ORCHIECTOMY DISHCARGE INSTRUCTION: After you have recovered and discharged from the hospital, someone must take you home. You can not drive or take a taxi. You need to walk or exercise your legs to avoid blood clots, DVT( Deep Venous Thrombosis) formation which can be lethal. At the same time, I want you to rest so you do not cause any bleeding. You need to take one antibiotics prescribed to you at bed time and pain medicines written for you are as needed, but bag of ice wrapped in a towel can be very beneficial to minimizing swelling and for comfort. I will most likely see you the next day for your recheck. You will have a scar gel glue over your incisions. Do not touch or peel it off. They will fall off/ peel off in couple of weeks. Do not remove the sutures on your incisions. They are absorable. Allow them to fall off on their own.
If you are from out of town, 1-2 days after surgery and when you are comfortable, you may fly back home. If you are not taking pain medicine, you can drive.
DILIATION PROCEDURE - I would like you to dilate initially 3 times per day for 10-15 minutes at a time, utilizing the dilators you have purchased (www.vaginismus.com). Start with the largest dilator that does not cause significant pain or discomfort. Dilation is usually uncomfortable although tolerable and it gets better with time. Do not fear. You should be able to gradually increase the size of dilator diameter within the next week or two. You should actually increase to the next size dilator within 10 days of surgery, the next size after 7 days and so on. Depth is important to regain when initially dilating each time and you may want to place a permanent mark on the dilator of choice to see that you reach that each time. Depth can be measurably increased with persistence but also can be sacrificed and lost with neglect. There may also be blood and/or suture material which you will notice upon removing the dilator, especially during the first few weeks. USE PLENTY OF LUBRICATION always. You should also use a quarter-sized dollop of METROGEL ointment once you have regained depth. If your dilator meets resistance, back it out, add more lube and try it again. Sometimes a slight twisting motion may facilitate getting past these tender points. You may even choose to use a bit of your pain medication prior to dilating but remember DILATION IS ESSENTIAL.
DILATION FREQUENCY - You should dilate 3 times daily for 10-15 minutes at a time. You should be as religious as possible initially. After 3 months you can decrease to 2 times daily and once daily after 6 months. Thereafter, you may experiment with a less frequent dilation schedule, especially if you are having receptive intercourse. Although some patients seem to maintain depth very well, (USE IT OR LOSE IT) remains the time-honored mantra.
INTERCOURSE - Is possible after 6 weeks post operatively with care and gentleness. You must be liberal with lubrication. Do take it slowly, and remember that the tissue is still fragile and sensitive, and it will take months to heal. Regular intercourse will take the place of dilations, but common sense becomes the rule here. Stay well hydrated by drinking at least 8 glasses of water per day. Bladder infections are far more common in women because of the shorter urethral length, so always void before and after intercourse and sexual activity.
DISCHARGE - There will be some blood-tinged discharge on your pads for at least a few weeks. This may even have a frankly reddish color. This goes away as healing advances. Odor will change from a somewhat unpleasant healing odor to a more natural feminine odor as your vagina populates itself with native bacteria. This takes months but will be a welcome change. Your vagina is lined with squamous epithelium, the same lining that covers the vagina in natural women. As a result, you will forever more have some vaginal discharge. Normally, this is a whitish-yellowish color. Excessive vaginal discharge, especially in the first few weeks after surgery, can be of some concern in indicating an overabundance of bacteria or an imbalance in the bacteria and may require antibiotic treatment. The purpose of the METROGEL ointment used during dilation is to keep anaerobic bacteria from overpopulating the vagina while your natural bacterial composition takes place during this time. It is an antibiotic ointment and that can be used if an unpleasant odor develops in the future, although I ask you to have your primary doctor to prescribe this for you. Douching (usually with a cap of white vinegar in warm water) is encouraged by some surgeons, although this should not be used for the first 6 months post operatively as it depletes the normal bacteria of the vagina that maintain normal vaginal health and well-being. For the short-term, douching can be helpful as an inexpensive alternative to the METROGEL ointment, 2 or 3 times weekly. Your smell will be your best clue as to how things are down there. I also recommend daily 10-15 minutes warm baths beginning 2 weeks after your release from hospital. Add a handful of EPSON salts also as this can be helpful in drawing blood flow to the areas of healing and help maintain cleanliness. Yeast infections too are not uncommon and can be treated with over-the-counter medications of your choice (MONISTAT, etc). If not improved, see or ask your primary care physician for other therapy for yeast infection. STDs (sexually transmitted diseases) are possible despite the absence of vaginal and cervical lining. This includes HIV and its associated precautions.
