Clitoral Hood Research Articles

The development of the external genitals in female human embryos and foetuses. Part 1: Perineal thick skin, clitoris and labia.

Concomitant with the rupture of the cloacal membrane in the 6th week of development, the intermediate layer of the perineal-skin epithelium thickens. We investigated its distribution and the development of the corresponding subcutaneous compartments in serial sections of female human embryos and foetuses and prepared 3D reconstructions to establish topographic relations. The thick-skin area becomes restricted to the outlets of the genital and intestinal tracts. The clitoris and labia majora become identifiable at ~7 weeks. The mesenchymal mass inside the clitoris soon divides into the glans and the cavernous bodies. The clitoral hood forms between 10 and 14 weeks as a fold of tissue that extends from proximal to distal over the glans. Due to the caudal bending of the clitoral shaft, the labia majora gradually cover the clitoris after ~14 weeks. The labia minora form at ~8 weeks from the ridges of thick-skin epithelium that flank the genital exit. They are continuous ventrolaterally with the clitoral hood and ventromedially with the apex of the cavernous body. Dorsally, their dense subcutaneous mesenchymal core extends to the anal canal. Between 8 and 14 weeks, the urethra lengthens axially, while the vaginal vestibule extends ventrally. In this period, the urethral plate of female embryos is mitotically active but does not increase in volume, which suggests that it contributes to vestibular growth. In conclusion, we observed a temporal correlation between the development of the thick-skin epithelium and that of the external genitals, with a distribution that is reminiscent of the dihydrotestosterone-sensitive skin.

Barbie Deformity after Edge Labiaplasty: Classification and Repair Algorithm.

Influenced by the popularity of "Barbie" shape of labia minora, edge labiaplasty has become the preferred option among patients and surgeons alike. However, excessive or inappropriate resection of labial free edges may lead to morphological deformities and dysfunctional symptoms termed as "Barbie deformity". This study aims to report a classification of Barbie deformity and a repair algorithm to help surgeons select appropriate surgical methods. A total of 216 patients with Barbie deformity were classified into 3 degrees. Among these, 119 patients underwent repair surgeries by different methods corresponding to the degree of deformity. The surgical outcomes of 87 patients were assessed via follow-up questionnaires. Preoperative and postoperative levels of general psychological distress and self-esteem were compared for 46 patients using standard scales. Barbie deformity was identified on 338 sides: 158 were Grade I, 106 were Grade II, 74 were Grade III, and 187 had vestibular mucosa exposure. Repair surgeries were performed on 189 sides: 53 via edge trimming, 99 via wedge excision, 32 with an island clitoral hood flap, and 5 with Gress's composite method. The complication rate was 4.8%. Genital appearance was improved in 96.6%, preoperative discomfort was resolved or significantly reduced in 74.2%, and overall satisfaction was 86.2%. The general psychological distress and self-esteem scores also improved significantly after surgery. The goal of repairing Barbie deformity is not only to improve the appearance of the genitals but to also restore the position and function of the mucosa. Preventing Barbie deformity is much more important than repairing it.

Cosmetic Gynecology: Is There Enough Exposure in the Obstetrics and Gynecology Residency?

