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Aksel S, Derpinghaus A, Cao M, Li Y, Cunha G, Baskin L. Neurovascular anatomy of the developing human fetal penis and clitoris. J Anat 2024; 245:35-49. [PMID: 38419143 PMCID: PMC11161816 DOI: 10.1111/joa.14029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/15/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
The human penile and clitoral development begins from a morphologically indifferent genital tubercle. Under the influence of androgen, the genital tubercle forms the penis by forming a tubular urethra within the penile shaft. Without the effect of the androgen, the genital tubercle differentiates into the clitoris, and a lack of formation of the urethra within the clitoris is observed. Even though there are similarities during the development of the glans penis and glans clitoris, the complex canalization occurring along the penile shaft eventually leads to a morphological difference between the penis and clitoris. Based on the morphological differences, the main goal of this study was to define the vascular and neuronal anatomy of the developing penis and clitoris between 8 and 12 weeks of gestation using laser scanning confocal microscopy. Our results demonstrated there is a co-expression of CD31, which is an endothelial cell marker, and PGP9.5, which is a neuronal marker in the penis where the fusion is actively occurring at the ventral shaft. We also identified a unique anatomical structure for the first time, the clitoral ridge, which is a fetal structure running along the clitoral shaft in the vestibular groove. Contrary to previous anatomical findings which indicate that the neurovascular distribution in the developing penis and clitoris is similar, in this study, laser scanning confocal microscopy enabled us to demonstrate finer differences in the neurovascular anatomy between the penis and clitoris.
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Affiliation(s)
- Sena Aksel
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Amber Derpinghaus
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Mei Cao
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Yi Li
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Gerald Cunha
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Laurence Baskin
- Department of UrologyUniversity of CaliforniaSan FranciscoCaliforniaUSA
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Cuendias P, Vega JA, García-Suárez O, Suazo I, Cobo R, García-Piqueras J, García-Mesa Y. Axonal and Glial PIEZO1 and PIEZO2 Immunoreactivity in Human Clitoral Krause's Corpuscles. Int J Mol Sci 2024; 25:6722. [PMID: 38928429 PMCID: PMC11203881 DOI: 10.3390/ijms25126722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/13/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Krause's corpuscles are typical of cutaneous mucous epithelia, like the lip vermillion or the glans clitoridis, and are associated with rapidly adapting low-threshold mechanoreceptors involved in gentle touch or vibration. PIEZO1 and PIEZO2 are transmembrane mechano-gated proteins that form a part of the cationic ion channels required for mechanosensitivity in mammalian cells. They are involved in somatosensitivity, especially in the different qualities of touch, but also in pain and proprioception. In the present study, immunohistochemistry and immunofluorescence were used to analyze the occurrence and cellular location of PIEZO1 and PIEZO2 in human clitoral Krause's corpuscles. Both PIEZO1 and PIEZO2 were detected in Krause's corpuscles in both the axon and the terminal glial cells. The presence of PIEZOs in the terminal glial cells of Kraus's corpuscles is reported here for the first time. Based on the distribution of PIEZO1 and PIEZO2, it may be assumed they could be involved in mechanical stimuli, sexual behavior, and sexual pleasure.
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Affiliation(s)
- Patricia Cuendias
- Grupo de Investigación SINPOS, Departamento de Morfología y Biología Celular, Universidad de Oviedo, 33006 Oviedo, Spain; (P.C.); (J.A.V.); (O.G.-S.); (J.G.-P.)
| | - José A. Vega
- Grupo de Investigación SINPOS, Departamento de Morfología y Biología Celular, Universidad de Oviedo, 33006 Oviedo, Spain; (P.C.); (J.A.V.); (O.G.-S.); (J.G.-P.)
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Providencia, Santiago de Chile 4810010, Chile;
| | - Olivia García-Suárez
- Grupo de Investigación SINPOS, Departamento de Morfología y Biología Celular, Universidad de Oviedo, 33006 Oviedo, Spain; (P.C.); (J.A.V.); (O.G.-S.); (J.G.-P.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
| | - Iván Suazo
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Providencia, Santiago de Chile 4810010, Chile;
| | - Ramón Cobo
- Servicio de Otorrinolaringología, Hospital Universitario “Marqués de Valdecilla”, 39008 Santander, Spain;
| | - Jorge García-Piqueras
- Grupo de Investigación SINPOS, Departamento de Morfología y Biología Celular, Universidad de Oviedo, 33006 Oviedo, Spain; (P.C.); (J.A.V.); (O.G.-S.); (J.G.-P.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
- Departamento de Anatomía, Histología y Neurociencia, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Yolanda García-Mesa
- Grupo de Investigación SINPOS, Departamento de Morfología y Biología Celular, Universidad de Oviedo, 33006 Oviedo, Spain; (P.C.); (J.A.V.); (O.G.-S.); (J.G.-P.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain
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von Fritschen U, Strunz C, Scherer R, Fricke A. Sensitivity after Clitoral Reconstruction in Patients with Female Genital Mutilation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5851. [PMID: 38881961 PMCID: PMC11177814 DOI: 10.1097/gox.0000000000005851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/08/2024] [Indexed: 06/18/2024]
Abstract
Background In the past decades, reconstructive choices after female genital mutilation extended beyond de-infibulation and scar release. The current trend to expand techniques addressing sexual and aesthetic aspects by reconstructing the clitoris and prepuce, and dissecting the clitoral nerves raises concern, as there is a paucity of evidence on the functional outcomes and suspected iatrogenic lacerations. Methods A total of 128 female genital mutilation patients were included in the study. To evaluate clitoral sensitivity after elevation, the Semmes-Weinstein-monofilament test was performed before and after genital reconstruction. Results Preoperatively, patients with a visually intact clitoris showed significantly better sensitivity compared with patients with a mutilated clitoris or infibulation (P < 0.0001). Surgery was performed in 84 patients. After clitoral reconstruction (CR), 70 of 73 patients were able to perceive 2.83 monofilaments (95.9%), whereas three perceived 3.61. Patients with a visually intact clitoris served as control, and 95.0% perceived 2.83 monofilaments. We showed a significant improvement of clitoral sensitivity (P = 0.0020) in the subgroup consisting of patients with a mutilated clitoris in whom the test was performed before and after reconstruction. Conclusions Clitoral sensitivity improves significantly after CR. Seventy of 73 patients attained the same sensitivity as unharmed women. No patient showed a decreased sensitivity compared with their preoperative findings. Therefore, our study supports the argument that CR offers sufficient improvement of objective clitoral sensitivity without additionally addressing clitoral nerves.
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Affiliation(s)
- Uwe von Fritschen
- From the Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Berlin, Germany
- Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Regensburg, Germany
| | - Cornelia Strunz
- Desert Flower Center, Center of Colorectal and Pelvic Floor Surgery, Hospital Waldfriede, Berlin, Germany
| | - Roland Scherer
- Desert Flower Center, Center of Colorectal and Pelvic Floor Surgery, Hospital Waldfriede, Berlin, Germany
| | - Alba Fricke
- From the Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Berlin, Germany
- Department of Plastic and Hand Surgery, University of Freiburg Medical Centre, Medical Faculty of the University of Freiburg, Freiburg, Germany
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Uloko M, Isabey EP, Peters BR. How many nerve fibers innervate the human glans clitoris: a histomorphometric evaluation of the dorsal nerve of the clitoris. J Sex Med 2023; 20:247-252. [PMID: 36763957 DOI: 10.1093/jsxmed/qdac027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION It is frequently quoted in mainstream media that the clitoris has "8000 nerve endings." However, no study has yet quantified the number of nerve fibers (axons) innervating the human clitoris. The dorsal nerves of the clitoris (DNCs) are the primary source of sensation and somatic clitoral innervation. Therefore, reporting the number of axons in the DNCs is an important step in our understanding of clitoral innervation and sexual response with implications for many fields of medical practice. The purpose of this study is to quantify the mean number of axons in the human DNCs and to report the approximate mean number of nerve fibers that innervate the human glans clitoris. METHODS DNC samples were obtained from 7 transmasculine patients undergoing gender-affirming phalloplasty surgery. At the time of nerve coaptation, a small excess of the DNC (5 mm) was collected for analysis at the proximal level of the clitoral body, just distal of the emergence of the DNCs from underneath the pubic symphysis. Samples were placed into 3% glutaraldehyde fixative, postfixed in 1% osmium tetroxide, and serially dehydrated in ethanol and toluene. Samples were then embedded in araldite, sectioned on an ultramicrotome into 1-μm cross sections, and counterstained with 1% toluidine blue. Histomorphometric evaluation was performed at 1000x magnification with a Leitz Laborlux S microscope and image analysis software (Clemex Vision Professional) to obtain an axon counts. Descriptive statistics were performed to yield a mean and standard deviation of the number of axons in the DNCs. Assuming anatomic symmetry between bilateral DNCs, mean total number of somatic nerve fibers innervating the human glans clitoris was obtained by doubling the mean count of the DNCs. RESULTS Seven sample DNCs were collected. Of those, 5 were analyzed as 2 did not have sufficient nerve tissue present. The mean number of nerve fibers in the human DNCs was 5140 (SD = 218.4). The mean number of myelinated nerve fibers innervating the human clitoris was 10,281 (SD = 436.8). CONCLUSION This study is the first to report the number of axons in the human DNC, at a mean 5140. Given the bilateral nature of clitoral innervation and symmetry of anatomic structures, the approximate mean number of myelinated axons that innervate the human glans clitoris is 10,280. When the uncaptured unmyelinated fibers and contributions from the cavernosal innervation are accounted for, it is clear that far Moree than 8000 axons innervate the human clitoris.
