Parental concerns about genital differences in children with congenital adrenal hyperplasia persist regardless of the selected intervention.

BACKGROUND: Congenital Adrenal Hyperplasia (CAH) due to 21-hydroxylase deficiency (21HD) can affect the in utero development of the genital anatomy of people with the 46XX karyotype. Health professionals engage parents in decision-making regarding managing genitals with this difference, including genital surgery options and patient communication. AIM: We sought to investigate parental communication with their daughters regarding clitoral size variation related to neonatal CAH. METHODS: Semistructured in-person interviews of 24 parents of chromosomal XX children with clitoral size variation attributable to a neonatal CAH diagnosis comprised 3 management categories: (1) clitoral reduction surgery (RS) (7 parents, 9 children), (2) clitoral concealment surgery (CS) (8 parents, 8 children), and no surgery on or around the clitoris (NS) (9 parents, 7 children). OUTCOMES: Four representative themes, Obvious Choice, Still Different, Parental Burden, and Ignorance Is Bliss, were common across all 3 treatment groups. RESULTS: For most parents, none of the 3 options of genital appearance alteration via clitoral reduction, clitoral concealment surgery, or avoidance of clitoral surgery ameliorated concerns, with most parents expressing an aversion to educating their child on the topic of genital differences, past treatment, or future function. CLINICAL IMPLICATIONS: Reliance on surgical treatment pathways to manage this psychosocial concern is ineffective in alleviating parental uncertainty without the application of psychosocial interventions. STRENGTHS AND LIMITATIONS: This was a qualitative study but was limited to parents of children with a specific genital difference, without direct exploration of parental values regarding the clitoris or the application of adequate psychosocial care. CONCLUSION: Healthcare services must have an impact on parental ability to engage in essential communication with their children in cases such as clitoral size variation related to neonatal CAH. Improved communication skills allow parents to engage in more genuine decision-making and adapt to enduring genital reality, including possible future sexual challenges for their adult child, without resorting to burdensome strategies focused on attempts to perpetuate a benevolent ignorance.

Efficacy of in-office lysis of clitoral adhesions with excision of keratin pearls on clitoral pain and sexual function: a pre-post interventional study.

BACKGROUND: Keratin pearls are foci of central keratinization within concentric layers of squamous cells that can form under the clitoral prepuce and cause pain (clitorodynia); in-office removal of keratin pearls may reduce clitoral pain and improve sexual function. AIM: This study aims to investigate clitoral pain and sexual function in women with partial clitoral phimosis and keratin pearls before and after in-office lysis of clitoral adhesions with keratin pearl excision (LCA-KPE). METHODS: A pre-post interventional study evaluated patients who underwent LCA-KPE between January 2017 and February 2023 in 2 metropolitan gynecology clinics specializing in vulvar pain. Patients presenting with keratin pearls and partial clitoral phimosis identified through retrospective chart review were asked to complete postprocedure questionnaires and provide subjective responses on clitoral discomfort, sexual function, sexual distress, and their experience with in-office LCA-KPE. Bivariate analyses with paired t tests were conducted to determine the effect of LCA-KPE. Qualitative data were analyzed with thematic coding. OUTCOMES: An 11-point pain visual analog scale was utilized to determine pre- and postprocedure clitoral discomfort and difficulty with orgasm. Female sexual dysfunction was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised. RESULTS: A total of 32 of 74 patients who met inclusion criteria completed postprocedure surveys (43% response rate). Mean clitoral pain for respondents was 6.91 at baseline and 2.50 after LCA-KPE (P < .001). Mean difficulty with orgasm was significantly decreased from 5.45 at baseline to 3.13 after LCA-KPE (P < .001). Participants had a mean FSFI total score of 17.68 after treatment compared with a mean total baseline FSFI of 12.12 (P = .017). The mean FSFI score for pain was 2.43 at follow-up compared with 1.37 at baseline (P = .049). There was no significant difference in the mean Female Sexual Distress Scale-Revised score before vs after the procedure (P = .27). Qualitative themes described the procedure as painful but worthwhile, with 77% of participants reporting the overall experience as positive. Recurrence rate overall was 28%, with a median of 2 repeat procedures. CLINICAL IMPLICATIONS: Recognizing keratin pearls as a structural cause of clitoral pain and offering in-office treatment is an important tool in addressing clitorodynia and improving sexual function. STRENGTHS AND LIMITATIONS: This is the largest study to date documenting the occurrence, identifying associated pain conditions, and evaluating procedural outcomes for clitoral keratin pearls. This study was limited by a relatively small sample size. CONCLUSION: In-office LCA-KPE significantly reduced clitoral discomfort and difficulty with orgasm.

