Defining Ideal External Female Genital Anatomy Via Crowdsourcing Analysis

Background Despite existing anthropometric data in the literature regarding the variation of female external genital anatomy, the ideal aesthetic characteristics have yet to be defined. Objectives Authors used crowdsourcing in order to better evaluate preferred anatomic characteristics of external female genitalia. Methods Fifty-six total images were digitally created by altering the proportions of the labia minora, labia majora, and clitoral hood. Images with differing ratios were presented in pairs to Amazon Mechanical Turk (Seattle, WA, USA) raters. Three different experiments were performed with each varying two of the three image characteristics to permit two factor modeling. The Bradley-Terry-Luce model was applied to the pairwise comparisons ratings to create a rank order for each image. Preferences for each anatomic variable were compared using chi-squared tests. Results A total of 5000 raters participated. Experiment 1 compared differing widths of the labia majora and labia minora and determined a significant preference for larger labia majora width and mid-range labia minora width (p=0.007). Experiment 2 compared labia minora width versus clitoral hood length and showed a statistically significant preference for wider majoras (p<.001), but no significant preference in clitoral hood length (p=0.54). Experiment 3 compared clitoral hood length versus labia minora width and showed a statistically significant preference for mid-range labia minora widths (p<.001) but no significant preference in clitoral hood length (p=0.78). Conclusions Raters preferred a labia majora to labia minora width ratio of 3:1 with minimal preference in clitoral hood length.

Clitoral HOOD granulosa cell tumor; case report and review of literature

Background: Granulosa Cell tumors (GCT) are a sex-cord stroma tumor comprising of 1-2% of ovarian malignancies. Derived from Schwann cells, GCTs are comprised of granulosa cells, a cell of the ovarian stroma. Patients with these tumors present with signs of increased estrogen such as vaginal bleeding, irregular menstruation and rarely hirsutism and virilization.8,10-12 The majority of GCTs are found in the skin, subcutaneous tissue and submucosa with a handful of case reports discussing primary GCTs in the clitoris.3,7 Surgery is required for definitive tissue diagnosis and staging. In this case report, we present a case with tissue diagnosis for granulosa cell tumor found on the clitoral hood. Case: A 56-year-old, female, G6P3033 initially presented for evaluation of persistent clitoral cyst for >2 years Initial evaluation was significant for 1 cm clitoral cyst that was firm, smooth and fluctuant with no irregular borders; with worsening vulvodynia. The patient underwent clitoral hood mass excision. The mass was excised entirely and the post-operative recovery was uncomplicated. Pathology findings were significant for completely excised granulosa cell tumor; margins were negative for tumor. Immunohistochemical stain was positive for CD56, CD68, Vimentin, and S-100, and negative for AE1/13, CD31, CD34, SMA, and Desmin. Conclusion: When evaluating chronic, persistent, or recurrent masses, it is important to take into consideration both benign and malignant causes. Definitive diagnosis is established pathologically. Patients with confirmed GCT should be thorough evaluated pre-operatively with blood work and appropriate imaging. Upon diagnosis, patient with GCT should be regularly followed for recurrence and surveillance.

