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PubMed1996

Sensate pedicled neoclitoroplasty for male transsexuals: Amsterdam experience in the first 60 patients.

The results of vaginoplasty by inversion of penile and scrotal skin in male-to-female transsexuals, in general, are satisfying. Cosmetic and functional considerations dictate the construction of a neoclitoris ventral to the urethral orifice. Embryologically, the glans penis and clitoris are homologues and mutual substitution seems to be the logical approach. In this paper, the long-term results in the first 60 patients using the pedicled sensate neoclitoroplasty according to Brown are presented and discussed. It has proven to be a safe technique that leads to satisfying cosmetic and functional results in nearly all patients. It should be considered state of the art in primary gender-confirming surgery for male-to-female transsexuals.

Clitoris↗
PubMed1992

The surgical management of infants and children with ambiguous genitalia. Lessons learned from 25 years.

Over a 25-year period, 91 children with ambiguous genitalia have received surgical management. Female sex assignment was made for 79. Of these, 60 patients underwent extensive clitoral reconstruction consonant with the female assignment. Forty-two patients had vaginal reconstruction. Factors relating to success include: (1) prompt and appropriate sex assignment; (2) early and accurate diagnosis; (3) conservative reconstruction of the clitoris at an early age (less than 1 year); and (4) choice of vaginal reconstruction based on the severity of the malformation. Long-term follow-up demonstrates satisfactory anatomic and functional results when clitoral surgery alone was required. Functional results for patients with extensive vaginal reconstruction have been compromised. Physicians caring for children with congenital intersexual anomalies can expect to encounter a wide spectrum of anatomic and physiologic derangements. Cosmetic appearance alone is an inadequate measure of success because endocrinologic, social, psychological, and sexual factors must be blended into comprehensive evaluation of these patients. The management plan must be flexible and individualized, incorporating long-term follow-up to adulthood.

Clitoris↗
PubMed1997

Intraoperative recording of the bulbocavernosus reflex.

OBJECTIVE: To demonstrate the feasibility of intraoperative monitoring of the bulbocavernosus reflex (BCR) as an indicator of the functional integrity of sacral nervous structures to aid in preventing their intraoperative injury. METHODS: Intraoperative BCR was elicited by electrical stimulation of the dorsal penile/clitoral nerve in 119 patients anesthetized with propofol, fentanyl, and nitrous oxide, with short-acting relaxant. Thirty-eight patients underwent surgery without risk, whereas 81 underwent surgery with risk of damage to sacral structures. Different patterns of stimuli were applied through silver/silver chloride disc electrodes placed on the dorsal aspect of the penis in males and over the clitoris (cathode) and adjacent labia (anode) in females. Recordings were made from the anal sphincter using intramuscular wire electrodes introduced within a 27.5 gauge needle, with two electrodes each inserted in the right and left hemisphincter muscles. Preoperatively, some patients had minor urinary problems in controlling their sphincters. RESULTS: The BCR was reliably recorded without habituation under this anesthetic regime. Optimal stimulating parameters were found to be double pulses (0.5-ms duration), with an interstimulus interval of 3 ms, stimulating rate of 2.3 Hz, and intensity of 20 mA. With these parameters, it was possible to record the BCR intraoperatively in all patients. Isoflurane and nitrous oxide significantly suppressed the BCR, and muscle relaxant completely abolished it. CONCLUSION: We demonstrated that it is feasible, under certain anesthetic regimes, to intraoperatively monitor the BCR in both children and adults (24 d to 74 yr of age) who did not have significantly affected function in sacral nervous structures.

Adolescent↗
PubMed1978

Construction of male genitalia in the transsexual, using a tubed groin flap for the penis and a hydraulic inflation device.

A technique for construction of external male genitalia in a transsexual patient is presented in detail. The McGregor groin flap is used for penile construction, and the Scott inflatable prosthesis is used to produce an erection. The shape of the penis is improved by secondary local excisions, and the clitoris is bivalved and inserted at the base of the penis to allow sexual sensation. The appearance and the function of the constructed genitalia have been deemed quite satisfactory by this transsexual patient.

Adult↗
PubMed2003

A review of the physiology and pharmacology of peripheral (vaginal and clitoral) female genital arousal in the animal model.

