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PubMed1982

Clinical variability of congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency.

Studies in 18 Jewish families from Morocco, Tunis, Turkey and Iran revealed 26 patients with congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency. The clinical expression of androgen excess varied widely in affected females, and range from solely enlarged clitoris in the mildest forms to severely hypertrophied clitoris with penile urethra and fused labial-scrotal folds in the most extreme forms of masculinization. Intermediate degrees of severity were manifested by ambiguous genitalia. There was no correlation between the degree of virilization and the signs of mineralocorticoid excess. Severe volume-induced hypertension leading to vascular accidents and death were also observed in severe as well as in mildly virilized patients, while completely masculinized females were sometime normotensive. Overt hypokalemia was present in 6 patients but was not a constant feature of hypertensives. However, all affected individuals, except for 2 infants, had very low levels of plasma renin activity suggesting that a state of volume expansion was indeed present in the majority of cases, even though changes in blood pressure did not always occur. The clinical expression of this disorder is characterized by a wide range of variability in the signs of both androgen and mineralocorticoid excess, which do not necessarily correlate with the quantity of hormones secreted.

Adolescent↗
PubMed2004

Anatomical studies of the female genitalia: surgical reconstructive implications.

Surgery for patients with genital ambiguity must be based on an accurate diagnosis, thorough understanding of the genital anatomy and realistic expectations for the patient, family and treating multi-specialty team. The goal is to create a functional and cosmetic outcome consonant with the gender assignment with the least amount of morbidity to the patient and family. An understanding of the normal genital neuroanatomy is essential for a successful surgical approach and outcome. Based on fetal human specimens, we have refined the three-dimensional relationship of the dorsal nerve of the clitoris, the female cavernosal nerve and the vaginal plexus. The surgical approach to patients with severe clitoral virilization should preserve erectile function and the neural innervation of the clitoris. When indicated, surgery should be performed in infancy to minimize psychological trauma and surgical complications from scarring. Herein, we review the neuroanatomy of the female genitalia and the implications for the rare patient who needs surgical reconstruction.

Clitoris↗
PubMed1980

Sexual dimorphism of the phallus in spotted hyaena (Crocuta crocuta).

The weight of the skinned phallus and the diameter of its shaft and glans did not differ significantly in the two sexes of spotted hyaena, but phallus length was greater in males. The urethra of the penis was surrounded by corpus spongiosum, while the urogenital canal of the clitoris was suspended beneath the erectile bodies in loose connective tissue, an arrangement compatible with dilatation of the canal during copulation and parturition. The average width of the phallic meatus in juvenile females exceeded that in males of any age and, in adults, the clitoridal meatus was > 10 times the width of the penile meatus. A robust retractor muscle situated dorsal to the urogenital canal further distinguished the clitoris from the penis; this muscle may play an important role in facilitating copulation.

Animals↗
PubMed1976

[Gross and light microscopic observations of the pudendal nerve of the guinea pig (author's transl)].

Using thirty six adult guinea pigs, the course and distribution of the pudendal nerve was observed macroscopically and then the constitution of the myelinated nerve fibers in these branches was studied with the fan-wise split preparation method (Fukuyama) and the cross sections embeded in paraffin wax. The main findings are summarized as follows: 1) The pudendal plexus in the guinea pig is formed most frequently by a bigeminal nerve which arises from the ventral ramus of the second sacral nerve at an average rate of 55.0% and the pudendal nerve is so independent from the sciatic nerve that the most part of the bigeminal nerve runs into the pudendal nerve. 2) The perineal nerve of the guinea pig arises most frequently with four roots (43.3%). The myelinated fiber constitution of this nerve is as follows: The small-sized fibers occupy 49.8%, the medium--sized 21.9%, the large--sized 15.1%, the maximum--sized 13.1% on an average, and the nerve fiber diameters observed in the cross section shows a bimodality in their distribution, of which the fibers in the higher peak are 1 mu to 2 mu and in the lower peak 5 mu to 8 mu. 3) The dorsal nerve of the penis or clitoris of the guinea pig arises most frequently with one root from the originating roots of the perineal nerve. The relationship between the sciatic and dorsal nerve appears to be scanty. The myelinated fibers of this nerve comprise 50.8% of small--sized, 28.4% of medium--sized, 14.7% of large--sized and 6.2% of maximum--sized fibers on an average. The fiber sized histograms constructed in the cross section shows a unimodality laying at 1 mu to 3 mu and the dorsal nerve of the clitoris contains more medium fibers 3 mu to 6 mu than the perineal nerve. From these results, it seems clear that the genital corpuscles are supplied by these medium fibers. 4) The inferior rectal nerve of the guinea pig arises from the perineal nerve in all cases, however, it is very slender. 5) The branch to the Obturator internus arises from the originating root or main trunck of the perineal nerve (51.7%). The myelinated fiber constitution of this branch is as follows: The maximum--sized fibers occupy 67.6%, the large--sized 16.2%, the small--sized 9.5% and the medium sized 6.8%. On the other hand, the fiber diameters observed in the transverse section are distributed around three peaks lying at 1 mu, 8 mu to 9 mu and 12 mu to 13 mu. 6) The branch to the accessory head of the Semitendinosus arises from the pudendal nerve at an average rate of 91.7%, of which this branch arises most frequently with one root from the originating root of the perineal nerve. The myelinated fiber constitution is as follows: The maximum--sized fibers 50.0%, the large--sized 23.9%, the small--sized 15.9% and the medium--sized 10.2% on an average. The histogram shows that myelinated fibers in this muscular branch consist of two groups of 1 mu to 2 mu and 12 mu to 14 mu...