A long-term complication of clitoral cyst after female genital mutilation.

Female genital mutilation (FGM) was seen in 30 countries, especially in Africa and also in Asia and the Middle East. According to WHO data, Somalia is where FGM is performed most frequently. Our study aimed to evaluate the recordings of patients with FGM who were diagnosed with a traumatic clitoral cyst. We identified the clitoral cyst cases between February 2015 and August 2020. We collected clinical, surgical, sociodemographic, and histopathological details such as age, marital status, patient resume, age at which FGM was performed, complaints, size of the cyst consultation reasons, FGM procedural long-term complications, sexual function, husband polygamic relationship status, and histological findings. A total of 21 patients diagnosed with clitoral cysts were included in the study. The technique was easily applied in every patient, and the cysts were removed intact, except in 2 patients. There were no intraoperative complications; only minimal bleeding was seen. Except for one patient, all had unilocular cysts, and the final pathological examination revealed an epidermal inclusion cyst. We observed a neuroma developed due to genital trauma due to FGM in one of our patients. Female circumcision and its consequences are not familiar to many healthcare professionals in the developed world. We want to increase awareness of female circumcision and its long-term complication of clitoral cysts among healthcare professionals worldwide.

No clitting! We need to talk about clitoris transplantation.

In the last two decades, genital transplants have emerged as another type of quality-of-life transplants. Successful allogenic transplantations of the uterus, ovary, testicle, and penis have all been reported. Yet, there is no discussion of clitoris transplantation in the medical literature, mass media, and everywhere else I searched. This surgery could be used for cisgender women who have a clitoral injury or disease or who have undergone female genital cutting. I examine the gender norms regarding sexuality and reproduction to show how they shape surgical advancements. My point in this paper is not to take a normative position on status of current genital transplantations. Rather, I highlight that their existence is due, at least in part, because they align with dominant gender norms: penis and testicle transplantations reinforce the importance of men's virility and the existence of "normal" male genitalia, whereas uterus and ovary transplantations uphold the conflation of women and reproduction and the strong valuing of women's fertility. That medical advances reflect cultural values is not a new claim. What is new in this paper is the discussion of how sexism norms-regarding the invisibility of the clitoris and the devaluing of women's sexual pleasure- has engendered various types of genital transplants, but not clitoris transplantation.

Construction of Sensitive Labia Minora-Clitoris-Clitoral Hood Complex in Sex Reassignment Surgery in Circumcised Populations: Butterfly Flap.

INTRODUCTION: The construction of the labia minora from preputial tissues in uncircumcised patients and the preservation of the sensitivity of the labia minora are not new ideas. However, evidently, this technique is designed for uncircumcised cases.There is no preputial tissue in the circumcised population. However, this tissue, whose inner and outer layers have different structures and appearances, is critical in the construction of the labia minora. Instead, there is an area of reepithelialization and reinnervation that heals secondarily or is closed primarily, depending on the circumcision. Also, this new skin area is devoid of the natural oily secretions of the prepuce. In addition, the removal of preputial tissue in circumcised individuals may cause uncertainty in terms of vascularity or sensitivity. In this study, we share our clinical experience regarding large labia minora creation (with preserved flap circulation without vaginal reconstruction concerns) and the use of most of the urethra as a mesh graft in the circumcised population. MATERIALS AND METHODS: Between 2010 and 2022, 19 cases were operated on with this technique. All cases were primary interventions for male-to-female sex reassignment. Because this design of the sensitive inner surface of the labia minora, which ensured vascular safety, was not found in the literature, the design was named "butterfly flap" because of its shape. EVALUATION OF SENSATION: The area corresponding to both wings of the butterfly flap was evaluated with the Semmes Weinstein Monofilament test, with the patient's eyes closed, in the preoperative period. Likewise, the sensitivity of the inner surface of the labia minora in the first year of 10 patients who were able to attend follow-up clinical examination was evaluated with the same method. RESULTS: In our study, a clitoris and a labia minora with sensory innervation were obtained by elevating the superior 180-degree area of the neurovascular bundle surrounding the penis and using the butterfly flap we prepared in the area fed by this bundle. Fourteen cases stated that the sensation of the newly formed labia minora was erogenous and different from the tactile sensation on the body of the penis.