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Affiliation(s)
- Maria Uloko
- Department of Urology, University of California San Diego, San Diego, CA 92121, United States
| | - Erika P Isabey
- Department of Obstetrics and Gynecology, University of Manitoba, Winnipeg R3E EP5, Canada
| | - Blair R Peters
- Transgender Health Program, Oregon Health & Science University, Portland, OR 97239, United States.,Division of Plastic Surgery, Oregon Health & Science University, Portland, OR 97239, United States
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Krege S, Falhammar H, Lax H, Roehle R, Claahsen-van der Grinten H, Kortmann B, Duranteau L, Nordenskjöld A. Long-Term Results of Surgical Treatment and Patient-Reported Outcomes in Congenital Adrenal Hyperplasia-A Multicenter European Registry Study. J Clin Med 2022; 11:jcm11154629. [PMID: 35956243 PMCID: PMC9369813 DOI: 10.3390/jcm11154629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Representatives for congenital adrenal hyperplasia (CAH) continue to desire early feminizing surgery in girls with 46,XX-CAH. The aim of this analysis, which included 174 46,XX- individuals with salt-wasting (SW) or simple-virilizing (SV) CAH, a female gender identity, and an age > 16 years participating in a multicenter cross-sectional clinical evaluation study (dsd-LIFE), was to evaluate the long-term results of surgery and patient-reported outcomes (PRO). The gynecological examination (n = 84) revealed some shortcomings concerning surgical feminization. A clitoris was absent in 9.5% of cases, while a clitoral hood was missing in 36.7% of cases. Though all women had large labia, they didn’t look normal in 22.6% of cases. Small labia were absent in 23.8% of cases. There was no introitus vaginae, and the urethra and vagina had no separate opening in 5.1% of cases. A mucosal lining was missing in 15.4% of cases. Furthermore, 86.2% of the women had scars at the region of their external genitalia. A vaginal stenosis was described in 16.5% of cases, and a meatal stenosis was described in 2.6% of cases. Additionally, PRO data showed a very-/high satisfaction rate of 21.3%/40.2% with cosmesis and 23.8%/38.1% with functionality, while 3.3%/10.7% showed a very-/low satisfaction with cosmesis as well as 5.6%/10.3% with functionality. The remaining women—24.6% and 23.8%—were indifferent. Satisfaction concerning sex life was very-/high in 9.6%/27.7%. In 12.0%/16.9% it was very-/low. Furthermore, 33.7% had no opinion. Furthermore, 27.0%/31.6% of the women reported that clitoriplasty, but not clitoridectomy, had a very-/positive influence on their lives, while 1.3%/8.9% felt it to be very-/negative, and 28.4% were indifferent. Vaginoplasty had a very-/positive influence in 25.7%/33.8% and a very-/negative effect in 3.6%/6.8%. 29.7% had no opinion. Additionally, 75.7% of the women preferred feminizing surgery during infancy/childhood, especially concerning clitoreduction. In conclusion, though the majority of the participants (76%) preferred early feminizing surgery and 60% described a positive effect on their lives, about 10% felt it to have been negative. About 15% of the women suffered from insufficient cosmesis and functionality after surgery. Sex life was even described as poor in nearly 30%. Therefore, the decision about early genital surgery in 46,XX-CAH girls should be considered carefully. Parents should get detailed information about possible complications of surgery and should receive support to understand that postponing surgery does not inevitably cause harm for their child. Importantly, genital surgery when performed in children should only be performed in expert centers with a specialized team including surgeons who are trained in feminizing surgery.
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Affiliation(s)
- Susanne Krege
- Department of Urology, Pediatric Urology and Urooncology, Kliniken Essen Mitte, 45136 Essen, Germany
- Correspondence: ; Tel.: +49-201-174-29003; Fax: +49-201-174-29000
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, 171 77 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Hildegard Lax
- Institute of Medical Informatics, Biometry and Epidemiology, University of Essen, 45147 Essen, Germany
| | - Robert Roehle
- Institute of Biometry and Clinical Epidemiology, Charite-University Medicine Berlin, 10117 Berlin, Germany
- Institute of Health, Charite-University Medicine Berlin, 10117 Berlin, Germany
| | | | - Barbara Kortmann
- Department of Pediatric Urology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Lise Duranteau
- Department of Medical Gynaecology and Reference Centre for Rare Diseases of Genital Development, Bicetre Hospital, APHP Paris Saclay University, 94270 Le Kremlin Bicetre, France
| | - Agneta Nordenskjöld
- Department of Women’s and Children’s Health, Center of Molecular Medicine, Karolinska Institutet, 17176 Stockholm, Sweden
- Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden
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Mapping a Danger Zone of the Dorsal Nerve of the Clitoris: Implications in Female Cosmetic Genital Surgery. Plast Reconstr Surg 2021; 148:1005-1010. [PMID: 34705773 DOI: 10.1097/prs.0000000000008412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The literature regarding the route of the dorsal nerve of the clitoris is sparse and lacks surgical focus. With an increasing number of procedures being performed on the labia, it is important to elucidate the route and note any variation from normal of the nerve. METHODS Fifty-one cadavers were dissected to yield 97 dorsal nerve of the clitoris samples. Measurements were taken from (1) the dorsal nerve of the clitoris penetration point of the perineal membrane to the urethra, (2) the nerve's penetration point of the perineal membrane to the pubic bone, (3) the angle of the clitoris to the branch point of the dorsal nerve of the clitoris, and (4) the branch point of the nerve to the distalmost point of the glans clitoris. Any anomalous branching patterns of the dorsal nerve of the clitoris were recorded and classified. RESULTS The means and standard deviations of each measurement were used to create a surgical danger zone. The mean of each measurement was (1) 34.63 mm, (2) 5.74 mm, (3) -3.07 mm, and (4) 30.40 mm, respectively. In addition, six distinct branching patterns were observed, organized, and classified based on the location and number of branches observed. CONCLUSIONS The dorsal nerve of the clitoris has multiple branching patterns and typically travels along the same course in most women. Further investigation of the course and three-dimensional position of the dorsal nerve of the clitoris is warranted to preserve sexual sensation as the frequency of procedures involving the female pudendum increases.
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Blayney F, Camuzard O, Klein A, Perchenet AS, Bertrand B, Philandrianos C, Massin V, Abellan-Lopez M, Casanova D. Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair. J Plast Reconstr Aesthet Surg 2021; 74:3394-3403. [PMID: 34253487 DOI: 10.1016/j.bjps.2021.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/29/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation. METHODS This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami. RESULTS At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm. CONCLUSION We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.
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Affiliation(s)
- Fanny Blayney
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France.
| | - Olivier Camuzard
- Pasteur universitary hospital, Plastic surgery department and Hand Reconstruction, 30 voie Romaine, 06001 Nice Cedex 1, France
| | - Arthur Klein
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | | | - Baptiste Bertrand
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | - Cécile Philandrianos
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | - Valentin Massin
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | - Maxime Abellan-Lopez
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
| | - Dominique Casanova
- Conception Hospital/assistance publique hôpitaux de Marseille Plastic, esthetic and Reconstructive surgery department Pr. Casanova PhD, 147, Boulevard Baille, 13005, Marseille, France
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The role of clitoral topography in sexual arousal and orgasm: transperineal ultrasound study. Int Urogynecol J 2021; 33:1495-1502. [PMID: 34028574 DOI: 10.1007/s00192-021-04830-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The clitoris has a critical pivotal role in female orgasm and arousal. The aim of this cross-sectional study was to evaluate topographic measurements of the clitoris, as well as to explore potential relationships between the clitoral complex and the orgasm domain of female sexual function, combining transperineal ultrasound with morphometric measurements. METHODS In sexually active, heterosexual, premenopausal women, three-dimensional transperineal ultrasound imaging was used to measure the subpubic angle, the anterior triangle area (ATA) of the genital hiatus, the levator urethra gap, and the anteroposterior and transverse diameters of the genital hiatus. Mons pubis thickness, clitoris-urethra distance (CUD), clitoris-fourchette distance, and fourchette-perineal body distance were measured using a caliper. Comparison of measurements and correlation with orgasm score were performed. RESULTS Among the 108 sexually active women, 30 (27.7 %) reported a low orgasm domain score. There were statistically significant differences between the low orgasm group and the control group in the ATA (4.05 vs 3.64 cm2 respectively; p = 0.03), CUD (21 mm; p = 0.04 vs 16.1 mm; p = 0.04), and volume of the glans clitoris (947.7 mm3 vs 1081 mm3; p = 0.02). There was a moderate and inverse correlation between clitoris-urethra distance and orgasm (r = -0.53, p < 0.001), and arousal (r = -0.42 p < 0.001). Broader ATA (OR = 0.47; 95 % CI = 0.23-0.99; p = 0.04) and longer CUD (OR = 0.57; 95 % CI = 0.44-0.73; p < 0.001) were identified as the only independent predictors of orgasm problems. CONCLUSIONS Longer glans clitoris-urethra distance and broad space for the deep structures of the clitoris is related to difficulty in reaching orgasm and arousal problems.
