Summer 2007 Newsletter

CARES Foundation, Inc.

Nerve Sparing Reduction Clitoroplasty:
Analysis of Clitoral Sensitivity and Viability

Jennifer Yang, M.D. and Dix P. Poppas, M.D.
Institute for Pediatric Urology
New York Presbyterian Hospital

Introduction

Enlargement of the clitoris is often a prominent manifestation of virilizing congenital adrenal hyperplasia (CAH) and other disorders of sex development (DSD).

Management of the physical and potential psychological affects faced by these children and their families requires a compassionate and multidisciplinary approach. The surgical management of patients with ambiguous genitalia has been the focus of debate for many years and remains in large part unresolved.

Surgical correction of the enlarged clitoris has undergone many changes in the past three decades, from clitorectomy that was typical until the 1960s, to recession clitoroplasty as an alternative, to today’s most widely accepted and used reduction clitoroplasty that preserves the glans, nerves and vascular bundle while excising part of the erectile bodies. Despite these advances, however, the published literature describing surgical outcomes and functional results reflects data collected on a wide variety of outdated, currently unused surgical techniques by various surgeons at numerous institutions. Currently, there is no published long-term follow up data on modern techniques used at a single center.

In this study, we report our results using a nerve sparing technique for reduction clitoroplasty based on the current understanding of female clitoral anatomy. Unlike other studies in the literature, all of the patients in this study underwent a nerve sparing reduction clitoroplasty using modern techniques performed by a single surgeon. While this is the largest cohort with follow-up clitoral viability and sensitivity ever reported, one limitation of this study was the lack of a normal population for comparison. Although the results presented here suggest relative normal clitoral sensitivity in these patients, continued follow up, as well as use of validated instruments to determine sexual function once the patient becomes sexually active, are indicated. At that time, it may be feasible to obtain similar test results from an age-matched normal control group for comparison.

Results

A total of 51 patients, ages 4 months to 24 years, with clitoromegaly associated with ambiguous genitalia underwent a modified reduction clitoroplasty. Thirty-two of these patients were between 0 to 2 years of age, five patients were 2 to 5 years of age and 11 patients were greater than 5 years of age. Of these patients, 46 (90%) were genetic females with congenital adrenal hyperplasia. On initial examination, four (8%), 22 (43%), 11 (21%) and six patients (12%) were rated Prader Score of II, III, IV and V respectively. The remaining patients (16%) were undocumented.

Our evaluation of post-operative results included assessment of the overall cosmetic appearance, capillary perfusion (blood flow) testing and, in selected patients, sensory testing of the clitoris. Follow up of the patients ranged from 1 week to 8 years with a mean follow up time of 24.4 months (two patients were lost to follow up). No infections, tissue death from lack of blood flow or other postoperative complications were identified. None of the patients in the study group were identified as requiring further revision of clitoris.

Both clitoral sensitivity testing and vibratory testing results revealed heightened clitoral sensitivity relative to surrounding genitalia.

Of the group we reviewed, a total of 49 patients (96%) had blood flow testing of the clitoris. All patients had a viable clitoris with normal blood flow when compared to the blood flow received by the nail bed.

Ten of the 49 patients (20%) were over 5 years of age and were considered candidates for clitoral sensory testing (CST) using a cotton-tip stimulator. Using a scale of 0 (no sensation) to 5 (maximum sensation), the patient was asked to report the degree of sensation at various points of the inner thigh and genitalia (labia majora, labia minora, vaginal introitus and clitoris). Inner thigh stimulation was set at level 3 for each patient and used as a baseline to compare other areas tested. Patients reported increased sensitivity at the labia minora and clitoris (degree of sensation of 3.6 +/- 0.9 on average at the labia minora and 4.8 +/- 0.4 at the clitoris). The mean time after surgery for the patients who underwent CST was 2.0 ± 0.8 years. No variations in the sensibility results were reported on follow-up visits. Two patients reported no change in sensation when tested before and after clitoroplasty.

In addition, 9 of these 10 patients also had vibratory sensory testing performed using a Bio-thesiometer designed to quantify the ability of patients to detect vibratory stimuli. A quantitative measure was established by recording the amplitude of vibration (on a scale from 1 to 10) which correlated to the threshold. For this variable, greater amplitude of vibration (a higher number) meant a lesser degree of patient ability to sense vibration. The results indicated increased vibratory sensitivity at the clitoris and introitus compared to the labia and thigh (the average values for the introitus, clitoris, labia and thigh were 3.56, 1.61, 5.08, and 5.83 respectively.)

Conclusion:

To our knowledge this is the first report of a follow-up testing of clitoral viability and sensation after a reduction clitoroplasty. The nerve sparing reduction clitoroplasty described in this report leaves the dorsal neurovascular bundles of the corporal bodies and the glans clitoris intact. This is a safe and reliable approach to correct the enlarged clitoris. Sexual and social function of our patient cohort is difficult to assess until all patients reach sexual maturity and adolescence. Continued, long term follow-up is on going to document long-term sexual function using this nerve sparing approach for clitoroplasty.