Vaginoplasty, the surgery that constructs a vagina from penile and scrotal tissue, works by repurposing existing anatomy. Surgeons use skin, nerves, and tissue that are already there, reshaping them into structures that look and function like a natal vagina. The most common technique, penile inversion vaginoplasty, has been refined over decades and remains the standard approach, though newer methods using tissue from inside the abdomen are growing in popularity.
The Core Technique: Penile Inversion
The most widely performed method starts with carefully deconstructing the penis while preserving key tissues for reuse. The surgeon separates the outer skin from the underlying erectile tissue, keeping the skin largely intact because it will become the lining of the new vaginal canal. The erectile tissue inside the shaft (the spongy material that fills with blood during an erection) is removed, since leaving it in place would cause unwanted swelling.
Next, the surgeon creates a tunnel between the rectum and the urethra/prostate. This space becomes the new vaginal canal. The preserved penile skin is then turned inside out and used to line this tunnel, essentially creating a sleeve of skin that sits inside the body. If there isn’t enough penile or scrotal skin to achieve adequate depth, the surgeon may graft skin from another area of the body to extend it.
The outer portion of the anatomy is sculpted into labia using scrotal skin. The urethra is shortened and repositioned so that urination happens from the correct location. A small opening is left at the vaginal entrance, and the overall external appearance closely resembles natal female anatomy.
How the Clitoris Is Created
This is one of the most precise parts of the surgery. The tip of the penis (the glans) is rich in nerve endings, and surgeons use a small portion of it to construct a clitoris. The glans is carefully separated from the erectile bodies beneath it while keeping its nerve and blood supply intact. The key nerves run along the top of the shaft, most concentrated at roughly the 11 o’clock and 1 o’clock positions, with almost no nerve tissue along the bottom. Surgeons make their incisions along the underside, where nerve density is lowest, to avoid cutting through the sensory pathways.
A small segment of erectile tissue is left attached near the base so the new clitoris can still engorge slightly during arousal, similar to how a natal clitoris functions. The resized glans is then secured in the correct anatomical position beneath a hood formed from surrounding skin. Because the nerve supply is preserved rather than reconstructed, most patients retain strong sensation.
Alternative Techniques for Vaginal Depth
When penile skin alone isn’t sufficient, or when a surgeon wants to create natural lubrication capacity, two other tissue sources are used.
Sigmoid colon technique: A segment of the large intestine is detached from the digestive tract (bowel continuity is restored with staples and sutures), then routed down through the abdomen and connected to the vaginal opening. Because intestinal lining naturally produces mucus, this approach creates a self-lubricating canal. The procedure is more invasive since it involves abdominal surgery, and carries risks including rectal perforation and leakage at the reconnection site, though these are uncommon. In one surgical series of 63 procedures, five patients experienced these complications, all of which were repaired without long-term problems.
Peritoneal pull-through: A newer approach that uses the peritoneum, the thin membrane lining the inside of the abdominal cavity. Surgeons harvest flaps of this tissue laparoscopically (through small incisions with a camera), pull them down into the newly created vaginal space, and suture them in place. This tissue is thinner and more delicate than intestinal lining but also produces some natural moisture. Patients in published series have achieved vaginal depths of 14 to 16 centimeters with this method.
What Recovery Looks Like
The initial hospital stay is typically around five to seven days. A catheter remains in place during the first week, and packing inside the new vaginal canal is removed before discharge. Most patients need six to eight weeks before returning to normal daily activities, and penetrative intercourse is usually cleared around three months post-surgery.
The most demanding part of recovery is dilation: using a medical dilator to maintain the depth and width of the vaginal canal. Because the body treats the canal as a wound and will try to close it, consistent dilation is essential, especially in the first year. The schedule from UCSF’s transgender care guidelines breaks down like this:
- 0 to 3 months: Three times per day, 10 minutes each session
- 3 to 6 months: Once daily, 10 minutes
- 6 to 9 months: Every other day
- 9 to 12 months: Once or twice per week
If depth or width starts to decrease at any point, the schedule gets bumped back up. Many patients continue dilating once or twice a week indefinitely, though regular sexual intercourse can partially substitute for dilation over time.
Complication Rates
The most common complication is stenosis, a narrowing of the vaginal opening or canal. In one study of 87 patients, narrowing of the opening occurred in about 8% of cases, while deeper canal narrowing happened in roughly 2%. A modified surgical technique in the same study dropped the opening stenosis rate to under 3%, with zero cases of deeper narrowing. Other possible complications include urinary stream changes, wound separation, and, rarely, a fistula (an abnormal connection between the vaginal canal and the rectum), which can require additional surgery to repair.
Granulation tissue, small areas of overgrown healing tissue inside the canal, is common in the first few months and is typically treated in the office with silver nitrate, a chemical that cauterizes the tissue painlessly.
Sensation and Sexual Function After Surgery
Because the surgery preserves the nerve pathways from the original glans, most patients retain the ability to orgasm. In a study of 199 patients who had peritoneal flap vaginoplasty at NYU Langone, 86% of those with at least one year of follow-up reported being able to reach orgasm. The median time to first orgasm after surgery was about six months. Notably, only 81% of those same patients had been able to orgasm easily before surgery, meaning some patients actually gained orgasmic ability they hadn’t previously had.
Sensation typically returns gradually. Nerve healing is slow, and many patients describe a progression from pressure awareness to tingling to full erogenous sensation over the first 12 to 18 months. The clitoris tends to regain sensation faster than the vaginal canal lining, which may develop some degree of erogenous sensitivity depending on the tissue used and individual nerve regrowth.
Requirements Before Surgery
Vaginoplasty is not a walk-in procedure. Most surgical programs require at least 12 months of hormone therapy before surgery, along with one or two referral letters from mental health professionals confirming a consistent gender identity and readiness for the irreversible aspects of the procedure. Patients also typically undergo hair removal on the penile and scrotal skin beforehand, since hair follicles in the skin would otherwise grow inside the vaginal canal. Electrolysis of the donor skin can take six months to a year to complete and is one of the most time-consuming parts of the preparation process.