Animals↗
PubMed2003

Ultrastructural effect of sildenafil citrate on corpus cavernosum and other genital organs in female rats.

AIM: To determine the ultrastructural effects of sildenafil on the female genital organs. METHODS: Twenty female cycling Wistar albino rats weighing 250+/-20 g were randomly divided into two groups of 10 each. Rats of one group were gavaged with 0.5 mg.kg(-1).d(-1) of sildenafil 3 days in a week for 4 weeks and the other served as the controls. After cessation of treatment animals were sacrificed by cervical dislocation under methoxyflurane anaesthesia. The clitoris, vagina, uterus and bartholin glands were taken at the estrous and were fixed with 10% formalin solution for light microscopy and 2.5% glutaraldehyde and osmic acid for electron microscopy. RESULTS: Under the light microscope, the fibrocollageous tissue was found increased, the capillaries enlarged and the connecting tissue elements increased in the corpus cavernosum in the treated group. On electron microscopy, increased connective tissue, fibroblasts with notched nucleus, shorten immature collagen fibers without striation were seen. Abundant foldings and penetration with collagen bundles were observed in the basal membrane. Large connection complexes, especially gap junctions among the wide capillary endothelial cells were observed. CONCLUSION: There are evident histological changes due to sildenafil citrate in female rat corpus cavernosum. The clitoris and bartholin glands were the most effected organs. While the histopathological changes of clitoral tissue could be expected, an increase in the mass of bartholin gland was surprising.

Animals↗
PubMed1979

The clitoral index: a bioassay of androgenic stimulation.

The glans clitoris is a target organ that is responsive to androgenic stimuli and enlarges throughout life. The size of the glans clitoris can be quantitated by determining the clitoral index (CI), which is the product of the sagittal and transverse diameters of the glans. Four hundred ten patients, ranging in age from 17 to 35 years, were examined. Ninety-five percent of 249 normal women had a CI less than 35 mm2. Of 85 patients with clitoromegaly (CI greater than 35 mm2) in addition to at least 1 other clinical sign of excess adrogenic stimulation, 53 (62%) had abnormally high values for either or both total serum testosterone and 17-ketosteroid levels. The CI is a useful bioassay for the clinical recognition of excess androgenic stimulation.

17-Ketosteroids↗
PubMed1994

[Partial androgen insensitivity syndrome].

There were studied 13 individuals with partial androgen insensitivity syndrome (PAIS) and we observed hypertrophy of clitoris in 92.3%, female pubic hair in 69.2%, complete absence of vagina in 69.2% and normal female development of breasts in 38.5%. In the partial form of AIS more frequent than in the complete form surgery for inguinal hernia, for hypertrophy of clitoris and for artificial vagina was necessary. The discussed form of this male hermaphroditism is caused by rare and untypical mutations in the androgen receptor gene and a differential diagnosis must be performed by exclusion above all the anorchism, Mayer-Rokitansky-Küstner syndrome and congenital adrenal hypertrophy. Among all cases of AIS the frequency of PAIS appeared 28.3%.

