Clitoral Sensation Research Articles

Gender-affirming Robotic Tubularized Peritoneal Vaginoplasty: Feasibility and Outcomes

ObjectivesTo evaluate the outcomes of robot-assisted tubularized peritoneal vaginoplasty (RATPV) for trans-feminine patients desiring genital gender-affirming surgery (gGAS). MethodsWe retrospectively reviewed all patients (adults ≥ 18 years old) who underwent RATPV for gGAS at our institution (July 2020-July 2022). Initial technique involved anastomosing the peritoneal flap to the introitus. The updated technique anastomosed the flap intraperitoneally to inverted penile shaft skin. Patient demographics, intraoperative details, and postoperative outcomes are described. ResultsIn 33 patients, the median age was 26 years old (IQR:24-37) and BMI 26 (IQR:23-32). Median operative time was 406 minutes (IQR: 370-434) and robotic console time 177 minutes (IQR:154-220). Intraoperatively, the median vaginal depth was 17cm and diameter 3+cm. Median length of stay was 7 days. One-third (n=11) of patients had a complication within 30 days postoperatively (40% Clavien Dindo I and 60% Clavien II). No patient had a Clavien III+ complication.At a median follow up of 499 days (range: 137-835), some degree of vaginal stenosis occurred in 48% (11/23) of patients with the original approach versus 10% (1/10) of those with the newer approach (p=0.05). Median vaginal depth was 11.3cm. Three patients (9%) required revision vaginoplasty, all of whom had the original approach and had difficulty dilating postoperatively. All had clitoral sensation. ConclusionsRATPV is a safe and effective option for individuals seeking gender affirming vaginoplasty that obviates the need for laser hair removal prior to surgery. More research is needed into long term outcomes of this technique.

(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.

Anatomical Reconstruction following Female Genital Mutilation/Cutting.

International migration from high-prevalence regions has increasingly confronted nonendemic countries with female genital mutilation/cutting (FGM/C), and Western-based health care providers have seen a greater demand for surgical reconstruction of female anatomic units. The authors introduce novel surgical techniques developed by the first author for clitoral and vulvovestibular reconstruction and examine operative outcomes. The authors performed a retrospective cohort study of operative outcomes of the omega domed flap, neurotizing and molding of the clitoral stump (NMCS procedure), and anterior obturator artery perforator flap for preputial, clitoral, and vulvovestibular reconstruction, respectively. Between 2014 and 2021, the authors treated patients with all types of FGM/C, and analyzed various data, including demographics, clitoral sensation, and symptoms such as dysmenorrhea, dysuria, dyspareunia, and anorgasmia. The authors aimed to examine the efficacy and safety of these techniques in improving clitoral sensation and reducing symptoms. A total of 119 women (mean age, 31.0 ± 10.4 years) were included. The authors performed the omega domed flap (85%), the NMCS procedure (82%), or the anterior obturator artery perforator flap (36%), and had a 1-year follow-up period, which was attended by 94.1% of patients. Patients reported significant postoperative reduction of dysmenorrhea, dysuria, and dyspareunia, as well as significant improvement of clitoral sensation and ability to achieve orgasm ( P < 0.001). There was 1 major complication (loss of flap) reported. Secondary ambulatory interventions were performed in 10 patients (8.4%). By allowing for safe and effective anatomic reconstruction of the female genitalia, the described surgical techniques represent a new stage of treatment possibilities for women with FGM/C. Therapeutic, IV.

(125) Sexual Pain Symptoms in 910 Premenopausal Women with Vulvar Lichen Sclerosus

