GENERAL NOTE

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• The most common phalloplasty includes UL, vaginectomy, scrotoplasty, perineal reconstruction, and associated procedures like a SP tube insertion. These instructions cover this most common combination of procedures. Patients who elect to omit one or more of these procedures such as NO UL and NO vaginectomy may not need to worry about the catheter related instructions. 

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HOSPITAL STAY

• Day of surgery: surgery will take about 8 hours; after surgery, you will be on the 4th floor of CPMC Davies with multiple drains

  • ​Drains: groin drain, scrotal drain, donor site drain; these help prevent fluid from collecting; they will be removed before patients go home in most circumstances

  • Urinary catheters: 2 catheters are usually required (1 if no UL is elected)

    • Urethral catheter: will be plugged​

    • SP catheter (lower abdomen): will be attached to a drainage bag

  • Patients will not eat the first night in general. The reason for this is in case surgery is needed the following day. Almost always no emergency surgery is needed and patients are able to eat after an overnight observation.

• Days 1 and 2 after surgery

  • Patients can eat after an early morning assessment on Day 1.

  • Patients will be in bed during this period and their phallus blood flow will be checked often

• Days 3-5 after surgery​

  • If all is healing well, patients will be transfered to the 3rd floor for less intense monitoring to allow for more rest.​
  • Patients will remain in bed until Day 4 when they are allowed to get into a chair.
  • On Day 5, if all continues to heal well, and patients are able to sit well, they will walk around the room or the hall way. Patients are usually discharged on this day and the drains will be removed; the catheters will stay. On rare occasion, the urethral catheter will be removed.
• QUESTIONS AFTER DISCHARGE: if concerns arise that are not answered by the following instructions and FAQs, please contact us.
  • Arm, leg, phallus, or groin: contact the Buncke Clinic at 415-565-6136. 
  • Urethra, catheter, scrotum, perineum: G.U. Recon Clinic at 415-481-3890.
  • Emergent concerns: go to the CPMC Davies ER and let us know.

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DEFINITIONS

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• Fever: elevated body temperature; if greater than 101°F, notify your surgeon

• Rash: new red spots that develop on the skin

• Constipation: not having regular bowel movements (example: one large bowel movement per day or the equivalent is expected)

• Hematuria: blood in the urine. This is expected whenever there is a catheter. Hematuria may increase in volume and redness whenever patients are moving/walking more.​​

• Fistula: abnormal connection between a segment of the urethra and the skin, causing urine to come out of a separate opening​

• Bladder spasms: the catheter can trigger the bladder to contract forcefully, causing a sudden desire to void which can be painful and uncomfortable. A spasm may also cause pain at the original urethra via referred pain pathways. 

• Graft: tissue from somewhere on your body (typically lower abdomen, groin, or inner cheek) to cover another part of your body (typically the urethra).​

• Perineum: area between the scrotum and anus

• Diverticulum: outpouching of the urethra, usually near the native urethra

• Infection: surgical site that has redness that spreads beyond the incision line combined with increased pain and tissue swelling with or without pus

• DVT: deep venous thrombosis; a clot in a vein, typically in the legs. This can progress to a more serious blood clot in the lung, called a pulmonary embolism. This is potentially life threatening.

 

GENERAL INSTRUCTIONS

 

• Activity: Avoid any activity or position that puts strain or tension on your incisions.

  • Examples: sitting on your incisions; plopping into a chair; sit ups, pull ups, large strides with walking

  • Pain is the body’s way of telling you a certain movement or position may inhibit healing; listen to your body and limit those positions and movements.

  • Walking is encouraged (about 1 hour per day; example: six 10-minute walks). Check the surgical sites to make sure pressure/tension isn't applied on the incisions while walking. Smaller steps are usually required the first few weeks after surgery.

  • Stairs are ok as long as you take one step at a time.

  • No jogging for 8 weeks; start slow and gradually increase to your pre-surgery cardio routine.

  • Avoid sexual activity for 6 weeks.

• Return to work: for desk dominant jobs, some may return to work when their pain is well controlled and they have fewer catheters to manage (usually 3-4 weeks after surgery). For jobs that are more physically demanding, 8-12 weeks off may be more appropriate.

• Diet: eat normally whenever your appetite returns. Water is a good drink choice.​

• Showering: may shower in 7 days; no baths/pools for 8 weeks and sometimes longer if wounds have not healed by 8 weeks.

  • Make sure to gently wash with mild soap between the skin folds (examples: sides of the scrotum, behind the scrotum, between the scrotum and the phallus). Not doing so can lead to a buildup of skin, oil, sweat and dirt that can lead to bacterial overgrowth and potentially increased risk of infection.