Adolescent↗
PubMed1976

Sex determination of the lesser bushbaby (Galago senegalensis).

The gross anatomy of the external genitalia of newborn to adult lesser Galago was described. The penis is perpendicular to the body wall at birth and by about 8 wk of age the testes have descended into the scrotum. In the adult male the testes are permanently descended, the scrotum sessile, the penis is oriented obliquely rostral, and the genitalia are covered by luxuriant pelage. In the young female, the clitoris is also perpendicular to the body wall and the labia and vaginal orifice, although not obvious, are located at its caudal base. In the adult female, the clitoris remains perpendicular, is slender, essentially devoid of fur, and has the urethral opening in its tip. The labia and vaginal orifice are at its caudal base, obscured by fur. Effective and reliable methods for differentiating males from females were outlined.

Animals↗
PubMed1997

The anterior sagittal transanorectal approach: a modified approach to 1-stage clitoral vaginoplasty in severely masculinized female pseudohermaphrodites--preliminary results.

PURPOSE: We present a modified 1-stage clitoral vaginoplasty technique for severely masculinized female pseudohermaphroditism involving an anterior sagittal transanorectal approach with the patient prone after clitoroplasty according to the Passerini-Glazel procedure. MATERIAL AND METHODS: An anterior sagittal transanorectal approach with protective colostomy was performed in 2 patients with severely masculinized female pseudohermaphroditism and a normal rectum. The anorectal sphincteric mechanism was divided only in the anterior midline, and the perineal body and rectum were opened in the anterior rectal wall, providing excellent exposure of the urogenital sinus. The vagina was easily and fully separated from the urogenital sinus, the site of vaginal attachment to the urethra was sutured, and anastomosis was created between the vaginal neo-introitus and vagina. The rectum, perineal body and anterior sphincteric mechanism were reconstructed. RESULTS: Cosmetic and anatomical results are satisfactory. The vaginal neo-introitus is located just below the urethral meatus, the clitoris appears almost normal and in the vulvar region a mucous lining is present in the front wall of the perineum between the clitoris and vagina. Convalescence was uneventful. The patients had normal bowel control after colostomy closure and no urinary incontinence. CONCLUSIONS: Our modified technique favors easy and safe posterior anastomosis between the vaginal neo-introitus and vagina under direct vision. Furthermore, suturing the vaginal stump is easier than in the original technique, since the approach to the vagina is posterior, not transvesical.

Child, Preschool↗
PubMed1998

Vasculogenic female sexual dysfunction: vaginal engorgement and clitoral erectile insufficiency syndromes.

The first phase of the female sexual response, associated with neurotransmitter-mediated vascular smooth muscle relaxation, results in increased vaginal lubrication, wall engorgement and luminal diameter as well as increased clitoral length and diameter. Specific physiologic impairments of vasculogenic female sexual dysfunction include vaginal engorgement and clitoral erectile insufficiency syndromes. These syndromes exist when during sexual stimulation abnormal arterial circulation into the vagina or clitoris, usually from atherosclerotic vascular disease, interferes with normal vascular physiologic processes. Clinical symptoms may include delayed vaginal engorgement, diminished vaginal lubrication, pain or discomfort with intercourse, diminished vaginal sensation, diminished vaginal orgasm, diminished clitoral sensation or diminished clitoral orgasm. An animal model of this syndrome, with significant physiologic responses between the control and the atherosclerotic pelvic nerve stimulated hemodynamic responses, is discussed. Non-atherosclerotic, traumatic vascular disease of the ilio-hypogastric-pudendal arterial bed from pelvic fractures or blunt perineal trauma may also result in diminished vaginal/clitoral arterial blood flow following sexual stimulation. Diagnostic studies assessing the hemodynamic integrity of the ilio-hypogastric-pudendal arterial bed to the vagina and clitoris and new oral/topical pharmacologic strategies for enhancing vaginal/clitoral blood flow in patients with vasculogenic female sexual dysfunction are discussed. There is a growing body of evidence that women with sexual dysfunction will commonly have physiologic abnormalities, such as vasculogenic female sexual dysfunction, contributing to their overall sexual health problems.

Animals↗
PubMed1995

Malignant melanoma of the vulva. Evaluation of prognostic factors with emphasis on DNA ploidy in 75 patients.