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Botter C, Sawan D, SidAhmed-Mezi M, Spanopoulou S, Luchian S, Meningaud JP, Hersant B. Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: Anatomy, Technical Innovations and Updates of the Initial Technique. J Sex Med 2021; 18:996-1008. [PMID: 33931348 DOI: 10.1016/j.jsxm.2021.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 09/30/2022]
Abstract
INTRODUCTION Female genital mutilation (FGM) includes all procedures that involve partial or total removal of the female external genitalia or any other injury of the female genitalia that is performed for nonmedical reasons. FGM is classified into 4 types. Surgical clitoral reconstruction was first described by Thabet and Thabet in Egypt and subsequently by Foldès in France. The technique was then modified by different authors. AIM This article aims to provide a detailed description of clitoral surgical reconstruction and the modifications which have been made over time to improve the procedure while recalling current knowledge in the anatomy of the clitoris. METHODS We performed a broad systematic search in PubMed/Medline and EMBASE bibliographic databases for studies that report the surgical technique of clitoral reconstruction. From the anatomical point of view, we examined available evidence (from 1950 until 2020) related to clitoral anatomy, the clitoral role in sexual functioning, female genital mutilation/cutting, and surgical implications for the clitoris. MAIN OUTCOMES A review of the surgical techniques for clitoral reconstruction after female genital mutilation/cutting RESULTS: We described the current anatomical knowledge about the clitoris, and the procedures based on the surgical technique by Pierre Foldès, We included the technical modifications and contributions described in articles published subsequently. CONCLUSION Surgical repair of the clitoris for FGM offers anatomical and functional results although they still have to be evaluated. However, it should not be the only therapeutic solution offered to women with FGM. Botter C, Sawan D, SidAhmed-Mezi M, et al. Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: Anatomy, Technical Innovations and Updates of the Initial Technique. J Sex Med 2021;18:996-1008.
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Affiliation(s)
- Charles Botter
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France.
| | - Dana Sawan
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Mounia SidAhmed-Mezi
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Sofia Spanopoulou
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Stefan Luchian
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Jean-Paul Meningaud
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
| | - Barbara Hersant
- Department of Plastic, Reconstructive, Aesthetic and Maxillofacial Surgery, Henri Mondor Hospital, Créteil, France
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Bidault V, Botto N, Paye-Jaouen A, Leger J, Josset-Raffet É, Martinerie L, Peycelon M, El-Ghoneimi A. New method for early evaluation of clitoris innervation using clitoro-perineal reflex after feminizing genitoplasty in early childhood: a pilot-study. Sci Rep 2021; 11:7087. [PMID: 33782453 PMCID: PMC8007626 DOI: 10.1038/s41598-021-86434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 03/08/2021] [Indexed: 11/20/2022] Open
Abstract
A major complication of feminizing genitoplasty in children is the loss of clitoral sensation with serious impact at adult life. We suggest a new method to evaluate the surgical results during childhood based on the bulbocavernosus or clitoro-perineal reflex (CPR). The afferent pathway of CPR implies the intact sensory receptors on the clitoral glans. Girls with congenital adrenal hyperplasia who were followed-up medically without surgery or who underwent feminizing genitoplasty with or without clitoroplasty were included (2002-2018). All clitoroplasties were standardized reduction clitoroplasty with preservation of neurovascular bundles associated with vaginoplasty and vestibuloplasty. Standardized examinations were prospectively performed including the CPR starting at one year postoperatively. The reflex was triggered by gentle touch of the glans by a cotton swab. Contraction of the perineal muscles was considered positive. Thirty-two children were operated at a median age of 8.6 months (5.8-12.1). Median follow-up (FU) was 3.9 years (1.3-6.4). Twenty-four patients had clitoroplasties: 17 were tested for CPR at one-year FU, and all had a positive test. Eight girls had genitoplasty without clitoral surgery, two of them were tested and were positive. Ten patients were managed without surgery, two of them were tested for the CPR and were positive. The reflex was always triggered easily and repeated at least twice during the FU. The clitoro-perineal reflex is a simple, non-invasive and reproducible test in early childhood and may serve as an early evaluation tool of clitoral innervation after feminizing genitoplasty. These results need to be confirmed at long term and completed at adult life.
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Affiliation(s)
- Valeska Bidault
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Nathalie Botto
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Annabel Paye-Jaouen
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Juliane Leger
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
- Department of Pediatric Endocrinology, University Children Hospital Robert-Debré, APHP, University of Paris, Paris, France
| | - Éliane Josset-Raffet
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Laetitia Martinerie
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
- Department of Pediatric Endocrinology, University Children Hospital Robert-Debré, APHP, University of Paris, Paris, France
| | - Matthieu Peycelon
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France.
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France.
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11
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Nerve sparing feminizing genitoplasty with corporal septum excision in non-classic congenital adrenal hyperplasia. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.865468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Baskin A, Wisniewski AB, Aston CE, Austin P, Chan YM, Cheng EY, Diamond DA, Fried A, Kolon T, Lakshmanan Y, Williot P, Meyer S, Meyer T, Kropp B, Nokoff N, Palmer B, Paradis A, Poppas D, VanderBrink B, Scott Reyes KJ, Tishelman A, Wolfe-Christensen C, Yerkes E, Mullins LL, Baskin L. Post-operative complications following feminizing genitoplasty in moderate to severe genital atypia: Results from a multicenter, observational prospective cohort study. J Pediatr Urol 2020; 16:568-575. [PMID: 32624410 PMCID: PMC7735165 DOI: 10.1016/j.jpurol.2020.05.166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/17/2020] [Accepted: 05/23/2020] [Indexed: 12/14/2022]
Abstract
Disorders/differences of sex development (DSD) are congenital conditions in which there is atypical chromosomal, gonadal and/or phenotypic sex. While there remains controversy around the traditionally binary concept of sex, most patients with DSD are reared either male or female depending on their genetic sex, gonadal sex, genital phenotype and status of their internal genital tract. This study uses prospective data from 12 institutions across the United States that specialize in DSD care. We focused on patients raised female. Eligible patients had moderate to severe genital atypia (defined as Prader score >2), were ≤2 years of age at entry, and had no prior genitoplasty. The aim of this study is to describe early post operative complications for young patients undergoing modern approaches to feminizing genitoplasty. Of the 91 participants in the cohort, 57 (62%) were reared female. The majority had congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (n = 52), 1 had ovo-testicular syndrome, 2 had mixed gonadal dysgenesis and 2 had partial androgen insensitivity syndrome (PAIS). Of the 50 participants who received early genitoplasty, 43 (86%) had follow-up at 6-12 months post-surgery. Thirty-two participants (64%) received a clitoroplasty, 31 (62%) partial urogenital mobilization and 4 (8%) total urogenital sinus mobilization. Eighteen percent (9/50) experienced post-surgical complications with 7 (14%) being rated as Clavien-Dindo grade III. Both parents and surgeons reported improved satisfaction with genital appearance of participants following surgery compared to baseline. This information on post-operative complications associated with contemporary approaches to feminizing genitoplasty performed in young children will help guide families when making decisions about whether or not to proceed with surgery for female patients with moderate to severe genital atypia.
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Affiliation(s)
- Avi Baskin
- University of California San Francisco Medical Center, United States.
| | | | | | - Paul Austin
- Texas Children's Hospital and Baylor College of Medicine, United States.
| | | | - Earl Y Cheng
- Lurie Children's Hospital of Chicago, United States.
| | | | | | - Thomas Kolon
- Children's Hospital of Philadelphia, United States.
| | | | | | | | - Theresa Meyer
- Lurie Children's Hospital of Chicago, United States.
| | | | | | | | | | - Dix Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, United States.
| | | | | | | | | | | | | | - Laurence Baskin
- University of California San Francisco Medical Center, United States.
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13
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Bizic M, Stojanovic B, Bencic M, Bordás N, Djordjevic M. Overview on metoidioplasty: variants of the technique. Int J Impot Res 2020; 33:762-770. [PMID: 32826970 DOI: 10.1038/s41443-020-00346-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/28/2020] [Accepted: 08/13/2020] [Indexed: 11/09/2022]
Abstract
Number of gender dysphoric people increased over the last few decades with positive social acceptance of transpopulation. Genital gender affirming surgeries are of utmost importance in order to adjust body to the mind of these individuals. Creation of the phallus is usually the last step in transmen transition, which remains demanding and challenging for surgeons, with different options for phalloplasty available. The ideal phallus is esthetically appealing, with preserved tactile and erogenous sensation, enables standing micturition and sexual function with minimal donor-site morbidity. Metoidioplasty, as a variant of phalloplasty, uses the hormonally hypertrophied clitoris to create the neophallus. Metoidioplasty can be considered as a method of choice for thin-built individuals looking for male genitalia with preserved erogeneity, in one-stage genital gender affirming surgery. It can be combined together with removal of reproductive organs and vaginectomy. Preoperative consultation with patients and postoperative follow-up as well as multidisciplinary approach are essential for successful treatment.This literature review aims to assess and discuss different metoidioplasty approaches with a special reference to authors' current metoidioplasty technique.
