Gender Affirmation Surgery — Urological Aspects

See mental-health’s gender-dysphoria.md for the broader diagnostic and psychological-care picture — this page covers the genital (“bottom”) surgical options and referral pathway specifically.

Gender affirmation surgery is an effective treatment for gender dysphoria — patients rarely regret it later in life. Care is multidisciplinary: mental health providers, sexual health physicians, GPs, endocrinologists and surgeons.

Surgical options (“top” and “bottom” surgery)

	Female-to-male	Male-to-female
Facial	Facial masculinisation surgery	Facial feminisation surgery
Vocal	Vocal surgery (uncommon)	Vocal surgery, chondrolaryngoplasty
Chest (“top”)	Bilateral mastectomy	Breast augmentation
Genital (“bottom”)	Scrotoplasty, testicular prosthesis, metoidioplasty (± urethral lengthening), phalloplasty (± urethra, various flap types, ± penile prosthesis), hysterectomy + bilateral salpingo-oophorectomy, vaginectomy	Bilateral orchidectomy, scrotectomy, vaginoplasty (penile inversion or peritoneal pull-through), penectomy

Assessing suitability for surgery

Two models are used, each with trade-offs:

Model	Requirements	Trade-offs
WPATH standards of care	Mental health provider assessment (master’s-level qualification, ICD competence, capacity assessment, experience with gender dysphoria) confirming readiness	Careful, structured evaluation — but can be time-consuming, involves third parties, and is criticised by some as gatekeeping/paternalistic
Informed consent model	Patient capacity + detailed risk/benefit/alternatives discussion between clinician and patient directly	Faster, stronger clinician-patient relationship, aligns with low observed regret rates — but raises access/insurance-coverage questions and less formal psychological evaluation for some patients

Referral considerations — an ideal surgical candidate

• Psychologically stable (no active psychosis, depression, alcoholism, or intellectual disability precluding informed consent)
• A strong support network
• A clear idea of the desired surgery type
• Hormonal transition already begun/planned — minimum 6 months of hormone therapy is the current recommendation before “bottom” surgery
• Modifiable surgical risk factors optimised: smoking cessation (minimum 6 months), weight management (optimal BMI 21–29 — elevated BMI isn’t an absolute contraindication, but needs a careful risk/benefit discussion), diabetes stabilisation

Perioperative considerations relevant to the GP

• Hair removal — important for both phalloplasty and vaginoplasty (minimises hair within the formed urethra/vagina); usually organised by the gender surgeon
• Fertility planning — discuss sperm/ovarian cryopreservation before surgery or hormone therapy; this is a GP/physician-organised conversation, not just the surgeon’s
• Family planning — some patients prefer to have children before surgery involving reproductive organs, and may interrupt hormone therapy to achieve pregnancy
• Preoperative hormone levels — assess for anyone already on gender-affirming hormone therapy, ideally via the gender surgeon referral

Postoperative care and complications

• Regular follow-up, wound care, and dilation exercises (vaginoplasty) are standard
• Phalloplasty/metoidioplasty: may need additional surgery for complications; both short- and long-term complications exist
• Vaginoplasty: potential complications include infection, bleeding, rectal or bladder injury, loss of sensation, neovaginal stenosis or loss of depth

The GP’s role

Facilitate multidisciplinary referral, support hormone therapy and risk-factor optimisation pre-surgery, participate in fertility/family planning discussions, and provide ongoing postoperative primary care once surgical follow-up transitions back to general practice.