BACKGROUND: To the authors' knowledge, the potential prognostic value of DNA ploidy in vulvar melanoma has not been evaluated in previous series. METHODS: Clinical data and follow-up information were retrieved from the hospital records of 75 patients treated from 1956 to 1987. Histopathologic specimens were reviewed for histologic type, depth of invasion, vessel invasion, and ulceration. Flow cytometric DNA measurements were performed on paraffin embedded samples. RESULTS: Forty-three patients had International Federation of Gynecology and Obstetrics Stage I disease, 14 Stage II, 8 Stage III and 10 Stage IV. Sixty-five patients were treated by surgery, six by radiotherapy, and four patients with advanced disease received no therapy. The surgical procedure was local excision in 17 patients, vulvectomy in 22, and radical vulvectomy with inguinal lymph node dissection in 26. Five- and 10-year corrected survival rates were 46% and 37%, respectively. Recurrences were seen in 43 (66%) of the patients treated by surgery. Independent prognostic factors for corrected survival in the entire group of 75 patients were inguinal lymph node metastases (P = 0.016), angioinvasion (P = 0.027), tumor localization to clitoris, and multifocal tumors (P = 0.043). For the 65 patients treated by surgery, independent prognostic factors for disease free survival were angioinvasion (P < 0.001), age at diagnosis (P = 0.003), DNA ploidy (P = 0.004), and ulceration (P = 0.027). The independent prognostic factors for long term survival were tumor localization to clitoris (P = 0.018), DNA ploidy (P = 0.045), and inguinal lymph node involvement (P = 0.053). Radical surgery did not improve disease free or long term survival. CONCLUSIONS: DNA ploidy is an independent factor that predicts prognosis in patients with vulvar melanoma, and should be considered together with previously known factors. Radical surgery does not improve prognosis and is not recommended when the inguinal lymph nodes are clinically negative.

Adult↗
PubMed1992

High frequency of congenital adrenal hyperplasia (classic 11 beta-hydroxylase deficiency) among Jews from Morocco.

Steroid 11 beta-hydroxylase deficiency is relatively frequent in Israel among North African Jews. Over a 39-year period, 38 affected individuals from 25 families were diagnosed. Nineteen families came from Morocco, and in another 2, one parent came from Morocco (80% of all parents). Demographic studies showed that most of their grandparents were born in the region of the Atlas Mountains. In Israel, the overall incidence of the disorder is estimated between 1 in 30,000 to 1 in 40,000 births, but in offspring of Moroccan Jews the ratio is 1 in 5,000 to 1 in 7,000, with an allele frequency of 1 in 70 to 1 in 84 and a carrier frequency of 1 in 35 to 1 in 42. The clinical expression is characterized by a wide range of variability in the signs of androgen and mineralocorticoid excess. Virilization in the female ranged from enlarged clitoris in the mildest forms, to markedly hypertrophied clitoris with penile urethra and fused labial-scrotal folds in the most severe forms. Hypertension causing vascular accidents and death was observed in both severe and mildly virilized patients, whereas masculinized females were sometimes normotensive. Based on historical evidence, the origin of the ancestors, and the onomastic analysis of the families surnames, we propose that the mutation of 11 beta-hydroxylase deficiency in Jews from Morocco may have originated in either the ancient Jewish settlers or the native Berber tribes who lived in the region of the Atlas Mountains in the southern region of Morocco before the destruction of the Second Temple by the Romans, in the year 70 C.E.

Adrenal Hyperplasia, Congenital↗
PubMed2002

Characterization of diethylstilbestrol-induced hypospadias in female mice.

