GRS with Mr. James Bellringer, Charing Cross Hospital, January 2004

By Tamsin Piper

Referral: In January 2003 I was referred by Dr. Barratt and Dr. Lorrimer of the Charing Cross GIC for surgery with the unit at Charing Cross Hospital. This was after just over two years Real Life Experience.

First Consultation: My initial consultation was with Mr. James Bellringer, one of the unit's two surgeons (the other being Mr. Philip Thomas) at the beginning of June 2003. Following a physical exam, the surgical options were discussed. Mr. Bellringer indicated that it was likely that he would use the peno-scrotal flap technique, but would try for penile inversion if this proved possible. He advised that it would be sensible to have electrolysis of the genital area, and recommended use of EMLA cream (a local anaesthetic) during treatment.

Genital Electrolysis: I had 18 sessions (of 30 minutes) with Sara Thomas, an electrologist in Harrow, West London who has considerable experience in treating this area. Preparation for sessions involved clipping the hair back two or three days before, and application of the EMLA cream 2 hours before the session. To ensure the effectiveness of the cream, it was necessary to cover the area with cling-film, held in place with micropore tape. Even with the EMLA, some nerves were still very active leading to some sessions being painful. At the end of the treatment (foreshortened by the surgery date), approximately 80% clearance of the scrotal area had been achieved, with some sparse fine regrowth.

Second Consultation: My second consultation was at the beginning of January 2004, with Mr. Thomas. I had received a letter confirming my admission date for surgery as 20 January 2004, and advising me to cease taking hormone medication 3 weeks before admission. The unit had recently appointed a Gender Specialist Nurse, Iffy Middleton, who was also present. The consultation consisted mainly of confirming what would be done, and answering any questions I had. While waiting for the consultation, I was sent for blood tests and an ECG.

The Surgery

Day 1 (GRS -2): Following a light breakfast of cereal with milk and sugar, and a glass of orange juice I started my "clear fluids only" diet. I was to report to the ward at Charing Cross Hospital at 2 PM, which left me plenty of time for last minute shopping. I left home at midday (I live in London, so not far to travel) and arrived at 1:20 PM, giving time for one last cigarette (I know - slapped wrist) before going into the hospital.

On reporting to the ward I was asked to wait in the day-room while they sorted out my bed and had my records sent up (the letter I'd received helpfully forgot to mention that I was meant to report to Admissions first). I was then booked in by one of the nurses, and was later visited by Iffy to check over things. At about 6 PM I was given my first dose of PicoLax. This kicked in about an hour later and kept me going to the toilet regularly for the next few hours.

Day 2 (GRS -1): Visited in the morning by Mr. Bellringer and Iffy to sign the consent forms and discuss the procedure. I was told that the operation would be the following afternoon, and advised to shave the surgical area. I was also told that at some point tomorrow I would be visited by the anaesthetist. Iffy popped in again late afternoon to check everything was OK, and said that it's the first and last two days that really get you bored. In the evening was given second dose of PicoLax and first injection of anticoagulant.

Day 3 (GRS 0): Went for a shower (and shaved the surgical area). Made sure my hair was properly washed and conditioned, as this would be the last opportunity to do so for 5 or 6 days. During the morning I was measured for TED stockings (to prevent deep vein thrombosis) and given menus for lunch and dinner the following day. A short while later another nurse came in to start prepping me, asking questions about whether I'd shaved, removed jewelry, cosmetics etc. She forgot to tell me that I should get changed into gown and stockings at this point, so I had to rush it at 1 PM. Shortly after this I was visited by the anaesthetist (John Picard, I didn't dare ask if his middle name was Luke) who explained what would be done during the operation. I would be given a caudal anaesthetic (a bit like an epidural, but injected further down the spine) in addition to the general anaesthetic.

