P.A and Aeroflow Medical Director Aleece Fosnight

As transgender individuals begin their journey through transition, hormone therapy is a common steppingstone for those looking to match their outward appearance to their gender identity.

Even as this process is becoming increasingly common, there is still a long way to go in educating and informing individuals on how hormone therapy can affect the urinary tract and what can be done to help make this exciting journey as smooth as possible.

Please note that while I speak on hormone therapy and how it relates to transgender men and women, this information also applies to non-binary people who are seeking hormone therapy.

Urinary Health for Transmales

Transmales, or individuals who were assigned female at birth, are often on high levels of testosterone medication as they move through the process of transitioning.

This medication works to block ovarian function, in turn dropping estrogen levels. There are several side effects of high testosterone medication that individuals should be aware of including vaginal dryness, increased frequency of urinary tract infections (UTIs), urinary urgency and pelvic pain.

While these symptoms may not fully disappear, there are some measures you can take to lessen the above side effects associated with your medications.

  • Stay Hydrated – Drinking plenty of water can help maintain moisture levels in the body, working to combat vaginal dryness and the frequency of UTIs developing
  • Avoid Perfumed Products – Bubble baths, soaps, powders, lubricants, etc. can actually increase vaginal dryness
  • Utilize Natural Lubricants – Vitamin E, coconut oil and aloe vera are all-natural lubricants that can help soothe the genital area
  • Probiotics – Talk with your healthcare provider about introducing probiotics to your daily routine. Many individuals find that probiotics help to relieve vaginal dryness

If you begin to experience pelvic pain or dysfunctional voiding (over or under urination), a pelvic floor physical therapist can be helpful in improving these symptoms. Even if you aren’t experiencing these symptoms, regularly working with a therapist specifically trained in the pelvic floor can help resolve many issues including painful intercourse, incontinence, sexual dysfunction, and more.

Urinary Health for Transfemales

Transfemales, or individuals who were assigned male at birth are often on high levels of estradiol medications along with anti-androgens (spironolactone and finasteride are the typical medications started). These medications impact a transfemales lower urinary reproductive system by blocking testosterone which limits prostate growth and relaxes the pelvic floor, leading to urge and stress incontinence. As with transmale patients, pelvic floor physical therapists can often help to improve these symptoms.

Prostate issues are one of the leading side effects associated with estradiol and anti-androgen medications. Removal of testes and estrogen therapy can decrease risk of benign prostatic hyperplasia (BPH) (often referred to as an enlarged prostate), avoiding potential urinary tract symptoms associated with BPH such as urgency, frequency, incomplete bladder emptying and nocturia. It is important to also note that prostate cancer is more common in transfemales that started hormone therapy after the age of 50.

Gender Affirming Surgery

As another part of their journey through transition, individuals may elect to undergo gender affirmation surgery. There are various surgeries that can help a patient surgically transition their gender, and with most surgeries, issues and complications may arise. It is important to research and ask your healthcare provider questions to understand any risks associated with a gender affirming surgery.


For transmales, there are several options to consider when looking at gender affirming surgeries, also referred to as ‘bottom surgeries.’ Construction of a penis is performed via phalloplasty or metoidioplasty.

  • Phalloplasty – Utilizes grafted skin (typically from the arm or thigh) to form a neopenis. This surgery requires lengthening of the urethra to allow for urination through the penis. Issues from this surgery include the development of urinary stenosis and fistulas which can lead to UTIs and the possibility for use of intermittent catheterization to keep the urethra entact.
  • Metoidioplasty – Involves changing the clitoris into a penis. During this procedure, the surgeon will also perform a vaginectomy, removing the vagina. Different from the phalloplasty, this procedure creates a micropenis only and does not improve the ability for the patient to stand to urinate.

Once this transformation has taken place, there are some simple toileting techniques that can be used.

  • Use of an STP (stand-to-pee) device helps to align with their gender, however, can complicate using a male restroom with limited stalls. Users must also be diligent in cleaning the device as often as it should be, to reduce the risk of infections and skin irritation.
  • Standing to void causes hypertonicity of the pelvic floor muscles that leads to pain, dysfunctional voiding, constipation, and incontinence. As mentioned, ongoing appointments with a pelvic floor PT can help to address these and other issues related to the pelvic floor.
  • Reassurance that it is OK to sit to void if it will improve the patient’s urinary function.


Gender affirming surgeries for transfemales often involve shortening the urethra, which can lead to an increased risk for UTIs as well as scar tissue causing a risk for urethral strictures. Neurogenic bladder can occur after surgery and intermittent catheterization may be needed during recovery.

After this surgery, the prostate is now relocated to the anterior aspect of the neovagina which may cause difficulty with starting urination and/or emptying to completion. It is important to discuss new toilet techniques with your healthcare provider and sample them to see what works best for you. I find that after surgery, many transfemales prefer to sit during urination, which can actually make voiding easier and helps to align with their gender identity.


A Note to Healthcare Providers


Working in the healthcare field, I find that many transgender patients do not seek assistance or information from their doctor on their urinary tract concerns as they don’t think there is anything that can be done to improve their urology symptoms. It is vital that healthcare providers screen for urinary concerns and bathroom access safety as many transgender patients hold their need to void secondary to fear of going to the restroom and being “outed.”

This causes overall urinary/bladder (and even bowel) dysfunction and dysfunctional voiding that again can lead to ongoing issues such as urge incontinence, stress incontinence, overflow incontinence, and incomplete bladder emptying.  I will sometimes write a letter for bathroom access at my patient’s place of work – this can greatly improve the anxiety they may feel about using the proper restroom that aligns with their gender identity.   I will offer this even if they don’t ask for it – again they may feel embarrassed or do not know that they can ask for it. As with all patients, understanding is key to health, and it is vital to be proactive when having these conversations to ensure patients are getting the care they need.