How Do You Pee After Gender Reassignment Surgery?

Urination after gender reassignment surgery depends on which procedure you had, because the surgical anatomy is fundamentally different for feminizing and masculinizing operations. After vaginoplasty, you sit to urinate through a shortened, repositioned urethra. After phalloplasty or metoidioplasty, the goal is to urinate through a surgically constructed channel inside the new phallus, though not every version of these procedures includes that option. In both directions, there is a recovery period involving a catheter, a learning curve as you adapt to new anatomy, and a set of possible complications that surgeons are still working to reduce.

Urination After Vaginoplasty

In penile inversion vaginoplasty, the most common feminizing genital surgery, surgeons shorten the urethra and reposition its opening to sit between the neoclitoris and the vaginal canal, roughly where you would expect it on a typical vulva. You urinate sitting down, and in most cases the stream functions well enough that you do not think about it much once you have healed. That said, a systematic review and meta-analysis found that a splayed or poorly directed stream affected about 12% of patients, and narrowing of the urethral opening (meatal stenosis) occurred in about 7%.¹

The shortened urethra means the distance bacteria have to travel to reach the bladder is shorter than it was before surgery, which is one reason urinary tract infections become a more relevant concern afterward. Irritative symptoms like urgency, frequency, and waking up to urinate at night were reported in roughly 12% of patients in that same meta-analysis. About 9% experienced some degree of incontinence, and about 5% had urinary retention severe enough to need a catheter after the initial recovery catheter was removed.¹

Immediately after surgery, a Foley catheter drains your bladder for you, typically for about one to two weeks while the tissues heal. Once it comes out, the first few times urinating can feel strange. The sensation is different because the urethra is shorter and in a new position. Many patients report that sitting farther back on the toilet seat helps direct the stream, and some find a period of adjustment where they are more aware of the act than they were before. Over the first several months, most people settle into a routine that feels unremarkable.

Urination After Phalloplasty

Phalloplasty is the more complex picture. This surgery constructs a phallus, usually from a skin flap taken from the forearm, thigh, or abdomen, and if the patient wants to urinate standing up, the surgeon builds a new urethral channel inside it. That channel is called the neourethra, and it connects to your native urethra so that urine can travel from the bladder, through the native urethra, through the new tube, and out the tip of the phallus.

Building a tube from skin or grafted tissue and expecting it to carry urine without leaking or narrowing is one of the most technically demanding challenges in reconstructive surgery. The neourethra is typically made from a free flap or skin graft, and when problems arise, secondary repairs may involve tissue from the inside of the cheek (buccal mucosa) or other graft techniques.² The complication rates reflect that difficulty. In one cohort comparing outcomes with and without urethral lengthening, fistulas (holes where urine leaks through the skin) occurred in 43% of those who had the lengthened urethra, and strictures (scarring that narrows the channel) occurred in 60%.³ Those numbers are high, and they are a major reason patients and surgeons spend a lot of time discussing urethral lengthening as a decision rather than an assumption.

Improvements in technique have brought complication rates down over the past few decades, but they remain substantial.⁴ Surgeons have experimented with adding tissue layers to reinforce the urethra. One approach uses a gracilis muscle flap (a small muscle from the inner thigh) wrapped around the neourethra to improve blood supply and structural support. In one early series, this prevented fistula formation in four out of five cases where the full urethral tube was present.⁵ Another finding is that performing a vaginectomy at the same time as phalloplasty was associated with significantly lower rates of both stricture and fistula.⁶

Recovery after phalloplasty with urethral lengthening involves a longer catheter period, often three to four weeks, and a careful staged process of “voiding trials” where the surgical team checks that urine flows well before letting you rely on the new channel. If a stricture or fistula develops, it usually shows up in the first few months. A fistula often presents as urine leaking from a spot on the shaft, while a stricture shows up as a weak stream or difficulty starting. Many of these are correctable with additional procedures, though that reality is something patients need to be prepared for going in.

Metoidioplasty and Standing Urination

Metoidioplasty is a different masculinizing option that works with what testosterone has already done. Hormone therapy causes the clitoris to grow, and metoidioplasty releases the enlarged clitoris from surrounding tissue, straightens it, and can include urethral lengthening so that urine exits the tip. The procedure typically happens in one stage and may also include vaginectomy and scrotoplasty with testicular implants.⁷

The result is smaller than a phalloplasty, with an average length around 6 cm. About three quarters of patients in published series reported being able to urinate standing up, though about a quarter developed a stricture or fistula.⁸ A review of different urethral construction techniques found that combining buccal mucosa graft with labia minora flaps produced the best urinary outcomes, with a higher likelihood of standing urination and lower fistula rates. Even so, urethral complications can occur in up to about 15% of cases and may require additional procedures.⁹

The trade-off compared to phalloplasty is a smaller phallus with lower complication rates. Standing to urinate is possible for most, but not guaranteed, and some patients find the stream direction requires practice or adjustment at a urinal. A catheter is used during initial healing, as with phalloplasty, though the recovery is typically shorter.