Abstract Introduction Lichen sclerosus (LS) is an autoimmune inflammatory skin condition primarily affecting the vulva and perianal areas and leading to scarring that can affect sexual function. Most research on symptomatology of LS to date includes predominantly postmenopausal populations and focuses on pruritis, not sexual pain symptoms. Objective This study aims to characterize sexual pain symptoms associated vulvar LS among premenopausal women. Methods A cross-sectional web-based study was conducted in premenopausal women with clinical and/or biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating demographics, characteristics of symptoms, timing and accuracy of diagnosis, and concomitant autoimmune conditions. Numerical data were expressed as mean +/- standard deviation. Bivariate Pearson correlation was used to determine the relationship between age of symptom onset and time interval to diagnosis. Results Of the 956 responses received, 910 met inclusion criteria. Self-reported ethnicity of the study population was 87% White, 4% Latina or Hispanic, 3% Asian, and 1% Black. The mean age of the population was 36.5 years, ranging from 18-50 years. There was a 4.3-year mean delay in diagnosis, with average age of symptom onset of 27.7 years and average age of diagnosis of 33.2 years. There was an inverse correlation between the age at which symptoms began and the time interval to diagnosis with a Pearson correlation coefficient of -0.509 (t(805)=16.752, p&amp;lt;0.0001). Most prevalent symptoms were vulvar fissures (68%), dyspareunia (68%), tearing with intercourse or vaginal insertion (63%), and labial resorption (61%), with vulvar fissures (49%) and dyspareunia (46%). These symptoms were more common than introital stenosis (34%). Vulvar fissures (41%) and dyspareunia (35%) most often prompted medical attention. Thirty-six percent reported clitoral phimosis and 34% reported decreased clitoral sensation. Only 4% of respondents reported that decreased clitoral sensation prompted medical attention. Over 75% of respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (54%) or bacterial vaginosis (22%). Most common concomitant autoimmune condition reported was hypothyroidism (10%); which was significantly greater than the general population prevalence (2%) (p&amp;lt;0.0001). Post-hoc analysis indicated no statistical difference between biopsy-confirmed and clinically-diagnosed LS across all demographics and responses. Conclusions Vulvar LS affects sexual function in premenopausal women. LS symptoms in premenopausal women include vulvar fissures, dyspareunia, tearing with intercourse or vaginal insertion, and decreased clitoral sensation. Dyspareunia is present is over two-thirds of premenopausal women with vulvar LS, with vulvar fissures and tearing much more common and bothersome than introital stenosis. Patients are less likely to be affected by or seek medical attention for clitoral phimosis, even though it is present in over one-third of those with LS. Vulvar LS should be considered and evaluated in women of all ages presenting with vulvar symptoms. Sexual health and function should be a core outcome measure in LS research and addressed in the evaluation and treatment of this condition. Disclosure No

Principles and outcomes of gender-affirming vaginoplasty.

Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.

Female sexual function in bladder cancer: A review of the evidence.

Bladder cancer (BC) treatments are known to be invasive; nevertheless, research into the long-term effects is limited and in the context of sexual function often male focussed. Female sexual dysfunction (FSD) has been reported in up to 75% of female patients. This systematic scoping review examines the literature on sexual consequences of BC in female patients. This study aimed to systematically evaluate the evidence on female sexual function in BC to identify areas of unmet need and research priorities. We performed a critical review of PubMed, PsychMed, CINAHL, MEDLINE and the Cochrane Library in March 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews statement following Levac et al. methodology. Identified reports were reviewed according to the Critical Appraisal Skills Programme (CASP) criteria. 45 publications were included. There was an inconsistent use of patient-reported outcome measures (PROMs), with commonly used PROMs having a narrow symptom focus. However, common symptoms emerged: loss of desire, orgasmic disorders, vaginal dryness, dyspareunia, difficult intromission, reduced clitoral sensation, psychological concerns related to diagnosis, fear of contamination and body image. Sexual activity was reduced in most groups, despite women expressing a motivation to retain sexual function. The degree of symptom distress associated with FSD is underreported. Evidence emerged regarding a gap for women in clinician counselling and follow-up. The patient's perspective of FSD in BC patients is poorly understood and under-addressed in clinical practice. There have been very few qualitative studies of FSD in BC. Any intervention designed to address the problem must start with greater understanding of both the patients' and clinicians' perspective. We examined the evidence on sexual consequences of BC in women. It is apparent that despite common themes of sexual dysfunction emerging, the problem is poorly understood and addressed in clinical practice.