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Affiliation(s)
- Marta Bizic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia. .,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia.
| | - Borko Stojanovic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Marko Bencic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Noémi Bordás
- Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia.,Department of Urology, Kiskunhalasi Semmelweis Kórház, Kiskunhalas, Hungary
| | - Miroslav Djordjevic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
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14
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Uzan C, Marchand F, Schmidt M, Meningaud JP, Hersant B. Clitoral reduction: Technical note. ANN CHIR PLAST ESTH 2020; 65:e7-e13. [PMID: 32482351 DOI: 10.1016/j.anplas.2019.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/30/2019] [Accepted: 10/10/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- C Uzan
- Department of Maxillofacial and Plastic & Reconstructive Surgery Henri-Mondor Hospital, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - F Marchand
- Department of Maxillofacial and Plastic & Reconstructive Surgery Henri-Mondor Hospital, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - M Schmidt
- Department of Maxillofacial and Plastic & Reconstructive Surgery Henri-Mondor Hospital, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - J P Meningaud
- Department of Maxillofacial and Plastic & Reconstructive Surgery Henri-Mondor Hospital, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - B Hersant
- Department of Maxillofacial and Plastic & Reconstructive Surgery Henri-Mondor Hospital, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
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15
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Kelling JA, Erickson CR, Pin J, Pin PG. Anatomical Dissection of the Dorsal Nerve of the Clitoris. Aesthet Surg J 2020; 40:541-547. [PMID: 31768527 DOI: 10.1093/asj/sjz330] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The clitoris is the primary somatosensory organ of female sexual response. Knowledge of its neural anatomy and related landmarks is essential for safe genital surgery. OBJECTIVES The aim of this study was to describe the distal course of the dorsal nerves of the clitoris and associated structures. METHODS Clitorises of 10 fresh cadavers were dissected. Measurements of the dorsal nerves, suspensory ligament, clitoral body, clitoral hood, and clitoral glans were obtained. The course of the dorsal nerves was examined. RESULTS The dorsal nerves of the clitoris were larger than expected, ranging from 2.0 to 3.2 mm in diameter, on average, along their course in the clitoral body. In 9 of 10 specimens, the dorsal nerves could be traced to within 6 mm of the glans. They traveled deep to a superficial clitoral fascia but superficial to the tunica albuginea, were variably located between 10 and 2 o'clock, and were separated by the deep suspensory ligament (DSL) of the clitoris. The mean length of the descending clitoral body, from the angle to the base of the glans, was 37.0 mm. The mean distance from the pubic rim to the DSL was 37.7 mm. CONCLUSIONS The clitoral body is substantial in length, mostly lying superficially under the clitoral hood and mons pubis. The dorsal nerves of the clitoris are large and superficial, terminating at or near the base of the clitoral glans. Knowledge of this anatomy is critical prior to performing surgery near the clitoris.
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Affiliation(s)
- Joseph A Kelling
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Cameron R Erickson
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jessica Pin
- Baylor University Medical Center, Dallas, TX
| | - Paul G Pin
- Baylor University Medical Center, Dallas, TX
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16
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Nidal S, Kocherov S, Jaber J, Levi-Khademi F, Farkas A, Chertin B. Sexual function and voiding status following one stage feminizing genitoplasty. J Pediatr Urol 2020; 16:97.e1-97.e6. [PMID: 31917157 DOI: 10.1016/j.jpurol.2019.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/25/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND The data on long-term outcome of feminizing genitoplasty (FG) with regard to the sexual function and voiding status is limited and nearly always retrospective, reviewing only small numbers of patients. Furthermore, most articles only looked at the success as an adequately open vagina with a feminized appearance. Success should include normal erotic sensation, lubrication, sexual satisfaction, orgasm, and intercourse without discomfort. These latter factors are just beginning to be studied OBJECTIVE: To investigate sexual function and voiding status in women who underwent vaginal reconstruction in childhood. MATERIAL AND METHODS We retrospectively reviewed medical files of patients who underwent FG at our center from 1988 to 2000. In addition, patients were asked to complete the following standardized questionnaires: Female Genital Self-Image Scale (FGSIS), dysfunctional voiding and incontinence symptoms score (DVISS), and Female Sexual Function Questionnaire (FSFI). RESULTS patients underwent one-stage FG; of those, 36 with median age of 21 years (range 18-30 years) who completed the puberty period were included into this study. Of the participants, 15 (41.6%) lived in a committed partnership, and 12 (80%) had sexual intercourse on a regular basis. Total FSFI was 22.2 + 3.1 (mean + SE). Domain scores were 3.9, 4.3, 4.5, 4.3, 4.9, and 4.7 for desire, arousal, lubrication, orgasm, satisfaction, and pain, respectively (Summary Figure). None of the patients reported on daytime incontinence or enuresis. Female genital self-image was found to be positive in all patients and related positively to women's sexual function. DISCUSSION The general rate of the sexual activity of our studied population was similar to that published in the literature 80% in our study vs 60-87% published in the literature. The overall FSFI was 22, showing some evidence of the female sexual dysfunction. However, only one patient regarding pain during vaginal penetration demonstrated mild dyspareunia. At the same time, we have not found any desire, arousal, lubrication, orgasm, satisfaction problems. Furthermore none of our patients complained on lower urinary tract symptoms during questioning, while three girls with congenital adrenal hyperplasia presented during follow-up with dribbling incontinence, which resolved with introitoplasty and creation of the wide vaginal opening. CONCLUSIONS Our data demonstrate that one -tage FG in childhood is a long-term effective surgical procedure that does not cause voiding dysfunction. If a secondary intervention is required prior to the sexual life, simple introitoplasty usually solves the problem. The FSFI score showed overall acceptable sexual function, whereas mild dyspareunia was a major complain.
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Affiliation(s)
- Sumira Nidal
- Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, Israel
| | - Stanislav Kocherov
- Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, Israel
| | - Jawdat Jaber
- Pediatric Endocrinology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, Israel
| | - Floris Levi-Khademi
- Pediatric Endocrinology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, Israel
| | - Amicur Farkas
- Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, Israel
| | - Boris Chertin
- Urology and Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, Israel.
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17
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Baskin L, Cao M, Sinclair A, Li Y, Overland M, Isaacson D, Cunha GR. Androgen and estrogen receptor expression in the developing human penis and clitoris. Differentiation 2020; 111:41-59. [PMID: 31655443 PMCID: PMC6926156 DOI: 10.1016/j.diff.2019.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/28/2019] [Accepted: 08/28/2019] [Indexed: 12/21/2022]
Abstract
To better understand how the human fetal penis and clitoris grows and remodels, we undertook an investigation to define active areas of cellular proliferation and programmed cell death spatially and temporally during development of human fetal external genitalia from the indifferent stage (8 weeks) to 18 weeks of gestation. Fifty normal human fetal penile and clitoral specimens were examined using macroscopic imaging, scanning electron microscopy and immunohistochemical localization for the cellular proliferation and apoptotic markers, Ki67 and Caspase-3. A number of hot spots of cellular proliferation characterized by Ki67 localization are present in the penis and clitoris especially early in development, most notably in the corporal body, glans, remodeling glanular urethra, the urethral plate, the roof of the urethral groove and the fully formed penile urethra. The 12-fold increase in penile length over 10 weeks of growth from 8 to 18 weeks of gestation based on Ki67 labelling appears to be driven by cellular proliferation in the corporal body and glans. Throughout all ages in both the developing penis and clitoris Ki67 labeling was consistently elevated in the ventral epidermis and ventral mesenchyme relative to the dorsal counterparts. This finding is consistent with the intense morphogenetic activity/remodeling in the ventral half of the genital tubercle in both sexes involving formation of the urethral/vestibular plates, canalization of the urethral/vestibular plates and fusion of the urethral folds to form the penile urethra. Areas of reduced or absent Ki67 staining include the urethral fold epithelium that fuses to form the penile tubular urethra. In contrast, the urethral fold mesenchyme is positive for Ki67. Apoptosis was rarely noted in the developing penis and clitoris; the only area of minimal Caspase-3 localization was in the epithelium of the ventral epithelial glanular channel remodeling.
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Affiliation(s)
- Laurence Baskin
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA.
| | - Mei Cao
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Adriane Sinclair
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Yi Li
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Maya Overland
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Dylan Isaacson
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Gerald R Cunha
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
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18
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Baskin L, Derpinghaus A, Cao M, Sinclair A, Li Y, Overland M, Cunha GR. Hot spots in fetal human penile and clitoral development. Differentiation 2019; 112:27-38. [PMID: 31874420 DOI: 10.1016/j.diff.2019.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 10/28/2019] [Accepted: 11/11/2019] [Indexed: 11/29/2022]
Abstract
To better understand how the human fetal penis and clitoris grows and remodels, we undertook an investigation to define active areas of cellular proliferation and programmed cell death spatially and temporally during development of human fetal external genitalia from the indifferent stage (8 weeks) to 18 weeks of gestation. Fifty normal human fetal penile and clitoral specimens were examined using macroscopic imaging, scanning electron microscopy and immunohistochemical localization for the cellular proliferation and apoptotic markers, Ki67 and Caspase-3, respectively. A number of hot spots of cellular proliferation characterized by Ki67 localization are present in the penis and clitoris especially early in development, most notably in the corporal body, glans, remodeling glanular urethra, the urethral plate, the roof of the urethral groove and the fully formed penile urethra. The 12-fold increase in penile length over 10 weeks of growth from 8 to 18 weeks of gestation based on Ki67 labelling appears to be driven by cellular proliferation in the corporal body and glans. Throughout all ages in both the developing penis and clitoris Ki67 labeling was consistently elevated in the ventral epidermis and ventral mesenchyme relative to the dorsal counterparts. This finding is consistent with the intense morphogenetic activity/remodeling in the ventral half of the genital tubercle in both sexes involving formation of the urethral/vestibular plates, canalization of the urethral/vestibular plates and fusion of the urethral folds to form the penile urethra. Areas of reduced or absent Ki67 staining include the urethral fold epithelium that fuses to form the penile tubular urethra. In contrast, the urethral fold mesenchyme is positive for Ki67. Apoptosis was rarely noted in the developing penis and clitoris; the only area of minimal Caspase-3 localization was in the epithelium of the ventral epithelial glanular channel remodeling.
