Clitoral Size Research Articles

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

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

Neoclitoral location may affect sexual function in transgender women: a preliminary pelvic MRI study.

Assigned female at birth with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in MRI measurements of neoclitoris volume and distance between the neoclitoris and the neovagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone genital gender affirming surgery and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 MtFs operated with pubic neoclitoris technique (PNT) and 11 with neo-urethroclitoroplasty according to Petrović (NCP). The NCP group presented a neoclitoris mean volume of 1.04 (SD 0.39) cc vs 1.31 (SD 0.78) cc of the other group (p = 0.55). The mean distance between neoclitoris and neovagina was 4.20 (SD 0.57) cm in the PNT group and 2.55 (SD 0.45) in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous technique (FSFI 25.81 SD 3.02 vs 18.62 SD 9.92 p = 0.08; oMtFSFI 37.63 SD 8.28 vs 43.36 SD 13.02 p = 0.23). According to pelvic MRI measurements, this study suggests a correlation between neoclitoral location and oMtF sexual satisfaction.

Pilot sonographic study of clitoral blood flow and size after use of sexual devices

Over 50% of women in the United States report using sexual devices. These devices, which are often used recreationally to increase the likelihood of arousal and orgasm, can also be used therapeutically in the setting of sexual dysfunction. Despite their widespread use and association with improved sexual wellness, their effect on the clitoris has not been investigated. We aimed to evaluate changes in clitoral blood flow and size in response to stimulation with various sexual devices. Clitoral sonography was performed on a healthy volunteer before and after stimulation with each of the following sexual devices: wand applied externally, internal vibrator inserted vaginally, and air pulse stimulation of the glans clitoris. The scans were obtained with a Philips Lumify™ ultrasound (Koninklijke Philips N.V., Amsterdam, Netherlands) using a L12-4 linear array transducer (4–12 MHz) and a C5-2 broadband curved array transducer (2–5 MHz). We observed that stimulation with sexual devices increased blood flow to different areas of the clitoris, and led to changes in clitoral area and clitoral erectile length (CEL). Our findings suggest that female orgasms are of more than one or two types (clitoral versus vaginal), and likely occupy a spectrum. This may provide insight into using sexual devices as treatment options for female sexual dysfunction. Plus de 50 % des femmes aux États-Unis déclarent utiliser des dispositif sexuels, souvent utilisés à des fins récréatives pour augmenter la probabilité d’excitation et d’orgasme. Ils peuvent être également utilisés à des fins thérapeutiques dans le cadre d’un dysfonctionnement sexuel. Malgré leur utilisation répandue et leur association à l’amélioration du bien-être sexuel, leur effet sur le clitoris n’a pas été étudié. Nous avons cherché à évaluer les modifications du débit sanguin et de la taille du clitoris en réponse à la stimulation par divers sex toys. L’échographie clitoridienne a été réalisée sur une volontaire en bonne santé avant et après la stimulation avec chacun des dispositifs sexuels suivant : wand (masseur à baguette), vibromasseur interne inséré par voie vaginal, et stimulation par impulsion d’air du gland du clitoris. Les scans ont été obtenus avec un système à ultrasons Philips Lumify™ (Koninklijke Philips NV, Amsterdam, Pays-Bas) utilisant un transducteur à réseau linéaire L12-4 (4–12 MHz) et un transducteur à réseau incurvé à large bande C5-2 (2–5 MHz). Nous avons observé que la stimulation avec des jouets sexuels augmentait le flux sanguin vers différentes zones du clitoris et entraînait des modifications de la zone clitoridienne et de la longueur érectile. Nos résultats suggèrent que les orgasmes féminins sont de plus d’un ou deux types (clitoridien versus vaginal) et occupent probablement un large spectre. Cela peut donner un aperçu de l’utilisation de dispositifs sexuels comme options de traitement des dysfonctionnements sexuels féminin.