  • Note: it is ok to let the phallus hang for the duration of a short shower (5-10 minutes) to free up your hands for washing.​

    • Make sure to cover the donor site arm or thigh when showering.​

  • Sometimes it is hard to keep the thigh dressing dry. Some patients have used saran wrap, but this is not necessary and it is generally okay to get the thigh dressing (graft harvest site) wet. It is essentially a large scab. Allow it to air dry or fan dry it based on your comfort level. 

• Underwear: When wearing underwear, it may be more comfortable to have gauze over the incisions. Slightly loose boxer briefs tend to work well. You will typically have mesh underwear after surgery.

• Phallus positioning: Gently supporting the penis is ideal and this can be achieved with mesh underwear or slightly loose boxer briefs or a similar type of underwear. Don’t smash the phallus but avoid prolonged dangling of the phallus. Keeping the phallus in the 45-degree angle away from the plane of the body with a washcloth and/or gauze can help with healing faster and better. This keeps pressure off the incision between the phallus and the scrotum.

  • Important note: NEVER position the phallus upward and toward the side of the groin incision (where the vascular pedicle is); this can kink your blood vessels and compromise blood flow to the penis.

  • Avoid folding, smashing, or bending the phallus excessively as it can cause a permanent crease. 

  • Loose boxer briefs can be viewed as a large band aid that holds all the gauze/washcloths in the correct place to optimally position the genitals.

• Scrotum positioning: avoid sitting or smashing the scrotum. A wider walking stance and smaller strides may help. Paying attention when sitting may also help avoid smashing the scrotum. There will be frequent conscious crotch adjustments the first 4 weeks until things become second nature.

• Driving: Do not drive yourself until you are completely off prescription pain meds and all catheters have been removed.

 

SURGICAL SITE CARE

 

• Incisions: close observation and avoiding certain activities will help it heal. 

  • Avoid putting tension on the incisions.

  • Drainage is common and is yellow-red in color.

  • Swelling of the phallus and scrotum is common and usually takes a few weeks to months to resolve. It is expected and considered normal postoperatively. Swelling is not normal if it is worsening over time and combined with increased redness, pain, and fever.

  • Ointment (like medi-honey, aquaphor) is important to have.

    • For dry wounds, use Aquaphor daily to twice daily.

    • For wet or draining wounds, ointment may make things worse.

    • Ointment may be used on incisions to help dissolve annoying sutures faster as long as the incision isn't subject to a lot of tension with daily activity. 

  • Frequently, patients are provided mesh underwear with gauze; this can be removed a few hours later or the following day. If desired, this can be used for the first 3-7 days and combined with gauze to help keep the incisions clean and dry. Consider transitioning to boxer briefs when the incisions stop draining.

  • Gauze should be changed on average 1-2 x daily; the most frequently used gauzes are called 4x4s (4 inch x 4 inch). They do not have to be sterile but they should be clean. The combination of ointment, gauze, and mesh underwear may help with postop drainage and pain.

• Catheter care: know where your catheters are at all times and make sure it is not getting tugged.​ There are two catheters immediately after phalloplasty: the urethral catheter and the SP tube. The urethral catheter is usually removed 1-2 weeks after surgery.

• Urethral Catheter:​​

  • Hematuria is common with a catheter and usually resolves several weeks and rarely several months after the catheter is removed. Hydrate regularly with water to help with this.

  • Bleeding around a urethral catheter: this happens on occasion and usually resolves with time. If there is bright red bleeding araound the catheter, there may be an area of the urethra that is bleeding. Put a washcloth around the scrotum/perineum (area between scrotum and anus); the washcloth helps apply pressure over the likely bleeding site, and this will usually stop it. This may need to be repeated several times until the urethra heals. 

  • There will be leakage of bloody or cloudy fluid around the catheter; this is seen frequently and is expected. It will resolve when the catheter is removed and patients are urinating more regularly.

  • Urethral leakage: very common and often looks dark red and sometimes brown; allow it to drain. If the drainage is blocked by a scab, it is ok to remove the scab in the shower if easy to allow continued drainage. Your surgeons could also remove the scab at one of your postop visits.​

  • The urethral catheter will sometimes fill with urine on the inside; this is normal and not concerning.

  • Putting ointment at the tip of the phallus where the catheter is visible may make it more comfortable.

• Suprapubic SP tube/catheter:

  • Pain at the end of emptying the bladder/suprapubic (SP) catheter is common. This is from the bladder clamping or spasming around the suprapubic tube tip as the bladder empties. This may be minimized by timing the unclamping of the catheter so that there is some residual urine left in the bladder on purpose so that the bladder doesn't contract completely around the suprapubic tube tip.​​ A spasm may also cause pain at the original urethra via referred pain pathways.

