Treatment of the Enlarged Clitoris

Abstract

Management of the enlarged clitoris, because of its import for sexual function, has been and remains one of the most controversial topics in pediatric urology. Early controversy surrounding clitoroplasty resulted from many factors including an incomplete understanding of clitoral anatomy and incorrect assumptions of the role of the clitoris in sexual function. With a better understanding of anatomy and function, procedures have evolved to preserve clitoral tissue, especially with respect to the neurovascular bundles. These changes have been made in an effort to preserve clitoral sensation and preserve orgasmic potential. It is the goal of this manuscript to describe the different procedures that have been developed for the surgical management of clitoromegally, with emphasis on the risks and benefits of each. Equally important to any discussion of such a sensitive topic is an understanding of long-term patient outcomes. As we will see, despite its importance, there has been a dearth of data in this regard. Future work in the arena of patient satisfaction will undoubtedly play a major role in directing our surgical approach.

Keywords: clitoromegally; clitoroplasty; congenital adrenal hyperplasia; disorders of sex development; history.

Figure 1

Ventral nerve sparing clitoroplasty: anatomical diagram of cross-section of clitoral shaft. NVB with nerves (yellow areas), arteries (red areas), and veins (blue areas), which are between Buck’s fascia (D) and tunica albuginea (B), corpora cavernosa tissue (C), initial ventral points of incision to begin elevation of NVB and Buck’s fascia off of tunica albuginea (E), and vascular dartos layer (F) [From Poppas et al. (37)].

Figure 2

Ventral nerve sparing clitoroplasty: anatomical drawing of clitoroplasty. (A) Buck’s fascia and NVB elevated off of tunica albuginea, (B) tunica albuginea containing corpora cavernosa, and (C) point of transection of corpora cavernosa 1.5–2 cm distal to bifurcation [From Poppas et al. (37)].

Figure 3

Albuginea sparing clitoroplasty: lines of skin incision. When degloving the clitoris, special attention is taken to leave the entire inner preputial layer of skin of at the coronal margin along the dorsal aspect of the phallus. The incision is therefore carried out approximately 1 cm or more proximal to the coronal margin. This cuff of skin is highly sensitive, second only to the glans itself.

Figure 4

Albuginea sparing clitoroplasty: excision to remove corpora cavernosal tissue. Left lateral view demonstrating ventral location of incision into tunica albuginea. Inset demonstrates two parallel incisions on ventral aspect of shaft.

Figure 5

Albuginea sparing clitoroplasty: corporal tissue being shelled out of preserved tunica albuginea.

Figure 6

Albuginea sparing clitoroplasty: lateral view of corporal tissue dissected free from tunica albuginea. Note septum distracted anteriorly—this will be excised prior to folding of the tunica albuginea into cranial location under the mons pubis.

Figure 7

Albuginea sparing clitoroplasty: cross section of corpora cavernosa just distal to crural bifurcation. The proximal extent of the erectile tissue has been controlled bilaterally with 5-0 PDS ties. To provide proximal hemostasis, the ventral layer of the tunica albuginea is sutured to the inner layer of the dorsal aspect of the tunica albuginea just distal to the bifurcation with running 5-zero polydioxanone suture. Great care must be taken in this step to avoid placing the sutures too deep into the dorsal tunica albuginea for fear of injuring the exact nerves that one is aiming to preserve.

Figure 8

Albuginea sparing clitoroplasty: the glans clitoris sewn to the ventral aspect of the tunica albuginea at the level of the crural bifurcation. The ventral urethral plate that was reflected inferiorly for the dissection is then secured to the base of the glans.

Figure 9

Girth reduction clitoroplasty: once the clitoris has been degloved, (A) vessel loops are placed at the base of each corpora in order to maintain hemostasis. (B) The glans and corporal bodies are then divided in the coronal plane and the ventral aspect excised and discarded. (C) The shaft is then folded and sutured on each side so that the raw corpora cavernosa are approximated [From Hutson et al. (47)].

Figure 10

Corporal sparing dismembered clitoroplasty: neurovascular bundles and glans with attached urethral plate dissected free from paired corpora cavernosa [From Pippi Salle et al. (55)].

Figure 11

Corporal sparing dismembered clitoroplasty: once the bifurcation has been exposed, the corpora are divided sharply beginning caudally and progressing distally. The edges of the opened tunica albuginea are then approximated with fine absorbable suture to maintain hemostasis [From Pippi Salle et al. (55)].

Figure 12

Corporal sparing dismembered clitoroplasty: each corporal body is rotated inferolaterally and placed in a dartos pouch in the ipsilateral labia majora [From Pippi Salle et al. (55)].