Improvement in the Ability to Orgasm after the Non-Surgical Lysis Procedure for Clitoral Adhesions

ABSTRACT Introduction Clitoral stimulation is an essential component of the orgasm experience for many women during sexual intercourse. Stimulating the clitoris indirectly stimulates other parts of the genital area, including the vagina, and ultimately affects the ability to have an orgasm experience. In a 2017 study looking at women's experiences with genital touching, sexual pleasure, and orgasm by Herbenick et al, 36.6% of women noted clitoral stimulation was necessary for orgasm and another 36% of women indicated that even though clitoral stimulation was not required it did make orgasms feel better. Clitoral adhesions (CA) can be associated with the inability to reach orgasm with clitoral stimulation. CA occur when the prepuce adheres to the glans clitoris leading to discomfort, hypersensitivity/hyposensitivity, and chronic vulvodynia. Two lysis of CA treatment modalities exist - one surgical procedure and one non-surgical office-based procedure that stretches the preputial tissue open. There are no studies that explore the ability of the non-surgical lysis of CA procedure to improve a woman's ability to achieve orgasm with external clitoral stimulation. Objective The aim of this study is two-fold: 1) to evaluate the characteristics of women who were not able to orgasm with external clitoral stimulation prior to the non-surgical lysis of CA procedure and 2) to evaluate patient satisfaction and outcomes of the non-surgical lysis of CA procedure in these same women. 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 an IRB-approved retrospective chart review. An online survey was sent to these patients to evaluate the efficacy of the procedure in improving pain and sexual functioning, as well as patient satisfaction with the procedure. Results 41 women participated in the study (67% response rate) and 16 (39%) of them could not achieve orgasm with external clitoral stimulation prior to the non-surgical lysis of CA procedure. Of those 16 women who could not achieve orgasm from external clitoral stimulation, 6 (38%) were able to do so after the non-surgical lysis of CA procedure. Of these 6 women prior to the procedure, 67% had a diagnosis of vulvodynia/vestibulodynia, 67% reported discomfort or pain during sexual activity that involves physical touch of the vulva, and 83% reported lack of clitoral sensation. Unfortunately, 50% of these women who were able to orgasm with clitoral stimulation after the procedure did lose this ability over time. Nonetheless, 83% were extremely satisfied with the procedure and 100% would recommend it to a friend who also had CA. Conclusions The non-surgical lysis of CA procedure may be a worthwhile option for women who are unable to achieve orgasm with external clitoral stimulation. Of note, many of these women with CA who were unable to orgasm with clitoral stimulation also had pain or discomfort with sexual intercourse which may exacerbate the problem. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Sexual Pain Symptoms in Premenopausal Women with Vulvar Lichen Sclerosus

ABSTRACT Introduction Lichen sclerosus (LS) is a chronic, inflammatory skin condition that primarily affects the anogenital epithelium in women. Vulvar LS has historically been regarded as a condition of premenarchal girls and postmenopausal women, overlooking women of reproductive age. Although vulvar LS characteristically presents with pruritis, specialists in LS have clinically observed that premenopausal women often present with dyspareunia related to introital tearing and vulvar skin changes. Objective This study aims to characterize the clinical presentation of vulvar LS among premenopausal women related to sexual pain. Methods A cross-sectional web-based study was conducted in premenopausal women with biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating characteristics of symptoms, as well as timing and accuracy of diagnosis. Numerical data were expressed as mean +/- standard deviation. Bivariate Pearson correlation was used to determine the relationship between age of symptom onset and time interval to diagnosis. Results Of the 956 responses received, 503 met inclusion criteria of biopsy confirmed LS and premenopausal status. Self-reported ethnicity of the study population was 87% White, 4% Latina or Hispanic, 2% Asian, and 1% Black. The mean age of the population was 37 years, ranging from 19-50 years. There was a 4-year delay in diagnosis, with an average age of symptom onset of 27 years and average age of diagnosis of 32 years. There was an inverse correlation between the age at which symptoms began and the time interval to diagnosis with a Pearson correlation coefficient of -0.487 (t(455)=14.184, p&amp;lt;.0001). Most prevalent symptoms were dyspareunia (68%), tearing with intercourse or vaginal insertion (63%), and decreased clitoral sensation (35%). Symptoms reported as most affecting the individual were dyspareunia (44%), tearing with intercourse or vaginal insertion (39%) and pruritis (25%), followed by decreased clitoral sensation (13%). Symptoms that most frequently prompted patients to seek medical attention were dyspareunia (35%), pruritus (31%), and tearing with intercourse or vaginal insertion (26%). Only 4% of respondents reported that decreased clitoral sensation prompted medical attention. Most prevalent skin changes included hypopigmentation (81%), vulvar fissures (72%), labial resorption (60%), clitoral phimosis (39%), and vaginal stenosis (37%), with vulvar fissures affecting the individual the most (48%) and prompting medical attention (39%). Sixty-six percent of respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (49%). Conclusions Vulvar LS affects premenopausal women and often causes skin changes related to sexual function. This condition is often misdiagnosed as vulvovaginal candidiasis, leading to a delay in diagnosis of 4 years, which is consistent with existing literature. LS symptoms in premenopausal women related to sexual function and pain include dyspareunia, tearing with intercourse or vaginal insertion, and decreased clitoral sensation. These symptoms may be more concerning to premenopausal women, who are more likely to be sexually active, than the classic symptoms of vulvar pruritis found predominantly in postmenopausal women. Vulvar LS should be considered and evaluated in women of all ages presenting with vulvar symptoms and sexual 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, has received research funding from Dare Science, SST, Endoceutics, The Cellular Medicine Association, and Ipsen for other projects, and is a consultant for Ipsen, SST, and AMAG

