Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for preoperative evaluation for gender-affirming vaginoplasty. Patient reports persistent gender dysphoria and has been on continuous feminizing hormone therapy for [Number] months/years. Patient meets WPATH SOC 8 criteria, including documented psychological readiness and stable mental health. No contraindications to surgery noted. Patient understands the risks, benefits, and irreversible nature of the procedure.
Clinical Examination Findings
Physical examination reveals well-developed secondary female sexual characteristics consistent with hormone therapy. Genital examination: Phallus and scrotum are present; skin quality is adequate for penile inversion vaginoplasty. No evidence of lichen sclerosus or significant scarring. Pelvic floor musculature is unremarkable. BMI is [Number], within acceptable range for surgical candidacy.
Treatment Protocol
Plan: Proceed with penile inversion vaginoplasty with clitoroplasty and labiaplasty. Preoperative clearance obtained from mental health provider and endocrinology. Patient instructed on hair removal requirements (electrolysis/laser) in the perineal and scrotal regions. Scheduled for preoperative labs, EKG, and anesthesia consultation.