  • A tugged SP tube or catheter often looks straight coming out of the abdomen and is often associated with intense bladder spasms.

    • Loosening the tension by repositioning the tubing may help​.

    • Sometimes, putting ointment where the catheter touches the skin and pushing the catheter in 1-2cm will help reposition the internal parts of the catheter to decrease the bladder spasms.

  • Plugging: plugging the end of the catheter (where the drainage bag tubing is attached) is ok when you are walking more.​​

  • Catheter related stones: on rare occasion, the urine can crystalize and form a shell or stone around a catheter; it is important to drink plenty of water to keep the urine dilute; a typical amount is 2-3 Liters of water per day. Adding lemon juice may also help. If this has happened with previous surgeries, let your surgeon know.

  • Scabs/debris around entry site: after a few days, a scab can form as can a build up of mucous looking debris. This is common. The scab will fall off on its own and mucous like drainage can be wipted away with gauze or gently washed in the shower.

    • Redness around catheter: redness localized to the skin around the catheter entry site is normal; if it spreads beyond the entry site, and there's an increase in pain, notify your surgeon.

• Donor Site: radial forearm and anterolateral thigh donor sites are managed similarly 

  • The mepitel silicone dressing stays on for about 3 weeks; it will be removed at your 3rd or 4th postop appointment.​

  • If the wrap around the mepitel is clean, you do not need to change it; we'll change it at your postop appointment. If the wrap is dirty, it is ok to remove and place another wrap around the donor site and mepitel.

  • You can wash your arm/thigh donor site around week 3; specific instructions will be provided. Generally, avoid direct water pressure on the donor site and use mild soap and water. 

  • Around 4 weeks postop, the skin graft on the donor site is well healed. Ointment like aquaphor should be applied daily. Only a thin layer is required. Mild lotions with minimal chemicals are also acceptable if there are no open wounds.​

  • Around 6 weeks postop, silicone sheets can be obtained over the counter and placed over the scar.

    • For RF phalloplasty patients, a silipos sleeve is recommended.​

  • Using lotion that has minimal dyes/fragrances and an SPF of 30 or greater when skin is at risk of sun exposure is recommended on the donor site.

 

POSTOPERATIVE CONCERNS

 

• Bleeding: a small amount of bleeding from the incisions (estimate is about a 4x4 gauze sized area of redness) is expected; sometimes holding pressure over the incision for 5 minutes (like holding pressure on a paper cut) is required. If there is any concern or the bleeding does not stop, contact your surgeons. If you need immediate attention, call 911 or go to the ER.​

• Infection: redness spreading beyond the incision combined with worsening swelling and pain, and sometimes fever are consistent with infection; notify your surgeon. If you notice chest pain or lightheadedness with these symptoms, call 911 immediately or go to the Emergency Room.

• UTI: Urinary Tract Infection. This is seen when the urine is consistently cloudy and more smelly than usual. Start the antibiotic and contact the office to let them know.

• Swelling: this is common and should worsen the first 1-2 days, stay about the same for the next 3-7 days, and then slowly improve thereafter. If swelling progressively worsens, combined with increased pain and redness around the incision, this is an infection. Bruising is common and is not a sign of infection.

• Pain: this is very common and should stay about the same for a few days and gradually improve thereafter. It is not normal if the pain progressively worsens without any activity (that is, pain not brought on by any particular activity).

  • Leg pain: if there is leg pain combined with swelling, especially with one leg more so than the other, there is a chance you could have a DVT. Go to the ER to get evaluated. 

  • Urethra pain: deeper pain near the original urethra is likely referred pain from the catheter and/or an intense bladder spasm.​

• Bladder spasms: with a foreign body (the catheter) in your bladder, some patients get bladder spasms. Oxybutynin (aka Ditropan) can help decrease this pain/discomfort.

  • Keeping tension off your catheter (make sure it doesn't look like it's being tugged) will also help.​

• Early urination through the phallus: with catheter plugging starting after the first postop appointment, sometimes urine will empty both through the catheter and through the phallus. It will happen intermittently and is considered normal and not worrisome. 

• Wounds: occur commonly, especially behind the scrotum, at the junction between the base of the phallus and scrotum, and the perineum near the anus.

  • Wounds are managed by keeping them clean, using ointment regularly if the wound is dry, changing gauze regularly for draining wounds, minimizing tension on the wounds, and good nutrition.

  • Most wounds are wet in the beginning and using gauze alone is appropriate--changing the gauze 1-4x daily depending on the drainage amount.