Growing up with clitoromegaly: experiences of North American women with congenital adrenal hyperplasia

To describe experiences of clitoromegaly in women with congenital adrenal hyperplasia (CAH). CAH females (46XX, ≥16 years old) from the United States and Canada were eligible for a cross-sectional online survey (2019-2020) if reporting clitoromegaly (life-long: "growing up with a larger than average clitoris," secondary: "clitoris grew over weeks or months"). A multidisciplinary team and women with CAH drafted questions assessing net effects of clitoromegaly on 10 activities and 10 life domains. Fisher's exact test was used to compare net effect (positive-negative) vs. no effect (Bonferroni p=0.05/10=0.005). Of 97 women with CAH enrolled, 53 women (55%, median age: 36 years, advocacy group recruitment: 81%) reported recognizing clitoromegaly at median 11-13 years old, with 21% identifying it in adulthood. There was no difference in self-reported timing or clitoral shape between life-long or secondary clitoromegaly (p≥0.06). There were no net positive effects of clitoromegaly. Rather, clitoromegaly had net negative effects on 7/10 activities (p≤0.003) and no net effect (neutral) on 3 (Table). Women were less likely to wear tight clothing, change clothes in public locker rooms and play group sports. Women reported net negative effects for most romantic activities (dating, any sexual activity, pain-free sexual activity, having a partner see their genitalia, p=<0.003), but did not report a net effect on pleasurable sexual activity (p=0.12). Clitoromegaly had net negative effects in 9/10 life domains (p<0.001) and neutral on job self-perception (p=0.25). Few women reported any positive impact (2-6%). However, 49-59% of women experienced poor self-esteem, anxiety, gender self-perception and body image, while 36% felt "down or depressed." Also, 21-23% experienced negative self-perception as friends and parents, 42-47% reported negative effects on plans for romantic and sexual relationships. Responses did not differ with advocacy group membership (p≥0.02). Our findings support qualitative and case series evidence that clitoromegaly has a negative psychological outcome on women with CAH. Clitoromegaly may add to the burden of living with a chronic endocrine disease. Women with positive and negative experiences had the same opportunity to participate. Since we could not assess objective clitoral size, baseline virilization and exact nature of any childhood clitoral procedures, these data cannot be used to estimate the impact of specific clitoral size or effectiveness of early clitoral treatments. Clitoromegaly appears to be common among women with CAH. While experiences of clitoromegaly vary between women, the overall experience is negative in multiple social, romantic, and emotional activities and domains.

Reference values for the external genitalia of full-term and pre-term female neonates

Background and objectivesIdentifying virilisation of the genitalia in female newborns early during the neonatal period is important to diagnose pathologies. However, there is no clear threshold for clitoromegaly or for...

The Nomogram of Clitoral Length and Width in Iranian Term and Preterm Neonates.

Background and Objectives: Clitoromegaly is an important parameter in the evaluation of ambiguous genitalia in neonates, but the normative data for clitoral size in newborns have racial/ethnic differences. The present study aimed to determine clitoral length (CL) and clitoral width (CW) values and establish cutoff measurement to define clitoromegaly in both term and preterm Iranian neonates for the first time.Methods: A total number of 580 female newborn infants delivered at 28–42 weeks of gestation were enrolled in the study, and their CL and CW were measured on the first 72 h of birth. Data about birth weight (BW), body length (BL), and head circumference (HC) of newborns; mothers' age; and gestational age (GA) were recorded, too. Results were presented as mean ± standard deviation (SD) for quantitative variables and were summarized by frequency (percentage) for categorical variables. Backward stepwise regression analysis was used for prediction of CL and CW.Results: Among 580 Iranian female newborns studied, 187 were term neonates and the other 393 newborns were preterm. Mean ± SD values of CL were 6.11 ± 0.39 mm in term infants and 5.45 ± 0.64 mm in preterm infants (P < 0.001). Mean ± SD values of CW were 4.22 ± 0.43 in term infants and 3.68 ± 0.53 in preterm infants (P < 0.001). Regression analysis showed that CL was correlated with GA considered by last menstrual period, BL, BW, and HC; and CW was associated with GA, BL, and BW.Conclusion: This study suggests normative values (mean + 1, 2, and 3 SD) of CL and CW according to GA, which can be used as a reference for Middle East's newborns, especially Iranian newborn babies.

