Patient‐reported sensory outcomes in gender‐affirming phalloplasty: a single‐centre experience

OBJECTIVES: To evaluate longitudinal sensory patient-reported outcomes (PROs) after first-stage phalloplasty. PATIENTS AND METHODS: A 28-item electronic cross-sectional survey was administered to patients >1 year after first-stage radial forearm flap (RFF) or anterolateral thigh (ALT) flap phalloplasty at a high-volume academic centre. Sexual, erogenous, and tactile PROs were collected and analyzed with respect to donor sites, nerve coaptation patterns, postoperative complications, and engagement in neurosensory rehabilitation protocols. RESULTS: A total of 92 of 178 (51.1%) eligible patients completed the survey. Patients were a median (interquartile range) of 4 (2.5-5.8) years out from RFF (n = 76) or ALT (n = 16) phalloplasty. Most were able to orgasm with phallic stimulation (64.8%) and perceive light touch (93.2%), pain (90.8%), vibration (88.5%), deep touch (79.5%), and temperature (73.9%). A small subset of patients who experienced phallic turgor syndrome or partial flap loss in the acute postoperative period (n = 13 [17.1%]) were significantly less likely to perceive vibratory sensation in their phallus (57.1% vs 94.5%, P < 0.001). RFF patients with coaptations involving at least the (i) clitoral and lateral antebrachial cutaneous (LABC) nerves and (ii) ilioinguinal and posterior antebrachial cutaneous (PABC) nerves (n = 54) were significantly more likely to experience light touch (100%) compared to other RFF coaptation patterns (81%, P = 0.005) and patients undergoing ALT flap phalloplasty (84.6%, P = 0.037). Patients who engaged in nerve rehabilitation at least weekly were more likely to experience orgasm with masturbation of the phallus by a partner (47.6% vs 24.4%, P = 0.04). CONCLUSION: Most patients experience some degree of tactile and erogenous sensation after phalloplasty. Touch perception is optimised with the RFF donor site and coaptation of the clitoral and ilioinguinal nerves to the LABC and PABC, respectively. Weekly engagement in sensory rehabilitation improves the erogenous capacity of the phallus.