I was collected at 2 PM and taken to the theatre. The anaesthetist started inserting the lines and then induced anaesthesia, after which I remember nothing until I came around at 6 PM in Recovery swearing at the pain and asking the time. I used the morphine self-doser, then passed out again and was taken back to the ward. I came round again an hour later to discover my dad and sister just arriving to visit. Had a few sips of water, which induced nausea and vomiting. I also spotted that I was wearing a dressing that looked like a sumo wrestler's belt, and the three tubes poking out of it (the catheter and two wound drains). There were also two lines in the back of my left hand for the morphine and for a saline drip. The nurses were doing observations every hour, and I managed to sleep in between these. About 10 PM I tried drinking and had a tentative bite of something to eat. Nausea, vomit, back to sleep.

Day 4 (GRS 1): Throughout the night I had been taking sips of water or squash whenever I woke up, to try to rehydrate myself. I woke up at 3AM and couldn't get back to sleep so I decided to read for a while and tried elevating the head end of the bed. Over time I managed to take it to almost vertical without serious discomfort. During this period I also tried eating a Cadbury's Twirl, and managed to do so without nausea or vomiting, but needed to take sips of water after each bite. I went back to sleep about 5am, only to wake up very alert an hour later. I felt too awake for some reason, and my mind was buzzing with activity.

At 8.30 AM I had a light breakfast of cereal. At 9 AM, Iffy came in to say she'd be back with Mr. Bellringer later in the morning. They came back at midday, and Mr. Bellringer cut open the dressing to take a look at the work. He was quite happy, but explained that there was a possibility I may experience some tightness at the back of the opening. He said that if this was the case, I would need to come back in about 6 months for a simple procedure under local anaesthetic to nick it open. He also explained that he had been able to perform a penile inversion, rather than the peno-scrotal technique. I guess I'll be able to find out where he has used the scrotal skin, as there will be some bald areas from the electrolysis.

I had my lunch, then Iffy returned to change the dressings and remove the drains. The new dressing consisted of two small wound dressings and an enormous pad, all held in place by loose fitting mesh hospital knickers. I was told that the larger pad could be removed later on. A few phone calls from friends in the afternoon, then some visitors in the evening, after I'd had my dinner. During the afternoon I was seen by a nurse from the Pain Team, who disconnected the morphine as I was no longer using it (I took my last dose from it at 3 AM).

During the morning, after the second bag of saline was empty, I was started on intravenous antibiotic (metronidazole, an antibiotic that is most effective against anaerobic bacteria). The second dose was hooked up at 11 PM. During the night I tried sleeping on my side (to relieve the pressure I'd been experiencing on my buttocks). I kept waking up with the sweats, although I wasn't running a temperature.

Day 5 (GRS 2): Woke up at 6.30 AM and was hooked up to my third (and last) does of antibiotic. Had breakfast (a bit more than yesterday) at 8.30 AM, then one of the two lines in my hand was removed. Had a wash and changed my dressings. Decided to go with the large pad only (it has a water tight covering on the outside, so should stop blood leaking out onto sheets).

I'd been walking gently during the morning, although my body is still very drawn from the lack of food, so not much energy. Had lunch about midday. Visitors again in the afternoon and early evening (either side of dinner), then went to the toilet. As I was taking the dressings down, something popped out. It appeared to be part of the resin packing from around the urethra. Hopefully this won't cause problems later on. As I was mobile, one of the nurses swapped my catheter to a leg bag, which meant I had to be careful about sleeping and also remember to empty it out frequently.

Day 6 (GRS 3): Woke up at 6 AM with stomach pains. I thought I might be slightly constipated so I asked for a mild laxative. It turned out not to be needed, as I managed to go to the toilet at 8 AM, just before breakfast. After I had eaten, a nurse removed the second line from my left hand. Later in the morning I went for a walk down to the ground floor, and had a sneaky cigarette outside the hospital. The first for three days, it felt really good, but left me feeling light-headed. During the evening I found that I was emptying the leg bag quite frequently, and during the night I woke up with kidney pains. These eased off after a while, so probably nothing serious.

Day 7 (GRS 4): Very little happened today. Carried on with walking about. Iffy and Mr. Bellringer both visited today to check up, and told me that the catheter and packing would be coming out tomorrow. Iffy also spoke about dilation, which would start when the packing is removed.