Post Penile Inversion Vaginoplasty Clinical Examination: Considerations and Techniques.

Post Penile Inversion Vaginoplasty Clinical Examination: Considerations and Techniques.

Sensation-preserving clitoral reduction surgery: A preliminary report of our experience.

Background:The knowledge that preservation of clitoral sensation is essential for future sexual satisfaction gave rise to sensation-preserving clitoral reduction surgery. We present our results of sensation-preserving clitoral reduction procedure in the small group of patients.Aims and Objectives:To show our technique and result of sensation-preserving clitoral reduction surgery.Materials and Methods:This is a retrospective study of cases with clitoromegaly, over a 5-year period, in which sensation-preserving clitoral reduction procedure was done by us at our centre. Demographics, indication for clitoral reduction, operative procedure, operative time, any intraoperative difficulty or problem, anaesthesia type, post-operative stay and outcome were analysed. Pre-operative and post-operative evaluation for clitoral viability done in all the cases, and evaluation for clitoral sensory testing and vibratory sensory testing done in selected cases.Results:A total of eight cases were operated in the last 5 years. Five were due to congenital adrenal hyperplasia. Immediate post-operative period was uneventful in all. Cosmetic appearance and viability were satisfactory in all the cases. In five cases, clitoral sensory testing and vibratory sensory testing were done, an average degree of sensation of 3.2 at the labia minora and 4.7 at the clitoris and an average values clitoral vibratory sensory testing for the introitus, clitoris, labia and thigh were 3.56, 1.61, 5.08 and 5.83, respectively.Conclusions:Clitoral enlargement in girls is a rare problem. Sensation-preserving ventral clitoral reduction surgery leads to preservation of neurovascular bundles leads to acceptable cosmesis and preserved sensation.

Differences in Sexual Function Between Trimesters During Pregnancy: An Observational Study

OBJECTIVE: The aim of this study was to evaluate differences in sexual function between trimesters, and factors (in addition to pregnancy) that influence sexual function during pregnancy.STUDY DESIGN: This observational study was conducted at a tertiary referral center with 372 pregnant women. Seventy-two of the women did not complete the questionnaire (rejections or missing data) and the overall response rate was 80.6%. Among the remaining women, 43 of them excluded due to depression. Beck Depression Inventory was used to evaluate depression. Index of female sexual function questionnaire was used to assess sexual function. Index of female sexual function had a total and six sub-domain scores which assess the quality and frequency of sexual intercourse, desire, overall satisfaction, ability to achieve orgasm, and degree of clitoral sensation (c.sensation).RESULTS: Total index of female sexual function and quality, satisfaction, orgasm, and c.sensation sub-domain scores were lowest in the third trimester. Older age, lower level of education, and lower level of income negatively affected total index of female sexual function scores. Quality scores were lowest in older women and women with lower education. Frequency scores were highest during the second trimester. Desire scores were highest in women aged between 18 and 25 years, in women who were newly married (1-3 years), and during the second trimester. Satisfaction scores were lowest in women older than 35 years, and highest in newly married women. Orgasm scores were highest in women aged 18-25 years, in newly married women. CONCLUSIONS: Sexual function in women during the third trimester of pregnancy is generally affected negatively.