Neurological Considerations for "Nerve-Sparing" Cosmetic Genital Surgeries Performed on Children with XX Chromosomes Diagnosed with 21-Hydroxylase Congenital Adrenal Hyperplasia and Clitoromegaly.

Congenital adrenal hyperplasia (CAH) is most often caused by adrenal deficiency of 21-hydroxylase (21-OH). The resulting increase in androgens can cause clitoromegaly in fetuses with XX chromosomes. 21-OH CAH is the most common reason for cosmetic clitoroplasty in childhood. "Nerve-sparing" (NS) clitoral reduction surgeries are described as offering optimal cosmesis, while sparing sensation and nerve function. The methods used to demonstrate NS surgery efficacy, however, such as electromyography and optical coherence tomography, do not evaluate the small-fiber axons that comprise the majority of axons in the clitoris and that transduce sexual pleasure. Although some data show sparing of a portion of the main dorsal nerve trunk of the clitoris, the overall neurobiological consequences of elective clitoral reductions have received little attention. NS surgeries remove dorsal nerve branches that transduce sexual sensation, as well as the corpora cavernosa and cavernous nerve, which provide clitoral autonomic function. While most outcome studies focus on surgeons' perceptions of cosmetic results, studies that assess small-fiber function indicate significant nervous system and sexual impairment. Studies assessing children's clitoral function after surgery with vibrational testing have been ethically condemned. Decades of advocacy against medically unnecessary childhood genital surgeries have highlighted the subsequent physical and psychological harm. Recent studies with CAH patients indicate gender diversity and a lower prevalence of female gender identification than is often cited to justify feminizing surgery. The most effective and ethical NS technique for CAH may be acceptance of gender, sexual, and genital diversity as the infant develops into childhood, adolescence, and adulthood.

Gender Affirming Graft Only Vaginoplasty.

OBJECTIVE: To describe our technique for performing gender affirming graft only vaginoplasty. METHODS: In graft only vaginoplasty, penile skin is used only for the external genitals, and the entire vaginal canal is created from a full thickness skin graft. The inner scrotum is excised and used as a skin graft to line the vaginal canal. The outer scrotum is left in place then moved medially to form the labia majora. The penile skin and Dartos fascia are incised dorsally and ventrally then advanced to the posterior perineum to become the labia minora. The glans clitoris is constructed from a W-shaped dorsally-based portion of the glans penis, and the clitoral hood is constructed from the distal 2-3 cm of penile shaft skin. The posterior wall of the introitus is formed from a posterior perineal flap. RESULTS: The patient presented here is a 26-year-old transgender woman with marked and sustained gender incongruence. She is circumcised, has typical penile length, scrotal contents are normal, and all hair has been removed on the scrotum and perineum. She underwent graft only vaginoplasty, as shown in the accompanying video. CONCLUSION: Gender affirming graft only vaginoplasty allows for construction of the vaginal canal from a full thickness skin graft, and construction of external genitals from penile and scrotal skin. Advantages of this approach include availability of more tissue for construction of the external genitals and an external skin to graft anastomosis. The procedure is modified slightly when the patient has a small scrotum, short penis, or is uncircumcised.

Standardized Photography of Female Genitalia and Anatomical Evaluations.

BACKGROUND: Standardized photographic recording and anatomic evaluation are crucial to refined and comprehensive preoperative design and enhanced aesthetic effect of female genital cosmetic surgery. OBJECTIVES: The authors aim to propose a standard photographic scheme and physical examination form for the anatomical assessment of patients undergoing female genital surgery. METHODS: The scheme containing 2 positions (standing and lithotomy positions) and 11 views (1 frontal and 2 oblique views from standing position; 6 frontal views with labia minora open and closed, pulled to the opposite side, clitoral hood pushed up, posterior fourchette stretched; 2 oblique views from lithotomy position) (2P11V) is applied to record pre- and postoperative appearance of the vulva. The evaluation form is utilized to record characteristics of different anatomical subunits during photography. RESULTS: Two hundred forty-five patients who underwent female genital surgery were enrolled in the research from October 2018 to October 2022. All the patients received preoperative and postoperative 2P11V photography with about 5-minutes' shooting time. Various anatomical variations containing hypertrophy and prolapse of mons pubis, redundant types of labia minora and clitoral hood, incremental exposure of clitoral glans, hypo- to hypertrophy of labia majora, disappearance of interlabial groove, hypertrophy of posterior fourchette, and relation of subunits were accurately documented. CONCLUSIONS: 2P11V photographic scheme displays the isolated features of each organ and proportion relation among different parts of vulva. The standard photographic record and physical examination form offer detailed anatomical structure to surgeons and facilitate surgeons to carry out an accurate surgical design, which deserve to be promoted and applied.

