Genital Reconstructive Surgery Research Articles

From clitoridectomies to ‘designer vaginas’: The medical construction of heteronormative female bodies and sexuality through female genital cutting

This paper contributes to an ongoing critical discussion of sexuality and female genital cutting (FGC) offered by feminists, human rights activists, and academics. While most research to date focuses on the current practice of FGC in the African context, this limited understanding prohibits consideration of other instances and types of FGC. Three distinct historical and cultural contexts of FGC are addressed in this paper: (1) the practice of medical clitoridectomy in Victorian England and the use of clitoridectomies in North America in the mid twentieth century, (2) the ongoing Western use of genital surgery, and (3) the current trend of elective genital plastic surgery to create “designer vaginas” in the twenty-first century. This discussion reveals how various cultures and people–including women themselves–use FGC to influence and enforce Western medically constructed female embodiment(s) of heteronormative femininity and sexuality.

INTRACAVERNOUS PROSTAGLANDIN E1 INFUSION IN DIABETES WITH ASSOCIATED ISCHEMIC NECROSIS OF THE GLANS PENIS

Penile necrosis is a rare event. It has been described as a complication of diabetes or in systemic vasculitis.1 Ischemic damages may also arise following genital reconstructive surgery. Necrosis of the glans is generally the first evidence of a broader lesion that may involve the urethra and perineum in so-called Fournier’s necrotizing fasciitis.2 A solitary lesion of the glans without shaft involvement has been described rarely. A hyperbaric camera represents one of the best therapeutic solutions in these patients, although intracavernous infusion of prostaglandin has been shown to be particularly effective.

72: Role of Fibrin Sealant as Tissue Glue in Complex Genital Reconstructive Surgery

72: Role of Fibrin Sealant as Tissue Glue in Complex Genital Reconstructive Surgery

Who will make room for the intersexed?

Between 1.7 and 4% of the world population is born with intersex conditions, having primary and secondary sexual characteristics that are neither clearly male nor female. The current recommended treatment for an infant born with an intersex condition is genital reconstruction surgery to render the child as clearly sexed either male or female. Every day in the United States, five children are subjected to genital reconstruction surgery that may leave them with permanent physical and emotional scars. Despite efforts by intersexed people to educate the medical community about their rejection of infant genital reconstruction surgery, the American medical community has not yet accepted the fact that differences in genital size and shape do not necessarily require surgical correction.Genital reconstruction surgery may involve removing part or all of the penis and scrotum or clitoris and labia of a child, remodeling a penis or creating a vaginal opening. While the initial surgery is typically performed in the first month of a child's life, genital reconstruction surgery is not only performed on infants.

Effects on Gender Identity of Prenatal Androgens and Genital Appearance: Evidence From Girls With Congenital Adrenal Hyperplasia

Females with congenital adrenal hyperplasia (CAH) resulting from 21-hydroxylase deficiency are relatively common among those with intersex conditions. Prenatal androgen exposure is independent of rearing gender, and it is possible to assess variations in gender identity in relation to genital appearance and genital surgery. For these reasons, the authors determined gender identity, using a 9-item interview, in 43 girls with classic CAH who ranged in age from 3-18 years. Seven girls identified as tomboys and 29 control girls also were evaluated. The latter included 25 unaffected sisters and cousins of girls and boys with CAH as well as 4 sisters of tomboys. Each of the interview items was scored for sex-typicality. Girls with CAH, on average, had gender scores intermediate between those of tomboys and control girls. Only 5 of the 43, however, had scores outside the control range. The difference in scores between girls with CAH and control subjects was statistically significant and could not be ascribed to outliers. Tomboys also had significantly higher scores than control girls; 3 of 7 were outside the control range. There was significantly more variation in gender identity in tomboys than in girls with CAH or control subjects. Gender identity did not correlate significantly with age. The CAH and control groups were similar in some items of gender identify such as discomfort with being a girl and the wish to be a boy. In the girls with CAH, there was no evident connection between gender identity and either the degree of genital virilization or the age at which genital reconstructive surgery was carried out. Moderate androgen excess early in development, in the form of CAH, clearly increases the risk of atypical gender identity, but this risk could not be predicted from genital virilization in the present study. These females are sex-atypical in some respects but not in others. It does not seem likely that gender role behaviors can predict gender identity or sexual orientation in this population. In addition, behavior cannot be predicted from any single parameter such as the degree of androgen exposure, the appearance of the genitals, or the child-rearing environment.

