Clitoral Hood Research Articles

(135) Keratin Pearl Excision for Clitorodynia and Female Sexual Dysfunction

Abstract Introduction Clitoral adhesions occur when the clitoral prepuce adheres to the glans clitoris. This can cause accumulation of desquamated epithelial cells under the prepuce, resulting in the formation of smegmatic pseudocysts and keratin pearls. A keratin pearl is a focus of central keratinization within concentric layers of squamous cells. Presence of these firm, millimeter-sized masses can lead to clitoral irritation and hypersensitivity (similar to a grain of sand in the eye). Although keratin pearls have been described in the literature, there is little known about their clinical presentation or association with female sexual dysfunction (FSD). Objective Investigate the effectiveness of keratin pearl excision as a treatment for clitoral pain and female sexual dysfunction. Methods A retrospective chart review was conducted in two metropolitan gynecology clinics specializing in vulvar pain between January 2017 and December 2021. Patients presenting with clitoral pain (clitorodynia) were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed via review of the clinical notes. Adult patients with documented clitoral pain as well as clitoral adhesions (clitoral phimosis) and keratin pearls noted on exam were included in the study. Female Sexual Dysfunction (FSD) was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Prospective data was collected via an electronic follow-up survey. Data were presented in means and percentages. Results Fifty-eight patients met inclusion criteria. Average age at presentation was 35 years (range 19-73 years). Self-reported ethnicity of the study population was 81% White, 7% Hispanic, 5% Asian, 2% Black, with no response from 5% of participants. Preliminary results show that patients reported a 66% decrease in mean clitoral discomfort (p < 0.0001) and a 52% reduction in mean difficulty with orgasm (p = 0.019) after excision of keratin pearls. Patients who completed the follow-up questionnaire (n = 18) had a mean FSFI total score of 18.3 compared to mean total baseline FSFI of 13.11 (p = 0.03). The mean FSFI score for pain was 2.85 at follow up compared to 1.52 at baseline (p = 0.01). The mean FSFI score for orgasm was 3.36 at follow up compared to 2.16 at baseline (p = 0.03). Although not statistically significant, most likely because of a small sample size, the mean FSFI score was higher at follow-up than at baseline for lubrication (45%), arousal (42%), satisfaction (19%), and desire (17%). Patients had no change in mean FSD-R score from baseline to follow up. Conclusions Clitorodynia associated with clitoral adhesions and keratin pearls occurs in women of all ages. Excising keratin pearls may reduce female sexual dysfunction. These preliminary results suggest that excising keratin pearls may improve clitoral discomfort and reduce difficulty with orgasm. Excising keratin pearls may also lead to an improvement in overall female sexual function. Disclosure No

Standardized Photography of Female Genitalia and Anatomical Evaluations.

Standardized photographic recording and anatomic evaluation are crucial to refined and comprehensive preoperative design and enhanced aesthetic effect of female genital cosmetic surgery. The authors aim to propose a standard photographic scheme and physical examination form for the anatomical assessment of patients undergoing female genital surgery. 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. 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. 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.

V09-03 GENDER-AFFIRMING CLITOROPLASTY: TWO VERSIONS AND RATIONALE FOR CHOICE

You have accessJournal of UrologyCME1 Apr 2023V09-03 GENDER-AFFIRMING CLITOROPLASTY: TWO VERSIONS AND RATIONALE FOR CHOICE Michele Fascelli, Geolani Dy, Blair Peters, and Daniel Dugi Michele FascelliMichele Fascelli More articles by this author , Geolani DyGeolani Dy More articles by this author , Blair PetersBlair Peters More articles by this author , and Daniel DugiDaniel Dugi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present two techniques for creating the neoclitoris in gender-affirming vaginoplasty and vulvoplasty, preputial skin flap clitoroplasty and urethral flap clitoroplasty. METHODS: The technique to be used is chosen prior to skin incision. After penile disassembly, the the glans is reconstructed to form the clitoris, based on the corona. The tissue used to construct the clitoral hood and labia minora differs by technique, and the decision to use one technique or the other is based on patient anatomy. RESULTS: We demonstrate two techniques and their post-operative results. We chose the preputial skin clitoroplasty for all uncircumcised patients and patients with adequate penile skin, both distal to and proximal to the circumcision scar. We chose the urethral flap clitoroplasty technique for circumcised patients with penile skin insufficient for the preputial skin technique. CONCLUSIONS: These two techniques for clitoroplasty provide surgical options adaptable to individual anatomy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e837 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michele Fascelli More articles by this author Geolani Dy More articles by this author Blair Peters More articles by this author Daniel Dugi More articles by this author Expand All Advertisement PDF downloadLoading ...

