Metoidioplasty: Pros and Cons

Metoidioplasty is a genital masculinization surgery that uses the patient’s own genital tissue to create a neophallus. Prior to the procedure, hormone therapy is necessary to achieve a hypertrophied (enlarged) clitoris. With hormone treatment, the clitoris can grow to around 6 to 7 centimeters in length, depending on the individual’s response.

This gender-affirming surgery allows for the construction of a small but sensitive penis, enabling the person to urinate while standing and maintaining erotic sensitivity. The original nerve connections of the clitoris are preserved, resulting in a natural-looking outcome, although the final size of the penis is small.

It is a less invasive option than phalloplasty, as it does not require skin grafts from other parts of the body. Additionally, a scrotal pouch is created, where silicone testicular implants can be placed in a secondary surgery.

This gender-affirming surgery for trans men typically lasts between 5 and 6 hours and is performed under general anesthesia. During the procedure, a urethra is constructed from the base of the clitoris to the tip using a flap from the anterior vaginal wall — approximately 5 to 7.5 cm long and 2 to 3 cm wide – and a skin flap from the labia minora. The goal is to create a tube through which the person can urinate while standing.

Next, the scrotum is created by mobilizing the labia majora toward the back and suturing them along the midline to form the scrotal pouch. The insertion of testicular implants is usually delayed for several months to avoid complications due to pressure or swelling.

It’s important to clarify that there is no single “correct” way to experience masculinity. Some individuals value urinary functionality (being able to urinate standing up), others prioritize aesthetics, sensitivity, or the possibility of engaging in penetrative sex. There are also trans men who do not feel the need for genital surgery at all. Therefore, the choice of one technique over another depends largely on each man’s expectations and goals.

Here are the main advantages of metoidioplasty that make this surgery appealing:

One of the main reasons many people opt for metoidioplasty is the preservation of erotic sensitivity. Since clitoral tissue is used, which retains its original nerve connections, the neophallus maintains the capacity for intense sexual pleasure.

Through urethral reconstruction (urethroplasty), the urethra can be lengthened and extended to the tip of the neophallus, allowing the person to urinate while standing—a very common desire among trans men.

The result of metoidioplasty is a small penis that is aesthetically recognizable as a phallus, without visible scarring in other body areas, as may occur with phalloplasty.

Metoidioplasty uses genital tissue only, without the need for distant grafts as in phalloplasty. It also requires less operating time and has a shorter recovery period.

Now that you’re familiar with the advantages of metoidioplasty, here are the main drawbacks:

The person must undergo hormone treatment to enlarge the clitoris, so that metoidioplasty is feasible. This process can take 1 to 2 years to reach the desired development. Medical assessment must determine whether the growth is sufficient for surgery. If growth is limited, this technique is not recommended, as the results may not be satisfactory.

The main limitation of metoidioplasty is the small size of the resulting penis, which directly depends on the degree of clitoral hypertrophy from hormone therapy. This may not align with some trans men’s expectations regarding genital appearance.

The neophallus achieved through metoidioplasty usually does not allow for penetrative sex, as it typically lacks the length and rigidity required.

In some cases, constructing or lengthening the urethra can lead to risks such as fistulas or urethral strictures (narrowing), which may require additional surgeries.