Development and Validation of Urological and Appearance Domains of the Post-Affirming Surgery Form and Function Individual Reporting Measure (AFFIRM) for Transwomen following Genital Surgery.

As feminizing gender-affirming surgery becomes increasingly accessible, functional outcomes are increasingly relevant. We aimed to develop and validate the first patient-reported outcome questionnaire focusing on postoperative symptomatology and quality of life. Questions were developed from interviews with postoperative transwomen followed by face validation from a multispecialty clinician group. The measure was co-administered with established relevant questionnaires for concurrent validity testing. Participants were asked to complete the questionnaire at baseline and at a 2-week retest interval. The AFFIRM questionnaire is a 33-item patient-reported outcome measure comprising Appearance, Urological and Gynecologic domains, each scored to create a composite AFFIRM score. A total of 102 women participated, with 60% completing the test-retest. The overall Cronbach's α for AFFIRM was 0.79, and domain α for AFFIRM-A, AFFIRM-U and AFFIRM-G was 0.85, 0.87 and 0.42, respectively. Test-retest demonstrated score reliability (z values -1.862 to -0.005, p >0.05) with intraclass coefficients demonstrating moderate to good absolute correlation (0.54 to 0.88). The AFFIRM-A and AFFIRM-U correlated well with the Genital Appearance Satisfaction Measure and Urinary Distress Inventory-6, respectively (ρ 0.556 and 0.618, p <0.001); 89% of participants confirmed congruence between their external genitalia and gender identity, 87.8% reported clitoral sensation and 75.6% expressed satisfaction with vaginal caliber. Reported symptoms included a misdirected urinary stream (68.9%), nocturia (51.3%), urinary frequency (29.7%) and vaginal pain (46.7%). Transwomen have diverse symptoms not captured by unstructured questions or cisgender questionnaires. The AFFIRM questionnaire is the first tool available to reliably evaluate outcomes following feminizing gender-affirming surgery.

Novel Clitoral Reconstruction and Coverage With Sensate Labial Flaps: Potential Remedy for Female Genital Mutilation.

Complications caused by female genital mutilation (FGM), such as clitoral pain, reduced sensation, and diminished sexual function, can be alleviated by clitoral reconstruction, which can also improve the aesthetics and restore the anatomy of the genitalia. The aim of this study was to create sensate labial flaps to cover the neoclitoris and assess the outcome of the procedure. Between December 2018 and July 2020, 40 patients with FGM underwent clitoral reconstruction and coverage with sensate labial flaps donated by the remnant of the labia minora and were followed prospectively. Flaps were mapped on the less-mutilated labia minora according to recent descriptions of arterial anatomy and innervation. Before the surgery, the patients' clitoral sensation was assessed on a 6-point scale and they were also given the Female Sexual Functional Index (FSFI) questionnaire to complete. Eight and 24 weeks postoperatively, the same assessment was repeated and the data compared. The mean Female Sexual Functional Index score increased significantly from 11.64 (range, 2.8-25.6) preoperatively to 29.14 (range, 12.8-35.4) postoperatively. Similarly, clitoral sensation increased significantly from 2.35 (range, 1-4) before the surgery to 4.9 (range, 2-6) after the surgery. In total, 95% of patients benefited from the surgery. Clitoral reconstruction with sensate labial flaps after FGM resulted in significant improvements in sexual function, clitoral sensation, genital aesthetics, and self-esteem.

New method for early evaluation of clitoris innervation using clitoro-perineal reflex after feminizing genitoplasty in early childhood: a pilot-study