Labiaplasty in Adolescents: Indications and Treatment Protocol.

Adolescents constitute a unique group of labia minora hypertrophy patients, but the necessity and benefits of labiaplasty for adolescents remain controversial. The purpose of this study was to summarize the surgical indications, the details of the treatment procedure, postoperative complications, and therapeutic outcomes of labiaplasty in the adolescent population. A retrospective chart review was performed of adolescent patients aged <18 years old who underwent labiaplasty between January 2016 and May 2022. Patient characteristics, surgical method, concomitant procedures, procedure side, operative time, complications, and follow-up data were recorded. A total of 12 patients aged <18 years were included in this study. All procedures were performed for functional reasons. The mean [standard deviation] operative time was 61.75 [20.77] minutes (range, 38-114 minutes). Unilateral labia minora hematoma within 24 hours occurred in 2 of the 12 patients (16.7%) and surgical evacuations were performed immediately. All patients were followed up electronically at 42.33 [16.88] months (range, 14-67 months). Notably, 83.33% (10/12) of patients reported being very satisfied, and 16.67% (2/12) of patients were satisfied. There was no patient dissatisfaction. Preoperative discomfort was completely resolved in 9 patients (75.00%) and significantly improved in 3 patients (25.00%). Furthermore, no patients indicated that symptoms were not improved or made worse. In the adolescent population, severe hypertrophy of the labia minora and the clitoral hood will cause discomfort, affecting the quality of life and mental health. Therefore, labiaplasty is a safe and effective procedure in adolescents to improve genital appearance and quality of life.

Genital Mutilation in India - An Evil Practice

Female Genital Mutilation commonly known as FGM/C has in recent times been an eye opener for the Ministry of Women and Child Development and set the system in motion. FGM/C is practised mostly by the Dawoodi Bohra community with one million members in India. khatna, khafz, and khafd, the procedure is performed on six- or seven-year-old girls and involves the total or partial removal of the clitoral hood. Female genital mutilation/ cutting (FGM/C) involves the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons, and said practice has no health benefits for girls as well as for women.

Fused Clitoral Hood Presenting as a Periclitoral Mass.

Periclitoral masses are seldom reported. One cause is a congenitally fused clitoral prepuce (or clitoral hood). 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. Fused clitoral prepuce causing trapped sebaceous material can mimic an expanding periclitoral mass and should be considered in the differential diagnosis.

Labiaplasty for Symptomatic Grade III-BCD1 Labia Minora

A 16-year-old girl presented with symptomatic symmetrically enlarged butterfly-shaped Grade III (4.1–6 cm, measured from the hymen to the distal edge (cranial/caudal)-BCD [1] (‘B’ – Cosmetic bother, ‘C’ –Clitoral hood involvement, ‘D’ –Dyspareunia due to labia minora or Discomfort with physical activity) labia minora of 4 years duration. She was a virgointacta, hence ‘D’ was Discomfort from physical activity. She had an uncomplicated surgical reduction direct excision labiaplasty1 10 years ago. At her six week review, her labiaminora had completely healed with very satisfactory results.

MULTI-DISCIPLINARY INTERVENTION FOR LABIAL FUSION IN A CASE OF VULVAL LICHEN PLANUS.

Vulvo-vaginal lichen planus is a very distressing and rare forms of non-venereal genital dermatoses. Erosive variants of Lichen planus often have a protracted course and has a higher risk of malignant transformation. This case was a 53-year- old woman, previously diagnosed with lichen planus on conservative treatment, who now presented with symptomatic labial adhesions and urinary complaints like urgency, frequency and poor urine stream. Clinical examination revealed normally developed labia majora, partially but extensively fused labia minora including the clitoral hood. Urethral opening was not visualised, while a small vaginal orifice was seen with no ulcerations. A multi-disciplinary team consisting of urologist and plastic and cosmetic surgeon dissected out the labial adhesions with the electrocautery and reconstructed the vaginal and urethral openings. Cystoscopy followed by urethral dilatation was done for urethral narrowing. Postoperatively, on following up the patient the adhesions were completely separated, and the area healed well. No recurrences were noted. Though aggressive management with topical steroids and other measures often improves symptoms on short term basis, few patients may require long term management by multi-disciplinary team to optimize the outcomes.