Introduction While cosmetic gynecology has gained popularity, the training experience for obstetrics and gynecology residents in this area is limited and not standardized. The primary objective was to investigate the exposure of obstetrics and gynecology residents to cosmetic gynecologic procedures including hymenoplasty, labia majora reduction, vaginoplasty, G-spot amplification, labiaplasty, clitoral hood reduction, and vaginal laser therapy. The secondary objective was to assess their comfort in performing the procedures after graduation. Methods This is a non-validated cross-sectional survey of obstetrics and gynecology residents and their exposure to cosmetic gynecology procedures. Using the Fellowship and Residency Electronic Interactive Database Access System, the Accreditation Council for Graduate Medical Education-accredited Obstetrics and Gynecology residency programs in the United States were identified, and the residency program coordinators were asked to distribute the survey. Data regarding demographics, program-specific characteristics, and exposure to certain cosmetic gynecology procedures were obtained and reviewed. Participants' reported comfort with the independent practice of certain cosmetic gynecology procedures after graduation was also obtained. Descriptive statistics were completed. Results A total of 96 responses were received. Approximately 50% of participants were exposed to cosmetic gynecology during training. Moreover, 70.9% of residents disagreed that they would feel confident in defining the included procedures. Furthermore, 87.5% disagreed that they would feel comfortable performing the procedures independently. A minority of participants were also unsure of the indication for cosmetic gynecology procedures, with 15.4%, 7.1%, 5.7%, and 4% unaware of the surgical indication for hymenoplasty, vaginoplasty, labiaplasty, and labia majora reduction, respectively. No participant knew the indication of surgery for vaginal laser therapy or clitoral hood reduction. Conclusions In the setting of current cosmetic gynecology training, nearly 90% of residents were not comfortable with these surgeries after graduation. Exposure to cosmetic gynecology for obstetrics and gynecology residents was limited. Without adequate exposure, residents may face difficulty performing procedures and managing complications after graduation. Therefore, standardizing resident training for cosmetic gynecology should be considered.

(110) THE SURGICAL ANATOMY OF CLITORAL INNERVATION: A REVIEW OF THE CURRENT MEDICAL LITERATURE

Abstract Introduction The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms “(clitor*)) AND (innerv* OR nerv*) AND (surg*)” and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve’s exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure No.

Cosmetic Gynecology

Cosmetic Gynecology (CG) is a rapidly emerging subspecialty. With the large media coverage, it had gained popularity in last few years. This review aims to provide an overview of the advancements, techniques, and considerations in aesthetic gynecology. We discuss common procedures such as labiaplasty, vaginal rejuvenation, and clitoral hood reduction, highlighting their indications, surgical techniques, outcomes, and patient satisfaction. Additionally, we explore emerging trends such as non-surgical treatments using laser therapy and Platelet-Rich Plasma (PRP) for tissue rejuvenation. Ethical considerations, patient education, and the importance of a multidisciplinary approach are also discussed. GC addresses both functional as well as aesthetic aspect of female external genitalia and is being considered as an excellent opportunity to address psychosexual issues if present. Overall, aesthetic gynecology offers valuable options to improve women’s confidence, comfort, and quality of life.

Edge Labiaplasty with Clitoral Hood Reduction: Pitfalls and Pearls.

Edge Labiaplasty with Clitoral Hood Reduction: Pitfalls and Pearls.

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

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. 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). 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. 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. 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. 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. 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. In-office LCA-KPE significantly reduced clitoral discomfort and difficulty with orgasm.

The Need of Differential Diagnosis Between Vulvar Lichen Sclerosus and Autoimmune Dermatoses in Adolescent Girls.

Vulvar lichen sclerosus (VLS) is a chronic inflammatory condition affecting the anogenital region, which can manifest in prepubertal or adolescent patients. The prevailing theories point to autoimmune and genetic factors. The primary symptoms of VLS typically include vulvar itching, discomfort, dysuria, and constipation. Physical examination often reveals a characteristic figure8 pattern, involving the labia minora, clitoral hood, and perianal region. However, these symptoms and the age of onset are nonspecific and require differentiation from autoimmune dermatoses such as bullous diseases, pemphigus diseases, epidermolysis bullosa acquisita, and dermatitis herpetiformis. We performed this study to distinguish VLS from autoimmune dermatoses, and in doing so, uncover the underlying causes of chronic vulvar changes. This knowledge will enable healthcare providers to offer appropriate medical care to affected patients. The study was conducted between July 2020 and February 2021, with a sample of 55 girls aged 2-18years who did not have any systemic diseases. The study group was composed of 20 girls previously diagnosed with vulvar lichen sclerosus, while the control group included 35 girls without VLS. Questionnaires regarding the medical history of the children were completed by their legal guardians. Blood samples were collected and analyzed biochemically to assess human immunoglobulin A (IgA), IgG, and IgM antibodies against various substrates, including the desmosome of stratum spinosum, basement membrane zone, desmoglein 1 (DSG1), desmoglein 3 (DSG3), BP180-NC16A-4X, BP230gC, pemphigoid antigen, collagen type VII NC1, transitional epithelium, gliadin (GAF-3X), endomysium (EMA), and cellular nucleus (ANA). The analysis of the study group revealed that the most commonly observed signs and symptoms included: itching, soreness, burning sensations, and excoriation, as well as erythema or/and pallor of the skin and perineal mucosa. Among the assessed antibodies, only anti-GAF3x antibodies and ANA antibodies were detected. However, the results did not reach statistical significance (p > 0.5).

