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Iglesia CB, Yurteri-Kaplan L, Alinsod R. Female genital cosmetic surgery: a review of techniques and outcomes. Int Urogynecol J 2013; 24:1997-2009. [PMID: 23695382 DOI: 10.1007/s00192-013-2117-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 04/18/2013] [Indexed: 11/28/2022]
Abstract
The aesthetic and functional procedures that comprise female genital cosmetic surgery (FGCS) include traditional vaginal prolapse procedures as well as cosmetic vulvar and labial procedures. The line between cosmetic and medically indicated surgical procedures is blurred, and today many operations are performed for both purposes. The contributions of gynecologists and reconstructive pelvic surgeons are crucial in this debate. Aesthetic vaginal surgeons may unintentionally blur legitimate female pelvic floor disorders with other aesthetic conditions. In the absence of quality outcome data, the value of FGCS in improving sexual function remains uncertain. Women seeking FGCS need to be educated about the range and variation of labia widths and genital appearance, and should be evaluated for true pelvic support disorders such as pelvic organ prolapse and stress urinary incontinence. Women seeking FGCS should also be screened for psychological conditions and should act autonomously without coercion from partners or surgeons with proprietary conflicts of interest.
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Affiliation(s)
- Cheryl B Iglesia
- Section of Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center, Washington, DC, USA,
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52
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Paterson LQP, Amsel R, Binik YM. Pleasure and pain: the effect of (almost) having an orgasm on genital and nongenital sensitivity. J Sex Med 2013; 10:1531-44. [PMID: 23551826 DOI: 10.1111/jsm.12144] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The effect of sexual arousal and orgasm on genital sensitivity has received little research attention, and no study has assessed sensation pleasurableness as well as painfulness. AIM To clarify the relationship between sexual arousal, orgasm, and sensitivity in a healthy female sample. METHODS Twenty-six women privately masturbated to orgasm and almost to orgasm at two separate sessions, during which standardized pressure stimulation was applied to the glans clitoris, vulvar vestibule, and volar forearm at three testing times: (i) baseline; (ii) immediately following masturbation; and (iii) following a subsequent 15-minute rest period. MAIN OUTCOME MEASURES Touch thresholds (tactile detection sensitivity), sensation pleasurableness ratings (pleasurable sensitivity), and pain thresholds (pain sensitivity). RESULTS Pleasurableness ratings were higher on the glans clitoris than the vulvar vestibule, and at most testing times on the vulvar vestibule than the volar forearm; and at baseline and immediately after masturbation than 15 minutes later, mainly on the genital locations only. Pain thresholds were lower on the genital locations than the volar forearm, and immediately and 15 minutes after masturbation than at baseline. After orgasm, genital pleasurableness ratings and vulvar vestibular pain thresholds were lower than after masturbation almost to orgasm. Post-masturbation pleasurableness ratings were positively correlated with pain thresholds but only on the glans clitoris. Hormonal contraception users had lower pleasurableness ratings and pain thresholds on all locations than nonusers. There were no significant effects for touch thresholds. CONCLUSIONS Masturbation appears to maintain pleasurable genital sensitivity but increase pain sensitivity, with lower genital pleasurable sensitivity and higher vulvar vestibular pain sensitivity when orgasm occurs. Findings suggest that enhancing stimulation pleasurableness, psychological sexual arousal and lubrication mitigate normative increases in pain sensitivity during sexual activity, and underscore the importance of measuring both pleasure and pain in sensation research.
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53
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Anis TH, Aboul Gheit S, Awad HH, Saied HS. Effects of Female Genital Cutting on the Sexual Function of Egyptian Women. A Cross‐Sectional Study. J Sex Med 2012; 9:2682-92. [DOI: 10.1111/j.1743-6109.2012.02866.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
A review of the literature regarding the current state of knowledge of the anatomic and physiologic features of the female clitoris was conducted. Based on this evaluation, operations on the clitoris were reviewed. The anatomic and physiologic reconstruction problems of surgical techniques for female pseudohermaphroditism that have previously been reported were reviewed. The author suggests that clitoroplasty is essential for patients with ambiguous genitalia, but the decision regarding the correct procedure, taking into account anatomic and physiologic success, can be controversial. This may be because of unclear anatomic and physiologic definitions, even for healthy people. As a temporary solution, more conservative procedures for maximally effective treatment are suggested.
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Bekker MD, Hogewoning CR, Wallner C, Elzevier HW, DeRuiter MC. The Somatic and Autonomic Innervation of the Clitoris; Preliminary Evidence of Sexual Dysfunction after Minimally Invasive Slings. J Sex Med 2012; 9:1566-78. [DOI: 10.1111/j.1743-6109.2012.02711.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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56
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Clitoral reduction by ventral approach. Med J Armed Forces India 2011; 67:270-1. [PMID: 27365822 DOI: 10.1016/s0377-1237(11)60058-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Accepted: 01/03/2011] [Indexed: 11/22/2022] Open
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57
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Caruso S, Cianci A, Malandrino C, Cavallari L, Gambadoro O, Arena G, Pispisa L, Agnello C, Romano M, Cavallari V. Ultrastructural and Quantitative Study of Clitoral Cavernous Tissue from Living Subjects. J Sex Med 2011; 8:1675-85. [DOI: 10.1111/j.1743-6109.2011.02253.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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58
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Ginger VAT, Cold CJ, Yang CC. Surgical anatomy of the dorsal nerve of the clitoris. Neurourol Urodyn 2011; 30:412-6. [DOI: 10.1002/nau.20996] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 07/07/2010] [Indexed: 11/07/2022]
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Chirurgie réparatrice du clitoris après excision rituelle. ANN CHIR PLAST ESTH 2011; 56:74-9. [DOI: 10.1016/j.anplas.2010.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 04/25/2010] [Indexed: 11/17/2022]
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60
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Madzou S, Ouédraogo C, Gillard P, Lefebvre-Lacoeuille C, Catala L, Sentilhes L, Descamps P. Chirurgie plastique reconstructrice du clitoris après mutilations sexuelles. ANN CHIR PLAST ESTH 2011; 56:59-64. [DOI: 10.1016/j.anplas.2009.08.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 08/16/2009] [Indexed: 11/30/2022]
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61
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Hurwitz RS. Feminizing Surgery for Disorders of Sex Development: Evolution, Complications, and Outcomes. Curr Urol Rep 2011; 12:166-72. [DOI: 10.1007/s11934-010-0165-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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62
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VanderBrink BA, Stock JA, Hanna MK. Aesthetic aspects of reconstructive clitoroplasty in females with bladder exstrophy–epispadias complex. J Plast Reconstr Aesthet Surg 2010; 63:2141-5. [DOI: 10.1016/j.bjps.2010.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 01/21/2010] [Accepted: 02/01/2010] [Indexed: 11/25/2022]
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63
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Azadzoi KM, Siroky MB. Neurologic factors in female sexual function and dysfunction. Korean J Urol 2010; 51:443-9. [PMID: 20664775 PMCID: PMC2907491 DOI: 10.4111/kju.2010.51.7.443] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 06/30/2010] [Indexed: 01/23/2023] Open
Abstract
Sexual dysfunction affects both men and women, involving organic disorders, psychological problems, or both. Overall, the state of our knowledge is less advanced regarding female sexual physiology in comparison with male sexual function. Female sexual dysfunction has received little clinical and basic research attention and remains a largely untapped field in medicine. The epidemiology of female sexual dysfunction is poorly understood because relatively few studies have been done in community settings. In the United States, female sexual dysfunction has been estimated to affect 40% of women in the general population. Among the elderly, however, it has been reported that up to 87% of women complain of sexual dissatisfaction. Several studies have shown that the prevalence of female sexual arousal disorders correlates significantly with increasing age. These studies have shown that sexual arousal and frequency of coitus in the female decreases with increasing age. The pathophysiology of female sexual dysfunction appears more complex than that of males, involving multidimensional hormonal, neurological, vascular, psychological, and interpersonal aspects. Organic female sexual disorders may include a wide variety of vascular, neural, or neurovascular factors that lead to problems with libido, lubrication, and orgasm. However, the precise etiology and mechanistic pathways of age-related female sexual arousal disorders are yet to be determined. In the past two decades, some advances have been made in exploring the basic hemodynamics and neuroregulation of female sexual function and dysfunction in both animal models and in human studies. In this review, we summarize neural regulation of sexual function and neurological causes of sexual dysfunction in women.