The Attitude of Physicians Towards Female Genital Cosmetic Surgery.

IntroductionFemale genital cosmetic surgery (FGCS) is a trending topic in the field of gynecology practice. It is defined as any genital procedure that is not medically indicated but is designed to improve the appearance of the genitals. With the increasing demand for FGCS, little is known about the attitudes of physicians, especially gynecologists, toward FGCS. The study objective is to assess physicians' attitudes towards female genital cosmetic surgeries in Jeddah, Saudi Arabia.MethodsA cross-sectional survey was done among physicians in Jeddah, Saudi Arabia. Four-sectioned questionnaires were distributed to physicians. All board-certified consultants and registrars of obstetrics and gynecology, plastic, and reconstructive surgery in private/public hospitals were included in the study. Data management was done using the SPSS program version 19 (IBM Corp., Armonk, NY, USA).ResultsOut of 165 physicians, 40 were practicing physicians (female genital cosmetic surgery) (24.2%) while 125 were non-practicing physicians (75.8%). The age of practicing and non-practicing respondents ranges from 26 to 60 with a mean and standard deviation (42.6±8.6) and 24 to 60 (40.1±8.9) years old. Our study showed that there were females under 18 years old requesting FGCS from all physicians. Results of attitude towards FGCS showed that the majority of non-practicing physicians were more comfortable in providing advice about FGCS (N=53) and very confident about female anatomy (N=65). Non-practicing physicians also knew a lot more about the long and short-term risks of FGCS and discussed them all the time with their patients. In terms of giving advice on labiaplasty, clitoral hood reduction, perineoplasty, hymenoplasty, and G-spot augmentation procedures, practicing physicians were more confident compared to non-practicing physicians. Statistical analysis showed a significant difference between practicing and non-practicing physicians in terms of gender (p=0.001), career level (p=0.005) and type of work (p=0.006), giving advice on labiaplasty (p=0.001), clitoral hood reduction (p=0.001), perineoplasty (p=0.016) and G-spot augmentation (p=0.001), the number of patients per month, patients seeking advice about FGCS, knowledge about short-term and long-term risks and possible risks of FGCS, vaginal examination, offering referral/counseling and confidence in assessing female anatomy (all, p=0.001). ConclusionPhysicians in Jeddah, Saudi Arabia showed an overall positive attitude towards FGCS. The study suggests that with enough training and knowledge about FGCS, physicians could exhibit a more positive attitude towards FGCS.

Long-Term Follow-up in Labiaplasty in 414 Women: A Single-Center Experience in China.

Women with labial hypertrophy may opt for labiaplasty. The aim of the study was to analyze the complications, long-term follow-up of clinical outcomes and satisfaction in this population over the past 10 years.All women who underwent labiaplasty with or without clitoral hood reduction at our center between January 2008 and August 2020 were retrospectively identified. Retrospective study was conducted, recording follow-up outcomes, motivations, techniques, postoperative complications, reasons requiring reoperation, and surgical satisfaction concerned different clinical characteristics. A concrete analysis of each specific outcome and a detailed knowledge of these procedures were performed.A total of 52.41% reported functional impairment, 20.25% cited aesthetics complains, and 27.34% were motivated by both the previously mentioned reasons. Women undergoing surgical correction sometimes mixed with various psychological aspects. A total of 91.06% reported that they were moderately (6.04%) or extremely (85.02%) satisfied with the outcomes after surgery, and 37 (8.94%) reported dissatisfied. Revision surgery was needed in a small number of patients (n = 7 of 414 patients, 1.69%) because of undesirable appearance. The most common complication in our patients was asymmetry (6.28%). Women requested labiaplasty in the last 2 reasons or procedures or without psychological distress were more likely feel satisfied with the results (satisfaction rate >90%). There was a significant difference in satisfaction among the 3 concerns as well as between the 2 kinds of psychological conditions ( P < 0.05). Satisfaction of patients with aesthetic complains compared with the other 2 worries was significantly lower ( P < 0.05). There was no significant difference among the 3 procedures in this comparison group ( P > 0.05). In addition, satisfaction in labiaplasty with or without clitoral hoodoplasty, neither of which was statistically different ( P > 0.05). Patients aged 30 to 39 years reported the lowest satisfaction in comparison with the other age groups.Labiaplasty of the labia minora is the most commonly performed genital cosmetic surgery procedure. This study on 414 patients demonstrated that it is associated with a high degree of patient satisfaction and low morbidity and provided evidence of safety and effectiveness preliminary, indicating that the procedure may be regarded as safe.