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Affiliation(s)
- Laurence Baskin
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA.
| | - Amber Derpinghaus
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Mei Cao
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Adriane Sinclair
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Yi Li
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Maya Overland
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Gerald R Cunha
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
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19
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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Liao LM, Hegarty P, Creighton S, Lundberg T, Roen K. Clitoral surgery on minors: an interview study with clinical experts of differences of sex development. BMJ Open 2019; 9:e025821. [PMID: 31171549 PMCID: PMC6561419 DOI: 10.1136/bmjopen-2018-025821] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Clitoral surgery on minors diagnosed with differences of sex development is increasingly positioned as a violation of human rights. This qualitative study identified how health professionals (HPs) navigate the contentious issues as they offer care to affected families. DESIGN Qualitative analysis of audio-recorded semistructured interviews with HPs. All of the interviews were transcribed verbatim for theoretical thematic analysis. SETTING Twelve specialist multidisciplinary care centres for children, adolescents and adults diagnosed with a genetic condition associated with differences of sex development. PARTICIPANTS Thirty-two medical, surgical, psychological and nursing professionals and clinical scientists in 12 specialist centres in Britain and Sweden formed the interview sample. RESULTS All interviewees were aware of the controversial nature of clitoral surgery and perceived themselves and their teams as non-interventionist compared with other teams. Data analyses highlighted four strategies that the interviewees used to navigate their complex tasks: (1) engaging with new thinking, (2) holding on to historical assumptions, (3) reducing the burden of dilemmas and (4) being flexible. In response to recent reports and debates that challenge clitoral surgery on minors, HPs had revised some of their opinions. However, they struggled to reconcile their new knowledge with the incumbent norms in favour of intervention as they counsel care users with variable reactions and expectations. The flexible approach taken may reflect compromise, but the interviewees were often trapped by the contradictory values and assumptions. CONCLUSIONS If the pathology-based vocabularies and narratives about genital diversity could be modified, and normative assumptions are questioned more often, clinicians may be more adept at integrating their new knowledge into a more coherent model of care to address the psychosocial concerns that genital surgery purports to overcome.
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Affiliation(s)
- Lih-Mei Liao
- Women’s Health Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Peter Hegarty
- School of Psychology, University of Surrey, Guildford, UK
| | - Sarah Creighton
- Women’s Health Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tove Lundberg
- Department of Psychology, Lund University, Lund, Sweden
| | - Katrina Roen
- School of Social Sciences, University of Waikato, Hamilton, New Zealand
- Department of Psychology, University of Oslo, Oslo, Norway
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 554] [Impact Index Per Article: 92.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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Shen J, Isaacson D, Cao M, Sinclair A, Cunha GR, Baskin L. Immunohistochemical expression analysis of the human fetal lower urogenital tract. Differentiation 2018; 103:100-119. [PMID: 30287094 PMCID: PMC6589035 DOI: 10.1016/j.diff.2018.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/16/2018] [Accepted: 09/18/2018] [Indexed: 12/15/2022]
Abstract
We have studied the ontogeny of the developing human male and female urogenital tracts from 9 weeks (indifferent stage) to 16 weeks (advanced sex differentiation) of gestation by immunohistochemistry on mid-sagittal sections. Sixteen human fetal pelvises were serial sectioned in the sagittal plane and stained with antibodies to epithelial, muscle, nerve, proliferation and hormone receptor markers. Key findings are: (1) The corpus cavernosum in males and females extends into the glans penis and clitoris, respectively, during the ambisexual stage (9 weeks) and thus appears to be an androgen-independent event. (2) The entire human male (and female) urethra is endodermal in origin based on the presence of FOXA1, KRT 7, uroplakin, and the absence of KRT10 staining. The endoderm of the urethra interfaces with ectodermal epidermis at the site of the urethral meatus. (3) The surface epithelium of the verumontanum is endodermal in origin (FOXA1-positive) with a possible contribution of Pax2-positive epithelial cells implying additional input from the Wolffian duct epithelium. (4) Prostatic ducts arise from the endodermal (FOXA1-positive) urogenital sinus epithelium near the verumontanum. (5) Immunohistochemical staining of mid-sagittal and para-sagittal sections revealed the external anal sphincter, levator ani, bulbospongiosus muscle and the anatomic relationships between these developing skeletal muscles and organs of the male and female reproductive tracts. Future studies of normal human developmental anatomy will lay the foundation for understanding congenital anomalies of the lower urogenital tract.
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Affiliation(s)
- Joel Shen
- Department of Urology, University of California, San Francisco, San Francisco, CA, United States; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, United States
| | - Dylan Isaacson
- Department of Urology, University of California, San Francisco, San Francisco, CA, United States; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, United States
| | - Mei Cao
- Department of Urology, University of California, San Francisco, San Francisco, CA, United States; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, United States
| | - Adriane Sinclair
- Department of Urology, University of California, San Francisco, San Francisco, CA, United States; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, United States
| | - Gerald R Cunha
- Department of Urology, University of California, San Francisco, San Francisco, CA, United States; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, United States
| | - Laurence Baskin
- Department of Urology, University of California, San Francisco, San Francisco, CA, United States; Division of Pediatric Urology, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, United States.
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23
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Baskin L, Shen J, Sinclair A, Cao M, Liu X, Liu G, Isaacson D, Overland M, Li Y, Cunha GR. Development of the human penis and clitoris. Differentiation 2018; 103:74-85. [PMID: 30249413 DOI: 10.1016/j.diff.2018.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/21/2018] [Accepted: 08/21/2018] [Indexed: 12/17/2022]
Abstract
The human penis and clitoris develop from the ambisexual genital tubercle. To compare and contrast the development of human penis and clitoris, we used macroscopic photography, optical projection tomography, light sheet microscopy, scanning electron microscopy, histology and immunohistochemistry. The human genital tubercle differentiates into a penis under the influence of androgens forming a tubular urethra that develops by canalization of the urethral plate to form a wide diamond-shaped urethral groove (opening zipper) whose edges (urethral folds) fuse in the midline (closing zipper). In contrast, in females, without the influence of androgens, the vestibular plate (homologue of the urethral plate) undergoes canalization to form a wide vestibular groove whose edges (vestibular folds) remain unfused, ultimately forming the labia minora defining the vaginal vestibule. The neurovascular anatomy is similar in both the developing human penis and clitoris and is the key to successful surgical reconstructions.
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24
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Total urogenital sinus mobilization for ambiguous genitalia. J Pediatr Surg 2018; 53:808-812. [PMID: 28917585 DOI: 10.1016/j.jpedsurg.2017.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/11/2017] [Accepted: 08/11/2017] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Genital ambiguity is a very common phenomenon in disorders of sex development (DSD). According to the Chicago Consensus 2006, feminizing genitoplasty, when indicated, should be performed in the most virilized cases (Prader III to V). Advances in the knowledge of genital anatomy in DSD have enabled the development and improvement of various surgical techniques. Mobilization of the urogenital sinus (MUS), first described by Peña, has become incorporated by most surgeons. However, the proximity of the urethral sphincter prompts concern over urinary incontinence, especially for full mobilization of the urogenital sinus. OBJECTIVE To retrospectively evaluate the short-term surgical results of feminizing genitoplasty with total mobilization of the urogenital sinus in patients with DSD. METHODS Review of medical records of all patients undergoing feminizing genitoplasty with mobilization of the urogenital sinus. We evaluated the rates of complications from surgery and of urinary incontinence, as well as cosmetic results, according to the opinion of the surgeon and the family. RESULTS A total of 8 patients were included in the study. The mean age at surgery was 51months. Congenital adrenal hyperplasia (CAH) was diagnosed in six patients, and gonadal dysgenesis in the other two. The vagina was separated from the urethra, with suitable distance in all cases. No patient had urinary incontinence after surgery. The mean follow-up of patients was. 20months (3-56months). In all cases, surgeons recorded being satisfied with the aesthetic result of post-surgical genitalia. The family was recorded as satisfied with the aesthetic result of the genitalia after surgery. In every case, there was no need for a second surgical procedure. CONCLUSION The total mobilization of the urogenital sinus is a feasible and safe technique. The technique permits good cosmetic results, and urinary incontinence is absent. TYPE OF STUDY Therapeutic study. LEVEL OF EVIDENCE Level III.
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Abstract
Female patients with congenital adrenal hyperplasia (CAH) have varying degrees of atypical genitalia secondary to prenatal and postnatal androgen exposure. Surgical treatment is focused on restoring normal genitalia anatomy by bringing the vagina to the normal position on the perineum, separating the distal vagina from the urethra, forming a normal introitus and preserving sexual function of the clitoris by accepting moderate degrees of hypertrophy as normal and strategically reducing clitoral size only in the most severely virilized patients. There remains a need for continued monitoring of patients as they go through puberty with the possibility of additional surgery for vaginal stenosis. Anatomically based surgery and refinement in surgical techniques with acceptance of moderate degrees of clitoral hypertrophy as normal should improve long-term outcomes.
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Affiliation(s)
- Laurence S Baskin
- UCSF Benioff Children's Hospital, 1825 Fourth St, 5th Floor, San Francisco, CA 94143.