The Potential Coexistence of Autoimmune Thyroid Diseases and Pediatric Vulvar Lichen sclerosus.

Vulvar lichen sclerosus (VLS), a chronic inflammatory skin disorder, often coexists with autoimmune thyroid disease (AITD). VLS presents with subtle symptoms including vulvar itching and discomfort. Clinically, a "Figure 8" pattern involving the labia minora, clitoral hood, and perianal region is often observed. It is prevalent both in pre-pubertal girls and women aged 40-60, and the link between VLS and AITD remains unclear, with proposed causes including autoimmune, hormonal or genetic factors, and environmental triggers. This study addresses the lack of research on the association in children, aiming to investigate the largest group of underage girls to date. This study aimed to investigate the coexistence of thyroid autoimmune diseases in girls diagnosed with vulvar lichen sclerosus (VLS) and to assess the presence of antibodies for specific thyroid autoimmune diseases. Our study was conducted from July 2020 to February 2021, involving a sample of 55 girls aged 2-18 years old, all free from systemic diseases. The study group comprised 20 girls previously diagnosed with vulvar lichen sclerosus (VLS), while the control group included 35 girls without VLS. Legal guardians completed questionnaires detailing the medical history of their children. Blood samples were collected from all participants and subjected to biochemical analysis. The presence of human IgG antibodies against thyroid peroxidase and IgG antibodies against thyroglobulin was assessed using the immunoenzymatic method with commercially available ELISA kits. In the study group, common symptoms included itching, soreness, burning sensation, excoriation, and erythema or pallor of the skin and perineal mucosa. An evaluation of anti-thyroglobulin and anti-thyroid peroxidase antibodies revealed no statistical significance between the study and control groups (anti-TG p = 0.379, anti-TPO p = 0.96). Family history of autoimmune diseases showed no significant correlation with anti-thyroid antibodies in girls. Although no significant relation between VLS occurrence and antibody levels was found, it emphasizes the need for multidisciplinary medical care. Further research with larger patient groups is necessary.

(265) The Surgical Anatomy of Clitoral Innervation: A Review of the Current Medical Literature

Abstract Introduction The clitoris is a crucial structure for sexual arousal and orgasm in people with gynecological anatomy. Despite its functional importance, the innervation of the clitoris has historically been understudied. The innervation of the clitoris includes somatic afferents of the dorsal nerve of the clitoris, a branch of the pudendal nerve and sacral plexus, and autonomic afferents of the cavernous nerve, a branch of the inferior hypogastric plexus. Although we have identified these structures, there remains a paucity of research on surgical techniques to avoid clitoral innervation during pelvic surgery, despite the importance of these nerves in gynecological sexual function. Objective This paper aims to summarize the current literature on clitoral innervation with special attention paid to the anatomical locations of nervous structures within the pelvis to inform future pelvic surgeons and reduce sexual side effects related to clitoral nerve damage. Methods We performed a PubMed search from inception through June 14, 2023 utilizing the Medical Subject Headings (MeSH) search terms “(clitor*)) AND (innerv* OR nerv*) AND (surg*)” and imported this search into Covidence software. Included in the literature search were observational studies, clinical trials, review articles, correspondence, and communications, and only articles in English were included. Results An initial abstract screen of 200 articles resulted in 87 articles that were fully screened and 53 articles that were utilized as within the scope of this paper. 45 papers discussed the dorsal nerve of the clitoris, while 15 papers explored autonomic afferents via the cavernous nerve. Fourteen papers discussed both somatic and autonomic innervation to the clitoris. The anatomical location of the dorsal nerve of the clitoris has been tracked in 29 papers, most of which utilize cadaver dissection, with at least six anatomic variations identified. The cavernous nerve’s exact location, however, has not been traced as extensively as has the location of the dorsal nerve of the clitoris, perhaps due to its smaller diameter and shorter length. Additional innervation to the clitoris was proposed in 12 studies as well. Many studies suggested that commonly performed procedures, including midurethral sling placement for stress urinary incontinence, labiaplasty, clitoral hood reduction, clitoroplasty, and urogenital sinus repair may interfere with clitoral innervation if not otherwise modified. Two studies discussed sensory mapping techniques prior to pelvic surgery to account for anatomic variation in clitoral innervation. Conclusions The clitoris is a vastly innervated structure with both somatic and autonomic afferents whose locations and anatomic variations should be considered when performing pelvic surgery. Failure to consider not only the dorsal nerve of the clitoris but the cavernous nerve as well may have consequences that negatively impact clitoral sensitivity, engorgement and erection, orgasmic ability, and overall sexual function. Disclosure No.