Long-Term Results of Surgical Treatment and Patient-Reported Outcomes in Congenital Adrenal Hyperplasia-A Multicenter European Registry Study.

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.

Female Genitalia in Pornography: The Source of Labiaplasty Trends?

ABSTRACT Introduction Trends in appearance of female genitalia has been influenced by social media, entertainment industry, and even politics. Cosmetic labiaplasty has increased by 56% over the last decade. Wide availability and accessibility of pornography is another source where women and men learn about the anticipated normal appearance of the genitals. Objective The purpose of this review is to evaluate the current trends in appearance of female genitalia based on the most viewed pornography videos. We hypothesized that pornography may influence such trends in labiaplasty. Methods After panel of experts agreed on definitions and classifications of the different genital parts and beautification trends, we reviewed videos from the category “most viewed videos” on the most popular free pornography websites. We analyzed common representations of female genital appearance, including hair grooming (completely shaved, trimmed, natural), hyperpigmentation (natural with hyperpigmented perianal and labial skin vs. bleached with equal hyperpigmentation throughout), appearance of labia majora (thickness, length), appearance of labia minora (presence and length compared to the labia majora), clitoral hood appearance (status post clitoral hood reduction), and width of the genital hiatus. Results We reviewed the 25 most viewed videos from the five most popular free pornography websites. Among females and males, complete shaving of the pubic hair was the most common pattern, 56% (14) and 52% (13) respectively, followed by the trimmed pubic hair equally among both genders 40% (10). Only 8% of videos demonstrated labia majora resembling pre-pubertal (surgically enhanced) appearance. 44% of women had labia minora larger than labia majora, 36% had them at equal length, and 16% showed no labia minora. We did not see any dangling labia. 92% of videos demonstrated a normal appearing clitoral hood with no signs of surgical reduction. Bleaching or removal of natural hyperpigmentation was noted in 20% of videos. Wide genital hiatus consistent with vaginal delivery was identified in 16% of videos. No signs of pelvic organ prolapse, piercings, or other abnormalities were noted. Conclusions We found that the most popular pornography videos had a range of genital appearances. Pornogaphy definitely influenced hair grooming pattern. The most viewed videos on the most popular pornography sites may create expectations for both genders on the genital appearance of a partner. Disclosure No

Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions

ABSTRACT Introduction In clitoral adhesions (CA), a closed compartment of space under the clitoral hood can lead to accumulation of squamous cells and smegma, irritation, erythema, and infection. This causes the prepuce to adhere to the glans clitoris and prevents the corona, a ridge of tissue between the glans clitoris and the clitoral body, from being visualized. CA can cause discomfort, hypersensitivity or hyposensitivity, difficulty reaching orgasm, and chronic vulvar pain including clitorodynia. One treatment for CA is a non-surgical lysis procedure that is minimally invasive and stretches the preputial tissue open, yet there is a paucity of data on its effectiveness in treatment of symptoms and restoration of function. Objective To evaluate patient-reported outcomes of the non-surgical lysis procedure in order to determine if this procedure is an appropriate treatment for symptomatic CA that can be performed in the office-based setting. Methods 61 women who have been treated for CA using the non-surgical lysis procedure at one sexual medicine practice from 2017-2021 were identified using a chart review and an online survey was sent to patients to evaluate the efficacy of the procedure in improving pain and sexual functioning, as well as patient satisfaction with the procedure. Results There were 41 survey responses (67% response rate). All women that reported the ability to achieve orgasm from external clitoral stimulation maintained this ability after the procedure (n=24), and of the women that could not do so before the procedure (n=16), 6 were able to afterwards. 76% of respondents reported improvement in pain with 44%, 28%, and 4% reporting significant, moderate, and slight improvement. 63% reported improvement in sexual arousal with 25%, 25%, and 13% reporting significant, moderate, and slight improvement. 64% reported improvement in their ability to achieve orgasm with 26%, 18%, and 21% reporting significant, moderate, and slight improvement. 71% reported improvement in their satisfaction with sex with 27%, 17%, and 27% reporting significant, moderate, and slight improvement. 80% of respondents reported they could have comfortable physical/sexual stimulation within one month of the procedure, and 31% of respondents reported that it took one week or less. 93% of participants would recommend the procedure to a friend who also had CA. 65% and 18% of respondents reported being extremely and mostly satisfied with their decision to have the procedure. Conclusions These findings indicate that most patients reported improvement in their pain and sexual functioning, and no participants reported worsening in their pain, sexual arousal, or ability to achieve orgasm. 6 of 16 patients that could not achieve orgasm from external clitoral stimulation prior to the procedure were able to afterwards. Thus, the non-surgical lysis procedure could be considered as a treatment for pain and sexual dysfunction associated with CA. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raliegh, NC), Absorption Pharmaceuticals