Genital and pelvic reconstructive surgery

Genital and pelvic reconstructive surgery

Genital and pelvic reconstructive surgery

This issue of the Atlas of the Urologic Clinics is devoted to new reconstructive surgical procedures, including procedures in children, adult males, and adult females. The procedures are new, but not so new that follow-up and outcomes are not yet available; all of the procedures described have at least reached the point of having mid-term follow-up. I think it is safe to say that the procedures illustrated in this issue are current state-of-the-art. In addition, I am fortunate to be joined by a group of contributors, many of whom described the procedures that are illustrated; those who did not describe the procedures have extensive experience either with the concepts or procedures illustrated. It is truly an international panel of experts, and I am honored to present this issue.

Effects on gender identity of prenatal androgens and genital appearance: evidence from girls with congenital adrenal hyperplasia.

To address questions about sex assignment in children with ambiguous genitalia, we studied gender identity in girls with congenital adrenal hyperplasia (CAH) in relation to characteristics of the disease and treatment, particularly genital appearance and surgery. A 9-item gender identity interview was administered to 43 girls with classical CAH ranging in age from 3-18 yr, 7 tomboys, and 29 sister control girls. Groups were compared on total score and on individual items. Results showed that, on the total gender identity score, 88% of girls with CAH had scores overlapping those of control girls, but the average score was intermediate between control girls and tomboys. On individual items of gender identity (discomfort as a girl, wish to be a boy), girls with CAH were similar to control girls. Gender identity in girls with CAH was not related to degree of genital virilization or age at which genital reconstructive surgery was done. Thus, moderate androgen excess early in development appears to produce a small increase in the risk of atypical gender identity, but this risk cannot be predicted from genital virilization.

Congenital Urethral Stricture

No AccessJournal of UrologyPEDIATRIC UROLOGY: SOCIETY FOR FETAL UROLOGY1 Sep 2002Congenital Urethral Stricture Thomas S. Lendvay, Edwin A. Smith, Andrew J. Kirsch, and Mark Boddy Thomas S. LendvayThomas S. Lendvay More articles by this author , Edwin A. SmithEdwin A. Smith More articles by this author , Andrew J. KirschAndrew J. Kirsch More articles by this author , and Mark BoddyMark Boddy More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)64616-2AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Congenital Urethral Stricture." The Journal of Urology, 168(3), pp. 1156–1157 References 1 : Congenital obstruction of the posterior urethra. J Urol1919; 3: 289. Link, Google Scholar 2 : Congenital malformations of the urinary tract. New York: Praeger Publishers1983: 96. Google Scholar 3 : Urethral strictures in boys. J Urol1979; 121: 217. Link, Google Scholar 4 : Congenital urethral membrane causing urethral obstruction. J Urol1974; 111: 250. Link, Google Scholar From the Department of Urology, Section of Pediatric Urology, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia© 2002 by American Urological Association, Inc.FiguresReferencesRelatedDetailsCited by Bal H, Kurian J and Sen S (2017) The use of pedicled prepucial skin flap urethroplasty for proximal bulbomembraneous urethral stricture in childrenAnnals of Pediatric Surgery, 10.1097/01.XPS.0000503400.13933.ce, VOL. 13, NO. 1, (38-42), Online publication date: 1-Jan-2017. Johnson M, Brandes S and Coplen D (2014) Pediatric Urethral Strictures Advanced Male Urethral and Genital Reconstructive Surgery, 10.1007/978-1-4614-7708-2_37, (519-529), . Levin T, Han B and Little B (2007) Congenital anomalies of the male urethraPediatric Radiology, 10.1007/s00247-007-0495-0, VOL. 37, NO. 9, (851-862), Online publication date: 1-Sep-2007. Krishnan A, de Souza A, Konijeti R and Baskin L (2018) The Anatomy and Embryology of Posterior Urethral ValvesJournal of Urology, VOL. 175, NO. 4, (1214-1220), Online publication date: 1-Apr-2006. Volume 168Issue 3September 2002Page: 1156-1157 Advertisement Copyright & Permissions© 2002 by American Urological Association, Inc.Keywordsurogenital abnormalitiesurethral stricturecongenital, hereditary, and neonatal diseases and abnormalitiesurethraMetricsAuthor Information Thomas S. Lendvay More articles by this author Edwin A. Smith More articles by this author Andrew J. Kirsch More articles by this author Mark Boddy More articles by this author Expand All Advertisement PDF downloadLoading ...

Tissue engineering approaches for genital reconstruction.

Genital reconstructive surgery is required for a wide variety intersex anomalies. One of the major limitations of phallic reconstructive surgery is the availability of sufficient autologous tissue. Non-genital autologous tissue sources have been used for decades. Phallic reconstruction was initially attempted in the late 1930s using rib cartilage as a stiffener in patients with traumatic penile loss (Ftumpkin et al, 1994; Goodwin et al, 1952) This method, involving multiple staged surgeries, was soon discouraged due the unsatisfactory functional and cosmetic results. Silicone rigid prostheses were popularized in the 1970s and have been used widely (Bretan et al, 1989; Small et al, 1975). However, biocompatibility issues have been a problem in selected patients (Nukui et al, 1997; Thonmalla et al, 1987). Tissue transfer techniques using flaps from various non-genital sources, such as the groin, dorsalis pedis and forearm, have been used for genital reconstruction (Jordan et al, 1999). However, operative complications, such as infection, graft failure and donor site morbidity are not negligible. Phallic reconstruction using autologous tissue, derived from the patient’s own cells, may be preferable in selected cases.