(271) Patient with Severe Clitoral Phimosis and Smegmatic Cyst: A Case Report and Review of the Literature

Abstract Introduction Clitoral phimosis describes an attachment of the clitoral prepuce to the glans. This severe form of clitoral adhesions prevents the mobility and retraction of the clitoris and can be accompanied with clitorodynia, persistent arousal, and/or muted or absent orgasm. It often presents with a buildup of smegma and keratin pearls. Previous research suggests that these adhesions are found in up to 22% of women seeking evaluation for sexual dysfunction. Objective To describe a patient with a unique and severe presentation of untreated clitoral adhesions resulting in complete clitoral phimosis and a large pseudocyst, and to share an innovative and minimally invasive procedure option which preserved sexual function. Methods A 60-year old female presented with as a clitoral mass to a urology and sexual medicine practice for consultation regarding surgical excision of the mass with hopes to preserve clitoral sensation. Following an abdominal hysterectomy and bilateral salphingoophrectomy in 2010, the patient of interest presented to her gynecologist for an enlarging clitoris which progressed to form a mass over the course of several years. In 2022 she established care with a new gynecologist who referred her to a gyn-oncologist for concern of the now large mass. She underwent an MRI of the pelvis in September 2022 which revealed a 1.7 x 3.5 x 1.9 cm cystic lesion projecting from the prepuce. This was felt to be an epidermoid cyst or proteinaceous or hemorrhagic cyst arising from the vagina. After speaking to many specialists the plan was to undergo surgical excision, though preservation of sensation could not be guaranteed. The patient canceled surgery to obtain more information as preservation of clitoral sensation was a priority, at which point she presented to our clinic in April of 2023. Results On exam, there were normal labia majora and resorbed labia minora fusing with the clitoral mass. On further examination, complete phimosis with a pinpoint and closed phimotic ring visible and a large smegmatic pseudocyst that was not adherent to the clitoris was appreciated. Clitoral phimosis was discussed at length and as an innovative, yet relatively straightforward solution, our urological surgeon proposed a dorsal slit (in the operating room) procedure for removal of smegma and small excision of excess surrounding tissue. This approach would have little to no known effect on the clitoral nerves as they course dorsally and terminal at the clitoral glans and would allow full retraction of the clitoral prepuce. The procedure was performed in May 2023 under IV sedation. Copious amounts of smegma were irrigated from the cyst and no adhesions were appreciated. After the removal of the smegmatic pseudocyst, our patient reported improved sensation and orgasm without pain or cystic reaccumulation. She was instructed to dilate the opening to avoid re-adherence. Conclusions There is no standardized treatment for clitoral adhesions. This procedure improved our patient’s sexual function and orgasm ability and was spared from a major surgery with significant risks. Equipping physicians with fundamental knowledge about clitoral adhesions would likely result in earlier and more frequent intervention, preventing large and atypical masses like the one observed in this case. Disclosure No.

