around the stitches and then pat it dry with a clean towel.
It was really helpful to have Rowan around to reassure me when I was stressed about the surgery not being successful and just for the lazy company to be in bed together.
Day 5 – 15/01/2023
Today I stressed myself out by reading online about other people’s experiences of fistula repair. Mr C telling me I had a 95% chance of success allowed me to start believing that it would just be fine, but this was clearly not true for everyone in my position. Some people in forums and support groups spoke of having to have third or fourth surgeries for fistula repair, and some people said they’d just given up and were living with the leak.
The anxiety of having to wait three weeks after the op to see if it was successful was a lot. If the leak wasn’t repaired, it’s not clear how long I would have to wait to try again. I also started to feel like I just didn’t want to go through the recovery again as it felt so long and emotionally taxing.
Day 6 – 16/01/2023
Today was a Monday and my GP sent me a text to confirm they’d be able to remove the stent catheter for me on the appropriate day. I requested an appointment for Thursday and they booked me in.
Rowan left last night for work this morning and my housemate Sam was also at work, so I had the day to myself in bed. I managed to shower by myself (just water, no soap, so as not to agitate the surgery site) and I slowly did some very light chores around the house. Sam’s partner came over to walk our dog, which was a huge help, so I was able to stay in bed from mid-afternoon for the rest of the day.
Day 7 – 17/01/2023
I was advised to change the catheter leg bag once a week and also to start using a new night bag. I got a bit frustrated trying to figure this out by myself, but it was actually very simple in the end and I felt silly for getting upset about it.
Again, I was able to shower alone and prepare quick meals for myself. I had planned to have a friend come and visit in the evening but I started to feel a bit depressed and physically uncomfortable so we rescheduled.
Day 8 – 18/01/2023
As I’m having the urethral catheter out tomorrow, I decided to travel to Brighton from my home in Newhaven and stay with a friend overnight. This was to break up the journey and make it much easier for me to get to the GP for my appointment tomorrow.
The journey was about an hour by bus and I was really stressed that my leg bag would fill up with urine before I could find anywhere to empty it. I took an empty container with me so that I could empty it if necessary and sat at the back of the bus on the top deck so I could do this without anyone seeing.
Day 9 – 19/01/2023
Today I had the catheter in my urethra removed. I felt very lucky in that the doctor who removed it for me is also trans and has previously undergone similar surgery. He was very sympathetic to the pain and discomfort I was experiencing and was able to reassure me that everything was normal and a part of the healing process. I don’t think this would have been such a soothing experience if a cis doctor was responsible.
In order to take the tube out gently, he told me to take a deep breath in and then he pulled on the tube as I breathed out. We did this for about three or four deep breaths until the tube was totally out. As soon as I saw it come out I felt a huge relief and had a little cry.
From looking at the area under my penis, the doctor said that I likely had an infection developing. He prescribed me an antibiotic cream to use a few times a day and also instructed me to wash it with saline and then pad it with sterile gauze.
With this tube removed, I was much more comfortable and felt fine to do a 20-minute walk across town to a friend’s house. I rested here for a little while and then took the bus home.
When I was back home, I took a look at my stitches with a little mirror. In the mirror, it seemed like some of the tissue that had been used to pad the stitches was coming apart, which I felt was a sign that the surgery was not successful. Luckily my housemate Sam is a doctor with surgical experience and was able to take a look and give me some reassurance.
I sent a photo to Caroline (the nurse) to ask about the infection and the tissue coming apart.
Day 10 – 20/01/2023
Caroline called me in the morning to say she’d received my photo and agreed that it did look infected. She said it was a good idea to use the cream and to keep everything as clean as possible. She also agreed that it did look like the tissue hadn’t healed together as it should, but that this was likely the skin level and didn’t mean the urethra would be leaking.
Caroline seemed confident that this could still heal by itself. She told me to keep an eye on it, get as much rest as possible and send new photos to her on Monday (two days’ time).
Day 11 – 21/01/2023
In the morning I felt fine to go for a short drive (as a passenger) for a little dog walk with Jack.