Clitoral HOOD granulosa cell tumor; case report and review of literature

Background: Granulosa Cell tumors (GCT) are a sex-cord stroma tumor comprising of 1-2% of ovarian malignancies. Derived from Schwann cells, GCTs are comprised of granulosa cells, a cell of the ovarian stroma. Patients with these tumors present with signs of increased estrogen such as vaginal bleeding, irregular menstruation and rarely hirsutism and virilization.8,10-12 The majority of GCTs are found in the skin, subcutaneous tissue and submucosa with a handful of case reports discussing primary GCTs in the clitoris.3,7 Surgery is required for definitive tissue diagnosis and staging. In this case report, we present a case with tissue diagnosis for granulosa cell tumor found on the clitoral hood. Case: A 56-year-old, female, G6P3033 initially presented for evaluation of persistent clitoral cyst for >2 years Initial evaluation was significant for 1 cm clitoral cyst that was firm, smooth and fluctuant with no irregular borders; with worsening vulvodynia. The patient underwent clitoral hood mass excision. The mass was excised entirely and the post-operative recovery was uncomplicated. Pathology findings were significant for completely excised granulosa cell tumor; margins were negative for tumor. Immunohistochemical stain was positive for CD56, CD68, Vimentin, and S-100, and negative for AE1/13, CD31, CD34, SMA, and Desmin. Conclusion: When evaluating chronic, persistent, or recurrent masses, it is important to take into consideration both benign and malignant causes. Definitive diagnosis is established pathologically. Patients with confirmed GCT should be thorough evaluated pre-operatively with blood work and appropriate imaging. Upon diagnosis, patient with GCT should be regularly followed for recurrence and surveillance.

A Case of Preterm Ovarian Hyperstimulation Syndrome Presenting With Vaginal Bleeding

Background: Preterm ovarian hyperstimulation syndrome (POHS) is a rare syndrome described in preterm female infants. This is associated with high serum estradiol and gonadotropin levels, multiple follicular ovarian cysts, and edema of the hypogastric, labial and upper leg regions. This usually occurs at 30 to 39 weeks post-conceptional age (PCA). Vaginal bleeding may or may not be present. We present an unusual case of POHS that had a delayed presentation at 5 months of age (45 weeks PCA) with vaginal bleeding. Case presentation: An extremely premature female infant presented with vaginal bleeding at 5 months of age. Workup revealed pubertal gonadotropins indicating ovarian hyperstimulation. She had mild swelling in the hypogastric region. No breast buds were palpable and there was no clitoromegaly. At the time LH (22.2 mu/ml), FSH (8.3 mu/ml), Estradiol (502.2 pg/mL), and Testosterone (111 ng/dL) were all highly elevated. Multiple ovarian follicles were visualized on her pelvic ultrasound, with generous ovarian dimensions: right ovary (3.6 x 1.6 x 1.9 cm, volume 5.7 cc) and left ovary (2.5 x 2.4 x 1.5 cm, volume 4.7 cc). The largest follicle measured 8.8 mm. The uterus was 3.3 x 1.3 x 1.7 cm, with endometrial stripe thickness of 3 mm. There was no endometrial or adnexal mass. Cosyntropin test showed adequate peak cortisol (32.6 mcg/dL). Her newborn screen had been normal. Serial monitoring of her lab work showed a decrease in her gonadotropin and estradiol levels. She had a recurrence of vaginal bleeding about 3 weeks after initial presentation. By 50 weeks PCA the bleeding had resolved and the LH (1.2 mu/ml), FSH (1.5 mu/ml), estradiol (36 pg/ml) had reduced considerably. Complete normalization of LH (1.2 mu/ml), FSH (1.5 mu/ml), E (36 pg/ml), and testosterone (<7 ng/dl) was demonstrated by 55 weeks PCA. Conclusion: POHS has been attributed to the immaturity of the hypothalamic-pituitary-gonadal axis in preterm infants. Vaginal bleeding has been described in one case [1] several weeks after breast enlargement and swelling of clitoral hood, labia majora, hypogastrium and upper legs. In our case the baby presented with vaginal bleeding at 45 weeks that recurred about 3 weeks later and resolved by 50 weeks, with only minimal swelling. This case underlines the need to be aware of this etiology and its varied presentation. [1] Preterm ovarian hyperstimulation syndrome presented with vaginal bleeding: a case report. Altuntas et al. J Pediatr Endocr Met; 273(3-4):355-358.