A major complication of feminizing genitoplasty in children is the loss of clitoral sensation with serious impact at adult life. We suggest a new method to evaluate the surgical results during childhood based on the bulbocavernosus or clitoro-perineal reflex (CPR). The afferent pathway of CPR implies the intact sensory receptors on the clitoral glans. Girls with congenital adrenal hyperplasia who were followed-up medically without surgery or who underwent feminizing genitoplasty with or without clitoroplasty were included (2002–2018). All clitoroplasties were standardized reduction clitoroplasty with preservation of neurovascular bundles associated with vaginoplasty and vestibuloplasty. Standardized examinations were prospectively performed including the CPR starting at one year postoperatively. The reflex was triggered by gentle touch of the glans by a cotton swab. Contraction of the perineal muscles was considered positive. Thirty-two children were operated at a median age of 8.6 months (5.8–12.1). Median follow-up (FU) was 3.9 years (1.3–6.4). Twenty-four patients had clitoroplasties: 17 were tested for CPR at one-year FU, and all had a positive test. Eight girls had genitoplasty without clitoral surgery, two of them were tested and were positive. Ten patients were managed without surgery, two of them were tested for the CPR and were positive. The reflex was always triggered easily and repeated at least twice during the FU. The clitoro-perineal reflex is a simple, non-invasive and reproducible test in early childhood and may serve as an early evaluation tool of clitoral innervation after feminizing genitoplasty. These results need to be confirmed at long term and completed at adult life.

Treatment of the Enlarged Clitoris.

Management of the enlarged clitoris, because of its import for sexual function, has been and remains one of the most controversial topics in pediatric urology. Early controversy surrounding clitoroplasty resulted from many factors including an incomplete understanding of clitoral anatomy and incorrect assumptions of the role of the clitoris in sexual function. With a better understanding of anatomy and function, procedures have evolved to preserve clitoral tissue, especially with respect to the neurovascular bundles. These changes have been made in an effort to preserve clitoral sensation and preserve orgasmic potential. It is the goal of this manuscript to describe the different procedures that have been developed for the surgical management of clitoromegally, with emphasis on the risks and benefits of each. Equally important to any discussion of such a sensitive topic is an understanding of long-term patient outcomes. As we will see, despite its importance, there has been a dearth of data in this regard. Future work in the arena of patient satisfaction will undoubtedly play a major role in directing our surgical approach.

Genital Sensory Detection Thresholds and Patient Satisfaction With Vaginoplasty in Male-to-Female Transgender Women

IntroductionGender-affirming surgery is common for the treatment of gender dysphoria, but its effect on genital sensitivity is not well known. AimsTo investigate genital sensory detection thresholds in male-to-female transgender women postoperatively and their relation to psychological well-being and variables of satisfaction. MethodsProspective study on 28 transgender women at least 18 years old operated on at least 3 months before the study by a single surgeon (N.M.J.). Main Outcome MeasuresMedical complications; sensory detection thresholds for light touch, pressure, and vibration; and questionnaires on general and sexual satisfaction, sexual function, depression, and psychological well-being. ResultsSensory detection thresholds ranged from 0.07 to 2.82 g for light touch, with the neck being most sensitive; from 20.23 to 34.64 g for pressure, with similar results for the neck and clitoris; and from 0.0052 to 0.0111 V for vibration, with similar findings for all stimulation points. Satisfaction with the appearance of the labia, vulva, clitoris, and sexual function was good to very good. Frequency of sexual activities increased significantly postoperatively for orogenital stimulation and decreased significantly for frequency of fantasies (t = −4.81; P < .0001). Orgasmic function was reported by 80% of participants. Psychological adjustment was good to very good, with low depression scores. Sexual satisfaction was statistically and positively correlated with vaginal function and depth, clitoral sensation, appearance of the vulva and labia minora, and natural lubrication and negatively correlated with depression scores. ConclusionGender-affirming surgery yields good results for satisfaction with appearance and function. Genital sensitivity showed the best results with pressure and vibration.

Long-Term Sensitivity and Patient-Reported Functionality of the Neoclitoris After Gender Reassignment Surgery

IntroductionA cornerstone of treating gender dysphoria for transgender women is gender reassignment surgery (GRS) encompassing vaginoplasty and clitoroplasty. The neoclitoris is harvested as a flap with a neurovascular pedicle from the proximal dorsal part of the glans penis. Few long-term follow-ups exist on postoperative sensation and patient-reported sexual functionality of the neoclitoris. AimTo examine the sensitivity of the neoclitoris and its relation to orgasm and sexual function at least 1 year after GRS. MethodsTwenty-two patients were included, with a mean follow-up of 37 months (range = 12–63) after initial surgery. Tactile and vibratory sensitivities were measured with Semmes-Weinstein monofilaments and the Bio-Thesiometer vibratory measurement device, respectively. A questionnaire was provided to the patients, as were interview questions about body image, orgasm, pain, and general satisfaction with the surgery. Main Outcome MeasuresTactile and vibratory sensitivities of the neoclitoris and questionnaire on satisfaction with orgasm, sexual function, and general satisfaction. ResultsThe average tactile threshold for the clitoris was 12.5 g/mm2 and the average vibratory threshold was 0.3 μm. Most participants (86%) experienced orgasm after surgery, had no or little pain, and were satisfied with the surgery. No statistical correlation was found between better or worse objective pressure and vibratory thresholds and patient answers to questions about the clitoris in the Body Image Scale for Transsexuals questionnaire. ConclusionThe neoclitoris derived from the glans penis in GRS provides long-term clitoral sensation that is erogenous. Overall, the vast majority of patients who undergo male-to female GRS experience orgasm and are satisfied with the surgery.

