Metoidioplasty

What is a metoidioplasty?

A metoidioplasty is a type of gender affirmation surgery that uses the tissue from the clitoris to create a 1.5-inch to 2.3-inch (4 to 6 centimeters) neophallus. “Neo” means “new,” and “phallus” means “penis.”

Before a metoidioplasty, you should go through masculinizing hormone therapy for at least one year. Masculinizing hormone therapy is a gender-affirming treatment that uses testosterone to stimulate changes in your body, including a deeper voice and more body hair. It also increases the size of the clitoris.

Other names for a metoidioplasty include:

• Bottom surgery.
• Meta bottom surgery.
• Female to male (FTM) bottom surgery.
• Clitoral release surgery.

Why is a metoidioplasty surgery done?

People assigned female at birth (AFAB) sometimes request a metoidioplasty to align their physical bodies with their gender identities. It helps treat gender dysphoria.

The goal of a metoidioplasty is to provide a natural-looking penis of suitable length that allows you to urinate (pee) while standing. The goal of metoidioplasty is to provide a sexually sensitive penis that can be erect without a penile implant.

How should I prepare for metoidioplasty?

You’ll work with healthcare providers for at least a year to prepare you for metoidioplasty. Your preparations may include:

• A physical exam to assess your overall health and learn more about your medical history.
• Patient education, including literature and conversations with a provider so you fully understand the risks, benefits and postsurgical care requirements.
• A mental status exam from a qualified mental health provider (therapist, psychiatrist or social worker) to ensure your understanding of the procedure. They’ll ask why you want a metoidioplasty, explain how the procedure will affect your life and ask about your expectations. You’ll need surgery referral letters from two mental health providers.
• Take hormone therapy for at least one year.
• Live for at least one year in a manner consistent with your gender identity.
• Health recommendations to help reduce your risk of complications, such as quitting smoking.

Can I get other gender-affirming surgeries with a metoidioplasty?

Yes, you may also get other gender-affirming surgeries or additional changes at the same time as your metoidioplasty. These may include:

• Making your urethra longer (urethroplasty).
• Creating a scrotum (scrotoplasty) to add testicular prostheses.
• Closing your vagina (vaginectomy), which must include removing your uterus (hysterectomy) and may include removing your ovaries (oophorectomy).

What happens before metoidioplasty?

In general, before metoidioplasty, you’ll need to:

• List all of your allergies.
• List all of your prescription or over-the-counter (OTC) medications, including herbal supplements.
• Temporarily stop all blood-thinning medications, if you take them.
• Not eat or drink eight to 12 hours before your surgery.

If you must take some medications before surgery, you may take them with a small sip of water.

What healthcare providers make up a metoidioplasty team?

The following healthcare providers may make up your metoidioplasty team:

• Reconstructive urologist.
• Plastic surgeon.
• Anesthesiologist.

What happens during metoidioplasty?

An anesthesiologist will first give you general anesthesia before surgery. General anesthesia puts you to sleep. You won’t feel pain or experience any other sensations during surgery.

Then, a surgeon will use the tissue from your enlarged clitoris to form a penis. Depending on the type of approach your surgeon may use, they’ll:

• Release the clitoris by using a surgical knife (scalpel) to cut the ligaments that connect the clitoris to your pubic bone. This is a simple metoidioplasty.
• Insert a plastic tube (catheter) into your urinary bladder. They’ll thread the catheter through your neophallus to keep your urethra open.
• Use tissue from your vagina or cheeks (buccal mucosa) to make your urethra longer.
• Use vaginal tissue to increase the length and girth (circumference) of your neophallus.

How long does metoidioplasty take?

It depends on several factors, including whether or not your metoidioplasty care team performs other gender-affirming procedures at the same time. But in general, a metoidioplasty may take two to five hours to complete.

What happens after metoidioplasty?

