Bowel (intestinal) vaginoplasty

This operation is for people born without a vagina, or with a vagina that is not completely formed. This includes some Difference of Sexual Development (DSD) conditions and complex Mullerian (womb & vagina development) anomalies. 

• Having a vagina is not essential for sexual intimacy and pleasure, but it can be important for some people to have the option of penetrative vaginal sex.   
• When someone has a functioning womb (a womb able to have periods and the potential to carry a pregnancy) but does not have a vagina, they will have obstructed periods. This can lead to a build-up of blood with every period and increasing lower abdominal (tummy) pain.  

When vaginal dilation or other surgical procedures are not suitable, a bowel vaginoplasty may be recommended. 

The surgery is carried out in the operating theatre with you asleep under a general anaesthetic. The procedure is performed as a joint operation with the gynaecology, urology and colorectal (bowel) surgical teams.   

The operation takes around three to four hours. However, more time may be needed depending on the reason for the surgery and if a person has undergone previous surgery.   

A 10-15cm cut on the tummy is made. This is likely to be made in the midline (from the belly button downwards). A section of the intestine (bowel) is removed and the two ends of the remaining bowel are sewn together to keep the bowel continuous and functioning. 

A space for the new vagina is formed and the bowel section is fixed into this space with stitches that later dissolve.   

The bowel vagina will be stitched open at the entrance of the vagina and either open at the top with a connection to the womb, or closed at the top if there is no womb to attach the bowel vagina to.   

At the end of the procedure, before you wake up, a vaginal ‘mould’ will be put into the vagina- this is to help the vaginal healing. This is typically a small balloon filled with water. We use temporary stitches to help close the labia and keep the balloon in place in the vagina. 

The balloon remains in the vagina for around five days while you stay in hospital. It is then deflated by draining out the water and is gently removed from the vagina (this can feel a little uncomfortable but should not be painful). 

You will wake up in recovery after a short while and will be transferred to the ward. You will have a fine tube in your arm (drip or IV) giving you fluid until you are drinking.   

The surgical team will see you afterwards on the ward to let you know how the operation has gone. 

You will wake up with the mould in the vagina and there will also be a tube (catheter) in your bladder to drain away urine. 

The urinary catheter helps us check that your kidneys and fluid levels are healthy. It will be taken out when the vaginal mould is removed. 

You may also wake up with one or two small tubes (drains) coming out of your tummy. These tubes help drain small amounts of blood and fluid that may build up whilst you are healing inside. These drains are generally removed a couple of days after the operation.  

You will have some pain from the cut on your tummy and vaginal mould. You will be able to discuss the best options for pain relief with the anaesthetist before your operation. 

The surgical team will let you know when and what you can start eating after your surgery.  Typically, you will be able to drink fluids immediately after your operation and start a light diet the following day.  

The surgical and nursing team will help support you with getting out of bed and gently moving around with a vaginal mould.   

You will be given a daily injection to thin your blood during your stay in hospital following your operation. This is to reduce the risk of blood clots forming in the legs and the lungs. 

We will expect you to be in hospital for around seven days.  

You are likely to have some light vaginal bleeding and discharge for the first couple of weeks after the surgery. If you have a womb, then it’s common for there to be thick and dark red/brown discharge for the first few days. The surgical team will advise you on when to stop your hormonal medications.    

If you notice fresh bleeding or smelly discharge, then please contact the teams’ Clinical Nurse Specialist or your GP. These may be signs of an early infection that can be treated with antibiotic tablets.   

If you feel unwell with heavy bleeding, fever, chills, increasing pain, diarrhoea or vomiting you should attend your local A&E for potential admission and antibiotics through a drip (your local team can contact the UCLH team for advice).

The vagina will need regular dilation after surgery to help it heal without narrowing or re-obstructing. You will have seen the team’s nurse specialist in clinic to understand this and what it will involve.   

The nurse specialist will see you after your surgery - when the vaginal mould has been removed - and will help you get started using the vaginal dilators. They will help you plan a maintenance dilation schedule. 

Our psychology team can support you with how you feel about vaginal dilation.

Your team will discuss this with you after the procedure, depending on the operation you had and how you are feeling. Most patients having this surgery will need to stay in hospital for around a week.     

Generally, we recommend four to six weeks off school, college or work. Let the team or ward staff know if you need a sick certificate.    

To help with healing we recommend showers rather than baths for the first few weeks after the operation.  

A follow up appointment will be arranged for around six to eight weeks after the operation. We will check on how you are feeling after the surgery and give you advice about vaginal sex (you should not have sex before your follow up appointment).

When can I get back to exercise?

You should avoid heavy lifting or strenuous exercise for six weeks. Avoid swimming until your tummy wound has completely healed. 

When will I be able to drive?

You can drive again once you are able to do an emergency stop safely and without being in discomfort. You must make sure you are not drowsy from any painkillers you may be taking. You must tell your insurance company that you have had surgery.  

When can I fly?

We recommend that you don’t fly for one to two weeks after your surgery. Your doctor will also advise you about precautions to take before and during your flight.

All operations and anaesthetics carry risks that your doctor will discuss with you when you sign the consent form.   