Reduced Satisfaction and Increased Recurrence after Lysis Procedure for Clitoral Adhesions in Patients with Persistent Genital Arousal Disorder

ABSTRACT Introduction Clitoral adhesions (CA) occur when preputial skin that normally moves over the glans clitoris to expose the corona becomes adhered, creating a closed compartment that is vulnerable to irritation, erythema, and infection. CAs can be associated with persistent genital arousal disorder (PGAD), which is characterized by persistent or recurrent, distressing feelings of genital arousal that are not associated with sexual interest or thoughts. One treatment option for CA is a non-surgical lysis procedure that is minimally invasive and stretches the preputial tissue open, but this procedure has not been specifically studied in women with PGAD. Objective To determine if women with PGAD treated for CA with the non-surgical lysis procedure reported satisfaction and outcomes that were different from women without PGAD. Methods 61 women who have been treated for CA using the non-surgical lysis procedure at one sexual medicine practice between the years of 2017 and 2021 were identified using a chart review and an online survey was sent to patients to evaluate patient satisfaction and the efficacy of the procedure in patients with and without PGAD. Results 41 survey responses were received (67% response rate) and 4 women had a PGAD diagnosis. There was no difference in the procedure's ability to improve pain (50% vs 81%), ability to orgasm (75% vs. 63%), or sexual satisfaction (50% vs. 73%) between women with and without PGAD. 65% of all respondents (n=40) reported being “extremely satisfied” with their decision to have the lysis procedure; however, significantly fewer patients with PGAD reported being “extremely satisfied” as compared to the control group (25% vs. 69%; p=0.04). In addition, while only 27% of all participants reported that the procedure was painful, women with PGAD were significantly more likely to report pain than women without PGAD (75% vs. 22%; p=0.01). Lastly, 51% of respondents (n=37) reported recurrence of CA after the procedure, but the incidence of readherence was significantly higher in patients with PGAD compared to patients without PGAD (100% vs. 45%; p=0.02). The increased readherence in women with PGAD was not attributable to differences in post-procedural care (use of hormone cream, yeast cream, vaseline, or retraction of the clitoral hood) or risk factors for CA (history of yeast infections and urinary tract infections, use of hormonal-based contraceptives, blunt perineal or genital trauma, lichen sclerosus, or history of sexual pain) as these were not significantly different between study groups. Conclusions These results indicate that the non-surgical lysis procedure has similar efficacy in improving pain and sexual function in women with and without PGAD. However, this procedure may be a less favorable treatment for CA in women with PGAD as evidenced by lower reported satisfaction with the procedure, increased reports that the procedure was painful, and higher rates of readherence in this group. As only 4 women in our study had PGAD, future studies with more patients with both PGAD and CA may be necessary to provide insight into additional treatment options that may offer these patients more satisfaction and improved outcomes. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Clinical Presentation of Clitorodynia associated with Clitoral Adhesions and Keratin Pearls