PURPOSE: We review contemporary scientific data concerning the physiology and pharmacology of peripheral female genital arousal responses in the animal (rabbit and rat) model. MATERIALS AND METHODS: We reviewed the contemporary literature and our research studies concerning physiology and pharmacology of peripheral genital arousal from 3 experimental animal models, including genital smooth muscle cell culture, genital strip organ bath and in vivo animal model studies. RESULTS: Nitric oxide (NO) appears to be a key pathway mediating clitoral smooth muscle relaxation. In the vagina NO appeared to have a more controversial role in mediating vaginal muscularis smooth muscle relaxation. Vasoactive intestinal polypeptide induced vaginal smooth muscle relaxation. Functional alpha-adrenergic receptors were expressed in the clitoris and vagina, and mediated norepinephrine induced genital smooth muscle contraction. Androgens and estrogens modulated distinct physiological responses in vagina, and androgens facilitated vaginal smooth muscle relaxation. Papaverine hydrochloride, a smooth muscle relaxant, and phentolamine mesylate, an alpha-blocker, administered into the vaginal spongy muscularis layer increased vaginal wall pressure and vaginal blood flow. Sildenafil caused significant increases in genital (clitoral and vaginal) blood flow and vaginal lubrication in intact and ovariectomized animals. This response was more pronounced in animals treated with estradiol, suggesting that the NO cyclic guanosine monophosphate pathway is involved in the physiological mechanism of female genital arousal and that sildenafil facilitates this response in an in vivo animal model. CONCLUSIONS: To achieve improved understanding of the biological aspects of female sexual function, further research is needed in the physiology and pharmacology of peripheral (clitoral and vaginal) genital arousal in the animal model.

Animals↗
PubMed1995

On the vegetative and sensitive innervation of the Retractor clitoridis muscle in some domestic animals.

The retractor clitoridis muscle originates from the coccygeal vertebrae in the cow, ewe, goat and mare, and from the anal musculature in the sow. It terminates at the base of the clitoris. In all the species considered, a vegetative innervation was found. This was represented by isolated or grouped ganglion cells. Nervous sensitive supply was also present. This was represented by Pacinian, Pacinian-like and Golgi-Mazzoni's corpuscles, and by Krauses's end bulbs. A notable difference was found in the amount and type of these receptors. They were numerous in the sow, ewe and goat, and rare in the cow and mare. Additionally, in the sow, ewe and goat, all the above mentioned receptors were found, while, in the cow and mare, only Pacinian and Pacinian-like corpuscles occurred. The morphology of these receptors was described and hypotheses were made concerning their probable functional role.

Anal Canal↗
PubMed2006

Regional cerebral blood flow changes associated with clitorally induced orgasm in healthy women.

There is a severe lack of knowledge regarding the brain regions involved in human sexual performance in general, and female orgasm in particular. We used [15O]-H2O positron emission tomography to measure regional cerebral blood flow (rCBF) in 12 healthy women during a nonsexual resting state, clitorally induced orgasm, sexual clitoral stimulation (sexual arousal control) and imitation of orgasm (motor output control). Extracerebral markers of sexual performance and orgasm were rectal pressure variability (RPstd) and perceived level of sexual arousal (PSA). Sexual stimulation of the clitoris (compared to rest) significantly increased rCBF in the left secondary and right dorsal primary somatosensory cortex, providing the first account of neocortical processing of sexual clitoral information. In contrast, orgasm was mainly associated with profound rCBF decreases in the neocortex when compared with the control conditions (clitoral stimulation and imitation of orgasm), particularly in the left lateral orbitofrontal cortex, inferior temporal gyrus and anterior temporal pole. Significant positive correlations were found between RPstd and rCBF in the left deep cerebellar nuclei, and between PSA and rCBF in the ventral midbrain and right caudate nucleus. We propose that decreased blood flow in the left lateral orbitofrontal cortex signifies behavioural disinhibition during orgasm in women, and that deactivation of the temporal lobe is directly related to high sexual arousal. In addition, the deep cerebellar nuclei may be involved in orgasm-specific muscle contractions while the involvement of the ventral midbrain and right caudate nucleus suggests a role for dopamine in female sexual arousal and orgasm.

