Malaysian Females With Congenital Adrenal Hyperplasia: Surgical Outcomes and Attitudes

Background: Girls born with congenital adrenal hyperplasia have virilized external genitalia. There is considerable debate regarding both the outcomes of feminizing genitoplasty and timing of the surgery in this population. Objective: To investigate outcomes of females 46,XX individuals with CAH in Malaysia, the surgical outcomes of feminizing genitoplasty (FG) and their attitudes toward surgery. Study Design: This is a cross-sectional study involving the two main tertiary centers in Malaysia. All 46,XX patients with CAH and raised female, who had undergone FG were identified and invited to participate. Data on socio-demographic, medical profiles, and attitudes toward surgery were collected. A standardized evaluation of the external genitalia was undertaken including the anatomic and cosmetic evaluation by independent gynecologists. Results: Of 61 individuals identified, 59 participated-consisting of children (n = 12), adolescents (n = 29) and adults (n = 18). All but one had classical CAH (98.3%) and had undergone FG (n = 55, 93.2%) with surgery mostly undertaken by pediatric surgeons trained in DSD work (n = 44, 74.6%). Complications overall were low (20.3%), with repeat surgery rate of 9.1%. External genital examination was performed in 38 participants. Overall 36.8% had absent clitoral glands and 39.5% had a persistent urogenital sinus and in 10.5%, no vaginal orifices were seen. Poor cosmetic outcomes were present in 42.1% with 55.3% recommended for further assessment under general anesthetic. Almost half participants did not venture an opinion on FG, those who did varied from having a positive attitude toward it (18 participants) to 3 opining that it should not be done, or avoided or delayed. From the participants, 35.5% preferred FG to be done early in life compared to 44.0% of the parents. Conclusions: The reoperation rates of the feminizing genitoplasty surgeries were low however due to the anatomic and cosmetic outcomes, reassessment of the external genitalia of these CAH patients may be required once they consider becoming sexually active as they may require further treatment. Many factors such as cultural sensitivities and access to medical treatment and late diagnoses have an impact on attitudes toward FG.

Tissue-preserving feminizing clitoroplasty: a preliminary report

OBJECTIVE

To describe a tissue-preserving feminizing clitoroplasty that potentially allows for future total reversal to male and report on its initial result.

MATERIAL AND METHODS

A potentially reversible operation for feminizing clitoroplasty that preserves all available tissue was performed in three patients: two girls with congenital adrenal hyperplasia and a '46XY male' with androgen insensitivity. The phallus was disassembled into its individual components of the phallic skin, left and right corpus cavernosum, dorsal neurovascular bundle with the dorsal portion of the glans, and 'urethral plate-corpus spongiosum complex' with the ventral portion of the glans attached. Each corpus cavernosum was folded upon itself and then hidden in the subcutaneous fat to increase the size of the labia majora. The partially divided urethral plate was used to form the inner part of the labia minora and the clitoral hood. The phallic skin was partially divided and used to form the outer part of the labia minora. This operation allowed feminizing clitoroplasty to be completed without significant excision of any tissue, including the corpora cavernosa.

RESULTS

The operation was completed successfully in all three patients, two with concomitant inverted 'V' flap vaginoplasty. One patient had postoperative haematoma. All three have a cosmetically acceptable 'female look' to the satisfaction of themselves and their parents.

CONCLUSION

This preliminary result suggests that a cosmetically acceptable feminizing clitoroplasty can be performed with preservation of all phallic tissue, in particular the corpora cavernosa. This potentially reversible operation may be advantageous when feminizing genitoplasty has to be performed in a young child with disorders of sex development.

Tumoral cystitis in children

Three children aged 3-11 years had ultrasonography of the urinary tract for the investigation of dysuria and haematuria. A bladder mass was seen in these 3 children. One child had computed tomography scan, cystoscopy and bladder biopsy because rhabdomyosarcoma was considered. The biopsy revealed an inflammatory process. The urine culture of the other 2 children revealed E. coli. On ultrasonography, the inflammatory mass may appear homogeneously hypoechoic or may contain moderate level echoes. The mucosal surface of the mass may be smooth or lobulated. It is important to consider an infective cause for a bladder mass in children because computed tomography, cystoscopy and biopsy may be avoided.

Changes in serotonin contents in brain affect metabolic heat production of rabbits in cold

Elevating serotonin (5-HT) contents in brain with 5-hydroxytryptophan (5-HTP) reduced rectal temperature (Tre) in rabbits after peripheral decarboxylase inhibition with the aromatic-L-amino-acid decarboxylase inhibitor R04-4602 at two ambient temperatures (Ta), 2 and 22 degrees C. The hypothermia was brought about by both an increase in respiratory evaporative heat loss (Eres) and a decrease in metabolic rate (MR) in the cold. At a Ta of 22 degrees C, the hypothermia was achieved solely due to an increase in heat loss. Depleting brain contents of 5-HT with intraventricular, 5,7-dihydroxytryptamine (5,7-DHT) produced an increased Eres and ear blood flow even at Ta of 2 degrees C. Also, MR increased at all but the Ta of 32 degrees C. However, depleting the central and peripheral contents of 5-HT with p-chlorophenylalanine (pCPA) produced lower MR accompanied by lower Eres in the cold compared to the untreated control. Both groups of pCPA-treated and 5,7-DHT-treated animals maintained their Tre within normal limits. The data suggest that changes in 5-HT content in brain affects the MR of rabbits in the cold. Elevating brain content of 5-HT tends to depress the MR response to cold, while depleting brain content of 5-HT tends to enhance the MR response to cold.

Effects of brain monoamine depletion on thermoregulation, active avoidance, and food and water intake in rats

Intraventricular administration of 6-OHDA or 5,6-DHT suppressed food intake, whereas their effect on active avoidance produced a suppression with the former and an enhancement with the latter. The increased water intake was specifically associated with 5,6-DHT treatment in rats.