Clitoroplasty: past, present and future

Surgical timing and complications, with body image, quality of life, sexual function and genital sensation in patients with congenital adrenal hyperplasia

INTRODUCTION

The aim of this project was to document the long-term outcomes relating to sexual function, genital sensation, body image and quality of life, in an Australian cohort of adolescent and adult women with congenital adrenal hyperplasia (CAH) who have undergone feminising genitoplasty in infancy, childhood or adolescence.

MATERIALS AND METHODS

Identification and follow-up of women with CAH aged 12-40 years who had their first feminising genitoplasty or ongoing management at a single tertiary referral center with multidisciplinary care (n = 80). Medical records were reviewed for Prader stage, and operative outcomes. The prospective component of the study included tracing indivudals aged 12-40 years (n = 69), of whom 34 were contactable. Twenty-one responded to the invitation to participate in the study, completing some or all of a series of validated standardized questionnaires and/or participation in examination of external genital with sensation testing. Results were compared to a control population of similar age distribution (n = 23).

RESULTS

The median Prader stage was 3, median age at surgery was four months, median hospital stay of three days with 80 % of surgery undertaken by one surgeon. There was one major and eight minor complications. Re-operation rates were low. There was no difference between participants and controls in terms of sexual function, quality of life, or body image outcomes including genital appearance. Participants had increased sensitivity to soft touch on genital sensation testing compared to controls. Most participants (71 %) reported that early timing of surgery was 'good', four (19 %) felt their surgery was too late, one felt their surgery was too early, and one was unsure. Most were happy with the outcome of their surgery.

DISCUSSION

Outcomes after feminising genitoplasty are mixed and influenced not only by the surgery itself, but also the ongoing management of the condition alongside each patient's own cultural and social context. At present there is no comparative data available on the sexual, mental, body image and quality of life outcomes of young females with CAH who have had their operation delayed until adulthood. Our study is limited by low participant response rate, and difficulty recruiting 1:1 control population for all participants, but nevertheless provides some insight into the outcomes of these patients for which limited data is available.

CONCLUSION

In the population studied feminising genitoplasty in infancy and childhood had overall positive outcomes. This occurred in a tertiary center with expert multidisciplinary individualised care.

Gender determination and long-time follow-up analysis of mixed gonadal dysgenesis

INTRODUCTION

Mixed gonadal dysgenesis (MGD) is a rare disorder of sexual development. The management of MGD is challenging since the disease significantly impacts a patient's growth, hormone balance, and gonadal development. This article used a large population and a long follow-up period for its analysis.

OBJECTIVES

This study aims to summarize the gender determination basis and analyze the long-term follow-up of mixed gonadal dysgenesis.

METHODS

A total of 45 patients' clinical data were summarized and analyzed. Patients were divided by gender. Next, we followed up regarding the occurrence of complications after surgery, the patients' satisfaction with external genitalia appearance, the growth of the patients, counting the surgical pattern the incidence of surgical complications and the development of the patients' growth. All patients included in this study underwent chromosomal karyotype analysis, abdomen exploration, and pathological biopsy. After sex determination, 7 patients who were raised as female underwent clitoroplasty, and bilateral gonadectomy. 38 male patients underwent urethroplasty + one-sided gonadectomy.

RESULTS

Patient follow-up started in the third month after surgery. Female patients reported no surgery-related complications, while 14 male patients showed surgery-related complications. Additionally, 20 male patients (60.6 %) had a lower height compared to normal peers, 12 of which (36.4 %) were lower than the second standard deviation of the height of normal peers.

CONCLUSION

The clinical manifestations of mixed gonadal dysgenesis are variable, and the management is complicated. Children's gonadal function, external genital conditions, psychological evaluation, and parents' wishes should be considered before sex determination. In China, most patients are raised as males with a high incidence of postoperative complications. We found that short stature is a common feature in male patients, thus their height and growth should be carefully supervised. Patients should pay attention to their sexual function and sexual potential during adulthood.

