Surgical correction of virilised female external genitalia.

Recent investigations and reports on late results indicate that vaginal orgasm is more the exception than the rule, so that, for a woman, preservation of clitoral sensitivity is essential to a satisfying sexual life. All techniques involving total clitoridectomy, plastic imitations, or displacement of the clitoris under the symphysis must therefore be discarded. Even if plication or trapping of an enlarged clitoral shaft under the mons veneris can be regarded as sensitivity-maintaining procedures, they nevertheless do not yield satisfactory results, since painful sensations or a feeling of pressure may occur during erection. Hence, reduction-planess should use techniques which shorten the erectile parts of the clitoris and reduce its size, while still maintaining sensitivity. Good cosmetic and tactile results may be achieved by means of selective excision of the corpora cavernosa and lateral clitoral excisions. Reconstruction of the labia minora out of clitoral shaft skin is combined with separate creation of a neo-preputium clitoridis. Vaginal enlargement plasties have always been problematic, since shrinking particularly of the vaginal introitus, occurs in up to 25% of patients who undergo this operation. However, a sufficiently large pediculated perineal skin flap inserted into the "defect" of the posterior vaginal wall provides sufficient width of the vaginal introitus and canal. Partial vaginal aplasia, with the vagina opening into a urogenital sinus near the bladder, calls for additional abdominal mobilisation. For psychological reasons, vaginal dilatations are not to be recommended. If necessary, a second vaginal enlargement plasty should instead be performed later; this may be carried out without problems before puberty. To avoid the disadvantage of a dry skin flap which does not assimilate to normal vaginal mucosa even after many years and with oestrogen treatment, mobilisation of the posterior vaginal wall with displacement of real vaginal mucosa towards the perineum can be carried out. However, one-stage reconstruction of clitoris, vulva and vagina during early childhood is preferable in every case, in order to avoid the psychological damage which can undoubtedly otherwise be caused. An exception is the late onset form of congenital adrenal hyperplasia.