Relationship of orgasm with measurable dimensions of clitoris and visibility of clitoral glans

Aim: The clitoris is the dominant sexual organ in the female, varies in size and plays an active role in genital sensation and orgasm. Since the importance of clitoral glans visibility is known, surgeries of clitoris are increasing day by day. However, there is insufficient literature on the subject. The aim of this study is to determine the effect of measurable dimensions of clitoris and the clitoral glans visibility on female sexual function.Methods: Seventy-seven patients included in this cross-sectional study were examined in the lithotomy position and the measurable dimensions of the clitoris, the visibility of the clitoral glans and the length of the prepuce were noted. The Female Sexual Function Index (FSFI) was applied to all participants, which were divided into two groups, as those with normal orgasmic function and orgasmic dysfunction. One researcher made all measurements.Results: There were no statistically significant differences in clitoral glans width, length, or prepuce length (P=0.11, P=0.63, P=0.35, respectively). Clitoral glans was visible in 41 of 51 patients in the normal orgasmic function group, which was significantly higher than the group with orgasmic dysfunction (P&lt;0.001).Conclusion: Since there is a significant relationship between clitoral glans visibility and orgasm, genital surgeries performed to increase clitoral glans visibility can facilitate sexual satisfaction and/or increase orgasm intensity. The fact that the relationship between measurable dimensions of clitoris, length of prepuce and orgasm cannot be shown suggests that clitoral glans visibility is more important than clitoral size for sexual stimulation.

SUN-LB16 Clitoromegaly in Premature Infants: Is It Truly Pathologic?

Background: Normative data for clitoral size in premature infants are limited. Consequently, the potential for over-diagnosis is high; leading to unnecessary investigations, increased healthcare costs and parental stress. Several proposed mechanisms, e.g., persistence of fetal adrenal zone activity to term gestation, point to the transient physiologic nature of clitoromegaly in premature infants. Studies of normative data have shown a negative correlation between birth weight and clitoral size. We hypothesized that 1) the majority of clitoromegaly in premature infants is not associated with hormonal dysfunction and 2) lower birth weight and lower gestational age increase the likelihood of a formal consult in premature infants with perceived clitoromegaly. Methods: A retrospective chart review of female infants born at our institution from January 2012 to December 2018 with perceived clitoromegaly was conducted. Birth history, demographic and laboratory data were collected. Patients were divided into two groups: ‘formal consult’ and ‘no formal consult’ for clitoromegaly. True clitoromegaly was defined as clitoral length >9 mm or clitoral width >6 mm. Patients not meeting these criteria or those with clitoral edema, prominent clitoral hood were classified under false clitoromegaly. In the ‘no formal consult’ group, the documented discharge examination was used to assess persistence of clitoromegaly. Uni- and multi-variable logistic regression were used to determine factors that increased the likelihood of a formal consult. Results: 29 patients met inclusion criteria; 15 in the ‘formal consult’ group and 14 in the ‘no formal consult’ group. No significant differences were found between the groups in terms of birth weight, gestational age, race, ethnicity and maternal factors. History of IUGR (intrauterine growth restriction) was more common in the ‘formal consult’ group (60%) vs. ‘no formal consult’ group (21%) (p=0.04). Only 3/15 patients in the ‘formal consult’ group had true clitoromegaly; all 3 had normal 17-hydroxyprogesterone levels, and only 1 patient had transient elevation in androgen levels (androstenedione, deoxycortisol and testosterone). Of the ‘no formal consult’ group, only 3/14 patients had clitoromegaly noted on discharge; outcome was unknown for 1. Multi-variable logistic regression showed that lower gestational age (p=0.04) and history of IUGR (p=0.03), even after adjusting for birth weight, increased the likelihood of a formal consult. Conclusion: In summary, the majority of perceived clitoromegaly in premature infants is not associated with hormonal dysfunction. Lower gestational age and a history of IUGR increase the likelihood of a formal consult for clitoromegaly in these patients. Approximately half of the patients were noted to have false clitoromegaly indicating inconsistencies in examination technique and need for provider education.