Complete corporeal preservation clitoroplasty: new insights into feminizing genitoplasty

INTRODUCTION

46,XX Congenital adrenal hyperplasia (CAH) remains the first cause of genital virilization and current surgical techniques aim to restore female aspect of genitalia while preserving dorsal neurovascular bundle but not at the expense of not preserving erectile tissue. We aim to report our experience with a new surgical technique for clitoroplasty, completely preserving corporeal bodies, neurovascular bundles without dismembering the clitoris, in four patients with over a year follow up.

MATERIALS AND METHODS

After IRB approval four patients with 46,XX CAH and Prader 5 and 3 external genitalia, underwent feminizing genitoplasty. Complete preservation of erectile tissue was accomplished without a need to dissect dorsal neurovascular bundle. Glans size allowed no need for glanular reduction and there was no need to dismember the corporeal bodies.

RESULTS

Four patients 12 to 24-months-old underwent complete corporeal preservation clitoroplasty (CCPC), mean age was 18.5 months, mean follow up was 10.25 months. Vaginoplasty was performed in all patients with partial urogenital mobilization (PUM) and Urogenital Sinus flap (UF), only one severely virilized patient required a parasagittal pre-rectal approach to mobilize the vagina. We had no complications until last follow up.

CONCLUSION

To our knowledge, we are introducing the concept of CCPC without the need of disassembling the corporeal bodies, neurovascular bundle and glans. It stands as a new alternative for feminizing genitoplasty with complete preservation of erectile tissue and no dissection of neurovascular bundle. Although there is still lacking long-term follow-up, it represents a new step in conservative reconfiguration of the external virilized female genitalia.

Is nerve sparing clitoroplasty really a nerve sparing?

Background

Surgery for clitoral reduction has been practised for over half a century. The aim of clitoral surgery is to achieve normal clitoral morphology without compromising sexual function. To achieve these purposes, many techniques were developed since Young first reported reduction clitoroplasty in 1937. As the importance of the neurovascular bundle was realized, attempts were made to preserve this structure aiming at preservation of the sensory supply to the clitoris to achieve sexual satisfaction.

Methods

The study was conducted on six patients with congenital adrenal hyperplasia, who were operated upon with reduction clitoroplasty with neurovascular bundle preservation as a part of the genital reconstruction; surgery was done by single author (first author). Whole surgically removed corporal bodies were processed. Examination of the sections was done for the presence of nerve bundles related to the anatomical location of the neurovascular bundle using S100 immunohistochemical staining.

Results

In four cases, the presence of nerve fibers in the removed part of the corpus stained by S100 was high on the dorsal surface, with the presence of large nerve fibers (score 3–4), and low on the ventral surface with the presence of small nerve fibers (score 1). In the other two cases, it was low on both surfaces (score 1).

Conclusion

Subfacial clitoroplasty technique carries an inevitable risk of nerve injury and should be replaced by the subtunical technique.

Level of evidence

IV. Type of study: case series with no comparison group.

A Multicenter Cross-Sectional Study of Malaysian Females With Congenital Adrenal Hyperplasia: Their Body Image and Their Perspectives on Feminizing Surgery

OBJECTIVE

To explore the impact of congenital adrenal hyperplasia (CAH) on body image in Malaysian females with CAH and to understand the perspectives of these young women and their parents toward feminizing genitoplasty (FG).

DESIGN

Multi-center cross-sectional study.

SETTING

Two tertiary medical centers in Malaysia.

PARTICIPANTS

A total of 59 patients with CAH who were raised as females and more than 10 years old, and their parents.

METHODS

The CAH respondents completed the validated and translated Body Image Disturbance Questionnaires (BIDQ). All CAH respondents and their parents underwent semi-structured interviews to explore their views on FG.

MAIN OUTCOME MEASURES

Body image disturbance score and perspectives on FG.