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Affiliation(s)
- Kazem M Azadzoi
- Department of Urology, Veterans Affairs Boston Healthcare System and Boston University School of Medicine, Boston, Massachusetts, USA
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64
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Frost-Arner L, Aberg M, Jacobsson S. Clitoral sensitivity after surgical correction in women with adrenogenital syndrome: a long term follow‐up. ACTA ACUST UNITED AC 2009; 37:356-9. [PMID: 15328775 DOI: 10.1080/02844310310007863] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Surgical reduction of hypertrophy of the clitoris in early childhood, as well as vaginal reconstruction or vaginoplasty during the early teens, is required in girls with adrenogenital syndrome. In eight women (age >17 years) with adrenogenital syndrome, the sensitivity of the surgically reduced clitoris was evaluated by examination of vibration and light touch sensitivity, more than one year after vaginoplasty. When they were compared with a group of women who had not been operated on, the sensitivity to vibration and light touch were similar if the clitoris had been reduced as a one-stage procedure. In one woman who had had a second reduction, sensitivity was impaired. All women reported that the vaginal reconstruction was successful as far as sexual activity was concerned. Six of the eight had stable relationships with boyfriends or husbands. No pregnancies or children were reported.
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Affiliation(s)
- Lieselotte Frost-Arner
- Department of Plastic and Reconstructive Surgery, Malmö University Hospital, Malmö, Sweden.
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65
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Labial ring flap: a new flap for metaidoioplasty in female-to-male transsexuals. J Plast Reconstr Aesthet Surg 2009; 62:318-25. [DOI: 10.1016/j.bjps.2008.11.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 08/23/2008] [Accepted: 11/04/2008] [Indexed: 11/22/2022]
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Vaze A, Goldman H, Jones JS, Rackley R, Vasavada S, Gustafson KJ. Determining the Course of the Dorsal Nerve of the Clitoris. Urology 2008; 72:1040-3. [DOI: 10.1016/j.urology.2008.07.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Revised: 06/30/2008] [Accepted: 07/01/2008] [Indexed: 11/30/2022]
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Kalfa N, Liu B, Cao M, Vilella M, Hsieh M, Baskin LS. 3-dimensional neuroanatomy of the human fetal pelvis: anatomical support for partial urogenital mobilization in the treatment of urogenital sinus. J Urol 2008; 180:1709-14; discussion 1714-5. [PMID: 18708223 DOI: 10.1016/j.juro.2008.03.089] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Indexed: 10/21/2022]
Abstract
PURPOSE Retrospective reviews suggest that the functional outcomes of surgery of the urogenital sinus have often been unsatisfactory and to our knowledge the long-term results of newer surgical techniques have yet to be evaluated. A precise understanding of pelvic fetal neuroanatomy is germane for optimizing surgical correction of the urogenital sinus. MATERIALS AND METHODS The pelves of 10 human female fetuses were serially sectioned. Masson's trichrome staining and immunochemistry for the neuronal marker S100 (Dako Corp., Carpinteria, California) along with anatomical computer reconstruction allowed 3-dimensional analysis of the nerves in relation to the pelvic structures as an animated motion picture. RESULTS Two types of neuronal structures were identified. 1) A dense perivisceral foil of branching nerves closely surrounded the pelvic organs. The localization of most nerves was on the external faces of the viscera with a limited fraction in the rectovaginal and urethrovaginal septa. This innervation was from the anterior cephalad periurethral area to the posterior caudal perirectal area. 2) A significant amount of nerves surrounded the cephalad urethra on its anterior and posterior faces. CONCLUSIONS Based on these anatomical data during surgical repair of a urogenital sinus we would advocate minimal mobilization of the lateral faces of the vagina, avoiding dissection of the proximal urethra above the pubic bone and electing a vaginal flap in severe cases.
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Affiliation(s)
- Nicolas Kalfa
- Center for Study and Treatment of Hypospadias, Department of Urology, University of California-San Francisco Children's Medical Center, University of California-San Francisco, San Francisco, California 94143, USA
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68
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Martin-Alguacil N, Schober JM, Sengelaub DR, Pfaff DW, Shelley DN. Clitoral sexual arousal: neuronal tracing study from the clitoris through the spinal tracts. J Urol 2008; 180:1241-8. [PMID: 18707740 DOI: 10.1016/j.juro.2008.06.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Indexed: 11/29/2022]
Abstract
PURPOSE Although genital tactile stimulation is regarded as a precursor to sexual arousal and a recognized initiator of central nervous system arousal, specific afferent neural pathways transmit sensory stimuli of arousal, beginning at the epithelial level on the clitoris and following the course of arousal stimuli through the central nervous system. Limited knowledge exists of the pathway from the cutaneous receptors of nerves originating in the epithelial tissue of the clitoris and continuing to spinal cord afferents. Such information may contribute to an understanding of sexual arousal, particularly in female vertebrates. We further defined the neural pathways and mechanisms responsible for arousal originating in the epithelium of the clitoris as well as related neural pathways to the spinal cord in a murine model. MATERIALS AND METHODS We performed a comprehensive review of the published relevant clinical and histological material from human and nonhuman vertebrate studies. In 29 adult female C57B1/6 mice the distribution of pelvic nerves and vessels was mapped. Gross dissection of 4 female mice was facilitated by resin injection of the vascular system in 2. Neuronal tracing was performed in 25 mice that received clitoral injection of wheat germ agglutinin-horseradish peroxidase into the clitoris and were sacrificed after 72 to 96 hours. The spinal cord and periclitoral tissue were removed and fixed. Immunohistochemistry was performed. RESULTS Gross anatomy of the mouse clitoris showed that pudendal and hypogastric nerves have a major role in the innervation of the external genitalia. Neuronal tracing revealed that the greatest nerve density was noted in the L5/6 spinal cord. The distribution extended from S1 to L2 with no labeling seen in the L3 spinal cord. Wheat germ agglutinin-horseradish peroxidase labeling was seen caudal in levels S1 through L4 and rostral in L2. CONCLUSIONS Understanding the neuroanatomy of the clitoris using a murine model may provide a valuable tool for the study of sexual arousal disorders and the further understanding of sexual function related to neural pathologies and trauma.
