Analysis of Clitoral
Sensitivity and Viability
Yang, M.D. and Dix P. Poppas, M.D.
for Pediatric Urology
York Presbyterian Hospital
Enlargement of the
clitoris is often a prominent manifestation of virilizing congenital adrenal hyperplasia
(CAH) and other disorders of sex development (DSD).
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.
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of outdated, currently unused surgical techniques by various surgeons at numerous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.
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.
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.
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.
clitoral sensitivity testing and vibratory testing results revealed heightened clitoral
sensitivity relative to surrounding genitalia.
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
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
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.)
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.