ABSTRACT Introduction Clitoral adhesions occur when the clitoral prepuce adheres to the glans clitoris. This can lead to accumulation of desquamated epithelial cells under the prepuce, resulting in the formation of smegmatic pseudocysts and keratin pearls. A keratin pearl is a focus of central keratinization within concentric layers of squamous cells. Presence of these firm, millimeter-sized masses can lead to clitoral pain (similar to a grain of sand in the eye). Although keratin pearls have been described in the literature, there is little known about their clinical presentation or association with female sexual dysfunction (FSD). Objective Explore the clinical presentation of clitoral pain associated with clitoral adhesions and keratin pearls related to concomitant genitopelvic pain conditions and sexual dysfunction. Methods A retrospective chart review was conducted in two metropolitan gynecology clinics specializing in vulvar pain between January 2018 and September 2021. Patients presenting with clitoral pain (clitorodynia) were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed by review of the clinical notes. Adult patients with documented clitoral pain as well as clitoral adhesions (clitoral phimosis) and keratin pearls noted on exam were included in the study. FSD was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Data was presented in means and percentages. Results Forty-one patients met inclusion criteria. Average age at presentation was 35 years (range 19-73 years). Self-reported ethnicity of the study population was 73% White, 5% Hispanic, 5% Asian, 2% Black, with no response from 15% of participants. Vulvar lichen sclerosus was noted in 17% (7/41) of patients, with an average age of 46 years (range 24-73 years). Seventy-six percent (31/41) of patients also had the diagnosis of overactive (hypertonic) pelvic floor muscle dysfunction (PFD), 25% (8/31) had pudendal neuralgia and 10% (3/31) had interstitial cystitis/painful bladder syndrome. Forty-six percent (19/41) of patients had provoked vestibulodynia (PVD) associated with a hormonal factor (hormonal contraceptive use, postpartum/breastfeeding, perimenopause, or menopause). Recurrent vulvar candidiasis or tinea cruris was noted in 5% of patients. Four patients (10%) presented with clitoral pain alone and were not found to have other identified genitopelvic pain conditions. Baseline FSFI and FSDS-R data were available in 35 patients. Mean FSFI score was 13.25, with 91% of patients meeting criteria for FSD (total FSFI score &amp;lt; 26.55). Mean scores for FSFI domains were: desire (2.4), arousal (2.1), lubrication (2.5), orgasm (2.0), satisfaction (2.5), and pain (1.6). Mean FSDS-R score was 29.42, with 89% of patients meeting criteria for FSD (FSDS-R score ³11). Conclusions Clitoral pain associated with clitoral adhesions and keratin pearls occurs in women of all ages. Clitoral adhesions are not confined to patients with vulvar lichen sclerosus. A vast majority of patients with clitoral adhesions and keratin pearls have additional chronic vulvar pain conditions, most commonly overactive PFD, pudendal neuralgia, or hormonally-associated PVD. Clitoral pain with clitoral adhesions and keratin pearls is associated with FSD and sexual distress. Clitorodynia and clitoral phimosis should be identified in the clinical evaluation of genitopelvic pain. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; part-time employee of Dare Bioscience. Received research funding from Dare Science, SST, Endoceutics, The Cellular Medicine Association, and Ipsen for other projects. He is a consultant for Ipsen, SST, and AMAG

The First Report of Isolated Clitoral Hood Hair-Thread Tourniquet Syndrome: A Study of Six Patients.

Background and objectiveHair-thread tourniquet syndrome (HTTS) is a rare and potentially dangerous condition that occurs when a hair strand or fabric thread is wrapped around the penis, clitoris, toes, fingers, or other appendages, leading to focal edema, ischemia, and necrosis. This study aimed to examine the cases of six female patients with isolated clitoral hood HTTS.MethodsThis was a retrospective study involving six female patients (age range: two to six years) with isolated clitoral hood tourniquet who presented to the outpatient department (OPD) and emergency room (ER) of the pediatric and adolescent gynecology service at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 2010 and December 2021. Data related to patients’ clinical presentation, symptom duration, and management were recorded.ResultsThe most common symptom of isolated clitoral hood HTTS in all six cases was pain, followed by redness, itching, discomfort while sitting, and dysuria. Local signs included edema in three cases, tight hair tourniquet around a portion of the clitoral hood in four cases, and loose hair tourniquet around a portion of the clitoral hood in two cases, one of which was during the first episode in a patient who had recurrence (Case 1). Sedation and local anesthetic were used in five cases involving the local removal of four hairs and a strangulated skin. This was followed by local care and antibiotic ointment application. The edges were closed by interrupted stitches in two of the cases as the resulting wounds were broad. Limited clitoral unhooding was performed under general anesthesia in one patient, who had repeated bouts of autoamputation of parts of the hood tissue with resulting disfiguration of the remaining redundant hood, to avoid the additional risk of organ loss. Only two patients experienced recurring episodes.ConclusionsA high index of suspicion should be maintained when encountering these patients, which can facilitate a prompt resolution to save the affected tissue. HTTS should be suspected in all females presenting with a prominent clitoral hood, genital pain, structural abnormality, swelling, or discomfort. This is the first study to report isolated clitoral hood HTTS; it describes the presentation, manifestation, and management of patients with HTTS. It also addresses preventive strategies to alert mothers and treating physicians of the pediatric and adolescent-age group females to the defect and its underlying causes, particularly when patients have genital structural abnormalities such as excessive clitoral hood labial hypertrophy or ambiguous genitalia.