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Affiliation(s)
- Nieves Martin-Alguacil
- Department of Neurobiology and Behavior, Rockefeller University, New York, New York, USA
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69
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Acimi S. Clitoroplasty: a variant of the technique. Urology 2008; 72:669-71. [PMID: 18597836 DOI: 10.1016/j.urology.2008.02.077] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Revised: 01/19/2008] [Accepted: 02/05/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION To describe a variant of clitoroplasty. TECHNICAL CONSIDERATIONS Seven patients with virilized external genitalia were treated for a hypertrophied clitoris using this procedure. The principles of the technique include mobilization of the glans with its neurovascular bundle and an important symmetric reduction of the length and diameter of the corpora cavernosa, as well as the volume of the glans. CONCLUSIONS The objective of this technique is to preserve the sensitive glans and to create an excellent cosmetic aspect for the clitoris.
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Affiliation(s)
- Smail Acimi
- Department of Pediatric Surgery, University of Sidi-Bel-Abbès School of Medicine, Sidi-Bel-Abbès, Algeria.
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70
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Šedý J, Naňka O, Špačková J, Jarolím L. Clinical Implications of a Close Vicinity of Nervus Dorsalis Penis/Clitoridis and Os Pubis. J Sex Med 2008; 5:1572-81. [DOI: 10.1111/j.1743-6109.2008.00796.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
INTRODUCTION Factual presentations of sexual anatomy are required for educational purposes, for clinical and more general communication about sexual matters. To date, unambiguous, accurate and objective images with appropriate labeling to enhance specificity in communication have been lacking. AIM The aim of this presentation is to provide a comprehensive overview of anatomy of the distal vagina. We aim to simplify the anatomy to reduce the confusion of historical descriptions. In doing so, we aim to avoid sacrificing any of the specific detail. This would aid communication between clinicians, researchers, and the nonclinician regarding this anatomy. OUTCOME MEASURES AND METHODS: This article reviews the historical and current anatomical literature. Systematic dissection and photography, histological study, and magnetic resonance imaging have been used as the basis for this presentation. Digital technology has been used to label, color, and highlight photography to provide clarity and permit diagramatization of photography. No distortion has otherwise been used in presenting images from cadavers or anatomical research. RESULTS The anatomy of the distal vagina and surrounding structures is shown and described in detailed. The distal vagina, clitoris, and urethra form an integrated entity covered superficially by the vulval skin and its epithelial features. These parts have a shared vasculature and nerve supply and during sexual stimulation respond as a unit though the responses are not uniform. CONCLUSIONS Significant progress has been made in the field of female sexual anatomy and its pictorial representation. This may facilitate further progress in the related fields of female sexual health and education.
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Affiliation(s)
- Helen E O'Connell
- Departments of Surgery (Urology), The University of Melbourne, Royal Melbourne Hospital, Victoria, Australia. helen.o'
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72
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Martin-Alguacil N, Pfaff DW, Shelley DN, Schober JM. Clitoral sexual arousal: an immunocytochemical and innervation study of the clitoris. BJU Int 2008; 101:1407-13. [DOI: 10.1111/j.1464-410x.2008.07625.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Crouch NS, Liao LM, Woodhouse CRJ, Conway GS, Creighton SM. Sexual function and genital sensitivity following feminizing genitoplasty for congenital adrenal hyperplasia. J Urol 2008; 179:634-8. [PMID: 18082214 DOI: 10.1016/j.juro.2007.09.079] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Female sex assignment followed by cosmetic genitoplasty to feminize the genitalia in infancy remains standard practice in the clinical management of ambiguous genitalia. The effects of surgery on genital sensitivity have never been objectively evaluated. To our knowledge the current study is the first to evaluate genital sensitivity and sexual function in women with congenital adrenal hyperplasia. MATERIALS AND METHODS A total of 28 women with congenital adrenal hyperplasia and 10 normal controls were recruited. Details of prior genital surgery were obtained from medical records. Sensitivity thresholds for the clitoris and upper vagina were measured using a GenitoSensory Analyzer (Medoc, Ramat, Israel). Sexual function was assessed using a standardized measure. RESULTS Of 28 women with congenital adrenal hyperplasia 24 had undergone feminizing genital surgery. In women who underwent surgery there was significant impairment to sensitivity in the clitoris compared to controls. No difference was observed for the sensitivity threshold in the upper vagina, where surgery had not been done in any of the women. Data on the 4 women with congenital adrenal hyperplasia who had not undergone surgery were similar to those in controls. Sexual function difficulties were more severe in women who underwent surgery, especially vaginal penetration difficulties and intercourse frequency. Linear relationships were observed for impairment to sensitivity and severity of sexual difficulties. CONCLUSIONS Genital sensitivity is impaired in areas where feminizing genital surgery had been done and impairment to sensitivity are linearly related to difficulties in sexual function. The new information may help inform clinicians and parents making difficult decisions about genital surgery for infants with ambiguous genitalia.