Day 8 (GRS 5): Iffy and Mr. Bellringer popped in to visit all the trans patients on the ward. Iffy said she'd be back a bit later to do the removals. At 1 PM Iffy returned and removed the catheter first (feeling like razor blades being drawn though your urethra, followed for a few minutes by an intense stinging sensation). She then removed the packing and explained that Mr. Bellringer had used me to experiment with a different method of inserting the packing during surgery, to make removal easier. It was a very strange sensation, slightly uncomfortable but also quite pleasurable.

After cleaning me up, Iffy then introduced me to my new "Perspex Pals". I was given two of these, one 25 mm diameter and the other 30 mm diameter. They were the Charing Cross pattern dilators tooled from solid Perspex and polished smooth. Iffy then inserted the smaller one with lubricant, and seemed very pleased with the depth it had gone in. Later measurement revealed this to be 14 cm (5-1/2 inches). After five minutes of dilation with this one it was taken out and the larger one was lubricated. This was inserted by Iffy, who then let me take over to guide it to the depth I was comfortable with, which was the same as for the smaller one. The larger dilator was kept in for ten minutes, then withdrawn. Iffy then cleaned them up and left me to clean myself up. I was given new, smaller dressings and much better fitting hospital knickers. I was then able to go and have a shower (my first for 5 days) and it felt absolutely heavenly.

Later in the afternoon I went to the shop on the ground floor, and decided to try taking the stairs. I quite happily managed to go down three floors, and climbed up two floors on the way back. About 5.30 PM I had a pee for the first time since the catheter came out. It seemed to split into two streams and then started washing my buttocks, but I'd been warned to expect this while the area is still healing. In the evening I dilated for the second time, this time on my own. I had some trouble inserting the larger dilator, partly due to inexperience, but also due to pressure from a full gut. I think I hit a "sweet spot" at some point as I felt some sexual arousal, and my clitoris was responding. Afterwards I went for a walk.

Day 9 (GRS 6): Very boring day all told. Iffy and Mr. Bellringer visited in the morning to see how dilation and peeing were going. Carried on with dilating. The larger dilator went in easier during the second and third sessions. Continued walking and attempting stairs. Was able to walk down all 8 floors, and managed to walk up three floors coming back.

Day 10 (GRS 7): This was going home day. Dilated and had a shower after breakfast, then finished packing my stuff away. Iffy popped in about 10.30 with my bits from the Pharmacy and explained what I needed to do with them. The pack included Betadine pessaries (once a week) and Betadine douche kits (daily for ten weeks, then daily with water after that), a small supply of the painkillers I have been taking and some more AquaGel (lubricant). I was also told that I would be sent a date for an out-patient appointment which would be in about 2 months' time.

I called my friend and waited to be collected and driven home. During the evening, I realised that the suture lines were becoming inflamed (a sign that they are beginning to heal) and this made sleeping uncomfortable until I put a pillow between my knees to keep the legs apart.

Day 14 (GRS 11): Since returning home I have got into a routine of dilating after breakfast, followed by a bath, dilating early afternoon followed by douching, and then dilating around 8 PM followed by a second bath. I was slightly worried by an open sore near the clitoral hood, and thought that the suture line had pulled apart slightly. I took a photo with my digital camera and emailed it to Iffy to check that there wasn't a problem.

Day 15 (GRS 12): Iffy had replied saying that she'd shown the photo to Mr. Bellringer and that provided I keep the area clean and dry it shouldn't be a problem. That relieved me somewhat.

Conclusions: The surgery performed by Mr. Bellringer was very well done. Their practice of returning patients to solid food the day after surgery and getting them mobile as soon as possible seems to be very beneficial, as it removes the weakness experienced by many GRS patients. The nursing staff at Charing Cross were all very helpful and friendly, making such a difficult, and potentially fraught, time much easier. The appointment of a Gender Specialist Nurse seems to have been an excellent idea, as it gives a useful point of reference both during the stay in hospital and also while recovering at home.

© 2011 by Anne A. Lawrence, M.D., Ph.D. All rights reserved.