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 Particular SRS information
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Instructions after sex reassignment surgery
At the hospital
You must always keep your legs far apart at least 45 degree (triangular pillow will be placed between your knee while lying). It is important to avoid any external force which can interfere with the blood supply to the new wound.
Never get up or get out of bed before vaginal packing removal, unnecessary movement can interfere with the graft taking.
Ice pack applied to the surgical area is needed only the first day after surgery to prevent any further bleeding.
Exercise by raising your legs for 15-20 degree sometimes during a day is recommended to promote blood circulation in your legs.
Always take a lot of water to promote urination.
The vaginal packing, all drains and urinary catheter are normally removed on the fourth or fifth day after surgery.
The graft inside neovagina will be checked and the total depth of noevagina will be reported immediately after the first dilation.
Your first fee after removing the urinary catheter may take time, please feel relaxed and try to drink a lot of water.
The essence of vaginal dilatation
Vaginal dilatation after sex change surgery is the most important thing you can do to ensure the success of your sex change surgery.
If you gain the excellent depth after the SRS performed by me, but you ignore on your part to diligently dilate your new vagina, this will result in shortening of vagina due to the skin graft contracture.
Failure to dilate properly can result in serious injury. You will be instructed to gently dilate into the right direction after the vaginal packing is removed.
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Dilation instructions for Dr Chettawut's post-operative SRS patients
Dilation should commence within two days of the removal of vaginal packing.
The initial stage of your dilatations will be carried out under the close supervision
of my highly skilled and experienced nursing staff.
Each day that you remain in my care a member of my staff will come to you at
your hotel to instruct and assist you with your dilatation.
DO NOT attempt dilatation whilst unsupervised - wait until the nurse arrives.
When she considers you to be sufficiently skilled in performing this most
important and delicate of post SRS procedures without her supervision then she will tell you: Don't worry - it doesn't take for ever to acquire the skill and confidence!
Remember - ALWAYS wash your hands and your dilators (vaginal stents) before every dilatation.
The use of a condom to cover the stent ( to prevent any infection and to guard against any possible damage to the lining of your vagina) is necessary only for the first 4 - 5 days following pack removal.
Technique
With one or two pillows to support your head and shoulders a semi-sitting / lying
position with your legs comfortably apart and your knees bent is recommended.
Find a position in which you are most relaxed.
Always begin with the smallest size of dilator and have a mirror to hand to assist you
in locating the vaginal opening.
Lubricate the dilator and your vaginal opening quite liberally - make sure everything
is very slippery.
When you feel relaxed and at ease, take the mirror in your free hand to locate your vaginal opening and then, applying a gentle pressure, insert the dilator into your vagina.
Always push the dilator slowly to avoid wound laceration or skin graft damage.
If you have difficulty inserting the dilator you may need to add more lubricant and then try again.
You will find that slightly rotating/screwing the dilator can often help when you encounter resistance in obtaining further depth.
NB. The angle of insertion should at first be straight and then slightly downwards.
Dilation should not be painful at all unless your wound is not completely healed or you are pushing the dilator in the wrong direction.
Remember: do everything slowly and methodically. Don't rush - take your time.
When the dilator feels tight and you are unable to pass the dilator any further forward
you have reached your maximum depth.
At this point you must maintain a constant pressure on the dilator to keep it firmly pressed against the bottom of your vagina.
Keep it held in that position for the duration of that dilation period.
(See below for recommended dilation times.)
Check this depth with the marking on the dilator and ensure that you reach that mark
(or even deeper) in subsequent dilatations.
In observing this rule you will maintain your maximum depth and prevent any further skin graft contraction.
There is no reason at all to loose depth if:
(i) You are completely healed inside, and
(ii) You follow diligently the recommended dilation regime.
Frequency and duration of dilatations
The total dilation time per day should be between 1 to 2 hours.
In the long term, anything less than this is NOT enough.
After removal of the vaginal pack, dilatation using the smallest stent (Dr.Chet's stent No.1)
for 15 to 20 minutes once a day and for the first few days is sufficient.
Dilation should then be increased to TWICE a day and for 30 to 40 minutes per session.
Each session should comprise 10 to 15 minutes using stent No. 1 and 20 to 25 minutes
with stent No. 2.
After 10 days or so dilatations should be increased to THREE times per day and using
stents No.1 and No. 2 in the same time proportion as above.
When dilator No. 2 ceases to be a challenge you may progress to No. 3.
This event usually occurs about 6 to 8 weeks after your operation.
For those patients with a small pelvic girdle (narrow hips) the use of stent No. 4
may not be necessary or even possible.
For those with a larger pelvic girdle (broader hips) the appropriate time to begin using
stent No.4 will be at about 12 weeks after surgery.
However; not everyone manages to develop and maintain their vaginal depth within
the same time frame - it may take some a little longer than others.
A simple rule to observe is this: the time for moving up to No 4 stent will become
clearly apparent when the use of stent No. 3 has progressed comfortably and easily
to the point where it has ceased to present a challenge.
On using the biggest stents for the first time don't expect to reach maximum depth
on the first time you use them.
If full depth can be achieved with a smaller stent then you will, eventually, obtain the same depth with the larger stents.
Don't ever force it too hard. It will happen - just take time and care.
It is your responsibility to dilate for the rest of your life.
To ignore this advice may result in a shortening of your vaginal depth.
You may commence sexual intercourse 2 months after your surgery but remember
that one act of sexual intercourse is equal to just one dilation!
It is strongly recommended that you dilate 3 to 4 times per day for the first year
following your operation.
If, in following this protocol for a full year and having maintained your existing depth,
you may then embark upon your own schedule of dilation but remember this:
Regular dilation is (and remains forever) your responsibility.
Don't ignore it.
Dr Chettawut Tulayaphanich M.D., F.A.C.S(T)
(2006-7 © Dr.Chettawut Tulayaphanich; All rights reserved)
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