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Affiliation(s)
- Naomi S Crouch
- Middlesex Centre, University College London Institute of Women's Health, Elizabeth Garrett Anderson and Obstetric Hospital, and Institute of Urology, University College London Hospital (CRJW), London, United Kingdom
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Yang J, Felsen D, Poppas DP. Nerve Sparing Ventral Clitoroplasty: Analysis of Clitoral Sensitivity and Viability. J Urol 2007; 178:1598-601. [PMID: 17707043 DOI: 10.1016/j.juro.2007.05.097] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Indexed: 11/26/2022]
Abstract
PURPOSE Enlargement of the clitoris is often a prominent manifestation of virilizing congenital adrenal hyperplasia and other disorders of sexual development. Controversy persists regarding the viability and sensitivity of the clitoris following clitoroplasty. We present 51 consecutive cases of nerve sparing ventral clitoroplasty performed by a single surgeon. MATERIALS AND METHODS Nerve sparing ventral clitoroplasty was performed in all patients. Postoperative evaluation for clitoral viability included gross examination and capillary perfusion testing. Patients older than 5 years were evaluated for clitoral sensory testing and vibratory sensory testing. RESULTS A total of 51 patients 4 months to 24 years old (mean age +/- SD 4.6 +/- 6.8 years) with clitorimegaly underwent nerve sparing ventral clitoroplasty. Of the patients 41 had capillary perfusion testing of the clitoris, of whom all had a viable clitoris. Ten of the 41 patients underwent clitoral sensory testing. Patients reported an average degree of sensation of 3.6 +/- 0.9 at the labia minora and 4.8 +/- 0.4 at the clitoris. Nine of the 10 patients also underwent vibratory sensory testing. Average values for the introitus, clitoris, labia and thigh were 3.56, 1.61, 5.08, and 5.83, respectively. Mean time after surgery for the patients who underwent clitoral sensory testing/vibratory sensory testing was 2.0 +/- 0.8 years. No variations in the sensitivity results were reported at followup in 2 patients. CONCLUSIONS To our knowledge this is the largest report of followup testing of clitoral viability and sensation after clitoroplasty. Continued long-term followup is ongoing to document long-term sexual function using this nerve sparing ventral approach for clitoroplasty.
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Affiliation(s)
- Jennifer Yang
- Institute for Pediatric Urology, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York 10021, USA
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75
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Poppas DP, Hochsztein AA, Baergen RN, Loyd E, Chen J, Felsen D. Nerve sparing ventral clitoroplasty preserves dorsal nerves in congenital adrenal hyperplasia. J Urol 2007; 178:1802-6; discussion 1806. [PMID: 17707008 DOI: 10.1016/j.juro.2007.03.186] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Indexed: 11/25/2022]
Abstract
PURPOSE Masculinization of the female genitalia observed in patients with classic congenital adrenal hyperplasia often results in clitorimegaly. Reduction clitoroplasty is the most widely practiced corrective surgery for clitorimegaly, yet reservations about surgical intervention exist based on fears of nerve destruction during surgical removal of excess erectile tissue. In this study, we modified the reduction clitoroplasty and examined excised erectile tissue for the presence of dorsal nerves. MATERIALS AND METHODS We describe the development of the nerve sparing ventral clitoroplasty. Nerves were examined in situ using optical coherence technology. In addition, erectile tissue removed from 27 female patients with congenital adrenal hyperplasia was examined immunohistochemically for the presence of nerves by staining for neurofilament. Nerves outside of the tunica albuginea were counted and measured. Tissue from 2 adult females was also examined by immunohistochemistry. RESULTS Optical coherence technology visualized dorsal nerves in 3 patients with congenital adrenal hyperplasia (size 600 to 800 microm). In 4 of 27 patients undergoing nerve sparing ventral clitoroplasty, no dorsal nerve branches were visualized in excised erectile tissue. In another 18 patients 10 or fewer nerve branches were found. In patients who underwent nerve sparing ventral clitoroplasty 92% of dorsal nerves detected were 90 microm or less. In contrast, 88% of dorsal nerves found in the 2 adult specimens were 120 microm or greater. The maximum nerve fiber size observed in patient specimens was significantly smaller than the maximum nerve fiber size observed in control specimens. CONCLUSIONS Scarcity of large dorsal nerves in histological specimens excised using nerve sparing ventral clitoroplasty likely reflects their preservation within the congenital adrenal hyperplasia patients. This preservation is vital to future somatosensory and motor function of the clitoris.
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Affiliation(s)
- Dix P Poppas
- Department of Urology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York, USA
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Dabernig J, Shelley OP, Schaff J. The innervated free toe web flap for clitoris reconstruction. J Plast Reconstr Aesthet Surg 2007; 60:1352-5. [PMID: 17368123 DOI: 10.1016/j.bjps.2007.01.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 01/30/2007] [Indexed: 11/20/2022]
Abstract
Clitoris reconstruction is often used in transgender reassignment. Most techniques now reconstruct the clitoris using glans pedicled on the dorsal phallic neurovascular bundle. Other techniques of clitoris reconstruction re-shape retained elements of the proximal segment of the corpora cavernosa, as well as techniques mobilising local flaps. We are presenting a new technique for clitoris reconstruction using an innervated free web space flap. The operative technique and outcome are illustrated and discussed in this case report.
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Affiliation(s)
- Jörg Dabernig
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Jubilee Building, 84 Castle Street, Glasgow G4 0SF, UK.
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77
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Lesma A, Bocciardi A, Montorsi F, Rigatti P. Passerini-glazel feminizing genitoplasty: modifications in 17 years of experience with 82 cases. Eur Urol 2007; 52:1638-44. [PMID: 17408848 DOI: 10.1016/j.eururo.2007.02.068] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 02/28/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe modifications of Passerini-Glazel feminizing genitoplasty and report on long-term functional outcome. METHODS Modifications include vaginal dissection and disconnection from the urethrovaginal sinus as the initial stage of the procedure; large dissection of the neurovascular bundle on both dorsal and lateral faces of the clitoris; plication of the skin around the reduced clitoris; and suturing the lateral edge of the proximal portion of the mucocutaneous plate with the labia majora's medial edge to a plane deeper than the subcutaneous tissue. These modifications reduce bleeding and operating time, better preserve clitoral sensitivity, form the clitoral prepuce, and create labia minora. RESULTS Eighty-two patients underwent modified Passerini-Glazel feminizing genitoplasty. Mean operating time was 120min (range: 100-180). Forty-six patients (46 of 82, 56%) were assessed at a mean follow-up of 5 yr (range: 2-9). There were no cases of clitoral vascularization defect or urethrovaginal fistula. The urethral meatus was never hypospadic. The vaginal introitus was large and elastic in all cases. Vaginal caliber at the internal suture line was as large as the vaginal introitus and the distal native vagina in 20 (43.5%) of the 46 girls. All mothers and patients reported satisfaction with external genital appearance. CONCLUSIONS These long-term results suggest that our modifications of one-stage Passerini-Glazel feminizing genitoplasty facilitate the procedure and produce good cosmetic results.
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Affiliation(s)
- Arianna Lesma
- Department of Urology, Vita-Salute University, San Raffaele Hospital, Milan, Italy.
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Foldes P, Louis-Sylvestre C. Résultats de la réparation chirurgicale du clitoris après mutilation sexuelle: 453 cas. ACTA ACUST UNITED AC 2006; 34:1137-41. [PMID: 17137821 DOI: 10.1016/j.gyobfe.2006.09.026] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Accepted: 09/11/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Ritual excision is responsible for urologic, gynaecologic and obstetrical complications, whose surgical treatment has been fully described. Sexual sequelae deserve the same attention. We describe and analyze the results of a surgical procedure for clitoral rehabilitation. PATIENTS AND METHODS Women requesting this surgery between 1992 and 2005 have been prospectively included in this study. The skin covering the stump was resected and the clitoris identified. The suspensor ligament was sectioned in order to mobilize the stump, the sclerous tissues were removed from the extremity and the neo glans brought to a normal situation. Pre operative pain and clitoral impairment were assessed within five categories. The same was done with anatomical and functional postoperative results at six months. RESULTS Four hundred and fifty-three patients have been completely evaluated. Hospitalisation stay was 24 hours and the procedure never lasted more than 30 minutes. Minor early complications were recorded in 58 patients (hematoma, disrupture of the suture, pain). Four patients reported persisting pain at four months. A visible clitoral massif could be restored in 87% of the cases and a real improvement in clitoral function was obtained in 75% of the patients. DISCUSSION AND CONCLUSION This surgical procedure is easy and reliable. It provides promising cosmetic and functional results with minor complications.
