The Clinical Advisory Network on Sex and Gender was delighted to present a talk by physiotherapist Elaine Miller at our conference “Rethinking Youth Gender Medicine”, which was held at University College London in July.
Elaine’s talk highlighted the adverse effects of transgender hormones and surgery on urinary and sexual function and discussed the role of physiotherapy in helping relieve symptoms. Based on a literature review with Professor Ruth Parry, Elaine’s presentation revealed a lack of systematic research on pelvic health needs and stressed the importance of integrating patient experiences into future studies.
Elaine said that she became interested in this issue when she noticed a spike in young women attending her clinic with incontinence:
It’s not unheard of for us to get youngsters in clinic. But this was different because these were youngsters presenting with issues that would be familiar in a menopausal woman, but they were 30 years earlier, and they were all using cross-sex hormones. They were all in high levels of testosterone. So this matters because we know that the secondary effects of pelvic floor dysfunction, continence problems, pain, sexual dysfunctions impact people’s quality of life in a way that can be absolutely devastating. If you worry that you’re going to wet yourself in public, it affects everything that you do and everything that you think. It affects your confidence, your work, your social life, your willingness to leave the house. People with continence issues stop exercising. They stop being intimate with their partners, and they become very worried about odour control. They change what they wear, how they dress, and their sense of self is impacted. But I couldn’t find any information on this from the gender clinics. And emerging reports suggested that their patients have severe long-term pelvic disorders, but they’re not being studied systematically.
Please see below the abstract of the paper on which Elaine’s talk was based, a table with results of literature reviews on complications of transgender hormones and surgery and a reference list.
Unwanted effects of transgender-related hormones and genital gender surgery on urinary and sexual functioning: occurrence rates and a state-of-the-art literature review on effectiveness of pelvic health physiotherapy
Elaine Miller FCSP and Ruth Parry MMedSci, PhD.
ABSTRACT
Rationale
A large, growing and ageing population of trans-identified and detransitioned people have received transgender-related hormonal medications and/or genital surgery. These interventions carry risks of urogenital dysfunction, including continence problems, sexual dysfunction and pain. In the general population, pelvic health physiotherapy is an effective conservative treatment for these conditions; it is often recommended by specialist providers of gender-related genital surgery.
We conducted a state-of-the-art literature review of evidence on the effectiveness of pelvic health physiotherapy for trans-identified and detransitioned people. To establish potential need, we also collated best available evidence on the occurrence of urogenital problems following gender-related hormonal and/or genital surgical interventions.
Table 1 summarises reported occurrence rates and thus potential need for pelvic health physiotherapy. Reported rates vary widely, reflecting methodological weaknesses in this literature. Females and hormonal interventions have been studied much less than males and surgery. Phalloplasty and testosterone use are associated with higher reported rates of unwanted urogenital conditions than vaginoplasty and oestrogen use. Hormonal interventions without surgery also carry risks of urogenital complications.
State-of-the-art literature review methods
Methods of our state-of-the-art review will be provided in the full report. Throughout the study, we consulted a small number of trans-identified and detransitioned experts by experience.
Results
Five studies addressed pelvic health physiotherapy effectiveness: one randomised controlled trial [1]; one systematic review with a small physiotherapy subfocus [2]; two retrospective single-centre healthcare-record reviews [3, 4]; and one non-systematic literature review [5]. All but the systematic review were of low methodological quality. All focused on tertiary settings and phalloplasty. We found no evidence concerning females, hormonal interventions or detransitioned people.
Discussion
There is a clear deficit in robust research on both the need for and effectiveness of physiotherapy for urogenital symptoms in these groups. Best available evidence indicates considerable need, particularly among females, but is insufficient to support specific guidance or practice. However, given strong and adjacent evidence that pelvic health physiotherapy is effective for urogenital symptoms in other populations, we recommend its provision for people who are receiving or have undergone genital surgery and/or cross-sex hormones.
Well-trained pelvic health physiotherapists can provide conservative management of many unwanted effects of gender-related surgical and hormonal interventions. They have expertise in sensitive, professional communication, including working with people who have experienced trauma, are neurodiverse and/or are coming to terms with sexuality, alongside extensive skills in pelvic health assessment and treatment.
Conclusion
People who have received transgender-related hormones and/or genital surgery report urogenital symptoms, with rates higher among females. Evidence on physiotherapy effectiveness in these groups is lacking.
There is good evidence that pelvic health physiotherapy is a safe and effective conservative approach to urogenital conditions in the general population, including urinary problems in women [6], hypertonic pelvic floor in men and women [6], chronic pelvic pain in women [7], and urinary [8] and sexual [9] dysfunctions in men. Pelvic health physiotherapy should therefore be available to people receiving or having received gender-related hormonal medications and/or genital surgery who experience genitourinary conditions.
