Metoidioplasty is a gender-affirming surgery that creates a small penis from existing genital tissue. It works by releasing the clitoris, which has typically grown significantly after testosterone therapy, from the ligaments that hold it against the pubic bone. The result is a phallus that averages about 5.6 cm (roughly 2.2 inches) in length, with a range of about 4.8 to 10.2 cm depending on individual anatomy and the surgical technique used.
How the Surgery Works
Testosterone causes the clitoris to grow over time, sometimes substantially. But much of that tissue remains tethered beneath the skin by ligaments connecting it to the pubic bone. Metoidioplasty frees this tissue so it projects outward as a phallus.
The core of the procedure involves making an incision below the head of the clitoris, separating the skin from the underlying tissue, and cutting the suspensory and fundiform ligaments that anchor it in place. Once those ligaments are fully divided down to the bone, the tissue can extend to its maximum length. Some techniques also divide a band of tissue on the underside of the clitoris to gain additional length. The result is a small but functional penis made entirely from the patient’s own genital tissue, with natural erections possible because the internal erectile tissue remains intact.
Surgical Variations
Metoidioplasty isn’t a single procedure. It’s more of a framework with several options that can be combined based on a person’s goals.
A simple metoidioplasty focuses only on releasing the clitoris from its ligaments. It’s the least invasive version and carries fewer risks, but it doesn’t include urethral lengthening or scrotal construction.
More comprehensive approaches, sometimes called the Belgrade technique, divide all ligaments completely and may include several additional components: urethral lengthening (so you can urinate standing up), scrotoplasty (creating a scrotum from the labia majora, often with testicular implants placed in a later stage about four months afterward), and vaginectomy (removal of the vaginal canal). These components can be mixed and matched. Some people choose urethral lengthening but skip vaginectomy, for instance, or opt for scrotoplasty without urethral work.
Urethral Lengthening
One of the biggest decisions in metoidioplasty is whether to extend the urethra so that it exits through the tip of the new phallus. Without this step, the urethral opening stays in its original position.
Building a longer urethra requires donor tissue. Surgeons typically combine tissue harvested from the inside of the cheek (buccal mucosa) with a flap from the labia minora. The cheek tissue lines the section closest to the body, and the labial flap forms the outer portion of the new urethral tube. In one series of 38 patients, all reported being able to urinate while standing after this combined approach, though about a third experienced temporary dribbling or spraying that improved over time.
Urethral lengthening does carry meaningful complication risks, which is why some people opt out of it entirely. Choosing to have a vaginectomy at the same time significantly reduces the chance of urethral fistulas (abnormal openings that cause urine to leak), partly because the vaginectomy provides additional vascularized tissue that supports healing.
Complication Rates
The most common complications involve the new urethra, for those who choose urethral lengthening. In one study of 74 patients, 56.8% experienced some form of urethral complication. The breakdown: 45.9% developed a fistula at some point (though some healed on their own, leaving 36.5% with a permanent fistula requiring further surgery), and 18.9% developed a stricture, which is a narrowing that can obstruct urine flow.
These numbers are high, and they’re one of the main trade-offs people weigh when deciding between a simple metoidioplasty and a full reconstruction with urethral lengthening. Without urethral lengthening, the risk profile drops considerably since the most complication-prone element of the surgery is removed entirely.
How It Compares to Phalloplasty
Metoidioplasty and phalloplasty are the two main options for genital construction, and they involve very different trade-offs.
Phalloplasty creates a larger phallus using tissue transplanted from another part of the body, usually the forearm or thigh. It produces a penis closer to average adult size, but it requires multiple staged surgeries, leaves significant scarring at the donor site, and may or may not preserve erotic sensation depending on the technique. An implant is needed for erections.
Metoidioplasty produces a smaller phallus but uses only existing genital tissue, so there’s no donor site scarring and no risk of flap loss. Because the clitoral nerve bundle stays intact throughout the procedure, erotic sensation is reliably preserved, and natural erections occur without an implant. The surgery is shorter, requires fewer stages (typically one primary surgery plus a possible second stage for testicular implants), and has a faster overall recovery timeline.
The core trade-off is size versus sensation and simplicity. Some people choose metoidioplasty first with the understanding that phalloplasty remains an option later if they want more length.
Prerequisites
Metoidioplasty requires at least one year of testosterone therapy beforehand. This gives the clitoris time to grow to a size that allows the surgeon to work with it effectively. Some surgical teams also prescribe a topical hormone gel applied twice daily for three months before the procedure to maximize clitoral growth beyond what testosterone injections alone achieve.
Recovery
You’ll have a urinary catheter after surgery, which may be removed before you leave the hospital or at a follow-up appointment. Plan on at least six weeks of rest before returning to regular activities. During that time, short daily walks are typically encouraged to support healing, but anything strenuous is off the table. Your surgeon will give you a specific timeline for driving, returning to work, and resuming exercise based on which components of the surgery you had. Urethral lengthening and vaginectomy generally add to the recovery period compared to a simple metoidioplasty alone.