The Differential Diagnosis of Ambiguous Genitalia in the Newborn

Ambiguous genitalia: etiology, treatment, and nursing implications

The infant presenting with ambiguous genitalia is a challenge to both the medical and nursing staff. The birth of any infant with ambiguous genitalia is considered a physical and psychologic emergency requiring prompt recognition and treatment for a positive outcome. A review of the etiology, presentation, diagnosis, and treatment of ambiguous genitalia is presented. The important aspects of family care also are discussed.

Male pseudohermaphroditism: factors determining the gender of rearing in Saudi Arabia

OBJECTIVE

Experience with male pseudohermaphrodites at King Fahd Hospital of King Faisal University, Al-Khobar, Saudi Arabia from 1981 to 1991 was reviewed to ascertain the factors determining the gender of rearing.

METHODS

The records of 14 patients consisting of 6 prepubertal and 8 postpubertal patients were studied. None of the patients had any prior evaluation or treatment, since their gender assignment at birth was carried out by midwives in rural communities. The males presented to our hospital with ambiguous genitalia: small phallus, bifid scrotum, perineoscrotal hypospadias, and undescended testes (UDT). Most of those raised as females presented in the postpubertal period seeking remedy for deep voice, excessive musculature, facial hair, erection of the phallus, ejaculation, inappropriate attraction to the female sex, and primary amenorrhea. As their male genotype became determined, all the patients and/or their parents, with the exception of one, insisted on appropriate reconstructive surgery to the male gender. This report focuses primarily on 11 patients assigned a female gender at birth, 10 of whom insisted on a gender change.

RESULTS

Most adolescents and adults still complained of small penises after reconstructive surgery, but cherished their male role.

CONCLUSIONS

The male genotype is a more important factor than phallic adequacy in determining the gender of rearing in the Kingdom of Saudi Arabia, an observation attributable to the financial, social, and cultural benefits that the male gender confers in Saudi society.

Early gender assignment in true hermaphroditism

True hermaphroditism is a rare form of intersex anomaly where both male and female gonads are present. True hermaphrodites diagnosed in the past have been preferentially reared as males. However, based on the appearance of their external genitalia and the ability to reconstruct a functional genitourinary system, most of these children should be raised as girls. Between 1968 and 1987, we managed eight children with true hermaphroditism. The karyotypes were as follows: five 46XX, one 46XY, one 47XXY, and one 46XX/mosaic. Gonadal distribution was bilateral (two ovotestes) in two, lateral (testis and ovary) in two, and unilateral (ovotestis and ovary) in four. Seven patients were diagnosed shortly after birth. Six were raised as girls, two as boys. Based on a review of the relationship of external-internal genitalia, gonads, and karyotype of our own patients and those published by others, we believe that the appearance of the external genitalia alone allows a prompt and definitive gender assignment in infancy. This led us to develop a classification of external genitalia based on the following characteristics. Class I represents normal female genitalia, class II an enlarged clitoris, class III partially fused labioscrotal folds, class IV fused labioscrotal folds, class V a hypoplastic scrotum and penoscrotal hypospadias, and class VI represents normal male genitalia. We had two patients that were class II, two class III, three that were class IV, and one to IV should be raised as females; in class V, male gender assignment is preferable. This classification, based on the appearance of the external genitalia, allows a simple screening and prompt gender assignment in infants identified as true hermaphrodites.

Gender assignment in male pseudohermaphrodite children

Experience with male pseudohermaphrodites at The Hospital for Sick Children, Toronto, from 1976 to 1981 was reviewed to identify factors that had influenced gender assignment. Seventeen children with microphallus, ambiguous genitalia, and 46 XY karoytype were studied. Five had been raised as females and 12 as males. Of those raised as females, 3 were from families with prior experience of androgen insensitivity. The other 2 had gross perineal abnormalities in addition to genital ambiguity. Of those raised as males 6 were not considered for gender reassignment, 4 because they were too old at presentation, and the other 2 because of parental refusal. In this series the parents were not prepared to accept gender reassignment on the basis of a small phallus alone. Androgen stimulation so far has been a reliable indicator of phallic growth potential, but long-term follow-up is necessary to determine its true value.