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Phalloplasty – Aftercare

General Instructions:

  1. No strenuous physical activity of any type during the first 6 weeks after surgery. This means no vigorous bending, pushing, pulling, straining, running, or excessive walking.  You should, however, do light exercise, walking for 10-20 minutes 3 times a day during the first week after leaving the hospital, and then gradually increasing your activity over the following month.
  2. Do not lift anything that weighs more than 20 pounds for 6 weeks after surgery.
  3. Resume your regular diet as tolerated.
  4. Avoid excessive alcohol intake.
  5. Drink plenty of water or other fluids to avoid dehydration.
  6. No smoking for at least one month after surgery.
  7. Use pain medications as needed for pain or discomfort; remember to take miralax or other laxative to avoid constipation.
  8. Take antibiotics, stool softeners, aspirin, or other prescribed medication as directed.
  9. Don’t shower until given permission to do so, usually not until 10-14 days after surgery. When showering is permitted, use plastic wrap (like Saran wrap or a plastic bag) wrapped around your donor site(s) to keep the area(s) dry and away from the direct shower stream.
  10. Driving should be avoided while taking any narcotic pain medication or while you still have significant pain in the genital area.

Care of the Phallus, Scrotum, and Genital Area:

NOTE:  The doctors and nurses may refer to this part of your surgery as your “flap” or “free flap”.

  1. Avoid pressure on this area until the surgical site is well-healed. Pressure can interfere with blood flow to the transplanted tissue.
  2. If possible, try to elevate the phallus to decrease swelling and improve circulation. A rolled surgical dressing can be useful to prop the phallus up.
  3. Keep incisions clean and dry. Unless directed differently, incisions and surrounding skin can usually be lightly washed with soap and water.  Dressings, if present, may be re-applied as needed.
  4. If drains are in place, you may sponge bathe, lightly washing around the drains with soap and water. After cleansing, place a piece of surgical gauze around the drain site to prevent soiling of clothing.  Safety pins can be helpful in securing drains to clothing.
  5. Ice should not be applied to this area. Cold temperatures should be avoided for the first few weeks after surgery.  Moderate temperatures are recommended during this period.
  6. It is not generally necessary, in the immediate post-operative period, to apply any ointments or topical compounds to the incisions, as these can inhibit normal healing. Only apply ointments if specifically directed to do so.
  7. Note: if the phallus swelling worsens and starts to look purple, call your surgeon immediately.

Suprapubic Catheter Care:

  1. DO NOT pull or dislodge the suprapubic (urinary) catheter. There is an inflated balloon inside the bladder, and pulling on this can do internal damage to the bladder.
  2. Empty the urine bag at least 3 times daily or when it gets close to full.
  3. At some point, after directions from the doctor, you will start to plug the catheter instead of having it connected to the drainage bag all day. This allows the bladder to regain its tone and elasticity prior to the time the catheter is completely removed.  When your bladder feels uncomfortable, remove the catheter plug and drain the bladder into the toilet.
  4. When instructed, usually about 2-3 weeks after surgery, you can start to urinate through your phallus. After each time you urinate through the phallus, you should then empty the bladder completely through the suprapubic catheter by removing the plug.  The amount of urine drained through the catheter will gradually decrease as the urination through the phallus increases.
  5. Hematuria (blood in the urine) is common in anyone who has a suprapubic catheter. It will be intermittent and will occur off and on for as long as the catheter is in place. Hematuria is expected and is a normal part of your recovery.

Donor-Site Wound Care:

  1. Keep the dressing over the grafted area clean and dry. In most cases, the dressing will be removed 5 to 7 days after your surgery, before leaving the hospital.  Skin grafts require early immobilization, and it is important that the dressing not be removed prior to this, as it could increase the risk of graft loss.
  2. Following removal of the dressing, the area should be kept clean. The grafted area and surrounding skin can be gently cleansed with soap and water, avoiding trauma to the grafted site.  Avoid soaking the area until it is well-healed.  Care should be taken to avoid direct contact between the shower stream and the graft, until it is well-healed.
  3. If possible, the site should be elevated above the level of the heart to decrease swelling and discomfort. This is helpful for about 2 weeks after surgery.
  4. After the initial dressing is removed, a yellow Xeroform dressing may be placed over the site. Change this every 1-2 days, as directed by the doctors, and wrap it gently with surgical gauze.
  5. A neutral moisturizing lotion, such as Eucerin, can be applied beginning at about 2 weeks after surgery. Lotion should NOT be applied to any portion of the wound that remains open.  If there are small areas that remain open, a thin layer of antibiotic ointment, such as Neosporin or Bacitracin, can be applied.

Skin Graft Donor-Site Wound Care:

  1. The site where the split-thickness skin graft was taken is usually covered with an adherent yellow medicated gauze (Xeroform).
  2. If you have a Xeroform dressing, it is usually initially covered by a white gauze dressing, but this will be removed in the hospital. After that, leave the Xeroform dressing open to air.  Do not put any moisturizers, creams, medications, or water on it, and DO NOT REMOVE THE DRESSING!!  The Xeroform will become incorporated into a scab over the donor site.  It will peel up from the edges as healing occurs; the edges can be trimmed with scissors as needed, and will eventually fall off on its own.  A hair dryer with low or no heat can be used for 10 minutes twice a day to promote drying of the Xeroform/donor site.
  3. As the Xeroform dressing is trimmed away at the edges, the uncovered areas should have lotion applied to keep the new skin moist. Lotion should be applied to the entire donor site after the dressing falls off.