Adult↗
PubMed2004

Penile and clitoral stimulation for faecal incontinence: external application of a bipolar electrode for patients with faecal incontinence.

OBJECTIVE: The aim of this study was to assess the effect of a novel pudendal nerve stimulator on clinical and anorectal manometric parameters in patients with faecal incontinence. METHOD: Retrospective cohort analysis of consecutive patients presenting with faecal incontinence who had failed initial conservative treatment and were not suitable for surgical intervention in a university hospital incontinence clinic. Biofeedback using a pudendal nerve stimulator comprising a bipolar electrode applied to the base of the clitoris or penis. Electrical pulse voltage was self-titrated and defined periods of treatment were prescribed. Anorectal manometry and Cleveland incontinence scores were assessed. RESULTS: There was a significant reduction in incontinence symptom score after pudendal nerve stimulator treatment in the 42 patients treated and who had a complete set of data (median age 57 years (range 37-81); 39 female, 3 male). This was accompanied by significant improvements (P < 0.05) in anal sphincter tone, maximal tolerated rectal volume and the sustained rectoanal inhibitory reflex. CONCLUSIONS: An externally applied pudendal nerve stimulator improves symptoms and physiological evidence of faecal incontinence but long-term follow up is not available for these patients.

Adult↗
PubMed1988

Neurophysiological measurements in patients with genuine stress incontinence of urine and the relation of neurogenic defects to the presence of spina bifida occulta.

Neurophysiological measurements comprising surface electromyography (EMG) of the urethral and anal sphincters, measurement of the sensory thresholds of the dorsal nerve (DN) of the clitoris and the urethra and sacral reflex latencies from the dorsal nerve to urethra and anus and from the urethra to anus were performed in 44 females with genuine stress incontinence, in order to detect any relationship between the clinical disorder and a neurogenic defect in the innervation of the muscles involved in maintaining continence. Plain X-rays of the renal tracts (KUB films) were also studied to establish whether the prevalence of spina bifida occulta was increased in this group of patients and was a likely explanation for the nerve defects. Forty-three patients were found to have abnormal neurophysiological responses and the prevalence of spina bifida occulta was 50%, which compares with a prevalence of 17% in normal female controls. Genuine stress incontinence appears to be at least partly associated with defective innervation of the lower urinary tract and it is likely that in some cases the defect may be related to the presence of spina bifida occulta.

Adolescent↗
PubMed1999

Prolonged enhancement of the micturition reflex in the cat by repetitive stimulation of bladder afferents.

1. Prolonged modulation of the parasympathetic micturition reflex was studied in cats anaesthetized by alpha-chloralose. Reflex discharges were recorded from a thin pelvic nerve filament to the bladder and evoked by stimulation of the remaining ipsilateral bladder pelvic nerves or urethral branches of the pudendal nerve. 2. Stimulation of bladder or urethral afferents at Adelta intensity evoked micturition reflexes with a latency of 90-120 ms. Such reflexes were much enhanced following repetitive conditioning stimulation of the same afferents at 20 Hz for 5 min. 3. The reflex enhancement lasted more than 1 h after the conditioning stimulation. The effect was not prevented by a preceding complete transection of the sympathetic supply to the bladder. A prolonged suppression of the reflex was obtained after conditioning stimulation of afferents in the dorsal clitoris nerves. 4. It is proposed that the prolonged modulations of the micturition reflex represent physiological adaptive processes, which preserve a flawless function of the bladder during life. The observations provide a theoretical explanation for the beneficial effect of electric nerve stimulation in patients with voiding disorders.

Animals↗
PubMed1992

Vibratory perception thresholds in the female genital region.

Vibratory perception thresholds (VPT) were determined in the hands, feet and genital region by means of an electromagnetic vibrator and expressed in terms of amplitude of stimulator movements measured by an accelerometer. Eight healthy women volunteers aged 27-44 were examined on 8-11 occasions each during the menstrual cycle. Ninety-five further women, aged 35-45 were consecutively selected from the waiting list for hysterectomy for non-malignant disorders and examined on one occasion each. VPT measurements were correlated to menstrual phases and blood oestradiol values. In the healthy volunteer group the mean VPT for clitoris was 0.27 mu (SD 0.10, range 0.09-0.48), for hands 0.19 mu (SD 0.09, range 0.05-0.37) and feet 0.51 mu (SD 0.39, range 0.17-1.5). In none of the two groups were there any significant differences between the VPTs of the different phases of the menstrual cycles nor was there any significant correlation between VPT and serum oestradiol levels.