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26
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Abdulcadir J, Tille JC, Petignat P. Management of painful clitoral neuroma after female genital mutilation/cutting. Reprod Health 2017; 14:22. [PMID: 28178983 PMCID: PMC5299774 DOI: 10.1186/s12978-017-0288-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 01/20/2017] [Indexed: 12/02/2022] Open
Abstract
Background Traumatic neuromas are the result of regenerative disorganized proliferation of the proximal portion of lesioned nerves. They can exist in any anatomical site and are responsible for neuropathic pain. Post-traumatic neuromas of the clitoris have been described as an uncommon consequence of female genital mutilation/cutting (FGM/C). FGM/C involves partial or total removal of the female genital organs for non-therapeutic reasons. It can involve cutting of the clitoris and can cause psychological, sexual, and physical complications. We aimed to evaluate the symptoms and management of women presenting with a clitoral neuroma after female genital mutilation/cutting (FGM/C). Methods We identified women who attended our specialized clinic for women with FGM/C who were diagnosed with a traumatic neuroma of the clitoris between April 1, 2010 and June 30, 2016. We reviewed their medical files and collected socio-demographic, clinical, surgical, and histopathological information. Results Seven women were diagnosed with clitoral neuroma. Six attended our clinic to undergo clitoral reconstruction, and three of these suffered from clitoral pain. The peri-clitoral fibrosis was removed during clitoral reconstruction, which revealed neuroma of the clitoris in all six subjects. Pain was ameliorated after surgery. The seventh woman presented with a visible and palpable painful clitoral mass diagnosed as a neuroma. Excision of the mass ameliorated the pain. Sexual function improved in five women. One was not sexually active, and one had not yet resumed sex. Conclusion Post-traumatic clitoral neuroma can be a consequence of FGM/C. It can cause clitoral pain or be asymptomatic. In the case of pain symptoms, effective treatment is neuroma surgical excision, which can be performed during clitoral reconstruction. Surgery should be considered as part of multidisciplinary care. The efficacy of neuroma excision alone or during clitoral reconstruction to treat clitoral pain should be further assessed among symptomatic women.
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Affiliation(s)
- Jasmine Abdulcadir
- Department of Obstetrics and Gynecology, Geneva University Hospitals, 30 Bld de la Cluse, 30 Bld de la Cluse, 1211, Geneva, Switzerland. .,Faculty of Medicine, University of Geneva, Rue Michel Servet 1, 1205, Geneva, Switzerland.
| | - Jean-Christophe Tille
- Division of Clinical Pathology, Geneva University Hospitals, Rue Michel Servet 1, 1205, Geneva, Switzerland
| | - Patrick Petignat
- Department of Obstetrics and Gynecology, Geneva University Hospitals, 30 Bld de la Cluse, 30 Bld de la Cluse, 1211, Geneva, Switzerland
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27
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Wolffenbuttel KP, Menon VS, Grimsby GM, Ten Kate-Booij MJ, Baker LA. Clitoral hoodplasty in females with disorders of sex development. J Pediatr Urol 2017; 13:61.e1-61.e5. [PMID: 27623244 DOI: 10.1016/j.jpurol.2016.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/15/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The surgical management of girls with masculinized genitalia is gradually changing towards a more conservative approach. Reports on loss of clitoral sensitivity and related impairment of sexual function in women after feminizing genital surgery in childhood have been pivotal in this evolution. An exposed clitoral glans is occasionally seen at follow-up, and while patients may complain of aesthetics, no clitoral discomfort secondary to glans exposure has been reported. A technique has been developed to reconstruct the clitoral hood and the present study reports the preliminary results. OBJECTIVES To report the novel technique and preliminary results of clitoral hood reconstruction to cover an exposed glans after previous clitoroplasty in patients with congenital adrenal hyperplasia (CAH). PATIENTS AND METHODS Six female patients (mean age 13, range 4-21 years) with CAH sought medical help for clitoral concerns after previous reduction clitoroplasty. In two of the six patients, the main complaint was clitoral hypersensitivity or even pain. The clitoral glans was completely exposed in all patients, who were subsequently treated with a bi-laminar V-Y clitoral hoodplasty to create a mobile and natural-looking clitoral hood composed of an inner and outer preputial skin layer. RESULTS Postoperative covering of the glans was complete in five patients, and partial in one. The two patients with pre-operative pain became asymptomatic; all six patients were pleased with the cosmetic postoperative results. CONCLUSION Clitoral hoodplasty provides simple, yet effective, relief for women with cosmetic concerns or clitoral discomfort after previous feminizing surgery.
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Affiliation(s)
- K P Wolffenbuttel
- Department of Urology and Pediatric Urology, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, Netherlands
| | - V S Menon
- Children's Health - Children's Medical Center Dallas and Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G M Grimsby
- Children's Health - Children's Medical Center Dallas and Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Phoenix Children's Hospital, Phoenix, AZ, USA
| | - M J Ten Kate-Booij
- Department of Gynecology, Erasmus Medical Center, Rotterdam, Netherlands
| | - L A Baker
- Children's Health - Children's Medical Center Dallas and Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Wang LC, Poppas DP. Surgical outcomes and complications of reconstructive surgery in the female congenital adrenal hyperplasia patient: What every endocrinologist should know. J Steroid Biochem Mol Biol 2017; 165:137-144. [PMID: 26995108 DOI: 10.1016/j.jsbmb.2016.03.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 10/22/2022]
Abstract
Surgical management of classical congenital adrenal hyperplasia (CAH) in 46, XX females has evolved significantly. Virilization of the genitalia of 46, XX females with CAH begins prenatally as a result of excess fetal androgen production. Improved understanding of anatomy and surgical outcomes has driven changes in surgical techniques as well as the timing of surgery. For endocrinologists treating these patients, it is important to understand the outcome of genitoplasty, identify patients who need further treatment and direct these patients to experienced surgeons. We performed a literature search on PubMed of publications addressing CAH and genital reconstruction published in the English language from 1990 to the present. In accordance with our institutional review board, we performed a retrospective analysis of clitoroplasty and/or vaginoplasty procedures performed by a single surgeon at our institution from 1996 to 2015. We found that genital reconstruction in 46, XX CAH patients is associated with few immediate post-operative, infectious, and urinary complications. Vaginal stenosis is a common complication of vaginal reconstruction and requires evaluation by an experienced surgeon. Clitoral pain or decreased sensation can be associated with clitoral recession and clitorectomy. Outcomes in sexual satisfaction and gender identity can also be impacted by surgical technique and success. Long term follow up and patient reported feedback are crucial to our understanding and management of this special group of patients. Improved awareness and understanding of the complications of genital surgery will allow endocrinologists to know what to ask patients and be ready to provide them with a resource with the understanding and experience to help them improve their quality of life.
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Affiliation(s)
- Lily C Wang
- The Comprehensive Center for Congenital Adrenal Hyperplasia, The Komansky Center for Children's Health, Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States.
| | - Dix P Poppas
- The Comprehensive Center for Congenital Adrenal Hyperplasia, The Komansky Center for Children's Health, Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States
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Higuchi T, Holmdahl G, Kaefer M, Koyle M, Wood H, Woodhouse C, Wood D. International Consultation on Urological Diseases: Congenital Anomalies of the Genitalia in Adolescence. Urology 2016; 94:288-310. [DOI: 10.1016/j.urology.2016.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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30
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Shen J, Overland M, Sinclair A, Cao M, Yue X, Cunha G, Baskin L. Complex epithelial remodeling underlie the fusion event in early fetal development of the human penile urethra. Differentiation 2016; 92:169-182. [PMID: 27397682 DOI: 10.1016/j.diff.2016.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 06/20/2016] [Indexed: 11/17/2022]
Abstract
We recently described a two-step process of urethral plate canalization and urethral fold fusion to form the human penile urethra. Canalization ("opening zipper") opens the solid urethral plate into a groove, and fusion ("closing zipper") closes the urethral groove to form the penile urethra. We hypothesize that failure of canalization and/or fusion during human urethral formation can lead to hypospadias. Herein, we use scanning electron microscopy (SEM) and analysis of transverse serial sections to better characterize development of the human fetal penile urethra as contrasted to the development of the human fetal clitoris. Eighteen 7-13 week human fetal external genitalia specimens were analyzed by SEM, and fifteen additional human fetal specimens were sectioned for histologic analysis. SEM images demonstrate canalization of the urethral/vestibular plate in the developing male and female external genitalia, respectively, followed by proximal to distal fusion of the urethral folds in males only. The fusion process during penile development occurs sequentially in multiple layers and through the interlacing of epidermal "cords". Complex epithelial organization is also noted at the site of active canalization. The demarcation between the epidermis of the shaft and the glans becomes distinct during development, and the epithelial tag at the distal tip of the penile and clitoral glans regresses as development progresses. In summary, SEM analysis of human fetal specimens supports the two-zipper hypothesis of formation of the penile urethra. The opening zipper progresses from proximal to distal along the shaft of the penis and clitoris into the glans in identical fashion in both sexes. The closing zipper mechanism is active only in males and is not a single process but rather a series of layered fusion events, uniquely different from the simple fusion of two epithelial surfaces as occurs in formation of the palate and neural tube.