RESULTS

The 59 CAH respondents consisted of 12 children, 29 adolescents, and 18 adults. The majority were of Malay ethnicity (64.4%) with classical CAH (98.3%) and had undergone FG (n = 55, 93.2%). For the BIDQ scores, the median score (interquartile range) for general body image was 1.29 (0.71), range 1.00-3.29, whereas the genital appearance score was 1.07 (0.39), range 1.00-4.29, revealing a greater concern for general body parts over genitalia. With regards to FG, it was perceived as necessary. Infancy and early childhood were perceived as the best timing for first FG by both respondents and parents, most preferring single-stage over 2-stage surgery.

CONCLUSIONS

General body appearance concerns were greater than for genital appearance, with more impact on the patients' lives. Contrary to much international opinion, feminizing surgery was perceived as necessary and appropriate by CAH respondents and their families, and should be offered in infancy or early childhood. Future qualitative studies are recommended.

Clitoral reduction: Technical note

Clitoral hypertrophy is a rare genital malformation that can be congenital or acquired. In congenital forms, the most common cause is adrenal hyperplasia. The acquired forms are caused by endocrinological diseases, benign tumours or cysts. Idiopathic clitoral hypertrophies can be detected after the elimination of secondary causes. A complete assessment is needed to treat the origin of clitoridomegaly. The hypertrophy is often increased or unmasked during sexual arousal with the appearance of a true vulvar appendage in erection. It is often accompanied by a hypertrophy of the clitoral hood and can cause psychological suffering with an impact on the quality of sexual life. When the cause of clitoral hypertrophy is diagnosed, treated or stabilized, the plastic surgeon may be called upon for surgical correction. Reconstructive surgery in this area has evolved considerably since the historical clitoral amputations which led to the current technique of partial resection with sparing the dorsal neurovascular pedicle of the clitoris as described by Professor Paniel. We propose a modified conservative technique to treat clitoral hypertrophy and the clitoral hood and present two clinical cases: ventral reduction clitoridoplasty with preservation of the neurovascular pedicle associated with a chevron plasty of the clitoral hood and a lipofilling of the labia majora. The postoperative follow-up is simple with reports of great satisfaction from patients regarding their quality of life.

Female Genital Mutilation Reconstruction for Plastic Surgeons-A Call to Arms

The practice of female genital mutilation (FGM) is performed for historically engrained cultural beliefs with no recognized health benefits. FGM continues to be practiced secondary to motivating factors based on cultural beliefs, the majority of which aim to maintain the “purity” of the female victim. The World Health Organization has classified FGM into 4 types ranging from partial clitoral resection to complete clitoral excision along with the majority of the vulva. The list of short and long-term complications is extensive and morbid, including injury to the patient’s sexuality and feminine identity. Reconstructive surgery can be an important addition to psychotherapy for these women with the goal of correcting the appearance of the vulva to achieve a more normal appearance, and to restore clitoral function. We suggest that this represents an opportunity for plastic surgeons to use our wealth of reconstructive knowledge to provide restoration of form and function to FGM victims.

Long-term urinary symptoms in adolescent and adult women with congenital adrenal hyperplasia

BACKGROUND

Congenital adrenal hyperplasia (CAH) is an autosomal recessive condition resulting in excess androgen production. Females are typically born with ambiguous genitalia and often undergo feminising genitoplasty in infancy or childhood. Recently, there has been considerable international debate as to whether distressing urinary symptoms in CAH patients are truly present and, if so, whether these urinary problems are a consequence of the feminising genitoplasty.

OBJECTIVE

To identify and assess any urinary symptoms in an Australian cohort of adolescent and adult women with CAH who have undergone feminising genitoplasty in infancy, childhood or adolescence as a part of their management.

STUDY DESIGN

Females with CAH aged 12-40 years, who had undergone feminising genitoplasty, and were identified from a hospital database (n = 72). Those aged 12-15 years were assessed using the Paediatric Incontinence Symptom Index questionnaire in conjunction with sections of the Bristol Female Lower Urinary Tract Symptoms Scored Form questionnaire. Those aged 16-40 years were assessed using the Bristol Female Lower Urinary Tract Symptoms Scored Form questionnaire. Uroflowmetry studies and post-void residual volume ultrasounds were also conducted. Previously published normative data were used for the control population.