Table 1: Occurrence of unwanted genitourinary symptoms associated with gender related interventions for trans identifying people
| Population of interest | Type of study | Number of patients | Reported results(Irritative symptoms = frequency, urgency, nocturia) | Reviewers’ assessment of quality of reviewed studies |
| Males receiving vaginoplasty | Systematic review and meta-analysis23 studies[2] | Not reported | Incontinence ‘up to’ 15%*· Irritative urinary symptoms ‘up to’ 20% Sexual dysfunctions 25%-75%* | Low quality of information, significant risk of bias |
| Males receiving vaginoplasty | Systematic review and meta-analysis27 studies[6] | 3388 | Poor stream 12%, Incontinence 9% Irritative symptoms 12% Urinary tract infection 6% | Moderate risk of bias |
| Males receiving cross-sex hormones (and have not undergone surgery) | Prospective cohort study before commencing oestrogen then 3 to 12 months afterwards [7] | 47 | No significant changes in lower urinary tract symptoms except slight worsening of nocturia (at less than 12 months on feminising hormones) | N/A Not literature reviews |
| Males receiving cross-sex hormones (and have not undergone surgery) | Prospective survey, using validated tools[8] | 129 | Urinary leakage 55% in those 12 months or more on feminising hormones | N/A Not literature reviews |
| Females receiving phalloplasty | Systematic review and meta-analysis6 studies[2] | Not reported | Incontinence ‘up to’ 50% Irritative symptoms ‘up to’ 20% Sexual dysfunctions 54% | Low quality, significant risk of bias |
| Females receiving metoidioplasty | Systematic review 6 studies of metoidioplasty[9] | 870 (calculated using their table one) | We found no research reporting unwanted symptoms in the longer term. Complications reported: Stricture 25%· Fistula 21% NB., Waterschoot and colleagues 10] report that additional urethral lengthening procedure/s bring considerably higher risk of urinary complications | Low |
| Females receiving testosterone | Systematic review 57 studies[11] | Not reported | Pelvic pain 18-72% Dyspareunia 62-65% | ‘Low’ and ‘moderate’ with most studies |
| Females receiving testosterone | Cross sectional survey, using validated tools[12] | 68 current users of testosterone (2.6 years mean follow up) | Sexual dysfunctions 53% Anorectal symptoms 46% Urinary symptoms 87% Flatal incontinence 40% | “observational, small-scale, and [reliant] on self-reported outcomes” (pp 69) |
* Some reviews report occurrence rates as ‘up to’, and some report wide ranges of possible occurrence. This reflects variation of findings amongst studies, which in turn is likely to reflect methodological weaknesses including wide variation in length of follow duration, use of non-standardised measuring instruments, and lack of both control groups and blinding.
References
1. Ferrando CA, Mishra K, Grimstad FW, Weigand NW, Pikula C. A randomized trial comparing perioperative pelvic FLOor physical therapy to current standard of care in transgender Women undergoing vaginoplasty for gendER affirmation: the FLOWER Trial. Int Urogynecol J. 2023;34:2985–93. https://doi.org/10.1007/S00192-023-05623-0
2. Dominoni M, Scatigno AL, Pasquali MF, Bergante C, Gariboldi F, Gardella B. Pelvic floor and sexual dysfunctions after genital gender-affirming surgery: A systematic review and meta-analysis. Journal of Sexual Medicine. 2025;22. https://doi.org/10.1093/jsxmed/qdae146
3. Manrique OJ, Adabi K, Huang TCT, Jorge-Martinez J, Meihofer LE, Brassard P, et al. Assessment of pelvic floor anatomy for male-to-female vaginoplasty and the role of physical therapy on functional and patient-reported outcomes. Ann Plast Surg. 2019;82:661–6. https://doi.org/10.1097/SAP.0000000000001680
4. Jiang DD, Gallagher S, Burchill L, Berli J, Dugi D. Implementation of a pelvic floor physical therapy program for transgender women undergoing gender-affirming vaginoplasty. Obstetrics and Gynecology. 2019;133:1003–11. https://doi.org/10.1097/AOG.0000000000003236
5. Widenor RCL, Hofmann MC. Indications for the utilization of pelvic floor physical therapy for transgender women following gender-affirming vaginoplasty: A narrative review. https://home.liebertpub.com/trgh. 2025. https://doi.org/10.1089/TRGH.2021.0159
6. Ding C, Khondker A, Goldenberg MG, Kwong JCC, Lajkosz K, Potter E, et al. Urinary complications after penile inversion vaginoplasty in transgender women: Systematic review and meta-analysis. Canadian Urological Association Journal. 2023;14. https://doi.org/10.5489/CUAJ.8108
7. Yaish I, Amir H, Eilam H, Gold R, Groutz A. Effects of gender-affirming hormone therapy on lower urinary tract symptoms and sexual function among transgender individuals. International Journal of Gynecology & Obstetrics. 2025;168:1292–7. https://doi.org/10.1002/IJGO.15964
8. Ray A, Fernstrum A, Mahran A, Conroy B, Sheyn D, Rincon JP del. Lower urinary tract symptoms in transgender persons treated with estrogens (Abstract number MP30-20). J Urol. 2020;203 Supplement 4. https://doi.org/10.1097/JU.0000000000000869.020
9. Ortengren CD, Blasdel G, Damiano EA, Scalia PD, Morgan TS, Bagley P, et al. Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review. Transl Androl Urol. 2022;11:1762–70. https://doi.org/10.21037/TAU-22-174/COIF
10. Waterschoot M, Hoebeke P, Verla W, Spinoit AF, Waterloos M, Sinatti C, et al. Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery. J Sex Med. 2021;18:1271–9. https://doi.org/10.1016/J.JSXM.2020.06.023
11. van Vugt WLJ, van den Boogaard E, van der Tuuk K, Spinnewijn L, Kreukels BPC, Both S, et al. Gynecologic function and dysfunction in transmasculine and gender-diverse individuals using testosterone therapy: a systematic review. Am J Obstet Gynecol. 2026. https://doi.org/10.1016/J.AJOG.2026.01.036
12. da Silva LMB, Freire SND, Moretti E, Barbosa L. Pelvic Floor Dysfunction in Transgender Men on Gender-affirming Hormone Therapy: A Descriptive Cross-sectional Study. Int Urogynecol J. 2024;35:1077–84. https://doi.org/10.1007/S00192-024-05779-3/TABLES/3