Long-term perspectives for 46,XY patients affected by complete androgen insensitivity syndrome or congenital micropenis.

Controversy concerning optimal treatment for individuals affected by syndromes of abnormal sex differentiation can best be resolved with knowledge about long-term medical, surgical, and psychosexual outcomes of patients. Follow-up information has recently been gathered on older cohorts of the following patient groups: (1) those affected by complete androgen insensitivity syndrome (CAIS) raised female and (2) those affected by congenital micropenis raised male or female. As a group, women with CAIS were satisfied with their female gender and sexual function. However, a need for better patient education was identified for this specific population. Most patients with congenital micropenis, whether raised male or female, were satisfied with their gender. Regardless of sex of rearing, dissatisfaction with the appearance and function of the genitalia as judged by both physicians and subjects was evident. For patients with congenital micropenis, male sex of rearing was concluded to be optimal because genital reconstructive surgery is not required with this choice.

Surgical conversion of genitalia in transsexual patients.

To describe the techniques and outcome of genital and urethral reconstructive surgery during gender conversion as part of the treatment of transsexuals. From 1992 to 1999, 82 patients were surgically converted after previous sexual and hormonal therapy. Using the male genital tissue to create new female genitalia, and vice versa, 30 male and 52 female transsexuals were converted. For male-to-female transsexuals, the technique of penile skin inversion was used 29 times and sigmoidocolpoplasty five times (in one patient primarily and in four patients to correct inadequate neovaginal size after penile skin inversion). In female-to-male transsexuals, 28 meta-idoioplasties and seven neophalloplasties were performed using the groin skin-flap technique, with 42 breast reductions also included as a part of the therapy. Surgical gender reassignment of the male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm. Depending on the technique used in the reverse conversion, the patient maintained the ability to attain orgasm, and in many cases had a satisfactory appearance of the neopenis, with the potential to void while standing. The morphological proportions of each patient vary, and the different shapes and sizes of the tissues can be used for plastic operations. Thus the modelling of each individual genital in transsexuals can be considered 'original'.

Results of genitoplasty for virilized genitalia of 41 females with congenital adrenal hyperplasia

The results of genitoplasty performed at our clinic for 41 female patients with congenital adrenal hyperplasia (CAH) were reviewed. Among 57 females with CAH (56 with 21-hydroxylase deficiency and 1 with 11 beta-hydroxylase deficiency) diagnosed between 1961 and 1995, 41 underwent genitoplasty. For the rest of 16 patients, 1 received already clitorectomy, 11 (19%) needed no surgical reconstruction, 2 died before surgery, and 2 are in a waiting list for surgery. According to Prader's classification of virilized genitalia, 41 patients who received surgery included 8 of type I, 10 of type II, 17 of type III, and 4 of type IV. There was no patients of type V, and 2 were not classified because of previous surgery. Four patients underwent genitoplasty 7 times in total before visiting us. The age receiving initial genitoplasty at our clinic ranged from one year and 9 months to 20 years (median: 4 years and 5 months). Follow-up period averaged 17 years with the range of 2 months to 33 years. For enlarged clitoris, clitorectomy (amputation of clitoris) was carried out for 22 patients before 1975 and corporal resection for 17 after 1975. Two patients manifested recurrence of clitoromegaly after the surgery because of either incomplete resection of the clitoris or patient's ignorance of taking glucocorticoid regularly. Thirty-six patients needed labiovaginoplasty. Simple midline cutback was performed for 6 patients and Y-V plasty (skin flap labiointroitoplasty) for 30. Vaginal orifice was not identified in 5 patients at the initial surgery. Two patients received successful second introitoplasty at the older age than 10. Post-operative stenosis of vaginal orifice was confirmed in 6 patients and 3 underwent second introitoplasty. Among 23 patients older than 25 years at present, 7 got married and 4 raised 6 children with assistance of Caesarian section. Most of female patients with CAH needed genital plastic surgery including clitoroplasty and labiovaginoplasty. Corporal resection for enlarged clitoris with sufficient hormone therapy brought a satisfactory result. Y-V plasty for labiovaginoplasty proved to be an excellent method, especially from cosmetic viewpoint, but remained some problems as one stage operation including difficult identification of vaginal orifice and post-operative stenosis of introitus in some patients.