Adult↗
PubMed1979

A virilizing adrenal tumor with borderline elevation of urinary 17-ketosteroids and histochemical demonstration of a deficiency in the delta 5/delta 4-isomerase, 3 beta-hydroxysteroid dehydrogenase enzymatic system.

A 3-year-old girl affected by a virilizing tumor of the adrenal gland, without significant elevation in the levels of 17 ketosteroids (17-KS) urinary excretion, was studied clinically. Her symptoms started abruptyly at the age of 2, with progressive enlargement of the clitoris and the appearance of pubic hair. In various tests, the 17-KS levels barely exceeded the upper normal limits and at times remained within normal limits. The retropneumoperitoneum X-ray suggested an enlargement of the right adrenal gland and the presence of a neoplasm, which was actually discovered during surgery. Histopathological examination revealed a well-defined neoplasm, without capsule invasion and with accentuated cell polymorphism. Histoenzymology showed that the tissue lacked the enzymatic system involving 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD). Indoxylesterase (I.EST-A) activity identified the tumor as originating from the internal layers of the adrenal cortex. The histochemical findings were correlated to the clinical picture and the levels of urinary 17-KS.

17-Ketosteroids↗
PubMed2006

Genital sensation and sexual function in women bicyclists and runners: are your feet safer than your seat?

INTRODUCTION: Bicycling is associated with neurological impairment and impotence in men. Similar deficits have not been confirmed in women. AIM: To evaluate the effects of bicycling on genital sensation and sexual function in women. METHODS: Healthy, premenopausal, competitive women bicyclists and runners (controls) were compared. MAIN OUTCOME MEASURES: (1) Genital vibratory thresholds (VTs) were determined using the Medoc Vibratory Sensation Analyzer 3000. (2) Sexual function and sexually related distress were assessed by the Dennerstein Personal Experience Questionnaire (SPEQ) and the Female Sexual Distress Scale (FSDS). RESULTS: Forty-eight bicyclists and 22 controls were enrolled. The median age was 33 years. The bicyclists were older, had higher body mass indices (BMIs), were more diverse in their sexual orientation, and were more likely to have a current partner. Bicyclists rode an average of 28.3 +/- 19.7 miles/day (range 4-100), 3.8 +/- 1.5 days/week, for an average of 2.1 +/- 1.8 hours/ride. The mean number of years riding was 7.9 +/- 7.1 years (range 0.5-30). Controls ran an average of 4.65 +/- 2.1 miles/day (range 1.5-8) and 5.0 +/- 1.2 days/week. On bivariate analysis, bicyclists had significantly higher VTs than runners, indicating worse neurological function at all sites (P < 0.05). Multivariate analysis found significant correlations between higher VTs and bicycling at the left and right perineum, posterior vagina, left and right labia. Increasing VTs at the clitoris, anterior vagina, and urethra were associated with age. In bicyclists, there were no correlations between VTs and miles biked per week, duration of riding, or BMI. Composite SPEQ scores indicated normal sexual function in all sexually active subjects. Neither group suffered from sexually related distress. CONCLUSION: There is an association between bicycling and decreased genital sensation in competitive women bicyclists. Negative effects on sexual function and quality of life were not apparent in our young, healthy premenopausal cohort.

Adult↗
PubMed1997

Acquired clitoral enlargement. Diagnosis and treatment.

Clitoral hypertrophy is usually seen in congenital malformations, specifically in intersexual stages of hormonal expression. Acquired clitoral hypertrophy is a relatively rare condition, and data in the literature concerning this problem are sparse. Articles usually consist only of case reports. Among the contributing factors in the etiology of acquired clitoral hypertrophy, the following three are the most frequent: (1) endocrinopathies including virilizing tumors of the ovaries or adrenals, (2) neurofibromatosis (of both clitoral subcutis and corpora cavernosa), and (3) pseudohypertrophy of the clitoris. The first step in correcting acquired clitoral enlargement must be to determine and stop the cause of the hypertrophy, followed by a period of simple observation. If clitoral enlargement does not disappear over time, surgical correction is necessary.