Risks of this procedure include leak from where the bowel has been re-joined following removal of the segment (anastomotic leak). There is a one in 50 risk of this and this may require formation of a stoma (where the bowel is brought out to empty into a bag the tummy- this is usually temporary).  

There is a risk of injury to the neighbouring body parts, such as the urethra (tube that urine leaves the bladder through), bladder, ureters (tube that brings urine from the kidneys to the bladder), blood vessels and the bowel. If an injury happened and was recognised, then it would be repaired during the operation. If it is not recognised at the time, there may be the need for further surgery. Injury repair may involve a camera into the bladder (cystoscopy), longer-term urinary catheter use or the need for a stoma. 

It is possible that infection or injury to the urethra, bladder, or bowel may cause long-term incontinence (leakage of urine or stool).    

There is a small risk of bleeding. It is unlikely that this will be heavy or a require blood transfusion. 

Operating on bowel can lead to a temporary ‘ileus’. This is when the bowel becomes sluggish and doesn’t move the digesting food along quickly enough. This causes a sick feeling and vomiting. A tube may need to be passed down through your nose into your stomach to allow the gut to rest. Usually this resolves by itself after a few days.  

Occasionally, there may be a mechanical obstruction to the bowels, which prevents food from moving along. This would be diagnosed with a CT scan and may require further surgery. 

There is a risk of developing blood clots in the veins of the leg (deep vein thrombosis: DVT) which can travel to the lungs (pulmonary embolism: PE). To reduce this risk, you will have some tight socks to wear and will receive injections whilst you are in hospital. 

You will have antibiotics in theatre to reduce the risk of infection.   

Once you go home if you have increasing pain or fever, you should see your GP or go to your local accident and emergency department. Please update our team by email, or ask your local doctor to do so, so that our team are aware (uclh.pag.queries@nhs.net). 

Signs of an infection of the tummy wound include redness, gaping or ooze. This is typically treated with antibiotics, which your GP can prescribe. 

The bowel vagina and stitches could also become infected, if you notice fresh bleeding or smelly discharge then please contact GP or us. The change in discharge may be a sign of early infection, which can be treated with antibiotics. 

The entrance to the vagina may narrow with healing. Vaginal narrowing (stenosis) can limit the ability to have vaginal sex. To minimise this risk vaginal dilatation is recommended.  

Longer term risks

People with bowel vaginas can experience excessive mucus discharge from the bowel segment and need to routinely wear a pad. The bowel segment can develop inflammation, and this may be associated with an increased cancer risk. Some people with bowel vaginas need to perform vaginal washouts and a smaller number require follow-up vaginoscopies (camera into the vagina) to allow more extensive vaginal washouts.

Risks with a bowel vaginoplasty connecting to a functional womb

There may be difficulties finding a section of bowel which has sufficient blood supply to be used to connect the functional womb to introitus (opening of the vagina on the vulva - outside) and this would require a hysterectomy (removal of the uterus - with the intention of not removing the ovaries). 

There is a risk of re-obstruction from vaginal narrowing.  This can be associated with a return of pain and can often be complicated by infection and require hysterectomy. 

The gynaecology team will discuss how your uterus and vaginal differences can affect your future fertility and management of any future pregnancies with a bowel vaginoplasty.   

The obstructed menstrual blood and need for abdominal surgery increase the risk of scarring of fallopian tubes. This is associated with reduced fertility and an increased risk of ectopic pregnancy (pregnancy which does not develop inside the womb – most often involving a pregnancy inside the fallopian tube).  

We would anticipate an increased risk of future pregnancies being more at risk of late miscarriage, pre-term labour and fetal growth restriction (when a baby's growth slows or stops during pregnancy).  

Someone with a bowel vaginoplasty would not be able to have a vaginal birth and would need a Caesarean section to deliver future pregnancies (with delivery in a centre familiar with managing pregnancies with people who have had reconstructive pelvic surgery). 

The team will have also discussed alternative routes to parenthood of surrogacy (with the potential for an IVF pregnancy using your own eggs) and adoption.

Your doctor will consider the benefits and risks of having this surgery with you and your alternative options.   

Our team’s psychologists can help you decide if this operation is the right choice for you. They can also help you consider when would be the right time for you to have this operation.

In clinic your doctor will discuss the option of this surgery and your alternative choices. They will talk through the procedure what to expect on the day and recovery from the operation as well as go through the surgical risks.  

You will have the opportunity to meet the team’s psychologist who can help you with the decision process and your feelings about the procedure and using vaginal dilators afterwards. 

You will need to sign a consent form for the surgery. 

A few days to weeks before the operation you will need to come to hospital for a pre-operative assessment to have some blood tests and other routine investigations. 

You will need to have ‘bowel preparation’ the day before your operation. This is a strong laxative that cleans out the bowel.   

On the day of the operation, you will be seen by the surgical and anaesthetic teams on the ward before the operation. You will have the opportunity to ask any questions you may have since your last clinic appointment.

Louise Perry: Clinical Nurse Specialist 

Email: uclh.pag.queries@nhs.net 

Website: www.uclh.nhs.uk