Clitoral size in term newborns in Kumasi, Ghana

BackgroundData on normative clitoral sizes in newborns is relatively sparse and racial/ethnic differences have also been reported. This study was performed to establish norms for clitoral size in term Ghanaian female newborns.MethodsThis was a cross-sectional study of all apparently well full-term newborns of postnatal age < 48 h and birth weight between 2.5 and 4.0 kg delivered at Komfo Anokye Teaching Hospital between May and September, 2014. Anthropometric and genital parameters were documented for study subjects as well as parental socio-demographic indices.ResultsIn 612 newborn females studied, the mean (±SD) clitoral length (MCL) and the mean (±SD) clitoral width (MCW) were 4.13 ± 1.6 mm and 4.21 ± 1.1 mm, respectively. MCL was inversely related to birth weight (r = −0.62; p < 0.001) while MCW was inversely related to both gestational age (r = −0.1; p = 0.02) and birth weight (r = −0.54; p < 0.001). Babies with a clitoris that was completely covered by the labia majora had relatively lower clitoral sizes (p < 0.001) than those who had a partially covered or prominent clitoris. Neither MCL nor MCW differed significantly by birth length or maternal tribe.ConclusionsClitoral size varies with birth weight and gestational age. Babies with a completely covered clitoris are unlikely to warrant detailed clitoral measurements for clitoromegaly.

Restoring normal anatomy in female patients with atypical genitalia

Female patients with congenital adrenal hyperplasia (CAH) have varying degrees of atypical genitalia secondary to prenatal and postnatal androgen exposure. Surgical treatment is focused on restoring normal genitalia anatomy by bringing the vagina to the normal position on the perineum, separating the distal vagina from the urethra, forming a normal introitus and preserving sexual function of the clitoris by accepting moderate degrees of hypertrophy as normal and strategically reducing clitoral size only in the most severely virilized patients. There remains a need for continued monitoring of patients as they go through puberty with the possibility of additional surgery for vaginal stenosis. Anatomically based surgery and refinement in surgical techniques with acceptance of moderate degrees of clitoral hypertrophy as normal should improve long-term outcomes.

Pubertal outcome in a female with virilizing adrenocortical carcinoma

Adrenocortical tumors are neoplasms that rarely occur in pediatric patients. Adrenocortical carcinoma (ACC) is even more uncommon, and is an aggressive malignancy with 5-year survival of 55% in a registry series. There is a lack of information on long-term endocrine outcome in survivors. We describe a 10-year follow-up in a patient who presented at 3 years 5 months with a 1-year history of axillary odor and 6 months' history of pubic hair development with an increased clitoral size. Androgen levels were increased and a pelvic sonogram revealed a suprarenal mass of the left kidney. The tumor was successfully removed. At 6 years 11 months, androgen levels increased again. Workup for tumor recurrence was negative and the findings likely represented early adrenarche. The patient had menarche at an appropriate time and attained a height appropriate for her family.