Violence against Women: Comparing Female Genital Mutilation and Female Circumcision in Malaysia

The United Nations (UN) General Assembly resolution on 20 December 2012 declared female genital mutilation (FGM) illegal and a violation of women's rights. This declaration was made following the World Health Organization's (WHO) call to eradicate FGM in 1997. The prohibition includes all forms of mutilating, harming, or causing pain to the female genitalia. The female circumcision practice in Malaysia is also categorized as FGM by the United Nations Human Rights (UNHR) at the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) in 2018. In light of these developments, this qualitative study examines and compares the true nature and concepts of FGM and the female circumcision practice from the perspective of Al-Sunnah Al-Nabawiyyah. Documentation was employed for data collection, analysis, and interpretation. The findings reveal a significant divergence between FGM and female circumcision. Female circumcision is more similar to the aesthetic surgery of the female genitalia, known as clitoral hood reduction, which can enhance women's sexuality. In conclusion, female circumcision in Malaysia is not a torturous act that violates women's rights, but rather a safe practice following Islamic law. This study also proposes a comprehensive research initiative aimed at formulating secure and Sharia-compliant protocols for female circumcision.

The impact of labiaplasty on sexuality.

Hypertrophy of the labia minora and majora, or a prominent clitoral hood, are the primary reasons why women, particularly those seeking cosmetic gynecologists, may experience limitations in their social environments. At the same time, modern trends have made labiaplasty popular in recent years. This study investigated the effect of labiaplasty on women's genital self-perception and sexual functions. The composite reduction labiaplasty technique was performed on 33 women aged 18-50 with Grades 2-4 labia minora hypertrophy. The exclusion criteria included menopausal and sexually inactive women, as well as women with vulvar disorders, a history of vaginal or labial surgery, other gynecological disorders, psychological disorders, and malignancies. The Female Sexual Function Index (FSFI) and Female Genital Self-Image Scale (FGSIS) questionnaires were administered to the study subjects before and three months after their surgery, during their follow-up appointments. The mean age of the subjects was 30.73 ± 3.94 years. Their mean parity was 1.12 ± 0.82. Almost 70% of them had a university degree. Their most common reason for desiring labiaplasty was aesthetic concerns (48.48%). Their total FGSIS scores were 11.85 ± 1.35 preoperatively and 24.48 ± 1.66 postoperatively, and their total FSFI scores were 13.29 ± 1.68 preoperatively and 24.48 ± 1.66 postoperatively. Labiaplasty surgery is a safe surgical procedure. It has a positive effect on women's genital self-image and sexual functions.

Simultaneous Surgery of the Clitoral Hood-Labia Minora Complex with the Central Neurovascular Pedicle Retained.

Hypertrophy of the labia minora with clitoral hood redundancy always occurs simultaneously and should be considered in its entirety. This study investigated a new simultaneous procedure for the clitoral hood-labia minora complex (CLC) that retains the central neurovascular pedicle. This retrospective observational study, conducted between January 2021 and August 2022, included 29 patients with labia minora hypertrophy and clitoral hood redundancy who underwent a surgery wherein procedures on the CLC were performed simultaneously. A divisional design to separate the medial and lateral labia minora and to remove the skin and subcutaneous tissue asymmetrically, while retaining the central neurovascular pedicle and the natural margin of labia minora, was employed. Postoperatively, all patients were followed up via the Internet or at the outpatient clinic. The follow-up included observing postoperative outcomes and any complications and completing the satisfaction questionnaires. All the patients who underwent surgery showed good wound healing without discomfort of thread friction. Postoperatively, the labia minora had a natural appearance and retained sexual sensitivity. The scarring on the surgical incision was not evident. Hematoma and evident bilateral asymmetry occurred in one patient each. The satisfaction rate within 14 days and after 3 months of surgery was 96.6% and 92.6%, respectively. This method uses a hidden incision, to remove the hypertrophic tissue and retain the natural edge and shape of the labia minora. Qualitatively, the patients were highly satisfied. This method was safe, effective, and easy to implement. 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 .

Women's Knowledge, Attitudes, and Practice About Female Genital Cosmetic Surgery: A Cross-Sectional Study in Saudi Arabia.

