Controversies on clitoroplasty

Challenges in the treatment of late-identified untreated congenital adrenal hyperplasia due to CYP11B1 deficiency: Lessons from a developing country

BACKGROUND

Congenital Adrenal Hyperplasia (CAH) due to CYP11B1 is a rare autosomal recessive adrenal disorder that causes a decrease in cortisol production and accumulation of adrenal androgens and steroid precursors with mineralocorticoid activity. Clinical manifestations include cortisol deficiency, ambiguous genitalia in females (differences of sex development (DSD)), and hypertension. Medical treatment recommendations are well defined, consisting of glucocorticoid treatment to substitute glucocorticoid deficiency and consequently normalize adrenal androgen and precursors levels. Current guidelines also emphasize the need for specialized multidisciplinary DSD teams and psychosocial support. In many developing countries, care for DSD patients, especially when caused by an adrenal disease, is challenging due to the lack of infrastructure, knowledge, and medication.

OBJECTIVE

The study aims to report the conflicting decision-making process of medical treatment and sex assignment in late-identified CAH patients in developing countries.

METHODS

We describe the clinical and biochemical findings and the psychological assessment of five affected but untreated family members with CAH due to CYP11B1 deficiency.

RESULTS

All patients had a 46,XX karyotype, ambiguous genitalia, low cortisol levels, and hypertension. Two identified as males, two as females, and one had undecided gender. The patients were counselled that refusing treatment will lead to infertility and the potential risk of developing Addisonian crisis and severe hypertension. However, all 46,XX CAH males refused treatment with glucocorticoids due to the expected lowering of adrenal androgens as their main source of testosterone. None of the patients developed Addisonian crisis, probably due to some residual cortisol activity and glucocorticoid activity of elevated adrenal steroid precursors.

CONCLUSION

Medical treatment and sex assignment in late-identified 46,XX CAH patients in Indonesia may often depend on local and cultural factors. The management of DSD conditions may have to be individualized and integrated into the psychological and social context of the affected family.

Nerve sparing clitoroplasty in a rare case of idiopathic clitoromegaly

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

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

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

Antley-Bixler syndrome: surgical management of ambiguous genitalia - a case report

OBJECTIVE

To report a case of type 2 Antley-Bixler syndrome (ABS).

SUBJECT AND METHODS

A 3-year-old boy who had been raised male, with facial dimorphism and malformations of both elbows and forearms, was referred to our unit for ambiguous genitalia. Genetic testing confirmed the diagnosis of ABS. A surgical intervention was performed to correct the ambiguous genitalia through a combined perineal and transabdominal approach.

RESULTS

The postoperative course was uneventful and the patient was released from the hospital 10 days after the surgery.

CONCLUSION

Repair of the ambiguous genitalia in this patient was possible, but definitive inferences on the benefit of this intervention cannot be made without long-term follow-up.