RESULTS

Responses to the questionnaire indicated that CAH patients had a higher incidence of urgency, frequency, urge incontinence, unexplained incontinence and nocturnal incontinence, when compared to previously published control data. Average and maximum urine flow rates measured by uroflowmetry were within normal range; however, the 16-40-year-old age group had significantly increased mean post-void residual volumes (P < 0.001) (Summary table).

DISCUSSION

The presence of lower urinary tract symptoms in these patients has previously been interpreted as a direct outcome of feminising genitoplasty; however, these results could also be accounted for by the virilisation of pelvic floor musculature. Androgens have been shown to increase skeletal muscle mass, but their exact impact on the pelvic floor musculature requires further research. Three previous studies have measured post-void residual volumes in patients with CAH, all of which found it them be raised.

CONCLUSIONS

Patients with CAH appeared to have overall normal urinary flow but increased post-void residual volumes. The data suggested that this population of patients has an increased probability of incontinence, urgency, and frequency when compared to a control population. These results confirmed findings of other small studies; however, it remains unclear if these changes reflected the underlying diagnosis or were a consequence of management.

Nerve sparing clitoroplasty in a rare case of idiopathic clitoromegaly

Clitoromegaly is an embarrassing condition causing psychological stress, requiring intervention. The goals of clitoroplasty are to achieve normal genital anatomy and to preserve tactile sensation with a satisfactory sexual response. We present a rare case of idiopathic clitoromegaly managed by reduction clitoroplasty, preserving the dorsal neurovascular bundle and extensive network of nerves around the corpora to the glans and the creation of labia minora.

Anatomy of the clitoris and its impact on neophalloplasty (metoidioplasty) in female transgenders

The current management of female to male transgender surgery is based on the advances in neophalloplasty, perioperative care and the knowledge of the female genital anatomy, as well as the changes that occur to this anatomy with preoperative hormonal changes in transgender population. Since the clitoris plays the main role in female sexual satisfaction, its impact on the outcome in female to male transgender surgery is predictable. Although female genital anatomy was poorly described in majority of anatomical textbooks, recent studies have provided a better insight in important details such as neurovascular supply, ligaments, body configuration, and relationship with urethral/vaginal complex. This article aims to review current state of knowledge of the clitoral anatomy as well its impact on clitoral reconstruction in female to male sex reassignment surgery.

The role of clitoral anatomy in female to male sex reassignment surgery

Introduction. Controversies on clitoral anatomy and its role in female sexual function still make clitoral reconstructive surgery very challenging. We evaluated the role of clitoral anatomic features in female to male sex reassignment surgery. Material and Methods. The study included 97 female transsexuals, aged from 18 to 41 years, who underwent single stage metoidioplasty between March 2008 and January 2013. The operative technique involved vaginectomy, the release of clitoral ligaments and urethral plate, urethroplasty by combining buccal mucosa graft and genital flaps, and scrotoplasty with insertion of testicle prostheses. Postoperative questionnaire was used to evaluate aesthetic, functional, and sexual outcome. Results. The mean followup was 30 months. The mean length of the neophallus was 7 cm, compared to mean preoperative length of the hypertrophied clitoris of 3.3 cm. Complications occurred in 27.84% of all patients, related mostly to urethroplasty. Voiding while standing was achieved in all cases. None of the patients had problems in sexual arousal, masturbation, or orgasms. Conclusion. Accurate knowledge of the clitoral anatomy, physiology, and neurovascular supply is crucial for a successful outcome of female to male sex reassignment surgery. Our approach appears to ensure overall satisfaction and high quality of sexual life.