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Affiliation(s)
- P Foldes
- Service de chirurgie, centre hospitalier (CH), 20, rue Armagis, 78100 Saint-Germain-en-Laye, France
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Sedý J, Nanka O, Belisová M, Walro JM, Jarolím L. Sulcus Nervi Dorsalis Penis/Clitoridis: Anatomic Structure and Clinical Significance. Eur Urol 2006; 50:1079-85. [PMID: 16519989 DOI: 10.1016/j.eururo.2006.02.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Accepted: 02/06/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to correlate the anatomic and clinical significance of the prepubic course of dorsal nerve of penis and its groove on the pubic bone from the perspective of the surgeon. METHODS The course of the dorsal nerve of the penis/clitoris was studied in six male and six female formalin-fixed cadavers. Several parameters of the pubis were quantified and analysed in 286 isolated pelvises. RESULTS The course of the dorsal nerve of the penis is described in detail. This pubic sulcus was present in a majority of the pelvises examined. The dorsal nerve of the penis filled this groove, which we term the "sulcus nervi dorsalis penis/clitoridis." In contrast, the dorsal nerve and artery of the clitoris coursed in this groove in women. CONCLUSIONS The course of dorsal nerve of the penis is described in detail including a previously unreported pubic structure-"sulcus nervi dorsalis penis/clitoridis." In the majority of individuals, the dorsal nerve of the penis/clitoris courses through the sulcus in the pubis. Based on the anatomy of the pelvic region, compression of the dorsal nerve is more apt to occur at the inferior border of the pubis or in the pubic sulcus than in the pudendal canal.
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Affiliation(s)
- Jiri Sedý
- Institute of Anatomy, 1st Medical Faculty, Charles University, Prague, Czech Republic
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Rösch WH, Ebert A, Schott G. [Bladder exstrophy--epispadias complex. New goals--new ways?]. Urologe A 2006; 45 Suppl 4:219-24. [PMID: 16927080 DOI: 10.1007/s00120-006-1186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- W H Rösch
- Abteilung für Kinderurologie der Universität Regensburg in der Klinik St. Hedwig, Steinmetzstrasse 1-3, 93049 Regensburg.
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Martin-Alguacil N, Schober J, Kow LM, Pfaff D. Arousing Properties of the Vulvar Epithelium. J Urol 2006; 176:456-62. [PMID: 16813864 DOI: 10.1016/j.juro.2006.03.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Indexed: 10/24/2022]
Abstract
PURPOSE The initiation of genital tactile stimulation is regarded as a precursor to sexual arousal and perhaps in women it is the most easily recognized initiator of central nervous system arousal. Unfortunately little published material details the specific mechanisms preceding arousal, beginning at the epithelial level, which are the sensory precursors to arousal. Little is known about its cutaneous receptors, nerves and the other histochemical properties of this epithelial tissue that contribute to sexual arousal. Sexual sensitivity evaluations target female genital somatosensory pathways for cutaneous sensation by testing evoked potentials of nerves, hot/cold and vibratory sensory discrimination. The anatomical bases of these several sensibilities form a subject for future investigation. We reviewed the known influences and mechanisms responsible for the arousing properties of the epithelium in the female external genitalia as well neural pathways associated with sexual arousal originating from the vulvar epithelium. MATERIALS AND METHODS A comprehensive review was done of published, relevant clinical and histological material in human and nonhuman vertebrate studies. RESULTS Tactile stimulation of the vulvar epithelium initiates changes suggesting complex integrative mechanisms. Influences of skin temperature, hormonal environment, mechanical tissue compliance and inflammation as well as the large number of transmitters and neuropeptides involved in peripheral pathways serving female sexual arousal speak of a direct sensory role. CONCLUSIONS Genital epithelial cells may actively participate in sensory function to initiate sexual arousal by expressing receptors and releasing neurotransmitters in response to stimuli, resulting in epithelial-neuronal interactions.
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Affiliation(s)
- Nieves Martin-Alguacil
- Department of Neurobiology and Behavior, Rockefeller University, New York, New York, USA
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A Neuroanatomical Comparison of Humans and Spotted Hyena, a Natural Animal Model for Common Urogenital Sinus. J Urol 2006. [DOI: 10.1097/00005392-200601000-00098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Baskin LS, Yucel S, Cunha GR, Glickman SE, Place NJ. A Neuroanatomical Comparison of Humans and Spotted Hyena, a Natural Animal Model for Common Urogenital Sinus: Clinical Reflections on Feminizing Genitoplasty. J Urol 2006; 175:276-83. [PMID: 16406926 DOI: 10.1016/s0022-5347(05)00014-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Surgical treatment of the common urogenital sinus phallus has been one of the most challenging areas in pediatric urology. To better understand the neuroanatomy of the common urogenital sinus phallus, we evaluated an animal model naturally having this condition, the spotted hyena, Crocuta crocuta. We compared the neuroanatomy of male and female humans and spotted hyenas using anatomical, immunohistochemical and 3D reconstruction techniques. We also examined the implications of the pattern of clitoral innervation for the unique challenges faced by female spotted hyenas, the only extant species of mammal that mates and gives birth through the clitoris. MATERIALS AND METHODS Three adult male and 3 female spotted hyenas were studied. With the animals under anesthesia gross anatomical examination was performed before and after artificial erection. Histological analysis was performed on one 95-day fetal male and female spotted hyena specimens, and on 18 human male and female fetal external genitalia specimens using antibodies raised against the neuronal marker S-100. Three-dimensional computer reconstruction using serial sections allowed analysis of the neuroanatomy of the penis, clitoris and common urogenital sinus of the fetal spotted hyena and human. RESULTS Compared to other mammals, the clitoris and penis of spotted hyenas were remarkably similar in size and configuration in the flaccid and erect states. Male and female hyenas had a single opening on the tip of the glans penis/clitoris. The basic anatomical structures of the corporeal bodies in both sexes of humans and spotted hyenas were similar. As in humans, the dorsal nerve distribution was unique in being devoid of nerves at the 12 o'clock position in the penis and clitoris of the spotted hyena. Dorsal nerves of the penis/clitoris in humans and male spotted hyenas tracked along both sides of the corporeal body to the corpus spongiosum at the 5 and 7 o'clock positions. The dorsal nerves penetrated the corporeal body and distally the glans in the hyena. In female hyenas the dorsal nerves fanned out laterally on the clitoral body. Glans morphology was different in appearance in both sexes, being wide and blunt in the female and tapered in the male. CONCLUSIONS The neuroanatomy of the male and female external genitalia in the spotted hyena, Crocuta crocuta, although grossly similar, has distinct anatomical and functional characteristics. The clitoris of the spotted hyena is a classic example of a natural animal model of a common urogenital sinus. The neuroanatomical characteristics of the spotted hyena may be a useful model to simulate the anatomy of common urogenital sinus anomaly in humans.