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Affiliation(s)
- Joel Shen
- UCSF Benioff Children's Hospital, Division of Pediatric Urology
- Department of Urology, University of California San Francisco, 400 Parnassus Avenue, Box A610, San Francisco, CA 94143
| | - Maya Overland
- UCSF Benioff Children's Hospital, Division of Pediatric Urology
- Department of Urology, University of California San Francisco, 400 Parnassus Avenue, Box A610, San Francisco, CA 94143
| | - Adriane Sinclair
- UCSF Benioff Children's Hospital, Division of Pediatric Urology
- Department of Urology, University of California San Francisco, 400 Parnassus Avenue, Box A610, San Francisco, CA 94143
| | - Mei Cao
- UCSF Benioff Children's Hospital, Division of Pediatric Urology
- Department of Urology, University of California San Francisco, 400 Parnassus Avenue, Box A610, San Francisco, CA 94143
| | - Xuan Yue
- UCSF Benioff Children's Hospital, Division of Pediatric Urology
- Department of Urology, University of California San Francisco, 400 Parnassus Avenue, Box A610, San Francisco, CA 94143
| | - Gerald Cunha
- UCSF Benioff Children's Hospital, Division of Pediatric Urology
- Department of Urology, University of California San Francisco, 400 Parnassus Avenue, Box A610, San Francisco, CA 94143
| | - Laurence Baskin
- UCSF Benioff Children's Hospital, Division of Pediatric Urology
- Department of Urology, University of California San Francisco, 400 Parnassus Avenue, Box A610, San Francisco, CA 94143
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31
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Reifsnyder JE, Stites J, Bernabé KJ, Galan D, Felsen D, Poppas DP. Nerve Sparing Clitoroplasty is an Option for Adolescent and Adult Female Patients with Congenital Adrenal Hyperplasia and Clitoral Pain following Prior Clitoral Recession or Incomplete Reduction. J Urol 2016; 195:1270-3. [DOI: 10.1016/j.juro.2015.12.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Jennifer E. Reifsnyder
- Comprehensive Center for Congenital Adrenal Hyperplasia and Institute for Pediatric Urology, Komansky Center for Children’s Health, Department of Urology, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York
| | - John Stites
- Comprehensive Center for Congenital Adrenal Hyperplasia and Institute for Pediatric Urology, Komansky Center for Children’s Health, Department of Urology, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York
| | - Kerlly J. Bernabé
- Comprehensive Center for Congenital Adrenal Hyperplasia and Institute for Pediatric Urology, Komansky Center for Children’s Health, Department of Urology, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York
| | - Denise Galan
- Comprehensive Center for Congenital Adrenal Hyperplasia and Institute for Pediatric Urology, Komansky Center for Children’s Health, Department of Urology, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York
| | - Diane Felsen
- Comprehensive Center for Congenital Adrenal Hyperplasia and Institute for Pediatric Urology, Komansky Center for Children’s Health, Department of Urology, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York
| | - Dix P. Poppas
- Comprehensive Center for Congenital Adrenal Hyperplasia and Institute for Pediatric Urology, Komansky Center for Children’s Health, Department of Urology, New York-Presbyterian Hospital-Weill Cornell Medicine, New York, New York
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Mutilación genital y reconstrucción del clítoris. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2016. [DOI: 10.1016/j.gine.2015.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Overland M, Li Y, Cao M, Shen J, Yue X, Botta S, Sinclair A, Cunha G, Baskin L. Canalization of the Vestibular Plate in the Absence of Urethral Fusion Characterizes Development of the Human Clitoris: The Single Zipper Hypothesis. J Urol 2016; 195:1275-83. [PMID: 26926534 DOI: 10.1016/j.juro.2015.07.117] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE We characterized the early gestation development of the female external genitalia using optical projection tomography to visualize anatomical structures at high resolution. MATERIALS AND METHODS First and early second trimester human female fetal external genitalia were collected with consent after voluntary termination. Specimens labeled with anti-E-Cadherin antibody underwent analysis with optical projection tomography. Histological sections were immunostained for androgen receptor, 5α-reductase, Ki67 for proliferation and Caspase 3 for apoptosis. RESULTS Three-dimensional reconstructions demonstrated proximal to distal canalization of the epithelial vestibular plate and formation of a vestibular groove, which remained open. Ki67 was observed throughout with greatest density in the dorsal vestibular plate at the level of the opening groove. Staining for Caspase 3 was minimal in all sections. Androgen receptor staining was seen throughout the mesenchyme and in the apical epithelium of the dorsal vestibular groove. Throughout the epithelium and epidermis 5α-reductase staining was observed. CONCLUSIONS Early development of the external genitalia in the female is analogous to that in the male, demonstrating a similar opening zipper driving canalization of the vestibular plate with localized epithelial proliferation in the absence of significant apoptosis. Thus we hypothesize that the mechanism underlying the opening zipper must be androgen independent and the absence of androgen driven urethral fusion characterizes the normal development of the human clitoris.
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Affiliation(s)
- Maya Overland
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Yi Li
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Mei Cao
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Joel Shen
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Xuan Yue
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Sisir Botta
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Adriane Sinclair
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Gerald Cunha
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Laurence Baskin
- Division of Pediatric Urology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California.
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Alexander MS, Kozyrev N, Bosma RL, Figley CR, Richards JS, Stroman PW. fMRI Localization of Spinal Cord Processing Underlying Female Sexual Arousal. JOURNAL OF SEX & MARITAL THERAPY 2016; 42:36-47. [PMID: 25635474 DOI: 10.1080/0092623x.2015.1010674] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Using functional magnetic resonance imaging, the authors aimed to determine the roles of the human spinal cord in mediating sexual responses in women. Functional magnetic resonance imaging of the entire lower thoracic, lumbar, and sacral spinal cord was performed using a sexual stimulation paradigm designed to elicit psychological and physical components of sexual arousal. Responses were measured in 9 healthy adult women during 3 consecutive conditions: (a) erotic audiovisual, (b) manual clitoral, and (c) audiovisual plus manual stimulation. Functional magnetic resonance imaging results in healthy subjects demonstrate that this method is sensitive for mapping sexual function in the spinal cord, and identify several key regions involved in human sexual response, including the intermediolateral cell column, the dorsal commissural nucleus, and the sacral parasympathetic nucleus. Using spinal functional magnetic resonance imaging, this study identified many of the spinal cord regions involved in female sexual responses. Results from audiovisual and manual clitoral stimulation correspond with previous data regarding lumbar and sacral neurologic changes during sexual arousal. This study provides the first characterization of neural activity in the human spinal cord underlying healthy female sexual responses and sets a foundation for future studies aimed at mapping changes that result from sexual dysfunction, spinal cord trauma or disease.
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Affiliation(s)
- Marcalee S Alexander
- a Department of Physical Medicine and Rehabilitation , University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Natalie Kozyrev
- b Centre for Neuroscience Studies , Queen's University , Kingston , Ontario , Canada
| | - Rachael L Bosma
- b Centre for Neuroscience Studies , Queen's University , Kingston , Ontario , Canada
| | - Chase R Figley
- b Centre for Neuroscience Studies , Queen's University , Kingston , Ontario , Canada
| | - J Scott Richards
- a Department of Physical Medicine and Rehabilitation , University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Patrick W Stroman
- b Centre for Neuroscience Studies , Queen's University , Kingston , Ontario , Canada
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Park H, Kim W, Kim H, Yeo H. Reduction Clitoroplasty with Preservation of the Dorsal Neurovascular Pedicle in a 6-Year-Old Female: A Case Report. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2016. [DOI: 10.14730/aaps.2016.22.2.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Hyochun Park
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Wonwoo Kim
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Hoonnam Kim
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
| | - Hyeonjung Yeo
- Department of Plastic and Reconstructive Surgery, Daegu Fatima Hospital, Daegu, Korea
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Mazloomdoost D, Pauls RN. A Comprehensive Review of the Clitoris and Its Role in Female Sexual Function. Sex Med Rev 2015; 3:245-263. [DOI: 10.1002/smrj.61] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Miyashita T. Fishing for jaws in early vertebrate evolution: a new hypothesis of mandibular confinement. Biol Rev Camb Philos Soc 2015; 91:611-57. [DOI: 10.1111/brv.12187] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/18/2015] [Accepted: 03/19/2015] [Indexed: 12/21/2022]
Affiliation(s)
- Tetsuto Miyashita
- Department of Biological Sciences; University of Alberta; Edmonton Alberta T6G 2E9 Canada
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Stojanovic B, Djordjevic ML. Anatomy of the clitoris and its impact on neophalloplasty (metoidioplasty) in female transgenders. Clin Anat 2015; 28:368-75. [PMID: 25740576 DOI: 10.1002/ca.22525] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 01/20/2015] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Borko Stojanovic
- Department of Urology, University Children's Hospital, Tirsova 10, Belgrade
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Schober JM, Alguacil NM, Cooper RS, Pfaff DW, Meyer-Bahlburg HF. Self-assessment of anatomy, sexual sensitivity, and function of the labia and vagina. Clin Anat 2015; 28:355-62. [DOI: 10.1002/ca.22503] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 12/11/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Justine M. Schober
- Pediatric Urology, UPMC Hamot; Erie Pennsylvania
- Pfaff Laboratory of Neurobiology and Behavior, Rockefeller University; New York New York
| | - Nieves Martin Alguacil
- Pfaff Laboratory of Neurobiology and Behavior, Rockefeller University; New York New York
- Department of Anatomy and Embryology; School of Veterinary Medicine, Universidad Complutense de Madrid; Spain
| | - R. Scott Cooper
- Lake Erie College of Osteopathic Medicine; Erie Pennsylvania
| | - Donald W. Pfaff
- Pfaff Laboratory of Neurobiology and Behavior, Rockefeller University; New York New York
| | - Heino F.L. Meyer-Bahlburg
- NYS Psychiatric Institute/Department of Psychiatry; College of Physicians and Surgeons of Columbia University; New York New York
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Schober J, Aardsma N, Mayoglou L, Pfaff D, Martín-Alguacil N. Terminal innervation of female genitalia, cutaneous sensory receptors of the epithelium of the labia minora. Clin Anat 2015; 28:392-8. [DOI: 10.1002/ca.22502] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/11/2014] [Indexed: 01/11/2023]
Affiliation(s)
- Justine Schober
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
- UPMC Hamot; Erie Pennsylvania
| | - Nathan Aardsma
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
- Lake Erie College of Osteopathic Medicine; Erie Pennsylvania
| | - Lazarus Mayoglou
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
- UPMC Hamot; Erie Pennsylvania
| | - Donald Pfaff
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
| | - Nieves Martín-Alguacil
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
- Department of Anatomy and Embryology; School of Veterinary Medicine, Universidad Complutense de Madrid; Madrid Spain
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Martín-Alguacil N, Cooper RS, Aardsma N, Mayoglou L, Pfaff D, Schober J. Terminal innervation of the male genitalia, cutaneous sensory receptors of the male foreskin. Clin Anat 2015; 28:385-91. [DOI: 10.1002/ca.22501] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 12/05/2014] [Indexed: 12/15/2022]
Affiliation(s)
- Nieves Martín-Alguacil
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
- Department of Anatomy and Embryology; School of Veterinary Medicine, Universidad Complutense de Madrid; Madrid Spain
| | - R. Scott Cooper
- UPMC Hamot; Erie Pennsylvania
- Lake Erie College of Osteopathic Medicine; Erie Pennsylvania
| | - Nathan Aardsma
- UPMC Hamot; Erie Pennsylvania
- Lake Erie College of Osteopathic Medicine; Erie Pennsylvania
| | - Lazarus Mayoglou
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
- UPMC Hamot; Erie Pennsylvania
| | - Donald Pfaff
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
| | - Justine Schober
- Department of Neurobiology and Behavior; Rockefeller University; New York New York
- UPMC Hamot; Erie Pennsylvania
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Lee PA, Wisniewski AB, Baskin L, Vogiatzi MG, Vilain E, Rosenthal SM, Houk C. Advances in diagnosis and care of persons with DSD over the last decade. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2014. [DOI: 10.1186/1687-9856-2014-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Capek S, Tubbs RS, Spinner RJ. Do cutaneous nerves cross the midline? Clin Anat 2014; 28:96-100. [DOI: 10.1002/ca.22427] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 05/27/2014] [Accepted: 05/28/2014] [Indexed: 01/23/2023]
Affiliation(s)
- Stepan Capek
- Department of Neurosurgery; Mayo Clinic; Rochester Minnesota
- International Clinical Research Center, St. Anne's University Hospital Brno; Brno Czech Republic
| | - R. Shane Tubbs
- Division of Pediatric Neurosurgery; Children's Hospital; Birmingham Alabama
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The role of clitoral anatomy in female to male sex reassignment surgery. ScientificWorldJournal 2014; 2014:437378. [PMID: 24982953 PMCID: PMC4005052 DOI: 10.1155/2014/437378] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/20/2014] [Indexed: 11/29/2022] Open
Abstract
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.