Troubleshooting – What to Look For

Signs of Infection:  Increasing redness, pain, warmth, swelling, or drainage with pus at the surgical site.  Fevers and chills could be signs of infection.  Antibiotics are usually prescribed for the first 7 days after surgery to minimize this risk. Contact the office and/or office manager and schedule an earlier appointment to be seen by the physician.

Signs of Bleeding:  drainage of blood (as opposed to red-tinged thin liquid, which is normal drainage) from the wound, or severe bruising around the surgical site is commonly seen.  Drainage of a small or moderate amount of blood-tinged fluid is not uncommon and is not indicative of active bleeding.  If there does appear to be active bleeding at the donor site, direct pressure on the site with a gauze for 5-10 minutes continuously can be helpful.  If there is bleeding of the phallus, however, direct pressure should only be done if absolutely necessary, as pressure on the blood supply to the phallus can be potentially detrimental.  An accumulation of blood under the graft at the donor site can also lead to partial or total graft failure at the donor site; this can be treated in the office. Blood coming from the urethra at the tip of the phallus is normal drainage. If bleeding does not stop from the wound after several attempts of directed pressure for 5-10 minutes at a time, contact the surgeon.

Seroma is an accumulation of fluid at a surgical site.  If a significant fluid accumulation occurs under the skin graft at the donor site, it can cause loss of part of all of the graft.  Removal of this fluid can be performed in the office.

Graft Failure:  Portions, or rarely all, of the graft at the donor site can appear to “slough” from the wound.  In this case, the graft is no longer adherent to the wound bed, and it loses its blood supply, resulting in the loss of that portion of the graft.  Small portions of graft loss are not uncommon and usually heal well with the appropriate wound care.  If there are small open areas, due to partial graft loss, antibiotic ointment (Neosporin or Bacitracin) can be applied to these areas.

Wound Healing Problems can show up as separation of the wound edges at the               surgical site.  This can be caused by a variety of factors, and is usually a problem that can be managed by dressing changes and wound care.  Keep the area clean with soap and water and place a gauze dressing over the area to keep the area dry.  Most, if not all, of these open wounds heal with time and care. Contact Dr. Crane or Chen to discuss further if needed.

Diet

  1. Avoid Constipation:  Lack of activity postoperatively, as well as narcotic pain medications, can contribute to constipation. Take a Stool Softener for the first month after surgery. Use Prune Juice regularly, as needed. Miralax may be used.
  2. AVOID Metamucil or other fiber drinks, as they may contribute to more constipation during the period of reduced activity.
  3. Drinking plenty of water, may lead to a decreased incidence of urinary tract infections. Avoid soda and artificial drinks as it can anecdotally cause encrustation of the suprapubic tube and make it painful to remove.

Important Contact Information:

**For routine medical or logistical questions, please phone the office during normal business hours**

Office Phone: 415-625-3230

Office Hours:

  • Monday – Thursday, 8:00 am- 4:00 pm
  • Friday, 9:00 am- noon

 

For any of the below situations, please phone the office during normal business hours with any questions.

  • Swelling is a normal postoperative occurrence; please elevate your phallus as much as possible to encourage circulation and decrease swelling. Do not put the phallus in the waistband of your pants. You can expect swelling for 4-6 weeks postoperatively in the phallus and scrotum.
  • Postoperative pain is a normal postoperative occurrence; please take the medication as prescribed.
  • Postoperative pain medications cannot be called into pharmacies. Please contact our office before noon on Friday in order to arrange pick up of a paper prescription if you anticipate needing additional medications. Medications will not be called in over the weekend.
  • Itching is a normal side effect of postoperative pain medication; if you experience itching without a rash, you may take over the counter Benadryl or stop taking the medication and switch to extra strength Tylenol. If a rash is present with itching, discontinue the use of medication and take Benadryl as directed.  On occasion, a beefy red rash with small beefy red “dots” next to the rash is a sign of a fungal infection. Please call the office for an evaluation and/or prescription for an antifungal medication.
  • Nausea is a normal side effect of postoperative pain medication and constipation; make sure you are moving your bowels daily; if you experience nausea from constipation, take miralax or over the counter magnesium citrate.
  • Constipation is a normal side effect of postoperative pain medication; you may take an over the counter laxative or stool softener.
  • Blood in urine (hematuria) for the first 6 weeks is normal following surgery and typically resolves after the suprapubic tube is removed.
  • If your catheter is not draining, please reposition the urine bag below the bladder level to see if this affects the drainage. If repositioning is not effective, flush the catheter with water.
  • Postoperative incontinence is normal while your urethra is swollen. The urethra will be swollen for up to 12 weeks postoperatively. It can also be due to residual urine in your new lengthened urethra. Milking the underside of the phallus and shaking at the urinal will minimize the amount of post-void urine leakage.

 

**When the office is closed and there is a medical question that requires a same day response, please phone the office manager, Ursula Hansell.

For medical emergencies like shortness of breath, chest pain, uncontrollable bleeding, fevers greater than 101.5 F, and the inability to urinate after the catheter has been removed with severe lower abdominal pain (urinary retention) call Dr. Crane’s or Dr. Chen’s cell. Please do not use these numbers for routine concerns like paperwork, medication refills, activity questions, or routine expected postop issues (like swelling of wound, oozing)  as these lines need to be kept open for patients with medical emergencies.

For any life-threatening emergencies please call 9-1-1.