Introduction Vulvoplasty, or female genital cosmetic surgery (FGCS), refers to any surgical alteration of the vaginal or labial anatomy for aesthetic or medical reasons. It aims to restore or enhance the female genitals and can involve multiple procedures such as labiaplasty, clitoral unhooding, monsplasty, vaginoplasty, hymenoplasty, G-spot augmentation, frenuloplasty, perineoplasty, fat injections, or a combination of these. Labiaplasty is currently the most popular procedure among patients. Since the public is exploring FGCS benefits in the media, it can be foreseen that it will soon gain popularityamong the population of Saudi Arabia. As a result, the purpose of this study is to assesswomen'sattitudes and knowledge towards genital cosmetic surgeries in Saudi Arabia. Methods This correlational cross-sectional survey was conducted in Saudi Arabia among women aged 18 years and above, using an online self-structured questionnaire distributed from April 2023 to October 2023. The sample size of 594 respondents was determined based on a minimum requirement of 500 participants, with a confidence level of 95% and a study power of 95%. A convenient sampling method was employed to select participants, and data collection was carried out through a self-administered online questionnaire distributed via various social media platforms. The survey was self-structured, andCronbach's alpha values for all sections were greater than 0.7. These sections includedemographic characteristics, sexual life and obstetric history, and women's knowledge, practices, and attitudes toward FGCS. Descriptive analysis, chi-square test, and t-test were used for data analysis using SPSS software. Results A total of 589 eligible women were included in the study;284 (48.2%) were from the central region, and ages ranged from 18 to 65 years, with a mean age of 33.5 years. A total of 401 (68.1%) were married, 366 (62.1%) had a bachelor degree. Two hundred and ninety-one(49.4%) participants heard about FGCS, 165 (28%) knew that it involves surgical procedures to change the appearance of the female genitalia, 144 (24.4%) said it is also known as vaginal rejuvenation or designer vagina surgery and 200 (34%) knew it can involve procedures such as labiaplasty, clitoral hood reduction, or vaginal tightening, while 190 (32.3%) reported it is sometimes done for aesthetic reasons but may also be done for medical reasons. Only 45 (7.6%) had undergone FGCS, but 112 (19%) confirmed they consider undergoing FGCS for themselves. Four hundred and ninety-eight (84.6%) participants thought that it's important to have access to support services, such as counseling or peer support, 471 (80%) expressed that it's important that healthcare providers in Saudi Arabia are knowledgeable about FGCS, 425 (72.2%) were concerned about the potential risks and complications of FGCS. Conclusion In conclusion, the current study revealed that nearly one out of five women were knowledgeable about FGCS, mainly about the nature and types of the procedure. Higher knowledge levels about FGCS were associated with younger age, higher educational levels, and women who were more likely to consider undergoing FGCS in the future.

Lymphatic Pathways on Indocyanine Green Lymphography in Patients with Labia Minora Hypertrophy.

Labia minora hypertrophy (LH) is a growing aesthetic concern, yet its etiology and local lymphatic anatomy remain unclear. This study aimed to use indocyanine green (ICG) lymphography to investigate evidence of lymphedema in LH and clarify the anatomy of lymph vessels from the labia minora. Thirty-five patients with LH underwent preoperative ICG lymphography of their bilateral labia minora. The study reviewed demographic, ICG imaging, and measurement data to identify the characteristics of the superficial lymphatic anatomy in the labia minora. The ICG lymphography findings revealed that 97.1% of the observed patterns were linear, and 2.9% were dermal backflow patterns. Further analysis of the linear patterns revealed the presence of 3 main superficial pathways originating from the labia minora and connecting to the labia majora and clitoral hood. These pathways were identified as the superior, median, and inferior channels. Based on the observed lymphatic mapping in the labia minora, 3 types were classified: type 1 (superior and inferior channels) accounted for 75.0% (51 sides), type 2 (median and inferior channels) accounted for 8.8% (6 sides), and type 3 (superior, median, and inferior channels) accounted for 16.2% (11 sides). The study demonstrates that ICG lymphography enables clear visualization of superficial lymph flow from the labia minora. It also suggests that lymphedema is not a common pathologic feature of LH. Understanding the lymphatic anatomy of the labia minora can provide valuable guidance for surgical interventions involving the female external genitalia.