  • Once the gauze starts to stick to the wound, this means the wound is getting dry and may benefit from regular ointment application (usually 1-2 x per day). Aquaphor is usually best. 

• Drainage: it is expected/normal if it is a small amount of blood-tinged fluid. It is not normal if it there is a large amount of bright red blood or cloudy and cream colored draining, or if there is a large continuous volume of normal appearing drainage with no improvement.

• Fistula: these usually heal on their own. On occasion, leaving the SP tube in an extra 1-2 weeks may help with fistula healing. However, the pain/discomfort and increased risk of leaving the SP tube in longer must be considered.

  • Treatment: several options:

    • Delay urinating x 1-2 weeks and keep the catheter in longer.

    • Take the catheter out regardless (only possible if the stream from the tip is strong) and keep the fistula site clean; it may help to put ointment at the fistula site. 

    • Many fistulas will heal with or without a catheter (as long as the urinary stream remains strong from the tip of the phallus).

• Post urination leakage: Once the catheter is removed, post void dribbling can happen in the longer urethra. Putting some pressure behind the scrotum (the perineum) and on top of the scrotum, followed by gently milking the phallus from base to tip can help compress the residual urine out of your newly lengthened urethral. This will likely minimize the leakage after urination.

• Constipation: very common after surgery especially when needing to take pain meds regularly. Make sure to take miralax or other stool softeners while you are on pain meds. The goal is one large bowel movement (or its equivalent) per day.

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POSTOPERATIVE MEDICATIONS

 

• Take over the counter Tylenol 1000 mg every 6-8 hrs for baseline pain control. This will likely be needed for 3-7 days.​

• Narcotics: examples include Dilaudid, Hydrocodone, Oxycodone, Norco, Vicodin, Percocet, Tramadol​

  • Take 1-2 tablets every 6-8 hrs as needed for breakthrough pain (pain not controled with tylenol)

  • Over the counter ibuprofen 200-400mg is acceptable for further pain control if needed. Take it with meals. Ibuprofen may be taken at the same time as Tramadol and Tylenol since they are not in the same class.

  • Side effects*: itchiness, constipation, diarrhea, nausea, sweating, insomnia; liver problems (when acetaminophen is included); addiction

  • Do not take Tramadol if you are taking an SSRI (Selective Serotonin Reuptake inhibitor) medications such as Sertraline (Zoloft), Fluoxetine (Prozac), Escitalopram (Lexapro), Citalopram (Celexa), Paroxetine (Paxil), and Fluvoxamine (Luvox). Notify your surgeon to obtain a different pain medication.

  • Do not take Tylenol in addition to Percocet and Norco as these pain meds contain Tylenol (acetaminophen) already.​

• Miralax: stool softener to be taken while on pain medication; 17g by mouth daily (mix powder with liquid of your choice)

  • Side effects*: nausea, gas, drowsiness, stomach ache, loss of appetite

• Ditropan (oxybutynin): take 1 tab (5mg) every 8 hrs as needed for bladder spasms

  • Side effects*: dry mouth, headache, constipation in 5-10% of patients​

• Aspirin: 81mg or 325mg by mouth daily, for 4 weeks

  • Side effects*: bleeding, rash, abdominal pain, heartburn, headache

• May not be prescribed from Hospital due to confusion on when to take: Bactrim (trimethoprim/sulfamethoxazole): DS by mouth, twice per day, for 7 days (take only when prescribed or directed)

  • Side effects*: itching, rash, diarrhea, nausea, headache

  • If allergic to this or sulfa drugs, may substitute with  another antibiotic like Augmentin, Clindamycin, or Ciprofloxacin

  • Probiotic: it is generally a good idea to be on a probiotic like kefir, yogurt, kimchi, and/or other fermented foods; it is a really good idea to be on a probiotic when taking antibiotics.

 

*This is not a complete list of all the side effects that may occur with these medications. Getting side effects are infrequent; the side effects named are the more common ones for those who do experience side effects. Please call the office if you have any questions about your medications. Definitely notify us if you notice a rash that started soon after starting a new medication. If you notice shortness of breath or difficulty breathing after taking a new medication, call 911 and/or go to the nearest emergency room. You may be having a serious allergic reaction to the medication.

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Call office or your surgeon for fevers, chills, redness and pus from the incision, or pain not controlled with pain medication. If after hours, call the office phone number and leave a message; urgent messages will be relayed to the surgeons. If you feel it is a medical emergency and need immediate help, call 911 and/or go to the closest Emergency Room.

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IMPORTANT NUMBERS:

415 - 565 - 6136  for arm, leg, groin or penis concerns

415 - 481 - 3890  for scrotal, catheter, perineal concerns

Call either number for general concerns

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