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Affiliation(s)
- Laurence S Baskin
- Division of Pediatric Urology, UCSF Children's Hospital, San Francisco, USA.
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84
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Abstract
PURPOSE We present a comprehensive account of clitoral anatomy, including its component structures, neurovascular supply, relationship to adjacent structures (the urethra, vagina and vestibular glands, and connective tissue supports), histology and immunohistochemistry. We related recent anatomical findings to the historical literature to determine when data on accurate anatomy became available. MATERIALS AND METHODS An extensive review of the current and historical literature was done. The studies reviewed included dissection and microdissection, magnetic resonance imaging (MRI), 3-dimensional sectional anatomy reconstruction, histology and immunohistochemical studies. RESULTS The clitoris is a multiplanar structure with a broad attachment to the pubic arch and via extensive supporting tissue to the mons pubis and labia. Centrally it is attached to the urethra and vagina. Its components include the erectile bodies (paired bulbs and paired corpora, which are continuous with the crura) and the glans clitoris. The glans is a midline, densely neural, non-erectile structure that is the only external manifestation of the clitoris. All other components are composed of erectile tissue with the composition of the bulbar erectile tissue differing from that of the corpora. The clitoral and perineal neurovascular bundles are large, paired terminations of the pudendal neurovascular bundles. The clitoral neurovascular bundles ascend along the ischiopubic rami to meet each other and pass along the superior surface of the clitoral body supplying the clitoris. The neural trunks pass largely intact into the glans. These nerves are at least 2 mm in diameter even in infancy. The cavernous or autonomic neural anatomy is microscopic and difficult to define consistently. MRI complements dissection studies and clarifies the anatomy. Clitoral pharmacology and histology appears to parallel those of penile tissue, although the clinical impact is vastly different. CONCLUSIONS Typical textbook descriptions of the clitoris lack detail and include inaccuracies. It is impossible to convey clitoral anatomy in a single diagram showing only 1 plane, as is typically provided in textbooks, which reveal it as a flat structure. MRI provides a multiplanar representation of clitoral anatomy in the live state, which is a major advantage, and complements dissection materials. The work of Kobelt in the early 19th century provides a most comprehensive and accurate description of clitoral anatomy, and modern study provides objective images and few novel findings. The bulbs appear to be part of the clitoris. They are spongy in character and in continuity with the other parts of the clitoris. The distal urethra and vagina are intimately related structures, although they are not erectile in character. They form a tissue cluster with the clitoris. This cluster appears to be the locus of female sexual function and orgasm.
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Affiliation(s)
- Helen E O'Connell
- Department of Urology, NeuroUrology and Continence Unit, Royal Melbourne Hospital, Victoria, Australia. Helen.O'
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Meyer-Bahlburg HFL. Gender identity outcome in female-raised 46,XY persons with penile agenesis, cloacal exstrophy of the bladder, or penile ablation. ARCHIVES OF SEXUAL BEHAVIOR 2005; 34:423-38. [PMID: 16010465 DOI: 10.1007/s10508-005-4342-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This review addresses the long-term gender outcome of gender assignment of persons with intersexuality and related conditions. The gender assignment to female of 46,XY newborns with severe genital abnormalities despite a presumably normal-male prenatal sex-hormone milieu is highly controversial because of variations in assumptions about the role of biological factors in gender identity formation. This article presents a literature review of gender outcome in three pertinent conditions (penile agenesis, cloacal exstrophy of the bladder, and penile ablation) in infancy or early childhood. The findings clearly indicate an increased risk of later patient-initiated gender re-assignment to male after female assignment in infancy or early childhood, but are nevertheless incompatible with the notion of a full determination of core gender identity by prenatal androgens.
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Female Epispadias: Are We Missing the Diagnosis? J Urol 2005. [DOI: 10.1097/01.ju.0000164390.20115.b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Sarah M Creighton
- Elizabeth Garrett Anderson Hospital, University of College London Hospitals, Huntley Street, London, WC1E 6DH, UK.
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89
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Abstract
PURPOSE Female sexual dysfunction is a common disorder but there are few objective measures of female genital function. We present a novel technique to record electrical activity of the female genital erectile tissue. MATERIALS AND METHOD We placed concentric needle electrodes in the right clitoral crus and the bulb of 22 healthy women. Following spontaneous activity recording we stimulated the median nerve to activate the sympathetic nervous system. We simultaneously measured evoked activity in the clitoris and bulb, and hand sympathetic skin responses (SSRs). RESULTS Spontaneous electrical activity of the clitoris and bulb was present in 13 subjects. A total of 21 subjects had evoked activity in the bulb, while 18 had evoked activity in the clitoris. All subjects had hand SSRs. Evoked genital response latencies were similar to hand SSR latency (p > 0.05). Evoked electrical activity was recordable in the clitoris and bulb but it was more easily performed in the bulb. CONCLUSIONS Evoked electrical activity is more consistently obtained than spontaneous activity. These tests represent possible objective measures of female genital autonomic innervation, which may have relevance to female sexual function.
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Affiliation(s)
- Ugur Yilmaz
- Department of Urology, University of Washington, Seattle, Washington 98195-6510, USA
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90
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Abstract
The surgical correction of ambiguous genitalia has been a significant part of treatment for intersex conditions for the last 50 years, based on the belief that the child will be psychologically damaged by the uncorrected appearance. Despite widespread adoption of this policy, there is no evidence in the literature to support this approach. More commonly, the primary indication appears to be for the relief of parental anxiety. However, patients are increasingly expressing dissatisfaction with previous management, arguing that surgery should only be performed for strictly defined medical indications. Surgery may comprise treatment for the absent or shortened vagina, or for the correction of virilised external genitalia. The timing of such surgery is controversial, with many surgeons believing that a 'one-stage' procedure in infancy is appropriate. However, given that the vast majority of patients require further surgery at adolescence, others argue that deferral of vaginal surgery until after puberty is more appropriate. The role of clitoral surgery is contentious with many questioning the necessity of any operation in childhood for cosmesis which may impair subsequent sexual function. Despite claims that newer surgical techniques lead to a better result than previously, there remains little information in the literature regarding long-term functional outcomes following clitoral reduction procedures. Alternatives to vaginal and clitoral surgery are considered in this article. Vaginal operations should almost always take place at adolescence, given the poor outcomes of early surgery. When clitoral operations are performed, this should be for severely virilised individuals, with surgery best avoided for those with only mild or moderate virilisation.