Post Penile Inversion Vaginoplasty Clinical Examination: Considerations and Techniques.

Post Penile Inversion Vaginoplasty Clinical Examination: Considerations and Techniques.

Correcting gender dysphoria –the anatomical changes with male to female gender reassignment surgery

ABSTRACT Introduction &amp; Objectives Increased Global acceptance of transgender communities, gender-affirming genital reconstructive surgery is becoming more prominent. Formalised education and training however has not quite entered the curriculum of many surgical training programs yet it remains imperative we have an understanding of modified anatomy in out patients. We demonstrate anatomical reconstruction during the transition between male to female anatomy. Methods Patient consent was obtained to take a series of photographs during gender affirming surgery from male to female. Results Contemporary patients receive both spinal and general anaesthesia prior to positioning in standard lithotomy. A perineal incision of approximately 10cm in the midline raphae exposes the corpora and spongiosum. A simple bilateral orchidectomy was performed at the level of the external inguinal ring. A neovaginal cavity was created by firstly dividing the bulbospongiosus attachments to the perineal body and the space is both blunt and sharply dissected. Further dissection is carried out in the avascular perirectal fat plant anterior to the Denonvilliers fascia. During this dissection a 18-22Fr urethral sound is used to apply downward traction on the rectum. A sterile ultrasound sleeve is placed in the rectum to allow bimanual palpation to confirm intact rectal mucosa. A circumferential incision proximal to the glans is performed to aide degloving of the penis. Bucks fasica is left intact and distal penile skin will later be used to form the clitoral hood. The dorsal neurvascular bundle is raised off the corporal bodies but an attachment to the glans remains. A triangular section of dorsal glans is preserved and dissected off the tips of corpora. The penile tissue is then disassembled separating the corpus spongiosum from the corporal bodies. The corpora are amputated at the level of the pubis, remaining erectile tissue destroyed and oversewn for haemostasis. The Urethra is shortened to an appropriate length to allow the dorsal aspect to align between the neoclitoris and neomeatus. The ventral aspect is spatulated to expose the neomeatus. The penile skin flap is invaginated within the neovaginal space and the skin incised to expose the neoclitoris and neomeatus. The penile skin is then anastomosed to the neoclitoris and neomeatus The distal end of the penile skin flaps is oversewn to create a blind ending tube and thus creating the neovagina. Labia Majora are formed by excising excess scrotal skin to create an appropriate contour. This form of neovagina is compared to methods that involve intestinal and peritoneal lining transfer. Conclusions We have outline the stepwise transition of male to female anatomy with a conventional contemporary technique. Creation of a neovagina with penile inversion has become common practice in gender affirming surgery. However there are other means of creating genitalia with alternative tissues, which subspecialised practitioners should be aware. Disclosure Work supported by industry: no.