Clitoral Size and Location in Relation to Sexual Function Using Pelvic MRI

The female sexual response is dynamic; anatomic mechanisms may ease or enhance the intensity of orgasm. The aim of this study is to evaluate the clitoral size and location with regard to female sexual function. This cross-sectional TriHealth Institutional Board Review approved study compared 10 sexually active women with anorgasmia to 20 orgasmic women matched by age and body mass index (BMI). Data included demographics, sexual history, serum hormone levels, Prolapse/Incontinence Sexual Questionnaire-12 (PISQ-12), Female Sexual Function Index (FSFI), Body Exposure during Sexual Activity Questionnaire (BESAQ), and Short Form Health Survey-12. All subjects underwent pelvic magnetic resonance imaging (MRI) without contrast; measurements of the clitoris were calculated. Our primary outcomes were clitoral size and location as measured by noncontrast MRI imaging in sagittal, coronal, and axial planes. Thirty premenopausal women completed the study. The mean age was 32 years (standard deviation [SD] 7), mean BMI 25 (SD 4). The majority was white (90%) and married (61%). Total PISQ-12 (P < 0.001) and total FSFI (P < 0.001) were higher for orgasmic subjects, indicating better sexual function. On MRI, the area of the clitoral glans in coronal view was significantly smaller for the anorgasmic group (P = 0.005). A larger distance from the clitoral glans (51 vs. 45 mm, P = 0.049) and body (29 vs. 21 mm, P = 0.008) to the vaginal lumen was found in the anorgasmic subjects. For the entire sample, larger distance between the clitoris and the vagina correlated with poorer scores on the PISQ-12 (r = -0.44, P = 0.02), FSFI (r = -0.43, P = 0.02), and BESAQ (r = -0.37, P = 0.04). Women with anorgasmia possessed a smaller clitoral glans and clitoral components farther from the vaginal lumen than women with normal orgasmic function.

Female sexual function and the clitoral complex using pelvic MRI assessment

ObjectiveTo report basic measurements of clitoral anatomy, and explore potential relationships between the clitoral complex and female sexual function using MRI assessment. Study designIn this retrospective descriptive study, 20 sexually active women (≥18 years) who had a recent pelvic MRI for various gynecologic concerns were invited to participate. Outcome measures included demographic data, medical and sexual history, quality of life questionnaires: Female Sexual Function Index (FSFI), Body Exposure during Sexual Activities Questionnaire (BESAQ), and Short Form Quality of Life Questionnaire (SF-12). These data were then compared to detailed clitoral MRI measurements and analyzed using the Pearson correlation and Chi square test. ResultsFSFI domains of desire, arousal, lubrication, and orgasm were inversely correlated with clitoral size (p=0.01–0.04), as were SF-12 physical composite scores (p=0.003), suggesting improved sexual function and physical health in women with smaller clitoral structures (specifically the clitoral body and crus). ConclusionSexual function was improved in women with a smaller-sized clitoris, specifically the clitoral body and crus.

Self-Assessment of Genital Anatomy and Sexual Function Within a Belgian, Dutch-Speaking Female Population: A Validation Study

Data on self-perceived genital anatomy and sensitivity should be part of the long-term follow-up of genitoplasty procedures. However, no normative data, based on a large sample, exist to date. Validation of the Self-Assessment of Genital Anatomy and Sexual Function, Female version (SAGAS-F) questionnaire within a Belgian, Dutch-speaking female population. Seven hundred forty-nine women with no history of genital surgery (aged 18-69 years, median 25 years) completed an Internet-based survey of whom 21 women underwent a gynecological examination as to correlate self-reported genital sensitivity assessed in an experimental setting. The SAGAS-F enables women to rate the sexual pleasure, discomfort, intensity of orgasm, and effort required for achieving orgasm in specified areas around the clitoris and within the vagina, as well as genital appearance. The latter was similarly evaluated by an experienced gynecologist, and women were asked to functionally rate the anatomical areas pointed out with a vaginal swab. Sexual pleasure and orgasm were strongest, and effort to attain orgasm and discomfort was lowest when stimulating the clitoris and sides of the clitoris (P < 0.05). Vaginal sensitivity increased with increasing vaginal depth, but overall orgasmic sensitivity was lower as compared with the clitoris. Functional scores on the SAGAS-F and during gynecological examination corresponded highly on most anatomical areas (P < 0.05). Gynecologist's ratings corresponded highly with the women's ratings for vaginal size (90%) but not for clitoral size (48%). Replication of the original pilot study results support the validity of the questionnaire. The SAGAS-F discriminates reasonably well between various genital areas in terms of erotic sensitivity. The clitoris itself appeared to be the most sensitive, consistent with maximum nerve density in this area. Surgery to the clitoris could disrupt neurological pathways and compromise erotic sensation and pleasure.