The urethral duct and vagina are formed from the urogenital sinus (UGS) during the early neonatal period in mice. Neonatal estrogen exposure results in hypospadias, or the malpositioning of vaginal and urethral openings, with wide cleft clitoris. We sought to characterize diethylstilbestrol (DES) influence on UGS morphogenesis and hypospadias formation. Newborn (day 0) and 1-4-day-old female mice (ICR/Jcl) were given (s.c.) oil or 3.0 microg DES. Animals were killed 24 hr later; then hypospadias formation and epithelial apoptosis and proliferation within the developing UGS were assessed. DES did not alter normal UGS morphogenesis by day 1, in comparison with controls. However, hypospadias formation was observed in DES-treated mice by day 3. In these mice, the distal dorsal urethral duct appeared to fuse with and open into the lower vaginal solid cord region. Further, DES treatment produced a gradual significant increase in dorsal urethral epithelial apoptosis (P < 0.05) just prior to and during fusion and hypospadias formation. DES-induced urethral epithelial and sinus cord proliferation appeared significantly increased (P < 0.05) and unchanged, respectively, just prior to fusion. By day 5, DES-treated mice exhibited wide cleft clitoris. In addition, if DES was given on day 3 or 5, a gradual, distinct caudal shift in the vaginal-urethral junction was observed compared to mice treated on days 0-2. Although hypospadias was not induced when neonates were given DES on day 7, these mice continued to display early vaginal opening. Dose-response analysis indicated that 0.03 microg DES for 5 days is the lowest known critical dose for hypospadias induction. We have shown for the first time that DES-induced hypospadias onset may primarily be the result of changes in developing dorsal urethral epithelial cell apoptotic and proliferative activity, and that the location of DES-induced hypospadias formation is dependent on age at time of exposure.

Animals↗
PubMed1990

External genitalia of the rat: normal development and the histogenesis of 5 alpha-reductase inhibitor-induced abnormalities.

The normal histogenesis of the rat genital tubercle and the effect of exposure in utero to the 5 alpha-reductase inhibitor finasteride (L-652,931; MK-0906; Proscar) on that process were studied. In normal males and females, the genital tubercle was first seen on Day 14.25 of gestation. It contained a urethral plate which extended from the cloaca (and after Day 15.25, from the urogenital sinus) to the tip of the tubercle. On Day 18.25 the glans lamellae, which would separate the glans penis or the clitoris from the prepuce, began to develop in both sexes. Also on Day 18.25 a dense, midline plate of mesenchymal cells was first evident between the urogenital sinus and the rectum in normal males. This plate acted as a wedge, first increasing the separation between the rectum and the urogenital sinus, and subsequently separating the urethral plate from the surface epithelium in the genital tubercle. As a result, by Day 21.25 the urethra in males followed an "S"-shaped course, extending from the pelvis through the center of the glans penis to an orifice near the tip of the genital tubercle. In females, in which a mesenchymal plate did not develop, the urethral orifice remained at the base of the tubercle, and the clitoris contained the remnants of the urethral plate, extending as an open groove from the urethral orifice to the tip of the tubercle. Finasteride did not affect development of the genital tubercle in females. However, in males exposed to finasteride in utero, there was variable failure of the mesenchymal wedge to develop. As a result, the urethral plate remained in contact with the surface epithelium and eventually opened to form a groove on the ventral surface of the glans penis (hypospadias). Also, the persistence of the urethral plate along the ventral midline in finasteride-treated male fetuses and its subsequent opening as a groove interfered with development of the glans lamellae, causing displacement of the frenulum distally on the glans penis and the development of a cleft in the prepuce.

Androstenes↗
PubMed2002

A new technique for repair of exstrophy-epispadias complex.

We report a new method of repair of exstrophy-epispadias complex (EEC) at a second stage by using flaps from the skin between the penis and scrotum (the clitoris and labia majora in females) used in seven patients. The non-pigmented skin between the penis and scrotum in males or a band of skin between the clitoris and labia majora in female is mobilized in two flaps, which are rotated superiorly. Five patients were treated primarily by this method and two patients at the time of secondary reconstruction. There were six boys and one girl. Two patients were post-pubertal, one male and one female. Follow-up (6-12 months) revealed good cosmetic and functional results. If EEC is repaired in a single stage, the entire pelvic diaphragm is visualized from inside and the sphincters can be reconstructed around the bladder neck. This procedure gives better exposure of attachments of the corporal bodies to the pubic rami, allowing easier mobilization. The bulbospongiosus muscle can be reconstructed. A normal penoscrotal relation is achieved in male patients. The root of the scrotum, which is splayed out and wide, narrows. Rotation of the flaps superiorly normalizes the symphyseal area. In female patients the appearance of the mons pubis is satisfactory. In post-pubertal children the pubic hair distribution appears normal.

Bladder Exstrophy↗
PubMed2003

Hypogonadism and pubertal development in Prader-Willi syndrome.

