Whether your patient is a cisgender female or a transfeminine patient, urinary incontinence is unfortunately common and can have a significant negative effect on a person’s quality of life. While the incidence of incontinence is relatively well established in the cisgender population, these statistics remain elusive among transfeminine individuals. Many studies today currently examine cosmetic results, sexual function, and major complications rates, and are now starting to explore the long-term effects of these surgeries on the urinary tract.1
As gender-affirming surgery increases in prevalence, our knowledge regarding long-term outcomes impacting quality of life needs to subsequently improve. A few small studies have examined the rates of incontinence and urinary dysfunction among transfeminine patients. In one study, changes in voiding were reported in 32% of patients, with 19% reporting worse voiding and 19% reporting some degree of incontinence.2 A small series of 52 transgender female patients found rates of urinary urgency to be 24.6% and stress incontinence 23%.1,3 Another study of only 18 patients demonstrated a significant rate of incontinence at 33%, which was due to stress urinary incontinence and overactive bladder.1,4 Other studies noted postvoid dribbling to be as high as 79%.1,2
Dr. K. Ashley Brandt
Obtaining a thorough history is essential in evaluating patients with incontinence. Compared with cisgender females, risk factors for urinary incontinence in cisgender males are naturally different. For example, increasing age, parity, vaginal delivery, history of hysterectomy, and obesity are some risk factors for incontinence in cisgender women.1,6 However, in men, overall rates are lower and tend to be associated with factors such as a history of stroke, diabetes, and injury to the urethral sphincter – which can occur in radical prostatectomy.1
In addition to asking standard questions, such as caffeine use, beverage consumption, medication changes, physical activity, etc., the relationship of a patient’s symptoms to her vaginoplasty is crucial. Providers should elucidate whether patients experienced urinary symptoms prior to surgery, note the type of vaginoplasty performed, and determine if any temporal relationship exists with dilation or intercourse.
Communicating with the original surgeon and obtaining operative reports is often necessary to understand the flaps utilized and the current anatomic structures that were altered during surgery. Creation of the neovagina involves dissection through the levator ani, which can lead to neurologic injury and subsequently predispose patients to incontinence. The surgeon must be meticulous in their creation of the neovaginal space, particularly between the rectum and the prostatic urethra. As the dissection continues in a cephalad direction to the peritoneal reflection, the bladder can also suffer an iatrogenic injury.
In cases of the penile inversion vaginoplasty, a skin graft is typically used to line the neovaginal canal. If this graft fails to take appropriately it can prolapse and can contribute to urinary incontinence symptoms. Some surgeons will suspend the apical portion of the neovagina; however, the effect on rates of incontinence is mixed.
The physical exam of a transfeminine patient should consist of a general health assessment, neurological, abdominal, and genitourinary examinations. Palpation of the prostate is performed through the neovaginal canal if patent. During the urinary exam, the provider should make note of stenosis at the urethral meatus or urethral hypermobility. For patients reporting symptoms of stress incontinence, a cough stress test is useful. The neovagina should be carefully examined for fistula formation or any other structural abnormality.
Testing for urinary incontinence is similar to the evaluation in cisgender females in that every patient should undergo a urinalysis and a postvoid residual volume measurement, and should maintain a voiding diary. Indications for urodynamic testing are the same for transfeminine women and cisgender women – symptoms do not correlate with objective findings, failure to improve with treatment, prior incontinence from pelvic floor surgery, difficult diagnostic evaluation with unclear diagnosis.5,6 Cystoscopy is useful for patients experiencing hematuria, before anti-incontinence surgery, or prior to transurethral prostate intervention.1
Treatment is tailored to the type of incontinence diagnosed; however, there are no specific guidelines that are evidence-based for transfeminine patients after vaginoplasty. The therapies available are extrapolated from the general patient population. All patients can benefit from dietary modifications such as avoiding bladder irritants, monitoring fluid and caffeine intake, timed voiding, and pelvic floor exercises.1,6 If patients do not experience improvement from conservative measures, the mainstay treatment for overactive bladder is antimuscarinic agents. However, in cisgender male patients who have a prostate, these agents can lead to urinary retention related to bladder outlet obstruction, although the rates of urinary retention are low.1 Overall, these agents are relatively safe and effective in cisgender men with a prostate and by extension should be utilized in transfeminine patients when indicated.
In patients diagnosed with stress urinary incontinence, conservative options with weight loss, smoking cessation, and pelvic floor exercises should be attempted. If these measures fail in cisgender women, surgical treatment is often recommended. However, surgical treatment in transfeminine patients is significantly less straightforward and beyond the scope of this article.
Obstetrician/gynecologists are familiar with assessing and treating cisgender female patients reporting incontinence and should use this same knowledge for diagnosing and treating transfeminine patients. In addition, providers should be aware of complications of these procedures in evaluating patients presenting for symptoms of incontinence, as these complications directly contribute to incontinence in this patient population.1
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. Email her at obnews@mdedge.com .
References
1. Ginzburg N. Care of transgender patients: Incontinence. In: Nikolavsky D, Blakley SA, eds. Urological Care for the Transgender Patient: A Comprehensive Guide. Syracuse, NY: Springer, 2021:203-17.
2. Hoebeke P et al. Eur Urol. 2005;47(3):398-402.
3. Kuhn A et al. Fertil Steril. 2011;95(7):2379-82.
4. Kuhn A et al. Eur J Obstet Gynecol Reprod Biol. 2007;131(2):226-30.
5. Winters JC et al. J Urol. 2012;188(6s):2464-72.
6. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e66-81.