Testicular feminization: The androgen insensitivity syndrome

Testicular feminization (TF) is a syndrome due to androgen insensitivity. It occurs in a complete (CTF) and an incomplete (ITF) form. We have treated 21 patients with TF over the last 24 years. Eight patients presented because of ambiguous genitalia, seven presented as "females" with inguinal hernia and testes were found at surgery, five were diagnosed by karyotyping performed for a family history of TF, and one presented with an incarcerated hernia and primary amenorrhea. Two patients had prior surgery for inguinal hernia but the diagnosis was not recognized. All patients had a 46,XY karyotype. Patients with CTF were phenotypically female while those with ITF had a variable appearance of the external genitalia depending on the degree of androgen insensitivity. Seventeen patients underwent gonadectomy and one patient planned for delayed gonadectomy was lost to follow-up. Seventeen patients had been raised as females since birth. One patient with ambiguous genitalia, who was initially raised as a male, was reassigned female gender at 1 year of age when the diagnosis of ITF was made. Three patients were raised as males even after the diagnosis of ITF was made. Patients raised as males underwent multiple genital reconstructive procedures with poor results. In view of the poor anatomic and functional results of genital reconstructive surgery and the consequent psychological problems, patients with TF should be raised as female. Careful evaluation of infants with ambiguous genitalia and documentation of absent fallopian tubes in "females" presenting with inguinal hernia will lead to early diagnosis of TF, correct sex assignment, and early gonadectomy.

Genetic disorders of adrenal hormone synthesis.

Steroid 21-hydroxylase is the enzyme involved in 90-95% of cases of congenital adrenal hyperplasia (CAH). The general feature of CAH, which results from an enzymatic block at any stage in the synthesis of cortisol, is increased serum adrenocorticotropin and thus stimulated adrenal synthesis of steroids proximal to the block. All enzyme defects causing CAH are autosomal recessive traits. The early steps in cortisol synthesis are common to adrenal and gonadal steroid pathways, thus CAH caused by dysfunction of the enzymes supporting these steps is also characterized by insufficient production of gonadal hormones, causing impaired genital development in the genetic male. The absence of or severe reduction of steroid 21-hydroxylase activity also causes prenatal hypersecretion of androgens by the adrenal cortex, which results in external genital ambiguity in genetic females. This paper discusses the classical and nonclassical forms of CAH, their aetiology, diagnosis and treatment, and also describes recent advances in prenatal diagnosis and treatment which avoids the need for corrective genital plastic surgery in infancy.

Assessment and Support of Sexual Functioning in 458 Men Seeking Genitourinary Reconstructive Surgery

Horton and associates focused on an aspect of genital reconstructive surgery: restored or improved sexual functioning. The availability a physician skilled in the application of modern sexual counseling has been demonstrated in a group of 458 men to assist in maximizing the benefit of such surgery on patients' sexual and coital success. The sexual therapist was a valued member of the team approach to patient care. The necessity of psychiatric assessment for some was apparent, as it would be in any population of patients seeking plastic or corrective surgery. The association of the sexual therapist with various mental health professionals was important. The recognition of mental and emotional difficulties was primary, but the further skills the sexual therapist brought by application of sexual therapy techniques was also important. Men disadvantaged sexually by genital abnormality gained from a sensitive and educational approach, one that included their partners in the context of open communication and offered specific suggestions for their own specific needs and situations. Sexual therapy techniques and skills instruction added a vital dimension to the complete care of these men seeking correction of genital abnormalities. The techniques and approaches themselves were fairly straightforward and simple, as well as fairly standardized. Described by Masters and Johnson, Jones and others, they were clearly effective in enhancing comfort with sexuality and less pressured approaches to sexual behavior, and ultimately in enhancing sexual functioning itself.

The Use of Parenteral Testosterone Therapy in Genital Reconstructive Surgery

Previously, testosterone cream has been used for penile enlargement before genital surgery. The results not only were inconsistent but the absorption was variable. Therefore, we elected to study the use of parenteral testosterone as an adjunct before reconstructive surgery.In 44 patients with hypospadias (36), epispadias (5) or urethral fistulas (3) 2mg. per kg. testosterone enanthate were given intramuscularly 5 and 2 weeks before reconstructive surgery. Testosterone caused a mean increase in penile length of 2.7cm. and in circumference of 2.3cm. as well as local vascularity in all patients. In addition to surgical results the potential side effects of testosterone treatment were monitored 3 months to 1 year postoperatively. Basal testosterone levels were obtained in patients before and during therapy, and postoperatively. In addition, side effects, such as increased bone age and excessive pubic hair, were not a problem.The use of preoperative testosterone significantly contributed to the successful reconstruction of these patients, particularly those with a paucity of penile skin and those who had undergone previous repairs. Temporary penile stimulation by testosterone enanthate allows for an earlier penile operation as well as provides negligible side effects.