Clitoral length in female newborns: a new approach to the assessment of clitoromegaly

The normative data for the newborn clitoral length will enable physicians to avoid overdiagnosing or underdiagnosing disorders related to the condition. This study is the first to investigate clitoris length in newborn females in Turkey. Materials and methods: A total of 325 newborns with normal gestational age born by uncomplicated spontaneous vaginal delivery were included in the study. The body weight, body length, head circumference, and clitoral size were measured. Results: A special equation was generated to estimate clitoris length, and clitoral length percentiles were prepared. The 3rd (2.00 mm) and 97th percentile (8.04 mm) values for clitoris length were determined. The best cut-off point for cases where the labia majora covered the clitoris was determined. Conclusion: The equations and the percentile curves presented herein could be used as guides for expected clitoris length. Further studies, including larger measurement numbers, would enable the development of more sensitive equations and percentiles.

External Genital Proportions in Prepubertal Girls: A Morphometric Reference for Female Genitoplasty

An understanding of normal genital anatomy is essential for a successful surgical approach and outcome in feminizing genitoplasty. We sought to establish genital standards in female children through external genital measurements taken from the end of the neonatal period until the beginning of adolescence. This prospective study included 205 females who were anesthetized for surgery for various diagnoses between January 2007 and March 2008. Patient age ranged from 1 month to 10 years. Patients were divided into 4 age groups-1 to 12, 13 to 24, 25 to 60 and 61 to 120 months. Information on patient age, height, weight and, for patients younger than 1 year, head circumference was retrieved from patient charts. Measurements of clitoris length, clitoris width, labia majora length, left and right labia minora length and width, and perineal distance were recorded. Specific equations were generated using these values to estimate the expected external genital structure dimensions in girls. Length of labia majora vs age, length of labia majora vs body weight, perineal distance vs body weight, clitoral width vs body weight and clitoral length vs age reference percentile curves were prepared. The equations and percentile curves generated can be used as a guide in prospective feminizing genitoplasty. Furthermore, patients and their families can be informed regarding the variability of external genitalia dimensions. This information should ensure a healthier appreciation of the postoperative genitalia by patients and their families.

Congenital adrenal hyperplasia: Results of medical therapy on appearance of external genitalia

Girls with congenital adrenal hyperplasia show a variable degree of genital masculinization at birth. Antenatal dexamethazone treatment for the mother is known to reduce the severity of this condition. There are however few data on the effect of postnatal steroid therapy on the cosmetic appearance of the external genitalia. We report the appearance of the external genitalia of three girls with classical congenital adrenal hyperplasia followed up by steroid therapy alone. Growth of the labia majora and a relative reduction in clitoral size improved the appearance of the external genitalia in these three girls. There seems to be improvement in the external appearance of genitalia with postnatal steroid therapy. This could allay parental concerns and help in the planning of corrective surgery peripubertally with the informed consent of the child.

Critical androgen‐sensitive periods of rat penis and clitoris development

Androgen control of penis development/growth is unclear. In rats, androgen action in a foetal ‘masculinisation programming window’ (MPW; e15.5–e18.5)’ predetermines penile length and hypospadias occurrence. This has implications for humans (e.g. micropenis). Our studies aimed to establish in rats when androgen action/administration affects development/growth of the penis and if deficits in MPW androgen action were rescuable postnatally. Thus, pregnant rats were treated with flutamide during the MPW ± postnatal testosterone propionate (TP) treatment. To assess penile growth responsiveness, rats were treated with TP in various time windows (late foetal, neonatal through early puberty, puberty onset, or combinations thereof). Phallus length, weight, and morphology, hypospadias and anogenital distance (AGD) were measured in mid-puberty (d25) or adulthood (d90) in males and females, plus serum testosterone in adult males. MPW flutamide exposure reduced adult penile length and induced hypospadias dose-dependently; this was not rescued by postnatal TP treatment. In normal rats, foetal (e14.5–e21.5) TP exposure did not affect male penis size but increased female clitoral size. In males, TP exposure from postnatal d1–24 or at puberty (d15–24), increased penile length at d25, but not ultimately in adulthood. Foetal + postnatal TP (e14–postnatal d24) increased penile size at d25 but reduced it at d90 (due to reduced endogenous testosterone). In females, this treatment caused the biggest increase in adult clitoral size but, unlike in males, phallus size was unaffected by TP during puberty (d15–24). Postnatal TP treatment advanced penile histology at d25 to more resemble adult histology. AGD strongly correlated with final penis length. It is concluded that adult penile size depends critically on androgen action during the MPW but subsequent growth depends on later androgen exposure. Foetal and/or postnatal TP exposure does not increase adult penile size above its ‘predetermined’ length though its growth towards this maximum is advanced by peripubertal TP treatment.

