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Pelvic Pain After Gender Affirmation Surgery

by Allyson Augusta Shrikhande, MD, CMO

One of the foremost concerns for any medical professional should always be creating an environment that is safe, welcoming, and comfortable for all of their patients. To me, as a pelvic pain specialist, gender inclusivity is an important part of that equation. Pelvic pain is a common issue for transgender people, particularly after having gender affirmation surgery (sometimes referred to as bottom surgery or gender reassignment surgery). Unfortunately, trans health issues are often overlooked or not properly understood, causing confusion and reluctance to seek medical help.

What is gender affirmation surgery?
Gender affirmation surgery is a surgery for transgender individuals with a goal of alleviating gender dysphoria by providing the physical appearance and functional abilities which match their inner self. While this is a medically necessary procedure for many who are trans, it also significantly changes the anatomy of the pelvic region and can cause pain and a range of other side effects. It is typical to feel some pain or discomfort immediately after major surgery, but pain that does not subside or even worsens over time is not normal and should be treated.

How can gender affirmation surgery affect the pelvic floor?
Bottom surgery can have a major impact on the structures of the pelvic floor. Invasive surgery and other trauma to the area can cause the pelvic floor muscles to shorten, resulting in weakness and spasticity. Surgery can also cause the formation of scar tissue and pelvic adhesions which may affect blood flow and exacerbate pain.

Do post-surgery pain symptoms differ between transmen and transwomen?
Most of the potential symptoms remain the same across the gender spectrum. These include:

  • Abdominal pain

  • Pelvic pain

  • Pain with intercourse

  • Urinary symptoms (urgency, frequency, or incontinence)

  • Bowel symptoms (constipation, pain with bowel movement)

  • Pain with sitting

However, hormonal differences may exist from person to person which can affect your level of risk, and sex assigned at birth may make you more likely to have certain conditions which can cause scar tissue and other risk factors.

Are there pre-existing conditions that contribute to a higher risk of post op pain and dysfunction?
Conditions that can result in an increased risk of post op complications include:

  • Endometriosis

  • Adenomyosis

  • Fibroids

  • PCOS

  • Hernias

  • Chronic prostatitis

  • Hip pathology

  • Lower back and sacroiliac pain/dysfunction

  • Underlying gastrointestinal disorders such as IBS or celiac disease

  • Interstitial cystitis

  • Bladder pain syndrome

  • Joint hypermobility

How is post-operative chronic pain following transgender bottom surgery treated?
First, the issue is diagnosed through a review of your full medical history and a physical examination. A comprehensive outpatient pelvic rehabilitation program typically entails physical therapy, ultrasound guided peripheral nerve blocks and trigger points to alleviate stress on dysfunctional muscles and nerves, and oral or suppository medications as needed. Acupuncture, a specific restorative yoga program, and nutrition may also be part of the rehabilitation plan.

Listen to what your body is telling you
Everyone’s body works differently and everyone heals at their own pace, but no one knows better than you do when something isn’t right. Gender affirmation surgery is a major procedure and it’s not at all unusual to feel some pain and discomfort during recovery, but if you are dealing with pain that does not subside after a couple months or even grows worse over time, you should communicate this with your physician. Know that living with post op pain isn’t your only option.

Dr. Allyson Shrikhande, a board certified Physical Medicine and Rehabilitation specialist, is the Chief Medical Officer of Pelvic Rehabilitation Medicine. A leading expert on pelvic health and a respected researcher, author and lecturer, Dr. Shrikhande is a recognized authority on male and female pelvic pain diagnosis and treatment.