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Billings et al. Plast Aesthet Res. 2025;12:27 https://dx.doi.org/10.20517/2347-9264.2025.52 Page 9 of 18

the neophallus, although fewer (~60%) report preserved “erogenous sensation” and sexual function, defined
[86]
as satisfactory penetrative intercourse . In the same review, the authors reported 97.4% satisfaction with
the cosmetic appearance of neophallus constructed using RFFF, with comparable results (> 95%) for
abdominal-based approaches. Literature on orgasmic function post-phalloplasty is limited, but one cohort
study of 287 RFFF patients found that 100% achieved satisfactory orgasms postoperatively .
[91]
To achieve sufficient rigidity for sexual penetration after phalloplasty, individuals typically require an
erectile device. This is most commonly an internal inflatable prosthesis, though malleable prostheses and
other options are also available. Unfortunately, data suggest that failure rates for all types of erectile
implants are high, with additional risks of erosion through the neophallus or damage during repair and
[92]
replacement . These failure rates tend to be higher than those observed with anatomic phalluses, partly
due to the lack of the membranes surrounding native erectile tissue, which facilitate device insertion and
replacement.

Data on erectile function outcomes with implanted inflatable prostheses is limited, but one systematic
review (n = 15 studies) reports 51.4%-90.6% patient satisfaction with erectile function and 77%-100% of
patients reporting the ability to engage in penetrative intercourse. In general, sexual health outcomes are
underreported for phalloplasty, with one recent review noting that they are documented in fewer than half
[93]
of the relevant studies . More research is needed to better understand these outcomes.
Patients considering phalloplasty often inquire about ejaculatory function. Although ejaculation is not
expected after neophallus construction, some patients report experiencing it in community forums, and
patient-facing resources from surgical clinics suggest rates of around 10% [94,95] . However, literature on this
topic is sparse, and it is likely that any ejaculated fluid consists primarily of urine, given the anatomical
changes involved. Future research should aim to clarify this outcome, and surgeons performing phalloplasty
should assess and document it during follow-up visits.

Sexual health outcomes for metoidioplasty are also under-researched. One systematic review (n = 14 studies,
1,455 cases) reported high satisfaction rates and low regret rates. Notably, 100% of patients reported fully
preserved erogenous sensation, and 66%-77% retained orgasmic function during intercourse (100% with
masturbation). However, 87%-100% of patients reported an inability to engage in penetrative sex due to the
anatomy of the microphallus . As such, metoidioplasty is generally recommended only for individuals who
[96]
do not desire penetrative sex.

Testicular prostheses are typically implanted in the constructed scrotum during phalloplasty or
metoidioplasty as part of the staged procedure. The insertion of testicular prostheses is generally considered
low-risk, although complications like migration and erosion can occur [97-99] . Based on research in cisgender
men, testicular prostheses could potentially improve sexual function by alleviating gender dysphoria and
boosting sexual self-confidence in those who have undergone genital affirmation surgery. However, we
found no research on the effects of testicular prostheses on sexual well-being in transgender men [100,101] . See
Table 2 for a summary of how various GASs may affect sexual health.

THE ROLE OF ADJUVANT THERAPIES IN SEXUAL HEALTH AFTER GAS
Pelvic floor PT may be beneficial in supporting GAS patients throughout the perioperative period. In a
systematic review and meta-analysis (n = 25 studies, 8,566 cases), Dominoni et al. observed variable rates of
[111]
pelvic floor dysfunction following gender-affirming genital surgery . Among transgender women who
underwent vaginoplasty, pelvic organ prolapse occurred in 1%-7.5% of cases, urinary incontinence in 15%,