Abdominoplasty and Clitoris Evaluation: A Prospective Study on Sexual Pleasure in Women Undergoing Abdominoplasty.

INTRODUCTION: Being one of the most practiced procedures in plastic surgery, it is important to foster a better understanding of the effect of anatomical changes in the pubic area after abdominoplasty on sexuality in women. Since to date no study has been performed with this purpose, our aim is to evaluate the impact of the abdominoplasty on sexual pleasure and to perform an objective evaluation of changes in clitoral position and prepubic fat area after this procedure. MATERIALS AND METHODS: A prospective study has been performed in 50 women who expressed a desire to undergo abdominoplasty from January 2021 to December 2021. The primary endpoint was Sexual pleasure assessed by the "Sexuality Assessment Scale" before and 6 months after abdominoplasty in all patients. Furthermore, we evaluated the physical changes of the clitoris (clito-pubic distance, CP distance) and the prepubic fat area on magnetic resonance imaging before and 3 months after abdominoplasty. RESULTS: Patients mean age was of 42 ± 9 years, and mean body mass index of 26 ± 2 kg/m2. A significant difference (P < 0.0001) between sexual satisfaction before and 6 months after abdominoplasty (mean difference +7.4 ± 6.452) was found. Though there was no significant difference between the clito-pubic distance before and after abdominoplasty (mean difference -3.200 ± 2.499 mm; p= 0.0832), a significant difference was found in the size of the prepubic fat area before compared to after abdominoplasty (mean difference -1.714 ± 1.010 cm2; p = 0.0426). However, no significant relationship between these anatomical changes and sexual satisfaction was found. CONCLUSION: Our results show that abdominoplasty is associated with an increase in sexual satisfaction. The changes in the post-operative position of the clitoris were not statistically significant, contrarily to the size of the prepubic fat area, which was significantly modified and could partially explain the improved sexual pleasure. Authors were unable to statistically demonstrate a correlation between those anatomical modifications and sexual pleasure. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clitoral reconstruction: challenges and new directions.

Clitoral reconstruction (CR) has been the subject of several studies in recent years, mainly in the medical field. Women with female genital mutilation or cutting (FGM/C) seek clitoral reconstructive surgery to improve their sexual well-being, but also because they are affected by poor self- and body image. CR is supposed to help women with FGM/C reconstruct their sense of self, but the benefits and risks of this surgery have not been sufficiently explored. There are currently no recommendations supporting CR from mainstream medical bodies, and there have been very few ethical studies of the procedure. This article critically discusses the principal studies produced in the medical field and available reflections produced in the social sciences. Through the theoretical frameworks of postcolonial and feminist studies, the article discusses sexuality and pleasure, gender and identity, and race and positionality, with the aim of promoting collaborative work on CR between researchers and social and health professionals.

Why do parents recommend clitoral surgery? Parental perception of the necessity, benefit, and cost of early childhood clitoral surgery for congenital adrenal hyperplasia (CAH).

Historically, medical management of Congenital Adrenal Hyperplasia (CAH) in girls typically involved feminising surgery, which meant reducing the size and/or visibility of the enlarged clitoris. This practice may have become less routine but remains a common response to genital differences associated with CAH. Parents typically give permission for the child to undergo surgery in early childhood and recommend other parents facing a similar situation do the same. The current report is based on a qualitative content analysis of interviews with sixteen parents whose daughters with CAH had undergone one of two forms of clitoral surgery. We observed that: (i) some parents were initially unconcerned about their child's genital presentation; (ii) in general, clitoral surgery was considered as a readily available and natural response to the child's bodily difference; (iii) the parents acknowledged that there would be some risk but anticipated various benefits; and (iv) there was an absence of ethical considerations when the parents evaluated the various effects of surgery afterwards. We conclude from our analysis that parents of girls with CAH may not receive psychologically and ethically informed counselling to encourage critical reflections prior to authorizing genital surgery.

Autologous Platelet-Rich Plasma in Clitoral Reconstructive Surgery After Female Genital Mutilation/Cutting: A Pilot Case Study.