After the procedure, healthcare providers will stitch your incisions and cover them with bandages. You’ll also stop receiving anesthesia. After a few minutes, you’ll be conscious (awake) but will likely feel groggy. Providers will monitor your overall health and manage your pain once you fully wake up.

Once the providers determine you’re healthy enough and no longer require monitoring, you can go home. Most people go home after spending a day or two in the hospital.

You’ll need time to heal after a metoidioplasty. Sometimes, your healthcare team will perform the surgery in several steps. You may need other surgeries that take place four to six months after your first surgery.

What are the benefits of metoidioplasty?

One of the main benefits of metoidioplasty is relief from gender dysphoria. Achieving a physical appearance that aligns with your gender identity can help relieve:

• Emotional and psychological distress.
• Self-harm.
• Thinking of suicide (suicidal ideation).

Can you feel pressure after metoidioplasty?

Yes, most people retain full sensation in their neophallus after metoidioplasty. This is because your shaft contains the clitoral tissue and nerves.

Can you get erect after metoidioplasty?

Yes, you can have an erection after metoidioplasty.

Can you penetrate with metoidioplasty?

It depends. Some people can have penetrative sexual intercourse after metoidioplasty. But not everyone has the same results.

What size is a penis after metoidioplasty FTM surgery?

In most cases, your penis will be between 1.5 inches and 2.3 inches (4 to 6 centimeters) after metoidioplasty.

How do I pee after metoidioplasty?

The metoidioplasty procedure redirects your urethra through your neophallus. You’ll pee through your neophallus. Studies show that many people can pee standing up after metoidioplasty.

How successful is metoidioplasty?

The metoidioplasty success rate is good. A 2021 study of 813 people who had a metoidioplasty showed consistently good outcomes, including:

• Nearly 80% totally satisfied and 20% mainly satisfied with their results.
• 100% could pee while standing.
• 100% were satisfied with sexual arousal of their penis.

What are the risks or complications of metoidioplasty?

All surgical procedures carry some risk, including:

• Anesthesia problems.
• Healing issues.
• Infection.
• Scarring.

Metoidioplasty-specific complications include:

• Urethral strictures.
• Unwanted opening (fistula) in your urethra.
• Urinary tract infections (UTIs).
• Difficulties with sexual function, including dissatisfaction with erection quality, inability to orgasm during masturbation and inability to have penetrative sexual intercourse.

What is the recovery time?

You should be able to walk and do light activity about a week after metoidioplasty. Most people don’t resume their usual activities until at least six weeks after surgery. It’s important to remember your body is unique. Your recovery time might be different from others. Follow your healthcare provider’s instructions on managing any pain or discomfort as you recover.

When can I go back to work/school?

Most people can return to school or work about a week after metoidioplasty. But if you have a more physically demanding job, it’s a good idea to take more time off — you may need to take up to eight weeks off work to recover.

When should I call a healthcare provider?

You and your healthcare team will schedule regular follow-up appointments after a metoidioplasty to remove any stitches (if necessary) and see how your body is healing. It’s also a good idea to continue seeing a mental health professional with experience in transgender care after metoidioplasty. They can offer support as you navigate your recovery and adjust to life after surgery.

Call a healthcare provider or seek emergency care if you have:

• Signs of infection, including fever, chills, headache, discoloration, swelling or pus.
• Excessive bleeding.
• Difficulty or pain while peeing.
• Pain that lasts longer than expected or seems severe.

What is the difference between a phalloplasty and a metoidioplasty?

A metoidioplasty uses existing genitalia — clitoris and vaginal tissue — to create a penis. Most people have sensation in their penis and can get an erection after metoidioplasty surgery.

A phalloplasty uses large flaps of skin and muscle from other areas of your body, such as your forearm, thigh or back, to create a penis. A phalloplasty creates a penis that’s more likely to be larger and more natural looking, but you’ll need additional procedures to be able to have an erection (penile implant). Some people decide to have a phalloplasty after a metoidioplasty.