Clitoris↗
PubMed1990

Virilisation of female preterm infants.

Two cases of hypertrophy of the clitoris in premature girls are reported; this was associated with persistently high concentrations of adrenal fetal zone androgens.

Adrenocorticotropic Hormone↗
PubMed1999

Idiopathic clitoral hypertrophy.

We report a case of clitoral hypertrophy of unknown origin. A 3-year-old girl showed clitoral hypertrophy at birth. Biochemical analysis of peripheral blood and endocrinological examinations were normal. Other virilizing symptoms were not recognized. Clitoroplasty was carried out, and the clitoris has not enlarged 20 months after the operation. Her mother was administered cefotiam and terbutaline (beta-stimulant) during pregnancy because of threatened abortion. No virilizing agents such as progesterone were used during pregnancy.

Abortion, Threatened↗
PubMed1997

Effects of prenatal testosterone on sexual behavior, reproductive morphology and LH secretion in the female rat.

Sexual differentiation of many brain structures and functions is dependent on levels of testosterone (T) or its metabolites during certain 'sensitive' developmental periods. If T is present during these perinatal periods, masculinization and defeminization of sexual behavior occur; also, reproductive physiology, and central nervous system morphology and function are altered. The purpose of the present study was to characterize the influence of T at specific prenatal developmental intervals on offspring reproductive morphology, physiology, locomotor activity and sexual behavior during postnatal development. To avoid complications induced by endogenous testicular activity, only females were examined. Free T was used because of its relative short half-life, so that the effects induced by its administration on a specific gestational day (GD) could be evaluated. Pregnant rats received a single subcutaneous injection of either sesame oil (controls) or 5 mg of T on GD 16, 17, 18, 19, 20, 21, or 22. Female offspring of pregnant rats exposed to T displayed significant alterations in morphology and behavior. The anogenital distance, measured at 25 days postbirth, was significantly increased if T was administered on GD 16, 17 or 18. T treatment on GD 16 or each day thereafter through GD 20 significantly delayed the normal occurrence of vaginal opening (controls at 37.5 days vs. T treatment which ranged from 38.5 to 41.4 days). Abnormal vaginal morphology (enlarged clitoris) was also observed when T was injected during a similar prenatal interval (i.e. GD 16 to GD 22). Furthermore, prenatal T treatment on GD 18 (and each day thereafter), until GD 22 significantly decreased lordotic behavior compared to control values. However, exposure to T, on any prenatal GD did not alter the animals' ability to exhibit an induced luteinizing hormone (LH) surge. These results suggest that the onset for altered reproductive morphology occurs at least as early as GD 16, whereas the onset of sexual behavior sensitivity occurs precisely at GD 18, and that the normal pattern of adult LH release in females is not altered by prenatal androgen treatment using this specific paradigm.

Animals↗
PubMed1977

Sex-chromosome ratios in cattle and their relationship to reproductive development in freemartins.

Nineteen "female" Holstein-Friesian calves born co-twin with a bull were purchased shortly after birth. One subsequently was judged to be a normal female with 0% XY (100% XX) karyotypes in cultures of blood lymphocytes. However, one typical freemartin also had 0% XY (100% XX) Karyotypes in 300 cells when examined at three ages. Overall, 18 freemartins examined at 1, 24, and 52 weeks of age averaged 60.7%, 57.9%, and 55.5% XY cells, respectively (P greater than 0.05). No systematic relationship was found between the proportion of XY cells and the abnormalities of the reproductive organs, as judged by vaginal depth and clitoral development at 1, 24, and 52 weeks, and examination of the reproductive organs per rectum at 54 weeks of age. The clitoris of untreated freemartins and those treated with estrone or estradiol postnatally did not enlarge. Testosterone treatment caused enlargement. None of the hormones affected vaginal depth. These studies provide convincing evidence that the blood lymphocyte XX:XY karyotype ratio (1) is not related to the degree of masculinization and (2) is stabile in the postnatal freemartin. Thirdly, the freemartin reproductive organs do not respond to common sex-steroid hormones postnatally other than the clitoral response to testosterone.

Animals↗