Pelvic floor and sexual dysfunctions after genital gender-affirming surgery: a systematic review and meta-analysis

Background: Genital gender-affirming surgery has become a crucial step in the transitioning process of numerous transgender people. Aim: To highlight the consequences of genital gender-affirming surgery on pelvic floor function in transgender people. Methods: Medical databases (PubMed, EMBASE, and Cochrane Library) were consulted according to a combination of keywords. All papers published up to February 29, 2024 were considered. Two reviewers independently screened the abstracts of the selected studies and extracted data from the full-text articles included. Data were subsequently tabulated and compared for consistency. The bias associated with each included study was evaluated according to the Observational Study Quality Evaluation (OSQE) method. This study is registered on PROSPERO number CRD42024522580. Outcomes: Pelvic floor dysfunctions in individuals who undergo gender-affirming surgery, factors that may be involved in the increased prevalence of these dysfunctions and perspectives of treatment of the complications through pelvic floor physical therapy. Results: Twenty-five papers were considered for systematic review, while 17 studies were included for meta-analysis. There was significant statistical heterogeneity across the included studies. Among transwomen who had undergone vaginoplasty, pelvic organ prolapse occurred in 1%-7.5% of patients, urinary incontinence affected up to 15% of patients, while urinary irritative symptoms up to 20%. Sexual dysfunctions were reported by 25%-75% of patients. Among transmen who underwent hysterectomy and phalloplasty, pelvic organ prolapse occurred in 3.8% of patients, urinary incontinence affected up to 50% of patients, while urinary irritative symptoms up to 37%. Finally, sexual dysfunctions were reported by 54% of patients. Clinical implications: The findings of this study could be helpful for transgender patients pre-operative counselling. Strengths and limitations: This is the first systematic review and meta-analysis about pelvic floor dysfunctions in transgender people undergoing genital gender-affirming surgery. The main limitations are the limited number of studies included and their heterogeneity. Conclusion: Pelvic floor dysfunctions following genital gender-affirming surgery are an emerging issue. Adequate information for each surgical procedure, explicit postoperative instructions, continuity of care, communication with healthcare providers, and recommendation for tailored perioperative pelvic floor physiotherapy are necessary for a better surgical result.