Vaginal Preservation in Shaft-Only Phalloplasty: Y-to-V Advancement Technique for Clitoral Hood Redundancy and Reduction Labiaplasty.

As the prevalence and understanding of genital gender-affirming surgery have grown, so has the spectrum of surgical techniques to better serve a wider range of transgender and nonbinary individuals. Given the diverse spectrum of individuals seeking phalloplasty, patient-driven decision-making, beginning with the initial consultation, is critical. Phalloplasty is not a one-size-fits-all surgery, but instead should be viewed as an individually customized approach. This article discusses the technical details of vaginal preservation without scrotoplasty or clitoral tissue burial in a shaft-only phalloplasty. The technique involves degloving the clitoral shaft with inset at the ventral base of the phallus, addressing the redundant clitoral hood, and accompanying reduction labiaplasty with a Y-to-V adjacent tissue transfer. The phallus may be neurotized with clitoral nerves from one side of the clitoris and/or the ilioinguinal nerve. This technique obliterates the degloved clitoral hood and resuspends the labia minora anteriorly, improving final aesthetics and striving to meet the patient's genital goals.

(115) Prevalence of Clitoral Adhesions in Patients who have Undergone Breast Cancer Care

Abstract Introduction The incidence of female sexual dysfunction (FSD) in patients who have undergone breast cancer care is approximately 66-83% 1,2. Clitoral phimosis is a congenital or acquired condition in which the clitoral hood cannot be fully retracted and can be associated with sexual pain and impaired orgasmic capability. A paper by Aerts et al. in 2018 demonstrated a prevalence of clitoral adhesions/phimosis in patients presenting to their sexual medicine practice to be 22%3. Our sexual health clinic has observed that a large majority of patients who are diagnosed with FSD after treatment for breast cancer also have clitoral phimosis. This may remain underdiagnosed and undertreated since examination of the clitoris and clitoral hood is still not considered a routine portion of the gynecologic examination. Objective There is an increased prevalence of clitoral adhesions in patients who underwent breast cancer care. Methods This was a retrospective observational study. Data was collected from our IRB approved Sexual Health Clinic registry from August 2021 to November 2022. All female patients presenting to our clinic over the age of 18 with a diagnosis of breast cancer who underwent a pelvic exam were included. Patients who did not undergo treatment with an estrogen modulator for their breast cancer were excluded. Results A total of 25 patients presented to the clinic during this time period with a diagnosis of breast cancer. 24 patients underwent a pelvic exam. 23 patients previously underwent treatment with an estrogen modulator. Of these 23 patients, 15 patients (65%) had findings of clitoral adhesions, whereas 8 patients (35%) did not have evidence of clitoral adhesions. Table 1 presents severity of adhesions and associated diagnoses in patients with findings of clitoral adhesions. Conclusions This study serves as preliminary data from our clinic that would indicate that those with a diagnosis of breast cancer that were treated with an estrogen modulator have a higher incidence of clitoral adhesions than the general population. It is therefore our recommendation that all women who have a diagnosis of breast cancer should have a comprehensive vulvar exam including an inspection of the clitoral glans and prepuce. If the prepuce cannot be easily retracted, a diagnosis of clitoral adhesions should be considered. A pilot grant application has been submitted to further investigate prevalence, associated symptoms, severity and treatment efficacy over a longer period. Disclosure No

