Predictors of dilation difficulty in gender-affirming vaginoplasty

A necessary component of postoperative care in gender-affirming vaginoplasty is the dilation of the neovaginal canal. Difficulty with dilation can cause patient pain and distress, often decreasing compliance and leading to partial or complete closure of the neovaginal canal. This study sought to evaluate the sociodemographic, operative, and comorbid characteristics that contribute to patient difficulty with neovaginal dilation. A retrospective review of patients undergoing gender-affirming vaginoplasty between June 2019 and July 2023 was carried out. The primary outcome was consistent dilation difficulty reported during the follow-up clinic visits for any reason. Univariate and multivariate analyses were used to compare characteristics and outcomes of each group. Statistical significance was set at p<0.05. In total, 614 patients were included in the study, 506 (82.5%) patients had no dilation difficulty and 108 (17.5%) had dilation difficulty. Medicare insurance status (p=0.007), unemployment (p<0.001), hyperlipidemia (p=0.019), HIV (p<0.001), psychiatric diagnosis besides gender dysphoria (p=0.048), and primary peritoneal vaginoplasty (p=0.019) were associated with postoperative dilation difficulty. Multiple logistic regression revealed higher odds of dilation difficulty in patients who are unemployed (OR 2.740, 95% CI 1.587-4.732, p<0.001), have HIV (OR 2.588, 95% CI 1.290-5.190, p=0.007), have a psychiatric diagnosis besides gender dysphoria (OR 1.606, 95% CI 1.001-2.577, p=0.049), or received a primary peritoneal graft (OR 3.202, 95% CI 1.212-8.460, p=0.019). The risk of postoperative dilation difficulty may be associated with multiple aspects of the care spectrum. Understanding these risks and continued encouragement of dilation is critical to optimizing patient outcomes and dilation success.