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Neovaginal postsurgical complications
Neovaginas are surgically-constructed vulvo-vaginal tissues in transgender women that are designed to resemble the vaginas of cisgender women. Surgical techniques include using tissue from nongenital skin grafts, penile tissue, scrotal tissue, or intestinal tissue to create neovaginas (Bizic et al., 2014). The esthetic and functional utility of neovaginas are important for patients; thus, complications after transition surgery should be monitored closely.
One meta-analysis found that the most common complication was stenosis or stricture of the neo-urethra (14.4%), which could affect urinary function or predispose patients to urinary tract infections. One in 10 patients developed stenosis of the neovagina, which could affect sexual functioning.
Another significant complication of surgery is the development of intravaginal hairballs or the development of hair growth in the intravaginal area or introitus, which can be accompanied by pain and increased discharge. This can result from neovaginas created using tissue with hair follicles, such as the scrotum. This complication can be avoided by performing electrolysis or laser hair removal in these areas prior to surgery or by using nongenital skin grafts (Bizic et al., 2014, Suchak et al., 2015).
Other less common, but still significant, complications include wound infection (3.2%), neo-vaginal prolapse (1.6%), and recto-vaginal fistulas (1.0%; Dreher et al., 2018). The relatively common overall occurrence of complications should warrant the close monitoring of patients who have recently undergone surgery.
Not much is known about the microbiome of the neovagina. One study found that five patients developed symptomatic neovaginal candidiasis after penile inversion vaginoplasty. All patients presented with discharge, unpleasant odor, and severe itch, and the symptoms resolved with topical treatment (de Haseth et al., 2018).
One study mapped the microflora of 50 transgender patients and found that most patients had mixed microflora of aerobic and anaerobic species that are native to the skin and intestinal tract. Similarities with microflora that are found in association with bacterial vaginosis were observed (Weyers et al., 2009). A study on whether this flora differs significantly from that of cisgender women and whether microflora differences correlate with the activity of any vulvovaginal disease would be worthwhile.
MTF patients with neovaginas could be at risk for certain types of vulvovaginal cancer. A case report showed the development of human papilloma virus (HPV)-associated squamous cell carcinoma in a neovagina that was created from scrotal tissue. This suggests that the chronic inflammation from surgical incisions could increase the risk for the development of such cancer (Bollo et al., 2018).
Another report showed the development of a mucinous adenocarcinoma in a neovagina that was constructed from the colon (Kita et al., 2015). One study showed that the cytology of neovaginas resembles normal cervical cytology in only a minority of cases and concluded that patients with neovaginas should undergo routine cancer screening. This study also found that 5% to 10% of patients carried low- or high-risk HPV strains in their tissues (Grosse et al., 2017).
One case demonstrated the development of poorly controlled lichen sclerosis in the anal and neovaginal regions of a transgender patient (McMurray et al., 2017). Further studies should investigate whether transgender patients are more susceptible to chronic inflammatory conditions, such as lichen sclerosus, in the setting of surgical interventions. Although squamous cell carcinoma of the vagina is rare, chronic inflammation (particularly in the setting of lichen sclerosus) can predispose patients to the development of cancer.
Despite these suggestions for a possible increased risk of certain types of cancer, there is no strong evidence for increased screening of these patients. Furthermore, there are not enough data for the predicted incidence of developing cancer in this population, and there is no known timeline from surgery to cancer for these patients. Reports have found cancer development at a wide range of times postsurgery.
Until more data and/or guidelines exist, we recommend following the cervical cancer screening recommendations in terms of frequency of Papanicolaou tests on neovaginal tissue (U.S. Preventive Services Task Force, 2012). Similar to the recommendations for anal Papanicolaou tests, if factors exist that place a patient at a higher risk for HPV-related cancer (HIV positive-status, history of condyloma, or other genital HPV-related conditions), we suggest more frequent screenings (Kreuter et al., 2015, Liszewski et al., 2014). If an area of tissue is chronically inflamed, such as from lichen sclerosis, then the patient should be followed closely, similar to cisgender women with these conditions.
Benign neovaginal disease
A few benign conditions have also been reported in the neovaginas of transgender women. Several studies have demonstrated the presence of condyloma accuminata in transgender women, mainly in neovaginas constructed from penile and scrotal tissues (Brown et al., 2015, Galea et al., 2015, NureƱa et al., 2013, van der Sluis et al., 2016). These lesions can present with coital pain and bleeding (van der Sluis et al., 2016). Although the incidence is not known, it is suggested that the high rate of HIV in this population predisposes patients to having a high rate of HPV infection (NureƱa et al., 2013). Treatment options are similar to those in cisgender patients, including topical podophyllotoxin, excision, or laser evaporation (van der Sluis et al., 2016). There was also one reported case of condyloma gigantea in neovaginal tissue that was constructed from the prepuce and scrotum, which was treated with laser and repeated liquid nitrogen (Yang et al., 2009).
A case report also exists on a transgender woman with lichen sclerosus et atrophicus, which presented with several years of vulvar pruritis and burning. The patient was found to have involvement of the labia, clitoral hood, and perianal area. Multiple topical treatments, such as triamcinolone, camphor, menthol, and lidocaine, were attempted without success, and the patient received only some relief of pain and itch with oral gabapentin. Biopsy test results revealed lichen sclerosis with superimposed contact dermatitis. The patientās vaginal involvement could be explained by the construction of her neovagina with penile and scrotal tissue, but her perianal involvement was unusual because cisgender men usually do not have perianal involvement (McMurray et al., 2017). This presentation could be unique to transgender women in the context of their hormone use, chronic irritation, and trauma/scarring from surgery (BjekiÄ et al., 2011, Friedrich and Kalra, 1984).