Effect of Midurethral Sling Surgery on Vaginal Sensation.

Previous studies have reported changes in the sensory functioning of the vagina in women with pelvic floor disorder. To evaluate vaginal and clitoral sensation before and after surgery with trans-obturator tape (TVT-O, Ethicon Johnson & Johnson). Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina and clitoris 1 day before and 12 ± 4 months after surgery. Differences in thresholds to warm, cold, and vibratory sensations at a predetermined anatomic area of the genital region. Twenty-two women were admitted for midurethral sling surgery, and four were lost to follow-up. For the remaining 18 (mean age= 52 years, range= 37-65), we found a significant sensory decrease at the clitoral region to cold, warm, and vibratory stimuli after surgery. In contrast, in the anterior vaginal wall, there was a significant decrease only to warm stimuli after surgery. TVT-O can cause sensory loss in the clitoral and anterior vaginal wall region that can be measured and quantified. The effect of such sensory loss on sexual function and quality of sexual life needs further investigation.

Nerve Sparing Clitoroplasty is an Option for Adolescent and Adult Female Patients with Congenital Adrenal Hyperplasia and Clitoral Pain following Prior Clitoral Recession or Incomplete Reduction

In the past many female patients with congenital adrenal hyperplasia and atypical genitalia were surgically treated with clitoral recession or incomplete reduction of erectile bodies. We report the results of repeat clitoral surgery performed for clitoral pain or enlargement using a nerve sparing reduction clitoroplasty technique. We identified 6 female patients with congenital adrenal hyperplasia who had undergone prior clitoral recession or incomplete reduction elsewhere. They then presented to our center with clitoral pain or enlargement, where they were treated with nerve sparing clitoroplasty between 2000 and 2010. We collected patient reported data relating to clitoral sensation and sexual function outcomes. Mean ± SD age at evaluation for repeat clitoral surgery was 21 ± 7 years and mean age at clitoroplasty was 22 ± 8 years. Median postoperative followup was 9 months (IQR 32-6). All patients showed improvement with resolution of clitoral pain or enlargement. Clitoral pain and enlargement upon arousal can be a major concern for women with clitoromegaly and congenital adrenal hyperplasia after clitoral recession is performed. Our series suggests that clitoral recession or incomplete reduction in childhood may be an inadequate initial solution in the congenital adrenal hyperplasia population due to the potential for future androgen elevation and the possibility of later symptom development. In addition we found that patients may be successfully treated with nerve sparing clitoroplasty, resulting in resolution of pain and ability to engage in sexual activity.

The effect of pelvic organ prolapse repair on vaginal sensation.

The objective was to evaluate vaginal and clitoral sensation before and after robotic sacrocolpopexy for the repair of pelvic organ prolapse. Twenty-two women, mean age 63years (range 41-77), were admitted for robotic sacrocolpopexy repair of pelvic organ prolapse; 4 were lost to follow-up. Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina (anterior and posterior areas) and clitoris 1day before and a mean of 12 ± 4months following surgery. Student's paired t test was used to compare sensory thresholds before and after surgery. For the 18 women who completed follow-up, sensitivity was significantly higher after surgery (sensory threshold decreased) at the clitoral and vaginal regions, to cold and warm stimuli. In contrast, the vaginal and clitoral vibratory sensory thresholds did not change significantly following surgery. The repair of pelvic organ prolapse by robotic sacrocolpopexy could potentially play a role in restoring clitoral and vaginal wall sensation. The effects of these sensory changes on sexual function and the quality of sexual life need further investigation.