I felt pretty stressed that my leg bag seemed to fill with urine so quickly and had a lot of anxiety about how to deal with this when we were out of the van. My bladder is typically pretty bad, so I’m used to looking for toilets when I’m out, but having a full bag of pee strapped to my leg was a whole different stress.
When Jack left, he took Lexi (my dog) with him so I didn’t have to worry about getting out to walk her. This meant I had absolutely no reason to leave the house and could stay in bed to rest as much as I needed.
Rowan came over in the early evening to make dinner and watch movies and it was great to feel a bit more comfortable and mobile to spend time with them. Being able to have these moments of relative normality made it easier to look ahead to the whole thing being over and to have my body back.
While we were trying to get to sleep that night, I started to feel a kind of throbbing sensation in the urethra alongside feeling some pain in the stitches. It started out as just being uncomfortable, but I started to panic that something was wrong as I hadn’t experienced the throbbing before. It felt like there was fluid or something in the tube that wasn’t able to come out and was moving around.
The panic escalated pretty quickly, probably because I’d already been feeling fairly emotional with the anticipation of a bad outcome throughout the week. Rowan was able to calm me down and help me to believe it wasn’t anything too bad. Getting out of bed to walk a little — plus a codeine + ibuprofen combo — helped to ease the discomfort and I was eventually able to sleep.
Day 12 – 22/01/2023
Today, as requested, I sent some new photos of the potentially infected area to my nurse at the hospital. I could already see that the redness was improved and that everything looked to be healing okay.
Day 13 – 23/01/2023
Caroline wrote me back to ask how I felt things were progressing and to say that she thought the area was looking better. She suggested I continue to use the cream for a few days, but that otherwise everything looked on track.
Two Weeks Post-Op – 24/01/2023
I woke up and realised that I’d been bleeding in the night, which was a bit stressful as it hadn’t been happening that much. I had a scheduled phone check-up with Caroline in the morning and she reassured me that bleeding at this stage can be normal and to just keep an eye on it. She told me that I should send her a photo of my stitches next Tuesday and if she says all is well then I can go ahead and do the pee trial next Wednesday.
A very small amount of bleeding continued throughout the day but I tried not to think about it.
Day 15 – 25/01/2023
Again I woke up with blood in my pants but tried to reassure myself that it was just normal. I wasn’t in any pain and everything looked okay as far as I could tell.
Day 19 – 29/01/2023
Yesterday I came to Rowan’s house to spend the weekend. I managed to get all the way on the bus without the leg bag filling up.
Their housemates were away and very kindly offered to let us sleep in their bed as it’s low to the ground, unlike Rowan’s, which would have been impossible to sleep in while using the catheter night bag. The change of scenery was really welcome and again helped me to look ahead to things being back to normal.
Rowan is also still not completely recovered from their top surgery and it was cute to take care of each other in different ways. I’ve been incredibly grateful to all of the people who have been around to take care of me during this surgery (and the previous two), but it was very comforting to have someone close who was also going through a similar experience.
It was during this weekend that I started to question whether I’d made the right decision in not opting for a vaginectomy. This is something that I felt very strongly about not doing in 2018 but no longer feels important. Since it was my decision not to have this procedure that dramatically increased my chance of developing a fistula, I started to feel very negatively about the decisions I’d made previously.
To correct a fistula, it is possible to opt for a vaginectomy during the repair surgery. I started to feel like this was something I was willing to do to guarantee success from further surgery.
Day 21 – 30/01/2023
Today I was supposed to start a new full-time job, which would have required me to travel to London four times this week.
Fortunately, my new boss was very understanding that this wasn’t possible given my current state of recovery and agreed to postpone my start date by a week. Taking the train to London and back during rush hour (as well as working for eight hours in between) while still using the catheter, wasn’t something that felt possible.
This meant all I had to do today was take a bus home from Rowan’s house and continue resting.
Day 22 – 31/01/2023
Today was probably the most anxiety-inducing day of the whole experience. Tomorrow marks three weeks post-op, which means it’s time to do the pee test.
I sent a photo to Caroline and she said everything looked very healthy and that it was fine to go ahead tomorrow. It was hard to get to sleep from obsessing over the outcome and I was preparing myself for failure instead of getting excited about success.