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Affiliation(s)
- Naomi S Crouch
- Department of Gynaecology, Elizabeth Garrett Anderson Hospital, University College London Hospitals, London, UK
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Caruso S, Agnello C, Intelisano G, Farina M, Di Mari L, Cianci A. Placebo-controlled study on efficacy and safety of daily apomorphine SL intake in premenopausal women affected by hypoactive sexual desire disorder and sexual arousal disorder. Urology 2004; 63:955-9. [PMID: 15134988 DOI: 10.1016/j.urology.2003.12.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2003] [Accepted: 12/15/2003] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To verify whether apomorphine SL is effective in premenopausal women affected by arousal disorder with hypoactive sexual desire disorder. METHODS Sixty-two volunteer women, aged 26 to 45 years, affected by arousal disorders and hypoactive sexual desire disorder participated in the study, which consisted of two parts. The first was 4 weeks of a taken-as-needed, open-label, dose-escalation regimen starting at 2 or 3 mg of apomorphine SL. The second part of the study was for the nonresponders, who were randomly allocated to treatment in one of six possible sequences of three 2-week double-blind, crossover study periods with apomorphine 2 mg or 3 mg, washout, and placebo. Efficacy was assessed with the Personal Experiences Questionnaire using the 5-point Likert scale. The Personal Experiences Questionnaire quantified subjective arousal, desire, orgasm, enjoyment, and frequency of sexual relationships. RESULTS Fifty women completed the 4-week "as required" drug regimen, and 6 of them benefited from this treatment regimen (P <0.05). The 44 women who reported no change with respect to baseline participated in the double-blind crossover part of the study. Six women stopped taking the drug because of a fear of problems (two each during the 2-mg apomorphine, 3-mg apomorphine, and placebo periods). Adverse events were mild or moderate, both occurred during the "as required" part (10 patients) and during daily usage (6 patients) and were mainly nausea, vomiting, dizziness, or headache. However, during the placebo period, 2 women had adverse events, mainly headache. The daily intake of the drug was effective with both the 2-mg and 3-mg dosages compared with placebo for arousal and desire (P <0.05). The effects of 3 mg of apomorphine were better than those obtained with 2 mg (P <0.05). The orgasm, enjoyment, and satisfied by frequency scores improved during treatment with daily apomorphine compared with baseline and placebo. CONCLUSIONS The results of our study suggest that daily apomorphine SL may improve the sexual life of women affected by sexual difficulties. Additional studies are needed to define the daily use of apomorphine SL in large subgroups of women on the basis of etiology and the severity of sexual dysfunction.
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Affiliation(s)
- Salvatore Caruso
- Department of Microbiological Science and Gynaecological Science, Group for Sexual Research of European Federation of Sexology, University of Catania, Catania, Italy
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Schober JM, Meyer-Bahlburg HFL, Ransley PG. Self-assessment of genital anatomy, sexual sensitivity and function in women: implications for genitoplasty. BJU Int 2004; 94:589-94. [PMID: 15329118 DOI: 10.1111/j.1464-410x.2004.05006.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To assess the perceptions of healthy women of their genital anatomy and sexual sensitivity, and to provide suggestions for genitoplasty based on this information, as the success of genitoplasty has historically relied upon the surgeon's perception of the patient's anatomy and function, rather than the patient's perception of outcome in terms of appearance and erotic sensitivity. SUBJECTS AND METHODS Fifty healthy, sexually active, adult women (aged 20-56 years) with no history of genital surgery completed the female version of the Self-Assessment of Genital Anatomy and Sexual Function. This self- report questionnaire comprises written text and images enabling women to rate the appearance, size and position of clitoris and vagina, as well as the intensity of orgasm and effort required for achieving orgasm in specified areas around the clitoris and within the vagina. Anatomical locations were compared for these ratings by repeated-measures analysis of variance. RESULTS Anatomically, 46% of women described their clitoris as 'moderate-sized and raised', 42% as 'small and raised', and 78% reported that their vaginal opening was adequate for sexual penetration. The women reported the strongest orgasm and least effort to obtain an orgasm with stimulation of the area on and above the clitoris. For vaginal sensitivity, scores for orgasm intensity increased, and for orgasm effort decreased, with increasing vaginal depth, and they indicated less sexual sensitivity for the vagina than for the external genitalia. CONCLUSION The skin above the clitoris, and the clitoris itself, appeared to be the most sexually sensitive. During genitoplasty, attention to preserving skin-flap integrity in this area seems appropriate.
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93
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Abstract
PURPOSE The neuroanatomy of the female lower urogenital tract remains controversial. We defined the topographical anatomy and differential immunohistochemical characteristics of the dorsal nerve of the clitoris, the cavernous nerve and the nerves innervating the female urethral sphincter complex. MATERIALS AND METHODS A total of 16 normal female human pelvic specimens at 14 to 34 weeks of gestation were studied by immunohistochemical techniques. Serial sections were stained with antibodies raised against the neuronal markers S-100 and neuronal nitric oxide synthase (nNOS), vesicular acetylcholine transporter, calcitonin gene-related peptide and substance P. The serial sections were computer reconstructed into 3-dimensional images. RESULTS Under the pubic arch at the hilum of the clitoral bodies the branches of the cavernous nerves joined the clitoral dorsal nerve to transform its immunoreactivity to nNOS positive. The cavernous nerves originated from the vaginal nervous plexus occupying the 2 and 10 o'clock positions on the anterolateral vagina and they traveled at the 5 and 7 o'clock positions along the urethra. The urethral sphincter complex was innervated by nNOS immunoreactive and nonimmunoreactive nerve fibers arising from the vaginal nervous plexus and pudendal nerve, respectively. CONCLUSIONS The dorsal nerve of the clitoris receives nNOS positive branches from the cavernous nerve as a possible redundant mechanism for clitoral erectile function. The urethral sphincter complex has dual innervation, which pierces into the urethral sphincter complex at different locations. The study of the neuroanatomy of the female lower urogenital tract is germane to the strategic design of female reconstructive surgery.
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Affiliation(s)
- Selcuk Yucel
- Department of Urology and Pediatrics, University of California-San Francisco Children's Medical Center, University of California-San Francisco, San Francisco, California 94143, USA
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94
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Abstract
Congenital adrenal hyperplasia (CAH) is a life-long disorder which poses management problems that are age- and sex-specific. The condition merits an organised, multi-disciplinary transitional care format similar to the kind that is now well established for Turner's syndrome in many centres. In the eyes of the paediatrician, achieving optimal growth is the primary target of CAH management during infancy and childhood. Fixation on this objective can be to the detriment of the patient because it may result in failure to appreciate the significance of metabolic disturbances that occur in later childhood, particularly in females, and which may be the progenitor of chronic problems with obesity, insulin resistance and infertility in adult life. Similarly, the care of the adult patient with CAH comprises more than just prescribing steroid replacement for primary adrenal insufficiency. The transition period between childhood and adulthood is an opportune time for review of the various management options and to assess the efficacy of steroid replacement, to consider alternative novel treatment modalities and to apply a checklist to the multi-faceted aspects of the medical, surgical and psychological needs of the patient.