(126) Development of a Patient Reported Outcome Measure for Lichen Sclerosus

Abstract Introduction Patient-reported outcome measures (PROMs) can provide information that complements the provider-assessed clinical outcome measures of gynecologic and dermatologic diseases. As part of a larger study on lichen sclerosus (LS), genetics and the microbiome, we noted discrepancy between clinical assessment of LS and participant symptoms. Without a PROM, it is impossible to compare our results to those in the literature. Lichen sclerosus is a chronic vulvar dermatosis that affects approximately 1 in 70 women and can cause scarring, sexual dysfunction and malignancy (Krapf, 2020). However, the severity of LS symptoms may not be representative of the current clinical appearance. For example, the patient may report extreme pruritus and general irritation, yet the vulva may not appear erythematous or even consistent with active disease. On the other hand, patients may incidentally be diagnosed w lichen sclerosus after the provider noted classic characteristics including white plaques, erythema, and architectural changes of the labia and clitoral hood and yet the patient may not realize they had a vulvar skin condition with a history of only minimal to no symptoms noted. Objective The aim of our study is to develop patient-reported outcome measures of lichen sclerosus to incorporate patient’s experiences of LS and be able to correlate them to clinical management. Methods Methods: We evaluated 25 initial participants with biopsy proven lichen sclerosus and collected incidence of patient reported outcome measures as the first step of developing a larger PROM based investigation. Results 25 participants enrolled in the study and completed questionnaires on symptoms. Many of these participants were not using topical steroid treatment for symptoms. Most commonly experienced symptoms were: prutitis (52%, n=13, burning (28%, n=7, general irritation (n=12, dryness (48%, n=8), dyspareunia (40% n=10). For many women, the symptoms radiated, woke them up from sleep and caused overall disruption of their quality of life. Conclusions The next step will be to create a prospective survey of women living with LS to collect the most important symptoms according to patients and not just frequency. We hope eventually therapeutic strategies can be targeted at treating these specific symptoms and managing the disease state. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Johnson and Johnson.

(061) The State of Female Sexual Medicine in a Major US City: A Comprehensive Evaluation of Mmedical Education in Chicagoland

Abstract Introduction Sexual health is a critical aspect of overall health and well-being. While research shows that roughly one-third of patients in the United States (US) have sexual dysfunction, only half of US medical schools require formal sexual health instruction. With limited standardization, medical students and trainees have little to no training in how to approach a patient with sexual health concerns. This results in under-preparedness among physicians in addressing essential issues related to female sexual medicine (FSM). Therefore, we identified the need to determine which components of FSM are included in medical education. Objective This study examines current preclinical and clinical curricula from medical institutions in the Chicagoland area to evaluate the extent to which FSM is being included in medical education in this major US city. Methods Preclinical curriculum materials on female sexual anatomy, physiology, and pathology, as well as Obstetrics and Gynecology (OBGYN) clinical materials (i.e., syllabi, synchronous lecture materials, and supplemental resources) were collected from all seven medical schools, including six allopathic and one osteopathic institution, in the Chicagoland area. To standardize our needs assessment, we utilized previous literature to identify specific components of medical school content to evaluate. Upon reviewing each institution's educational materials, we assessed goals of each syllabus in terms of required content and evaluated materials for topic saturation. Results Curriculum materials were collected from seven (n=7) medical schools. In the preclinical assessment, 4/7 discussed clitoral anatomy, with 1/7 mentioning the corona, 2/7 mentioning the clitoral hood, and 4/7 mentioning the corpus spongiosum. In addition, 4/7 discussed the physiology of the female orgasm, 3/7 highlighted the prevalence and epidemiology of female sexual dysfunction (FSD), 3/7 included information on treatment for FSD, and 1/7 taught a genitourinary physical exam specific to assessing FSD. When assessing clinical materials, 5/7 institutions dedicate 6 weeks to the core OBGYN clerkship. When comparing the aims specified in the clerkship syllabi, 5/7 institutions included topics related to FSM. Of these, only one institution had corresponding required synchronous clerkship time dedicated to these topics as a one-hour long lecture. One other program offered supplemental case-based gynecology modules including topics such as vulvar and vaginal diseases and chronic pelvic pain, though sexual pleasure, arousal, and libido were not discussed. Furthermore, only one program offered training to third-year clinical students in comprehensive sexual history taking practices, including screening for female sexual dysfunction. The format for this was an optional online module for students to complete independently. Conclusions Our focused needs assessment of both allopathic and osteopathic medical schools in the Chicagoland area reveals inconsistencies in outlined institution-specific course goals and thus highlights the need for restructuring the medical school curricula to include topics related to FSM. Future directions of this work will include proposing curricular recommendations to these institutions with the goal of standardizing and enhancing medical student exposure to FSM topics. FSM is a critical domain that requires consistent representation in medical education to equip physicians to recognize and treat patients with sexual dysfunction. Disclosure No