Three Weeks Post-Op – 01/02/2023
Today I woke up around 08:00, made a huge coffee and started drinking water. I wanted my bladder to be as full as possible to help overcome any anxiety about peeing. I disconnected the night bag, drained the urine from the leg bag, and then waited for it to fill up a bit again. I had been instructed to remove the leg bag and attach a flip-flo to the tube coming directly through my stomach. This then prevents the urine from leaving the body this way and means the bladder has to fill up.
I made another coffee and continued drinking water until I began to feel the urge to pee through the urethra. I decided the best way to do this was just to get naked and stand in the bath. I was fairly certain I would still have a leak, so I didn’t want to make a mess by trying to pee in the toilet. This would also easily allow me to see how much was leaking down.
I was standing in the bath for just a few seconds before pee came out of the tip of my penis. I looked down to see how much was leaking but everything was fixed completely perfectly. It feels pointless to try and describe how overwhelming and amazing this felt. I think it’s an emotion that would be hard for cisgender people to understand and naturally isn’t something I need to explain to other trans people.
After a few moments of happy crying and peeing all over the bathtub, I got out, cleaned up, and texted Rowan and a few close friends in disbelief that the whole thing had been a success (and then told the rest of the world on Instagram).
A little while later, I was in the kitchen with my housemate when the flip-flo burst and quite a substantial amount of urine leaked out. I totally forgot I was supposed to release leftover urine through the tube after peeing through the urethra. This was a messy mistake and one that I made again a few hours later.
The rest of the day was spent peeing very regularly – usually every 30 minutes or less – and often with a burning/stinging sensation. The nurse had explained to me that this was all normal and the bladder needed to get used to holding urine for extended periods again.
The frequency of my trips to the toilet gave me anxiety about sleeping. The time between realising I needed to pee and peeing was very short and it was basically impossible to hold pee in when my body decided I needed to go. I felt like I was probably going to uncontrollably pee in bed or that I would wake up throughout the night to go to the toilet. By some miracle, neither of these things happened. I fell asleep around 1 am and woke up at 7 am the following day without needing to pee at all.
Day 24 – 02/02/2023
The frequency of peeing this morning was very similar to yesterday. I had to go every 30 – 45 minutes and it was impossible to wait more than a few seconds as soon as the urge was apparent. However, around 4 pm I managed to go a whole hour without using the toilet.
I made it out for a short walk with my dog and came very close to using a urinal in a public toilet for the first time. Just as I was unbuttoning my jeans, a man walked in and came towards the urinal, so Lexi and I anxiously retreated into a cubicle.
Day 25 – 03/02/2023
Today was my first day out without the SP catheter, which my friend (who is a doctor, don’t worry) removed for me last night.
The nurse called to check everything was okay and we spoke briefly about the possibility of a mons resection — which is a surgery to kind of pull everything up a bit into a more optimum position for peeing at a urinal.
My penis is obviously very small, close to my body and kind of pointing down, so although I can now pee standing up (with a strong stream away from my body), the last few drops tend to go straight down. This means I’m peeing on my pants and jeans if I don’t pull them all the way down past my knees, which is obviously not ideal in a public toilet. The surgery would help to reduce this issue because the angle of the penis would be different.
My Meta Results
It’s now been about seven weeks since I had surgery and I’m really happy with the results. I love the way it looks and I love the way it feels. I love the sound of peeing from standing up and I feel A LOT safer using public toilets. I haven’t peed outside in nature yet, but I can’t wait to experience this.
I have a follow-up consult with Mr C in April, during which I’ll request the additional surgery. However, for now, I do consider this to have been a success. Experiencing a little burst of gender euphoria every time I go to the toilet has already been amazing for my mental health and happiness.
As with the last surgery, I now need to dilate again but I don’t really feel any rush to do it right now. I have found that the way I feel about that part of my body has changed a bit since the surgery and I might write a follow-up on that when I can understand more about it for myself.
Also, I do plan to try and use my Banana Prosthetics Meta Extension device to pee in public in the future, but for now, I’m just really enjoying peeing the way that I’m peeing.
As always, if you have any questions about this surgery or you’re struggling with a complication, then feel free to give me a shout anytime.
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