BACKGROUND: Postoperative healing after clitoral reconstruction (CR) for female genital mutilation/cutting can be long and painful due to prolonged clitoral re-epithelialization time (up to 3 months). Autologous platelet-rich plasma (A-PRP) might reduce postoperative clitoral epithelialization time and pain. OBJECTIVES: The authors assessed postoperative clitoral re-epithelialization time and pain after intraoperative clitoral administration of A-PRP. METHODS: Five consecutive women underwent CR (Foldès technique) followed by the administration of A-PRP Regen Lab SA (Le Mont-sur-Lausanne, Switzerland) plasma and glue, injected inside and applied above the re-exposed clitoris, respectively. We recorded surgical complications, postoperative clitoral pain (visual analogue scale), painkiller intake, time to complete re-epithelialization, and the experienced subjective changes in sexual response and perception of their own body image referred by women. RESULTS: Sexual distress/dysfunction as well as the desire to be physically and symbolically "repaired" were the reasons behind women's requests for surgery. None of the women suffered from chronic vulvar or non-vulvar pain. All women achieved complete clitoral epithelialization by day 80, 3 women between day 54 and 70, and only 1 woman was still taking 1 g of paracetamol twice a day at 2 months postoperative. She had stopped it before the 3-month control. There were no short- or long-term complications. All women described easier access and stimulation of their clitoris as well as improved sexual arousal, lubrication, and pleasure and claimed to be satisfied with their restored body image. CONCLUSIONS: A-PRP could expedite postoperative clitoral epithelialization and reduce postoperative pain after CR after female genital mutilation/cutting.

Vaginal Rejuvenation with Acellular Dermal Matrix.

Female genital cosmetic surgery consists of multiple procedures, usually including labiaplasty, clitoral prepuce reduction, labia majora augmentation, and vaginoplasty. The reasons for women to undergo these surgeries can be categorized as functional and aesthetic ones. In this study, we introduced the modified vaginoplasty with acellular dermal matrix (ADM) and briefly reviewed our experience in the combination of multiple procedures to achieve the optimal effect.

Non-hormonal Clitoromegaly due to Clitoral Priapism Caused by Appendicitis/Appendectomy

Clitoromegaly usually develops due to hyperandrogenism. There are a few cases of clitoromegaly described without clinical and biochemical hyperandrogenism. Clitoromegaly due to clitoral priapism and clitoral priapism after appendectomy have not been reported previously. A 7-year-old girl was referred for enlargement of the clitoris. She reported having a mild, pulsating clitoral pain starting three days after an appendectomy operation. Subsequently, painful swelling and an increase in the size of the clitoris was observed. Her growth and physical examination were otherwise normal. Causes of the clitoromegaly due to androgen excess were excluded after a comprehensive work-up. Color Doppler ultrasound revealed a high peak systolic velocity and resistance in the cavernosal artery, consistent with clitoral priapism. The clitoromegaly and associated symptoms improved significantly with oral pseudoephedrine and intracavernosal aspiration. This unique case illustrates that clitoral priapism is a rare, non-hormonal cause of clitoromegaly and may occur after appendectomy. Pseudoephedrine treatment is helpful in alleviating the symptoms.

A Review of Aesthetic Gynecologic Procedures for Women.

Aesthetic gynecologic surgery is gaining popularity among women and physicians. Aesthetic genital surgery for women encompasses both minimally invasive and open surgical procedures. Cosmetic genital procedures for women described in this article include perineoplasty, vaginoplasty, vaginal rejuvenation, labiaplasty, G-spot enlargement, Bartholin gland surgery, clitoral hoodoplasty, clitroplasty, hymenoplasty, and mons pubis plastic surgery. Based on a review of the literature for each procedure, the article discusses procedural methods and techniques, indications for implementation, potential consequences and side effects of the procedure, nursing implications, patients' motives for undergoing the procedure, and positions of scientific institutions relative to the procedure.

Fused Clitoral Hood Presenting as a Periclitoral Mass.

BACKGROUND: Periclitoral masses are seldom reported. One cause is a congenitally fused clitoral prepuce (or clitoral hood). CASE: A patient was referred to our gynecologic oncology practice with a suspicious periclitoral mass for evaluation of possible malignancy. The clitoral hood was, in fact, fused such that the glans was completely covered. Surgical excision of the distal prepuce (or clitoral hood) expelled trapped sebaceous material and revealed a normal-appearing glans clitoris. Clitoral hood reconstruction restored the patient's external genitalia to normal anatomy. CONCLUSION: Fused clitoral prepuce causing trapped sebaceous material can mimic an expanding periclitoral mass and should be considered in the differential diagnosis.