Reduction Clitoro-Labioplasty versus Clitoro-Labiectomy in Managing Adult Onset Clitoro-Labiomegaly

Objectives: To compare a new procedure of reduction clitoro-labioplasty to clitoro-labiectomy in the management of adult onset clitoro-labiomegaly, and to show the disadvantages of the latter procedure that produces female genital mutilation and sexual dysfunction. Methods: This controlled, descriptive, comparative and prospective cohort study was performed at Kasr El-Aini School of Medicine, Cairo University, Egypt. 47 cases of clitoro-labiomegaly, 12 with known causes of intersex, were diagnosed and treated by reduction clitoro-labioplasty. In addition, a control group of 53 more cases, 6 with known causes of intersex, were followed after treatment by clitoro-labiectomy. Clitoro-labioplasty was performed by excision of the anterior part of the fused corpora after separation at the glans-corporal junction and a reduction in the size of the remaining part of the corpora to reform a normal clitoral size. The neurovascular bundles were essentially preserved during this procedure. The protruded parts of the labia minora are then excised to preserve their normal dimensions. The main outcome measures were the postoperative anatomical result, patient’s satisfaction, the pre- and postoperative sex scoring, and sexuality. Results: Restoration of normal anatomy was successfully obtained after clitoro-labioplasty compared to partial or complete loss of these sensitive parts after clitoro-labiectomy. In addition, significant operative and postoperative complications were recorded in 27 cases with clitoro-labiectomy compared to none of the clitoro-labioplasty cases. The sex scores and sexuality improved significantly after the clitoro-labioplasty operation compared to clitoro-labiectomy (p < 0.005). Normalization of the sex scores and sexuality was found to be significantly related to preservation of critical clitoral length necessary for producing clitoral orientation and interest in sexuality. Conclusion: The new clitoro-labioplasty technique is able to preserve proper clitoral and labial anatomy and restore normal sexuality. Therefore it must be considered an essential line of treatment for clitoro-labiomegaly.

3-Dimensional Neuroanatomy of the Human Fetal Pelvis: Anatomical Support for Partial Urogenital Mobilization in the Treatment of Urogenital Sinus

Retrospective reviews suggest that the functional outcomes of surgery of the urogenital sinus have often been unsatisfactory and to our knowledge the long-term results of newer surgical techniques have yet to be evaluated. A precise understanding of pelvic fetal neuroanatomy is germane for optimizing surgical correction of the urogenital sinus. The pelves of 10 human female fetuses were serially sectioned. Masson's trichrome staining and immunochemistry for the neuronal marker S100 (Dako Corp., Carpinteria, California) along with anatomical computer reconstruction allowed 3-dimensional analysis of the nerves in relation to the pelvic structures as an animated motion picture. Two types of neuronal structures were identified. 1) A dense perivisceral foil of branching nerves closely surrounded the pelvic organs. The localization of most nerves was on the external faces of the viscera with a limited fraction in the rectovaginal and urethrovaginal septa. This innervation was from the anterior cephalad periurethral area to the posterior caudal perirectal area. 2) A significant amount of nerves surrounded the cephalad urethra on its anterior and posterior faces. Based on these anatomical data during surgical repair of a urogenital sinus we would advocate minimal mobilization of the lateral faces of the vagina, avoiding dissection of the proximal urethra above the pubic bone and electing a vaginal flap in severe cases.