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Affiliation(s)
- Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, P.O. Box 116, Hills Road, Cambridge CB2 2QQ, UK.
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95
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Affiliation(s)
- S M Creighton
- Elizabeth Garrett Anderson and Obstetric Hospital University College London Hospitals, London, UK.
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96
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Abstract
Surgery for patients with genital ambiguity must be based on an accurate diagnosis, thorough understanding of the genital anatomy and realistic expectations for the patient, family and treating multi-specialty team. The goal is to create a functional and cosmetic outcome consonant with the gender assignment with the least amount of morbidity to the patient and family. An understanding of the normal genital neuroanatomy is essential for a successful surgical approach and outcome. Based on fetal human specimens, we have refined the three-dimensional relationship of the dorsal nerve of the clitoris, the female cavernosal nerve and the vaginal plexus. The surgical approach to patients with severe clitoral virilization should preserve erectile function and the neural innervation of the clitoris. When indicated, surgery should be performed in infancy to minimize psychological trauma and surgical complications from scarring. Herein, we review the neuroanatomy of the female genitalia and the implications for the rare patient who needs surgical reconstruction.
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Affiliation(s)
- Laurence S Baskin
- Pediatric Urology, UCSF Children's Medical Center, University of California, Children's Hospital, San Francisco, CA 94143, USA.
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97
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Affiliation(s)
- S M Creighton
- Middlesex Clinic, Elizabeth Garrett Anderson and Obstetric Hospital, University College London Hospitals, London, UK.
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98
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Yucel S, Cavalcanti AG, Desouza A, Wang Z, Baskin LS. The effect of oestrogen and testosterone on the urethral seam of the developing male mouse genital tubercle. BJU Int 2004; 92:1016-21. [PMID: 14632867 DOI: 10.1111/j.1464-410x.2003.04511.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe the effects of exogenous oestrogens and androgens on urethral formation in the mouse, as the development of the mouse and human urethra have significant similarities, and understanding normal male urethral development may help to identify the causes of abnormal development, e.g. hypospadias. MATERIALS AND METHODS Timed-pregnant C57/6 mice were exposed to synthetic oestrogens and androgens. The morphology of the genital tubercles was examined histologically and with three-dimensional computer reconstruction. Specific attention was focused on the developing urethral seam. RESULTS Microscopic serial analysis confirmed the presence of an arrest in seam formation in about half of oestrogen-treated male fetuses. In contrast, there was acceleration of urethral fold fusion and a longer urethral tube in those treated with androgens. Oestrogen-treated fetuses had a thin periurethral spongiosa, in contrast to androgen-treated fetuses which developed a thicker periurethral spongiosa. The effect of oestrogens on seam area formation did not depend on the dose, but in contrast, in the androgen-treated fetuses it was. CONCLUSION Oestrogens and androgens have a direct effect on the fusion of the urethral fold that leads to seam formation. Normal urethral development depends on the delicate balance of these complementary hormones.
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Affiliation(s)
- S Yucel
- UCSF Children's Medical Center, Departments of Urology and Paediatrics, University of California, San Francisco, USA
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99
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Abstract
OBJECTIVE To describe metoidioplasty, a technique for creating a neophallus from an enlarged clitoris in female transsexuals, without needing the complex, multi-staged surgical construction of a large phallus, as this reconstruction is one of the most difficult in female transsexuals. PATIENTS AND METHODS From September 1995 to April 2002 metoidioplasty was used in 22 patients (aged 18-33 years). The technique is based on the repair of the most severe form of hypospadias and intersex. The 'urethral plate' and urethra are completely dissected from the clitoral corporeal bodies, then divided at the level of the glanular corona, and the clitoris straightened and lengthened. A longitudinal vascularized island flap is designed and harvested from the dorsal skin of the clitoris, transposed to the ventral side, tubularized and anastomosed with the native urethra. The new urethral meatus is brought to the top of the neophallus, and the skin of the neophallus and scrotum reconstructed using labia minora and majora flaps. RESULTS The mean (range) follow-up was 3.9 (0.5-6) years; the neophallus was 5.7 (4-10) cm, considered satisfactory in 17 patients but the remaining five required additional phalloplasty. The complications were urethral stenosis in two and fistula in three patients. CONCLUSIONS Metoidioplasty is an alternative to phalloplasty, allowing voiding while standing. In patients who desire a larger phallus, various techniques of phalloplasty can also be used.
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Affiliation(s)
- S V Perovic
- School of Medicine, Belgrade University, Yugoslavia.
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100
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Crouch NS, Minto CL, Laio LM, Woodhouse CRJ, Creighton SM. Genital sensation after feminizing genitoplasty for congenital adrenal hyperplasia: a pilot study. BJU Int 2004; 93:135-8. [PMID: 14678385 DOI: 10.1111/j.1464-410x.2004.04572.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess sensation in the clitoris and vagina in women with congenital adrenal hyperplasia (CAH) who have previously had genital surgery, and to evaluate sexual function in this group as the latter, and particularly the experience of orgasm, appear to be closely related to sensitivity. PATIENTS AND METHODS Six women were recruited from a multidisciplinary clinic specialising in intersex conditions, and representing an initial cohort from a larger ongoing study. The patients were asked to complete a postal questionnaire with a specialized sexual function assessment. Thermal, vibratory and light-touch sensory thresholds were assessed in the clitoris and vagina using a genito-sensory analyser and Von Frey filaments. RESULTS All six women had highly abnormal results for sensation in the clitoris. Only three of them had an introitus capable of admitting the vaginal probe, and the vaginal sensory data of all three were within the validated ranges. A self-administered sexual function assessment was completed by the five women who were sexually active. The scores indicated sexual difficulties, particularly in the areas of infrequency of intercourse and anorgasmia. CONCLUSIONS The sensory data for all six women were outside the normal range for the clitoris. The results for the upper vagina, which had not had surgery, were within normal ranges. These findings suggest that genital surgery may disrupt sensory input. Sexual function also appears to be impaired and this may relate to the compromised sensitivity and restricted introitus. The possibility that women with CAH have deficient clitoral sensation ab initio cannot be excluded. These striking findings must be evaluated further in the light of the controversy about the issue of genital surgery in children with CAH.
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Affiliation(s)
- N S Crouch
- Department of Obstetrics & Gynaecology, Elizabeth Garrett Anderson & Obstetric Hospital, University College London Hospitals, London, UK
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