Metoidioplasty is a gender-affirming surgery that creates a small penis from existing genital tissue that has been enlarged by testosterone therapy. The resulting phallus typically measures around 5.6 to 6.8 centimeters (roughly 2 to 2.7 inches). Unlike phalloplasty, which builds a larger penis using tissue from another part of the body, metoidioplasty works entirely with local tissue, preserving natural sensation and the ability to achieve erection without an implant.
How the Surgery Works
Before surgery, a person needs to have been on testosterone long enough for significant growth of the clitoris. Some surgeons also recommend topical hormone cream and a vacuum device beforehand to maximize size. The growth that testosterone produces is what gives the surgeon tissue to work with.
During the procedure, the surgeon frees the enlarged clitoris from the surrounding structures that hold it close to the body. Two things keep it in a curved, tucked position: the suspensory ligaments (which anchor it in place) and a strip of tissue on the underside called the urethral plate (which tethers it downward). The surgeon carefully releases both of these while preserving the nerves and blood supply that run just beneath the ligaments. Once released and straightened, the tissue projects outward as a small phallus. Surrounding skin from the labia is then used to cover and shape the shaft.
Types of Metoidioplasty
There are several variations, and they differ mainly in how much is done in one operation.
- Simple metoidioplasty releases the clitoris and straightens it but leaves the urinary opening in its original position. This is a less complex procedure, but it means you’ll still need to sit to urinate. Urethral lengthening can be added in a later stage if desired.
- Ring metoidioplasty adds a step: a flap of vaginal tissue is used to begin extending the urethra, creating a foundation for future urethral lengthening. It offers more straightening and length than the simple version.
- Full (Belgrade) metoidioplasty is the most comprehensive single-stage option. It includes complete release of all ligaments, urethral lengthening to the tip of the phallus using grafts from the inner cheek and local skin flaps, scrotoplasty (creation of a scrotum from the labia majora), and insertion of testicular implants. The goal is a fully masculine genital appearance in one surgery, with the ability to urinate standing up.
Additional Procedures
Metoidioplasty is often performed alongside other procedures depending on the person’s goals. Scrotoplasty reshapes the labia majora into a scrotum by rotating and joining the tissue at the midline beneath the new penis. Testicular implants can be placed inside the scrotum at the same time or during a later stage, though implants do carry risks of infection, displacement, and discomfort that lead some people to choose autologous tissue augmentation (using their own tissue to add volume) instead.
Monsplasty, which reduces the fatty tissue on the pubic mound, can be done at the same time to help the phallus project more visibly. Some people also undergo vaginectomy (closure of the vaginal canal) as part of the procedure, particularly with the full technique.
What to Expect for Size
Post-operative length closely tracks pre-operative size. In a study measuring outcomes, the median stretched length before surgery was 5.8 cm, and the median exposed length after surgery was 6 cm, a gain of roughly half a centimeter to one centimeter. The correlation between pre-operative and post-operative length was very strong, meaning that how much growth testosterone produced before surgery is the single best predictor of final size.
Interestingly, neither total time on testosterone nor BMI showed a meaningful correlation with final length. In other words, being on testosterone for five years versus two years didn’t translate to a larger result, and weight didn’t appear to be a factor either. The growth that matters happens in the first phase of hormone therapy, and a pre-operative measurement in the clinic gives a reliable preview of the surgical outcome.
Sensation and Sexual Function
One of the primary advantages of metoidioplasty is the preservation of erogenous sensation. Because the surgery works with the person’s own nerve-rich tissue rather than grafting from a distant donor site, sensation remains largely intact. Across studies, over 85% of patients reported preserved erogenous sensation, and arousal, desire, and masturbation satisfaction received similarly high ratings. Erectile function scores were 94% or higher in most studies, reflecting the fact that the tissue can become erect naturally without a prosthetic device.
Orgasm outcomes were more variable, ranging from 66% to 100% across different studies. The area where metoidioplasty falls short for some people is penetrative intercourse: only 0% to 24% of patients in most studies reported the ability to penetrate a partner, which is a direct consequence of the smaller size. Overall sexual satisfaction ranged from 53% to 88%. A systematic review concluded that metoidioplasty has largely satisfactory sexual health outcomes when penetrative sex is not a priority.
Standing to Urinate
Whether you can urinate standing up depends entirely on whether urethral lengthening is part of the procedure. Simple metoidioplasty leaves the urinary opening in its original position, so standing urination isn’t possible without a later surgery. The full technique extends the urethra to the tip of the phallus using a combination of inner cheek tissue grafts and local skin flaps, which does allow standing urination.
This is where the trade-off gets important: urethral lengthening significantly increases the risk of complications. In a study of 74 patients followed for a median of about 3.5 years, urethral complications of any kind occurred in nearly 57% of patients. Fistulas (abnormal openings where urine leaks through the skin) developed in about 46% of patients, with 37% becoming permanent. Strictures (narrowing of the new urethra that blocks urine flow) occurred in about 19%. Having urethral lengthening was the strongest predictor of these complications, increasing the odds of any urethral complication by more than 15 times compared to those who skipped it. Smoking was also a significant risk factor for fistulas. About half of patients with urethral complications needed corrective surgery.
How It Compares to Phalloplasty
The choice between metoidioplasty and phalloplasty comes down to what matters most to the individual. Phalloplasty creates a larger, more typically sized penis using tissue transplanted from the forearm, thigh, or back, but it requires a more extensive surgery with a donor-site scar, and the resulting phallus has no natural erectile function (a penile implant is needed later). Sensation in a phalloplasty depends on nerve hookups that take months to develop and are less reliable.
Metoidioplasty offers natural erection, preserved sensation, a shorter and less complex surgery, and no donor-site scarring. The trade-off is a significantly smaller phallus that typically cannot be used for penetrative intercourse. Despite these differences in size, research comparing the two approaches found no significant difference in overall satisfaction with genital appearance between the two groups. Both procedures carry similar types of urinary complications, including fistulas and strictures, though the rates and severity differ depending on the specific technique used.
Some people choose metoidioplasty as a first step, with the option of phalloplasty later if they want additional size. Others view it as their final surgery. Neither approach is inherently better; the right choice depends on individual priorities around size, sensation, surgical complexity, and recovery.