[Clitoral epidermoid cyst causing clitoromegaly. A rare case report]

Clitoromegaly is uncommon. It is mostly congenital, hormonal or tumoral. Epidermoid cyst is rare. It can be the consequence of trauma, but in some situations the cyst can be non-traumatic. We report the case of a 53-year-old woman who presented a misdiagnosis of clitoromegaly due to hormonal condition. Surgical exploration has highlighted an epidermoid cyst. This observation underlines the importance to evoke a cystic origin for clitoral hypertrophy and encourages us to propose imaging (ultrasound, MRI) in case of etiological doubt. The preoperative diagnosis must be made to preserve vascularization and innervation of the clitoris.

Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerations

A thorough insight into the female genital anatomy is crucial for understanding and performing pelvic reconstructive procedures. The intimate relationship between the genitalia and the muscles, ligaments, and fascia that provide support is complex, but critical to restore during surgery for correction of prolapse or aesthetic reasons. The external female genitalia include the mons pubis, labia majora and minora, clitoris, vestibule with glands, perineal body, and the muscles and fascia surrounding these structures. Through the perineal membrane and the perineal body, these superficial vulvar structures are structurally related to the deep pelvic muscle levator ani with its fascia. The levator ani forms the pelvic floor with the coccygeus muscle and provides vital support to all the pelvic organs and stability to the perineum. The internal female genital organs include the vagina, cervix, uterus, tubes, and ovaries with their visceral fascia. The visceral fascia also called the endopelvic fascia, surrounds the pelvic organs and connects them to the pelvic walls. It is continuous with the paraurethral and paravaginal fascia, which is attached to the perineal membrane. Thus, the internal and external genitalia are closely related to the muscles and fascia, and work as one functioning unit.

Controversies on clitoroplasty

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.

Microscope-assisted reduction clitoroplasty used to treat two patients with clitoromegaly

We report 2 cases of clitoromegaly, 1 in a patient with true hermaphroditism, and the other in a patient with adrenogenital syndrome. Both were treated surgically with reduction clitoroplasty. There are 3 different clitoroplasty procedures: clitorectomy, clitoral recession, and reduction clitoroplasty. Reduction clitoroplasty with preservation of the neurovascular bundle is considered superior in terms of formation of the external genitals and sensation. However, the disadvantages are that detachment of the neurovascular bundle from the clitoral shaft is difficult and that there is a high possibility of sensory and blood flow disorders in the clitoris. In an attempt to achieve safe and reliable surgical manipulation, we used a surgical microscope (OPMI 6-SDFC, Carl Zeiss Surgical GmbH, magnification x8) to detach the neurovascular bundle from the clitoral shaft in our 2 patients. Our impression is that our efforts were extremely effective. Furthermore, our experience leads us to believe that the procedure for neurovascular bundle detachment required in reduction clitoroplasty is not particularly difficult if performed with a surgical microscope by a plastic surgeon who regularly performs microsurgery. Because the procedure can be performed simply and safely, we believe that reduction clitoroplasty with preservation of the neurovascular bundle is the best overall of the 3 clitoroplasty procedures.

Disorders of sex development (DSDs), their presentation and management in different cultures

The way disorders of sex development (DSD) are viewed and managed in different cultures varies widely. They are complex conditions and even well-educated lay people find them difficult to understand, but when families are very poor and lacking in basic education, and the health system is starved of resources, traditional beliefs, folk remedies and prejudice combine to make the lives of children and adults with DSD extremely difficult and sad. Rumour and discrimination isolate them from their communities and they become devalued. People with DSDs desire the same things in life as everyone else-to find someone who will love them, to be valued as human beings, to feel at home in their own bodies, to be able to have satisfactory sexual relations should these be desired, to be able to trust their medical advisers and to be integrated into the general community. Long term outcome studies have been published from many countries, but these studies have not necessarily been critical of the values that underpinned the type of treatment given to the patients. There is a need for standardized instruments that would allow a true comparison of the quality of outcomes from the patients' perspective. Much could be done to improve equity between rich and poor countries for the benefit of people with DSDs. A focus on developing cheap, robust diagnostic tests, making essential medicines available for all, training surgeons to do better operations, educating health professionals, families and the general community in order to break down prejudice against people with DSDs, and training mental health workers in this specialized field, would do much to alleviate the burden of the condition.