Medically Reviewed by Sierra Brittingham, NP
Bottom surgery refers to gender-affirming procedures that modify the genitals to align with a person’s gender. These surgeries can be part of someone’s gender transition, but not everyone who is transgender or non-binary wants or needs bottom surgery. There are many different techniques and options, and each person’s unique goals, body, and choices are valid.
This guide offers a broad overview of bottom surgery options for both masculinizing and feminizing care. It’s meant to help people make informed decisions and to help loved ones and providers understand what these surgeries involve.
Table of Contents
Feminizing Bottom Surgery
Feminizing bottom surgery can include procedures to create a vulva (vaginoplasty or vulvoplasty) and/or remove the testicles (orchiectomy). Some people choose to have a vaginal canal constructed (vaginoplasty), while others only want external genitalia (vulvoplasty or zero-depth vaginoplasty).
Vaginoplasty
Vaginoplasty constructs a vagina, transforming tissue from the penis, scrotum, and testicles to create external and internal genitalia. This procedure is sought by trans women, transfeminine, and non-binary people. Goals can include comfort, anatomical congruence, and potential for sexual intimacy and orgasm. After surgery, consistent dilation is essential to maintain depth, and safer sex practices can help protect the healing tissue and reduce the risk of STIs.
Penile Inversion Vaginoplasty
This is the most widely used technique. Skin from the penis and scrotum is inverted to create a vaginal canal, vulva, clitoris, and labia. It allows for penetrative sex and typically includes urethral shortening and repositioning.
Robotic-Assisted Peritoneal Flap Vaginoplasty
A newer technique that uses tissue from the peritoneum (a thin layer lining the abdomen) to create the vaginal canal. It’s performed with robotic surgical assistance and may be ideal for people with limited genital skin or who want additional vaginal depth.
Zero-Depth Vaginoplasty
This creates the outer appearance of a vulva—labia, clitoris, and vaginal opening—but does not include a vaginal canal. This may be chosen by people who don’t want penetrative sex or prefer a shorter recovery time.
Vulvoplasty
This refers to creating external genitalia (vulva, labia, and clitoris) without creating a vaginal canal. Sometimes used interchangeably with zero-depth vaginoplasty.
Labiaplasty
A refinement procedure that shapes the labia after initial surgery. It may be part of the primary surgery or done as a touch-up.
Orchiectomy
Orchiectomy removes the testicles, sometimes also partially resizing or reconstructing the scrotum while leaving the penis intact. Trans women, transfeminine, and nonbinary individuals may pursue this surgery. Orchiectomy can reduce testosterone production, alleviating the need for blockers in feminizing hormone therapy. Following medical guidance is essential to promote healing, and safer sex practices help protect the area as it recovers.
Urethroplasty
In vaginoplasty, this shortens and repositions the urethra to a more typical feminine location, allowing seated urination.
Penectomy
Removal of the penis. This may be part of a surgical plan for people who want genital reconstruction without preserving the existing anatomy.
Masculinizing Bottom Surgery
Masculinizing bottom surgery includes options like metoidioplasty or phalloplasty. Some people choose these surgeries to pee while standing, have penetrative sex, or feel more at home in their bodies. Others may not want bottom surgery at all, or may only want one part (like a scrotoplasty).
Phalloplasty
Phalloplasty constructs a penis using tissue from areas like the arm, leg, back, or abdomen. Trans men, transmasculine, and nonbinary people may choose phalloplasty as part of their gender-affirming care. The procedure typically includes lengthening the urethra (connecting a neourethra formed from grafted or local tissue sources) and, in some cases, creating a scrotum from labial tissue. Understanding the nature of this surgery, potential risks, and long-term considerations is important for making informed decisions.
Metoidioplasty
Metoidioplasty is another type of bottom surgery that is different from phalloplasty. This option uses clitoral release (if the clitoris has been enlarged by testosterone therapy) and can involve urethral lengthening and other techniques to create a smaller phallus. Metoidioplasty offers a different aesthetic and functional outcome that may align well with some people’s gender goals. It is a valid and complete choice with unique benefits and considerations.
Scrotoplasty
Creation of a scrotum, often using tissue from the labia majora. Testicular implants may be added later or at the same time.
Urethroplasty
Lengthens the urethra to allow standing urination. Can be done in phalloplasty or metoidioplasty. This is one of the more complex parts of surgery due to potential complications like strictures or fistulas.
Vaginectomy
Removal or closure of the vaginal canal. Some people may choose this as part of phalloplasty or metoidioplasty.
Hysterectomy
A hysterectomy involves removing the uterus and is sometimes pursued by trans men, transmasculine, and nonbinary individuals for internal anatomical alignment. While this procedure can include the removal of the ovaries (oophorectomy) and fallopian tubes (salpingectomy), these are separate surgeries and are not always included. Hysterectomy does not alter external genitalia. After surgery, it’s important to follow all medical instructions for healing. Note that ectopic pregnancies (though rare) and STIs can still occur depending on what organs remain.
Choosing What’s Right for You
There is no “one-size-fits-all” version of bottom surgery. The right option depends on your goals, anatomy, health, and access to skilled surgeons. Some people pursue full reconstruction, while others may only want a scrotoplasty or orchiectomy. It’s also valid to want no surgery at all.
It’s okay to take your time, ask questions, and explore your options. Bottom surgery is not about meeting an external standard of what a body “should” look like—it’s about helping you feel more like yourself.
If you are thinking about bottom surgery, other factors to consider include:
- Recovery and Time Off: Recovery can vary depending on the procedure. Vaginoplasty and phalloplasty often require weeks off from work, while less invasive options like orchiectomy or zero-depth vaginoplasty may have shorter recoveries.
- Access and Insurance: Not all procedures are covered by insurance, and coverage rules vary widely. Some surgeons require letters from therapists or other documentation, while others follow informed consent models.
- Risks and Revisions: Like any surgery, bottom surgery comes with risks and the possibility of complications or revisions. Urethral complications are particularly common in masculinizing surgery. Choosing an experienced surgeon can reduce risks.
- Sexual Function: Many people report improved sexual well-being after bottom surgery. Some types of surgery preserve erotic sensation better than others, so it’s worth discussing with your surgeon what to expect.
Bottom surgery is a personal decision, and there’s no single “right” way to do it. Whether you’re exploring options or supporting someone who is, the most important thing is to center the person’s needs, goals, agency, and autonomy.
Your body is your own. You deserve options, respect, and care that affirms who you are.
