Pelvic Floor Anatomy in Male to Female Vaginoplasty andthe Role of Physical Therapy in Optimizing Long-Term and Patient-Reported Outcomes
Kian Adabi, BA, Tony Chieh-Ting Huang, MD, MSc, M. Diya Sabbagh, MD, Jorys Martinez-Jorge, MD, Pedro Ciudad, MD, PhD, Ricardo Galan, MD, Oscar J. Manrique, MD.
Mayo Clinic, Rochester, MN, USA.
BACKGROUND: Rapid increase in number of male to female vaginoplasties emphasizes the need for preoperative measures to optimize final surgical and patient reported outcomes. Hormonal therapy and socioeconomic factors may contribute to a higher incidence of pelvic floor dysfunction in patients undergoing male to female vaginoplasty. The purpose of this study is to evaluate the incidence of pelvic floor dysfunction in this population and the role of physical therapy in its treatment.
METHODS: From January 2017 to April, 2018, patients scheduled to undergo male to female vaginoplasty in a multi-disciplinary transgender clinic were enrolled. All patients were evaluated by physical therapist for pelvic floor dysfunction before and after surgery. Patient demographics and comorbidities were investigated for factors correlated with pelvic floor dysfunction. Those with symptoms underwent therapy. Assessment of symptoms severity and its impact on daily living were completed at 2-3 month intervals with physical therapy using the Urinary Distress Index (UDI-6) and Colorectal Anal Distress Index (CRAD-8) components of the Pelvic Floor Distress Inventory (PFDI-20) before and after surgery. A third component of the PDF-20, the Pelvic Organ Prolapse Distress Inventory (POPD-6) was also included in the postoperative assessment. A Pelvic Floor Dysfunction Index (PFIQ-7) was used to assess impact of symptoms of daily living.
RESULTS: Over a 16-month period, a total of 40 patients undergoing male to female vaginoplasty were identified with a mean age of 42.3 (19-72) years and body mass index (BMI) of 31 (22 -39). Comorbidities included 4 (10%) patients with diabetes and 6 (15%) with hypertension. Patients with symptoms had a significantly higher mean age (p < 0.01). Only one (2.5%) patient had new onset pelvic floor dysfunction after surgery and there was no significant increase in severity of symptoms in those with a previous pelvic floor dysfunction postoperatively. Physical therapy significantly (p < 0.01) reduced severity of symptoms and its impact on daily living as assessed by the UDI-6 and CRAD-8 before and after surgery, and by the PDFI-20 and PFIQ-7 postoperatively. CONCLUSIONS: There is a high incidence of pelvic floor dysfunction in patients undergoing male to female vaginoplasty that is evident prior to surgery. Preoperative screening is needed to ensure optimal final outcomes. Therefore, physical therapy before and after surgery can significantly improve symptoms and quality of life.
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