UNLABELLED: Genital abnormalities and disorders of pubertal development such as hypogonadism are common in Prader-Willi Syndrome (PWS). Depending on age, PWS patients present genital hypoplasia and delayed or incomplete gonadal maturation. Nevertheless, only a few evaluations have been made of these findings in this syndrome; in the cases previously reported the diagnosis of PWS has often been based only on clinical criteria and not confirmed by genetic analysis. In this paper we describe both external genital findings and spontaneous pubertal development in 84 patients aged from 2.1 to 35.4 (42 males, 42 females) affected by PWS. Diagnosis was made using the Holm and Cassidy criteria and was confirmed by genetic analysis (methylation test and/or FISH). We evaluated the presence of cryptorchidism, scrotal development, length of penis and volume of testis in males and outlook of labia minora and/or clitoris, age of menarche and features of menses (when present) in females; in both sexes we also evaluated the onset of puberty. All recruited males showed cryptorchidism, which was bilateral in 36 out of 42 patients (86%); 38 patients (90%) underwent orchidopexy. Small testes and scrotal hypoplasia were present in 76% and 69% of cases, respectively. In 76% of females, hypoplasia or absence of labia minora and/or clitoris was described. Spontaneous menarche occurred only in 14/32 cases (44%) over the age of 15 years, but menstrual cycles were often a periodical vaginal spotting. Primary amenorrhea was diagnosed in 56% of cases. Isolated premature pubarche was present in six males and in six females (14% of cases) while one male and two females were affected by precocious puberty (3.6%). CONCLUSION: Hypogonadism represents a common clinical feature in PWS, confirming the importance of such a major diagnostic criterion. Cryptorchidism was consistently present in all our cases. Patients with PWS commonly fail to spontaneously complete puberty, although some patients may have early pubarche or, more rarely, precocious puberty. In older subjects, hormonal replacement therapy is not always necessary and it must be reserved for selected patients.

Adolescent↗
PubMed1994

Reconstruction of the external genitalia in females with bladder exstrophy.

OBJECTIVES: A very characteristic genital anomaly accompanies bladder exstrophy in females. This includes anterior displacement and narrowing of the vagina and separation of the clitoris into two distinct bodies. The authors have had a relatively large experience with correction of this rare genital anomaly. From this experience, it began to appear that certain procedural details were associated with improved outcomes. The objective of this article was to review this experience and detail the reconstruction of the external genitalia in these patients. METHODS: All cases of bladder exstrophy in females presenting from January 1, 1970 to December 31, 1992 were reviewed. A total of eight patients who underwent surgical correction of the external genitalia were included. Data was obtained regarding urologic treatment, associated anomalies, corrective gynecologic procedures, complications and subsequent course. RESULTS: Corrective gynecologic surgery included enlargement of the vaginal orifice in all eight patients. Five patients had reapproximation of the bifid clitoris. Three patients performed postoperative dilatation therapy. Postoperatively, one patient experienced dyspareunia requiring a repeat procedure to enlarge the vaginal orifice. No patient had complications related to pelvic organ prolapse. CONCLUSIONS: Care should be taken not to extend the perineal incision too far posteriorly in reconstruction of the external genitalia in females with bladder exstrophy. Failure to do so may further predispose the patient to uterine prolapse. Post-operative dilator therapy may be an important adjunctive technique.

Adolescent↗
PubMed1983

Lymph drainage from the vulva.

Fifty-four patients with cervical cancer stage Ib were injected preoperatively with 99mTc-colloid in different areas of the vulva and three controls in the axilla. The radioactivity in the groins and the pelvis was measured with a scintillation camera and in the removed pelvic lymph nodes with a well counter. A low activity could be measured in the removed pelvic nodes of the controls indicating the radioactivity which had reached the pelvic nodes via the bloodstream. Clitoris and perineum had a bilateral lymph flow. In all the other patients the vast majority of the radioactivity was found in the ipsilateral lymph nodes. A significant, but small amount of activity was recorded in the contralateral nodes in 67% of the patients and in all patients injected in the anterior part of the labium minus. The medial external iliac lymph chain had an uptake of 73% of the total activity measured in the removed pelvic nodes. Only in 13% of the patients was the activity higher in the lateral than in the medial external iliac chain. Direct lymphatic pathway from the clitoris to the pelvic lymph nodes was not found. Anastomoses exist probably in 13 out of 42 patients between the presacral and/or common iliac nodes on both sides.

Adult↗