Hormonal therapy is usually continued while you are hospitalized but should be dropped typically by 50%. I like Estradiol 2 mg daily or the Climara patch 0.1 mg weekly or injectable Estradiol (because injectables and patches do not go through the liver and raise triglyceride levels). In my opinion estrogen levels and lipid profiles are the only blood tests that need to be followed by your general practitioner once you have completed surgery. I do feel mammography is wise on a schedule similar to that of natural woman. More study is clearly indicated in this area although some have strong feelings about the role that diet has in breast cancer. Pap smears are not necessary because your vagina is made from penile/scrotal skin, tissue that largely lacks the kind of vulnerability as that which exists in natural women. Pap smear is rarely done in natural women who have undergone hysterectomy. The prostate atrophies completely on estrogen so that routine exams are not necessary following GRS, but discuss that with your family practitioner on your yearly physical exam. I recommend a baseline PSA (prostate specific antigen) one year after your surgery. If normal, I would drop any residual concern you or your primary care doctor might have regarding the prostate.
Activity is encouraged as your strength allows but should be on a daily basis. I do not suggest lifting more than 10 pounds for 4 weeks after surgery. Heavy exercise (running, swimming, etc) should be about 6 weeks before resumption. Diet is unrestricted although as emphasis on fluids, fruits and vegetables are suggested. If you experience severe constipation, you should let us know. Bananas or mangoes are suggested daily. Milk of Magnesia or mineral oil is suggested in the meantime taken usually at bedtime. Constipation can remain a problem as long as you are taking pain medication. I also recommend Vitamin C and A along with protein for healing.
Final Appearance of your results depends upon many factors, but especially, time. You will normally feel that the appearance is at its worst about one week after returning home. If not, great! Within 4 weeks most stitches have dissolved, the swelling has gone down by 75%, and any bruising should have disappeared. About 3 months out things start looking really good although the healing and swelling continue to improve even up to one year out. If, however, things do not look to your satisfaction by 6 months, WE want to know. Although very few patients have ever have to return for follow-up of any kind, this always remains an option and you are welcome to schedule with us at any time. Touch-up work can require a second operation (so-called labiaplasty) but can be handled at times with a minor revision which is done normally at minimal cost. This is where E-photo to us can be of help. Future patients are also appreciative of the star-quality photos too, so don't forget to send us good news.
Complications following your release are unlikely although could include fever (greater than 101 degrees), redness of the skin, severe pain along any incision site, or excessive bleeding. A firm, tender swelling in one or both labia can be a sign of hematoma. This is an organized collection of
blood and clot beneath the skin that will normally resolve with time and heat, as long as it is small. Please check with
Dr. Fara Movagharnia. Slight separation of the skin along an incision site (especially as the stitches dissolve) is also a possible complication that requires lots of patience, with application of triple antibiotic ointment, (such as Neosporin) along the edges and a possible visit to local doctor.
Re-sewing of the broken-down incision is never an option because there will be a chance of more complication. Do continue to dilate although you may wish to use smaller diameter dilators that put less strain on the separated
tissue. Your body will heal itself with scar tissue that will fade and rarely be a long term problem. Occasionally, a patient will develop granulation tissue at this separation. Granulation tissue is a tender, sometimes oozy, reddish tissue that can bleed if touched. Granulation tissue is best treated by your local surgeon and possible excision or if small, application of silver nitrate. In order to heal faster and better I recommend my patients to take Vitamin C and A daily post surgery.
If you are still having problems, please let us know so that we might help you. Depending on the urgency of the problem, you may call us or send us an e-mail. Of course a telephone call is a better option if you need to contact me. You should have my cell phone number, if not call my office and if office is closed the message will give you my cell phone number. If you do need to see a physician after you have returned home, please have your doctor contact Dr. Movagharnia if there are any uncertainties about caring for you. An emergency is rare but should prompt Dr. Movagharnia's immediate attention. Try our office during office hours 8 till 4:30 pm on weekdays and for after hours, call Dr. Fara Movagharnia on the cell phone number provided to you on the day of your surgery.
Above all, please keep in touch especially if you move or have news to share with us. We are committed to your happiness and health and would like to hear that you are doing well with your new body.
Good luck and enjoy life!