Neurosensory Re-education following Gender-affirming Phalloplasty: A Novel Treatment Protocol

Abstract

Background: Sensory nerve transfers are performed as part of phalloplasty surgery. Despite this, sensory re-education to rehabilitate these nerve transfers has not been employed. Additionally, little attention has been paid to the role of the central nervous system in experienced sensation following phalloplasty. The purpose of this article is to report on the development of a targeted rehabilitation protocol to integrate and optimize peripheral and central contributions to sensation following phalloplasty. Methods: This neurosensory re-education protocol was constructed over four phases by a multi-disciplinary team (phalloplasty/peripheral nerve surgeon, reconstructive urologist, pelvic floor physiotherapists, nerve therapist, sex therapist, sexual medicine physician) and individuals with lived phalloplasty experience. The final protocol was approved by all team members and is supported here by qualitative narratives from people with lived phalloplasty experience. Results: The protocol is built to follow each stage of phalloplasty surgery. In each stage, exercises are grouped into three core themes: visualization, tactile stimulation, and sexual/erogenous stimulation. Visualization exercises progress from static to dynamic. Tactile exercises start at simple touch and progress toward targeted sensory stimulation. Sexual stimulation focuses on developing erogenous sensation in the phallus that is separate from erogenous sensation in the natal clitoral tissue. By recommendation of individuals with phalloplasty, the protocol is now integrated into our center’s phalloplasty care pathway for all individuals undergoing phalloplasty surgery. Conclusion: We introduce a novel protocol targeting peripheral and central contributions to sensation to provide a tool to help optimize experienced sensation for transmasculine individuals undergoing phalloplasty.

Donor and Recipient Nerve Axon Counts in Gender-affirming Radial Forearm Phalloplasty: Informing Choice of Nerve Coaptations

“…Sensation after phalloplasty is likely dependent on many factors such as nerve regeneration, sensory rehabilitation, and central processes such as cortical mapping and plasticity. 18 Despite these limitations, this is the first report of the axon counts and the donor-to-recipient axon ratios used in gender-affirming radial forearm phalloplasty. Future directions should include repeating this work when reliable methods are available that can also quantify and capture unmyelinated axon counts.…”

“…Sensation after phalloplasty is likely dependent on many factors such as nerve regeneration, sensory rehabilitation, and central processes such as cortical mapping and plasticity. 18 …”

Phantom sensation in genital gender-affirming surgery: a narrative review

“…Current understanding of genital sensation in the TGD population suggests there are important peripheral and central contributions to the sensation experienced following surgery, and approaches to optimize sensation should address both components. A novel neurosensory reeducation protocol for phalloplasty patients incorporates techniques in visualization and sexual/erogenous stimulation to target any central component of sensation and attempt to bridge the complex interplay between the peripheral and central nervous systems, utilized in concert with techniques aimed at peripheral nerve recovery such as tactile exercises [9 ▪ ]. There may be a role for similar protocols structured around other gender-affirming surgical procedures such as vulvoplasty and vaginoplasty.…”

“…Post-phalloplasty neruosensory re-education protocol (adapted with permission from Peters et al [9 ▪ ]). Exercises in each core area progress together in phases.…”

“…If this phenomenon can be harnessed and integrated into peripherally generated genital sensation, an opportunity exists to further improve the experienced sensation and sexual embodiment achieved following genital GAS procedures. Emerging literature discusses this potential role of phantom genital sensation, with a recent sensory rehabilitation protocol in gender-affirming phalloplasty being the first to acknowledge and integrate phantom penis sensation into the peri-operative treatment of phalloplasty patients [9 ▪ ].…”