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Balaya V, Aubin A, Rogez JM, Douard R, Delmas V. [The dorsal nerve of the clitoris: surgical applications]. Morphologie 2014; 98:8-17. [PMID: 24462285 DOI: 10.1016/j.morpho.2013.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/09/2013] [Accepted: 12/24/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To describe the course of the dorsal nerve of the clitoris (DNC) to better define its anatomy in the human adult and to help surgeons to avoid iatrogenic injury during surgical procedures. METHOD An extensive review of the current literature was done on Medline via PubMed by using the following keywords: "anatomie du clitoris", "anatomy of clitoris", "nerf dorsal du clitoris", "dorsal nerve of clitoris", "réparation clitoridienne", "transposition clitoridienne", "surgery of the clitoris", "clitoridoplasty". This review analyzed dissection, magnetic resonance imaging, 3-dimensional sectional anatomy reconstruction and immuno-histochemical studies. RESULTS The DNC comes from the pudendal nerve. He travels from under the inferior pubis ramus to the posterosuperior edge of the clitoral crus. The DNC reappears under the pubic symphysis and enters the deep component of the suspensory ligament. He runs on the dorsal face of the clitoral body at 11 and 1 o'clock. Distally, he gives many nervous ramifications, runs along the tunica and enters the glans. CONCLUSION The NDC might be surgically injured (i) under the pubic symphysis, at the union of the two crus of clitoris and (ii) on the dorsal surface of the clitoral body. The pathway of the DNC on the dorsal face of the clitoris permits to approach the ventral face of the clitoris without risk of iatrogenic injuries. The distance between the pubic symphysis and the DNC implies that the incision should be done just under the pubic symphysis. Distally, the dissection of the DNC next the glands appears as dangerous and impossible, considering that the DNC is too close to the glandular tissues.
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Affiliation(s)
- V Balaya
- URDIA EA 4465, université Paris Descartes, 45, rue des Saints-Pères, 75006 Paris, France; Service d'obstétrique et de chirurgie gynécologique, hôpital de la Pitié-Salpétrière, 47, boulevard de l'Hôpital, 75013 Paris, France
| | - A Aubin
- Laboratoire d'anatomie, faculté de médecine, université de Nantes, 1, rue Gaston-Veil, 44035 Nantes cedex, France
| | - J-M Rogez
- Laboratoire d'anatomie, faculté de médecine, université de Nantes, 1, rue Gaston-Veil, 44035 Nantes cedex, France
| | - R Douard
- URDIA EA 4465, université Paris Descartes, 45, rue des Saints-Pères, 75006 Paris, France; Service de chirurgie générale et digestive, hôpital Avicenne, 125, rue de Stalingrad, 93000 Bobigny, France; UFR SMBH, université Paris-Nord, 74, rue Marcel-Cachin, 93017 Bobigny, France.
| | - V Delmas
- URDIA EA 4465, université Paris Descartes, 45, rue des Saints-Pères, 75006 Paris, France; Service d'urologie, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France
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Bronselaer G, Callens N, De Sutter P, De Cuypere G, T'Sjoen G, Cools M, Hoebeke P. Self‐Assessment of Genital Anatomy and Sexual Function within a Belgian, Dutch‐Speaking Female Population: A Validation Study. J Sex Med 2013; 10:3006-18. [DOI: 10.1111/jsm.12326] [Citation(s) in RCA: 9] [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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Abstract
The management of congenital adrenal hyperplasia involves suppression of adrenal androgen production, in addition to treatment of adrenal insufficiency. Management of adolescents with congenital adrenal hyperplasia is especially challenging because changes in the hormonal milieu during puberty can lead to inadequate suppression of adrenal androgens, psychosocial issues often affect adherence to medical therapy, and sexual function plays a major part in adolescence and young adulthood. For these reasons, treatment regimen reassessment is indicated during adolescence. Patients with non-classic congenital adrenal hyperplasia require reassessment regarding the need for glucocorticoid drug treatment. No clinical trials have compared various regimens for classic congenital adrenal hyperplasia in adults, thus therapy is individualised and based on the prevention of adverse outcomes. Extensive patient education is key during transition from paediatric care to adult care and should include education of females with classic congenital adrenal hyperplasia regarding their genital anatomy and surgical history. Common issues for these patients include urinary incontinence, vaginal stenosis, clitoral pain, and cosmetic concerns; for males with classic congenital adrenal hyperplasia, common issues include testicular adrenal rest tumours. Transition from paediatric to adult care is most successful when phased over many years. Education of health-care providers on how to successfully transition patients is greatly needed.
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Affiliation(s)
- Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
| | - Dix P Poppas
- the Institute for Pediatric Urology, Comprehensive Center for Congenital Adrenal Hyperplasia, Komansky Center for Children's Health, New York Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
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Oakley SH, Mutema GK, Crisp CC, Estanol MV, Kleeman SD, Fellner AN, Pauls RN. Innervation and Histology of the Clitoral–Urethal Complex: A Cross-Sectional Cadaver Study. J Sex Med 2013; 10:2211-8. [DOI: 10.1111/jsm.12230] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lesma A, Bocciardi A, Corti S, Chiumello G, Rigatti P, Montorsi F. Sexual function in adult life following Passerini-Glazel feminizing genitoplasty in patients with congenital adrenal hyperplasia. J Urol 2013; 191:206-11. [PMID: 23933397 DOI: 10.1016/j.juro.2013.07.097] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE We assessed external genitalia sensitivity and sexual function in adults with congenital adrenal hyperplasia who had undergone Passerini-Glazel feminizing genitoplasty as children, and compared them to a control group of healthy counterparts. MATERIALS AND METHODS Inclusion criteria were congenital adrenal hyperplasia, Passerini-Glazel feminizing genitoplasty, adult age and penetrative vaginal intercourse. Thermal and vibratory sensitivity of the clitoris, vagina and labia minora were analyzed using the Genito Sensory Analyzer (Medoc Ltd., Minnetonka, Minnesota). Psychosexual outcome was assessed with the Beck Depression Inventory, Zung Self-Rating Anxiety Scale, Female Sexual Distress Scale and Female Sexual Function Index. Matched analyses were performed to compare outcomes in patients to controls (healthy medical students). All statistical tests were performed using SPSS®, version 18.0 RESULTS: A total of 12 patients (10%) entered the study. Thermal and vibratory clitoral sensitivity was significantly decreased in all patients compared to healthy controls (p <0.01). There was no difference in thermal or vibratory vaginal sensitivity between patients and controls. On the Female Sexual Distress Scale 11 patients (91.6%) and 11 controls (91.6%) described a stable satisfactory relationship. All patients reported active sexual desire, good arousal, adequate lubrication and orgasm. No significant difference in Female Sexual Function Index global score or single domain scores was observed between patients and controls. CONCLUSIONS Although clitoral sensitivity in sexually active patients with congenital adrenal hyperplasia treated with Passerini-Glazel feminizing genitoplasty is significantly reduced compared to controls, sexual function in those patients is not statistically or clinically significantly different from their healthy counterparts. Finally, 1-stage Passerini-Glazel feminizing genitoplasty seems to allow normal adult sexual function.
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Affiliation(s)
- Arianna Lesma
- Department of Urology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Aldo Bocciardi
- Department of Urology, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Stefano Corti
- Department of Urology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Giuseppe Chiumello
- Department of Pediatrics, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Patrizio Rigatti
- Department of Urology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Francesco Montorsi
- Department of Urology, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Shih C, Cold CJ, Yang CC. Cutaneous Corpuscular Receptors of the Human Glans Clitoris: Descriptive Characteristics and Comparison with the Glans Penis. J Sex Med 2013; 10:1783-9. [DOI: 10.1111/jsm.12191] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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