Choosing Not to Lengthen the Urethra

Not every person who gets phalloplasty opts for urethral lengthening. Some patients prioritize having the phallus for appearance and sexual function but are comfortable continuing to sit to urinate through their native urethral opening. This is a legitimate and increasingly discussed option, partly because skipping urethral lengthening dramatically reduces the risk of the most common complications. In the cohort mentioned earlier, the fistula rate dropped from 43% to essentially a single case, and UTIs dropped from 49% to 2% when the urethra was not lengthened.³

For some people, standing to urinate is a significant part of gender affirmation and worth the risk. For others, reducing complications and avoiding follow-up surgeries matters more. This is one of the most personal decisions in the entire surgical process, and good surgical teams walk through it in detail during preoperative consultations. Satisfaction research shows that both the appearance of the phallus and satisfaction with voiding are strong predictors of overall satisfaction after surgery, more so than the complication rate itself.¹⁰

Urinary Tract Infections After Surgery

UTIs deserve their own discussion because they are one of the most common post-surgical urinary issues in both directions of surgery. After vaginoplasty, UTIs were the most common infection in one single-center study, occurring in about 18% of patients. The median time to infection was less than two months after surgery.¹¹

Several factors make UTIs more likely after vaginoplasty. The shortened urethra is one, but there are others that are less obvious. The neovagina does not have the same protective bacterial environment as a natal vagina, and the larger urethral opening can allow bacteria easier access. Regular dilation (required to maintain vaginal depth) and douching can also introduce bacteria that would not normally be present.¹² Good perineal hygiene, cleaning dilators thoroughly, and wiping front to back are all standard advice, but even with good habits, the anatomy makes UTIs a recurring concern for some patients.

After phalloplasty with urethral lengthening, UTIs were strikingly common, affecting about half of patients in one cohort. The new urethral channel creates more surface area where bacteria can colonize, and any stricture or narrowing that causes incomplete bladder emptying further raises the risk.³

Pelvic Floor Physical Therapy

One finding that does not get enough attention is how much pelvic floor physical therapy can improve urinary outcomes, particularly for trans women undergoing vaginoplasty. A program that screened patients before surgery found that 42% already had pelvic floor dysfunction and 37% had bowel dysfunction before any surgery took place. When patients attended pelvic floor PT both before and after surgery, the rate of postoperative pelvic floor dysfunction was 28%, compared to 86% for those who only did PT after surgery.¹³

That is a substantial difference, and it suggests that starting pelvic floor work before surgery, not just after, gives the muscles and coordination a head start that pays off during recovery. Pelvic floor PT for this population involves learning to relax and contract the muscles around the urethra and pelvic bowl, which helps with both urinary control and the dilation process. Not every surgical center integrates this into the standard care pathway yet, but the evidence strongly favors it.

How Testosterone Alone Affects the Urinary Tract

Even before any surgery, testosterone therapy can change how the urinary tract behaves. A study comparing trans men on hormones to age-matched cisgender women found no significant difference in how fast urine flowed, but the trans men had significantly greater voided volumes and more urine remaining in the bladder after voiding. The percentage of residual urine relative to total bladder capacity was about 14% in the trans men versus about 6% in the cisgender women.¹⁴

This matters for a couple of reasons. First, if you are planning phalloplasty or metoidioplasty, your urinary baseline may already be different from what it was before hormones. Second, higher post-void residual means more urine sitting in the bladder between trips to the bathroom, which can contribute to UTI risk. Separately, one study found that after colpectomy (removal of the vaginal canal, a step in some masculinizing surgical plans), the maximum urine flow rate decreased from around 38-40 mL per second to about 29 mL per second.¹⁵ The flow was still well within normal range, but the change is worth knowing about so you do not worry that something is wrong when you notice a difference.

Hair Growth Inside the Neourethra

This is one of those complications that surprises people who have not researched phalloplasty in depth. When the neourethra is constructed from a skin flap (commonly the forearm), the donor skin may still contain hair follicles. If hair removal before surgery was incomplete, hair can grow inside the urethral channel. That hair can trap debris and bacteria, leading to infections, and can serve as a scaffold for urinary stones to form around.¹⁶

This is why thorough electrolysis or laser hair removal on the donor site is a standard part of pre-surgical preparation, and why it can take many months to complete before the actual surgery is scheduled. Even with diligent preparation, some follicles can be missed or can reactivate. If you notice recurrent UTIs or difficulty urinating months or years after phalloplasty, intraurethral hair growth is one of the things a urologist familiar with this surgery will check for. Treatment may involve endoscopic hair removal or, in more complicated cases, revision urethroplasty.

Long-Term Satisfaction and Voiding Outcomes

Despite the complication rates, satisfaction with urinary function tends to be high and improves over time. One prospective study of trans women after vaginoplasty found that patient satisfaction with both the functional and cosmetic results was high at an early postoperative assessment and increased further at a later follow-up, though the increase was not statistically significant.¹⁷ For trans men, satisfaction with voiding was one of the strongest predictors of overall satisfaction with the surgery, alongside satisfaction with the phallus’s appearance.¹⁰

One of the persistent challenges in this field is that the standard questionnaires used to measure urinary symptoms were designed for cisgender populations and do not always capture what transgender patients actually experience. A review noted that long-term urinary and voiding outcome measurements after both vaginoplasty and phalloplasty are still lacking, and existing validated questionnaires do not capture symptoms well in transgender and non-binary patients.¹⁸ That means the published numbers on urinary outcomes may not reflect the full picture of what patients deal with day to day. Better measurement tools are actively being developed, but for now, the best guidance often comes from other patients who have been through the process and from surgical teams with high-volume experience.

A study looking at trans men who had urethral lengthening found no clinically relevant differences in symptom scores or flow measurements before and after surgery, which is actually reassuring. It suggests that when things go well, the new urinary tract performs comparably to the original anatomy on objective testing.¹⁹ The challenge is that “when things go well” has to be weighed against the high revision rates. Most patients who go through this process accept a likely additional procedure or two as part of the journey, and surgical teams frame expectations accordingly.