Female cosmetic genital surgery: Complications

ABSTRACT Introduction Female cosmetic genital surgery is rapidly gaining popularity and acceptance as both the aesthetic and functional benefits of these procedures are becoming more and more appreciated and reachable. World Health Organization (WHO) defines health as „a state of complete physical, mental and social well-being and not merely absence of disease or infirmity”. Plastic surgeons and doctors of aesthetic medicine noticed that self-perception of the body image, beauty and physique strongly influences a woman's mental and social well-being. Cosmetic surgery is considered ethical and beneficial when intervention is able to improve the quality of life (QoL) and well-being of the patient. In recent years, however, a new aesthetic medicine concept has been developed into gynecological practice: correction and/or modifying the genital anatomy in the absence of a specific organic problem or disease with the objective of improving a woman's health perception. Objective Female cosmetic genital surgery refers to non-medically indicated cosmetic surgical procedures which change the structure and appearance of the healthy female genitalia. There are a number of procedures including: labiaplasty, vaginoplasty, perineoplasty, clitoral hood reduction, hymenoplasty and G-spot bulking. Complications of cosmetic female cosmetic surgeries are low, estimated between 2-4% and they vary depending on the procedure. Methods This systematic review will provide an assessment of complications associated with female cosmetic genital surgeries. The following databases has been searched from the study inception to July 2021: the Cochrane Central Register of Controlled Trials (Cochrane Library), PubMed, MEDLINE, Embase, Scopus, Web Of Science, ProQuest, ScienceDirect, UpToDate, Polish Medical Bibliography and consultations of Polish specialists and discussion forums of patients have been used. Results Woman's search for a „perfect” vagina and vulva is very often stimulated via the Internet promotional articles and advertisements offering and promising extraordinary cosmetic and functional improvements that are supposed to be achieved due to female cosmetic surgery. Many of these procedures, while elective, are not limited to aesthetic goal alone, e.g. the majority of women seeking labiaplasty also have a concomitant functional issue, whether it is discomfort from clothing or dyspareunia. Women should be carefully advised and screened pre-operatively for underlying psychological problems and sexual dysfunction. Female cosmetic genital surgeries should ideally be provided by a multidisciplinary team of healthcare professionals, including: surgeons, psychologists, psychosexual therapists, physiotherapists, with relevant training, demonstrated competence and with the required clinical governance arrangements in place. Conclusions Female cosmetic genital surgery is a rapidly expanding and poorly regulated field of cosmetic surgery. Despite the controversies, the relevant professional bodies should attempt to regulate training and standardize terminology. Well-designed prospective studies with long-term follow-up are needed. Patients should be carefully counselled and selected pre-operatively ideally by a multidisciplinary team. The request for female cosmetic genital surgery may be reasonable and whilst we respect an individual's right to choose, there needs to be increased regulation in this controversial area of medicine. Disclosure Work supported by industry: no.

Female sexual medicine: What are students learning in undergraduate medical education?

ABSTRACT Introduction In the United States, medical education on sexual medicine varies throughout the country and between institutions. With limited standardization, medical students and subsequent trainees have little to no training in how to approach a patient with concerns surrounding their sexual health. In 2018, half of the medical institutions in the United States required formal instruction in sexual medicine. Of those institutions that do include didactic material on sexual medicine, most of the material is dedicated to anatomy, physiology, and sexually transmitted infections, with limited or no information on sexual dysfunction and sexual history taking. Therefore, we identified a need to determine which components of sexual medicine, particularly female sexual medicine, are currently being covered in undergraduate medical education with the goal of proposing and developing standardized curriculum materials to be utilized by medical students during their preclinical education. Objective The aim of this study is to examine current preclinical curricula at all seven medical schools, including six allopathic and one osteopathic institution, in the Chicago, Illinois area to investigate which aspects of female sexual anatomy, physiology, pathology and pharmacology are being taught to medical students. Methods Curriculum materials on female sexual anatomy, physiology and pathology were collected from all seven medical schools in Chicago, Illinois. Courses covering topics on female sexual medicine varied between institutions due to differences in preclinical curriculum and coursework. To standardize our needs assessment, we utilized previous literature to identify specific components of anatomy, physiology, pathology, pharmacology, social sciences, and history and physical exam skills. Upon reviewing each institution's preclinical educational materials, we assessed curriculum content for saturation of specific concepts within each of the above areas. Results Curriculum materials were collected from seven (n=7) total medical schools in the surrounding Chicago, Illinois area. Out of the 7 institutions, 4/7 discussed clitoral anatomy, with 6/7 mentioning the glans, 1/7 mentioning the corona, 2/7 mentioning the clitoral hood, 6/7 mentioning the corpora cavernosa, 4/7 mentioning the corpus spongiosum, 6/7 mentioning the crus, 6/7 mentioning the bulb and 5/7 detailing the clitoral neurovasculature. In addition to the anatomy, 4/7 discussed the physiology of the female orgasm, 3/7 highlighted the rate and epidemiology of female sexual dysfunction (FSD), 3/7 included information on treatment for FSD, 1/7 taught a genitourinary physical exam specific to assessing FSD (external exam, internal exam, pelvic floor assessment), and 6/7 institutions included information on how to take a sexual history asking about sexual function, pleasure, and satisfaction. Conclusion Overall, our focused needs assessment of both allopathic and osteopathic medical schools in the Chicago, Illinois area highlights the need for restructuring of curriculum as it pertains to female sexual medicine and FSD in undergraduate medical education. Next steps include proposing individual curricular recommendations to institutions, due to the variation in current curriculum design, as to how they can better teach on areas surrounding FSD, while also aiming to standardize what medical students are learning during their preclinical years. Disclosure Work supported by industry: no.