The prosecution of Dawoodi Bohra women: some reasonable doubts

Muslim women of the Dawoodi Bohra community have recently been prosecuted because they customarily adhere to a religiously based gender-inclusive version of the Jewish Abrahamic circumcision tradition. In Dawoodi Bohra families it is not only boys but also girls who are circumcised. And it is mothers who typically control and arrange for the circumcision of their daughters. By most accounts the circumcision procedure for girls amounts to a nick, abrasion, piercing or small cut restricted to the female foreskin or prepuce (often referred to as ‘the clitoral hood’ or in some parts of Southeast Asia as the ‘clitoral veil’). From a strictly surgical point of view the custom is less invasive than a typical male circumcision as routinely and legally performed by Jews and Muslims. The question arises: if the practice is legal for the gander why should it be banned for the goose?<br /><br />Key messages<br /><ul><li>Wherever there is female circumcision there is male circumcision – the custom is gender-inclusive.</li><br /><li>The tradition of gender-inclusive Abrahamic circumcision has broad support among Dawoodi Bohra Muslim women.</li><br /><li>Female circumcision as practised by Dawoodi Bohra women is less invasive than male circumcision as legally practised by Muslims and Jews.</li><br /><li>Why should girls be excluded from the Abrahamic circumcision tradition? If it is legal for boys why shouldn’t it be legal for girls?</li><br /><li>Has the time come to rethink the expression ‘female genital mutilation’? Is it a ‘no brainer’ or has it made us ‘brain dead’?</li></ul>

Anatomical Dissection of the Dorsal Nerve of the Clitoris

Background The clitoris is the primary somatosensory organ of female sexual response. Knowledge of its neural anatomy and related landmarks is essential for safe genital surgery. Objectives The aim of this study was to describe the distal course of the dorsal nerves of the clitoris and associated structures. Methods Clitorises of 10 fresh cadavers were dissected. Measurements of the dorsal nerves, suspensory ligament, clitoral body, clitoral hood, and clitoral glans were obtained. The course of the dorsal nerves was examined. Results The dorsal nerves of the clitoris were larger than expected, ranging from 2.0 to 3.2 mm in diameter, on average, along their course in the clitoral body. In 9 of 10 specimens, the dorsal nerves could be traced to within 6 mm of the glans. They traveled deep to a superficial clitoral fascia but superficial to the tunica albuginea, were variably located between 10 and 2 o’clock, and were separated by the deep suspensory ligament (DSL) of the clitoris. The mean length of the descending clitoral body, from the angle to the base of the glans, was 37.0 mm. The mean distance from the pubic rim to the DSL was 37.7 mm. Conclusions The clitoral body is substantial in length, mostly lying superficially under the clitoral hood and mons pubis. The dorsal nerves of the clitoris are large and superficial, terminating at or near the base of the clitoral glans. Knowledge of this anatomy is critical prior to performing surgery near the clitoris.

A Case of Clitoral Hypertrophy of Unknown Origin

Clitoral hypertrophy is caused by disorders of sex development and it is observed from birth in most cases. We encountered a patient in whom normal morphology at birth may have acquired deformity and hypertrophy. The patient was a 10-year-old girl with a chief complaint of pudendal deformity. The clitoral hood was enlarged and the clitoris size was 8 x 5 mm on the first examination. Various tests were performed. Sex chromosome or hormonal abnormalities and tumorous lesions were not detected, and the ovaries, uterus, and vagina were normal, indicating that disorders of mullerian development were negative. In surgery, reconstruction of the vulva was performed following the Marberger method. The present case may have been a very rare case of acquired hypertrophy of unknown origin.

Management of Retained Genital Piercings: A Case Report and Review

The prevalence of genital piercing among women is increasing. As the popularity increases, the number of complications from infection, injury, and retained jewelry is likely to rise. Techniques to remove embedded jewelry are not well described in the literature. The purpose of this report was to describe a case of a patient with a retained clitoral glans piercing, discuss a simple technique for outpatient removal, and review current evidence regarding associated risks of clitoral piercings. A 24-year-old female presented to the emergency department with an embedded clitoral glans piercing. Local anesthetic was injected into the periclitoral skin and a small superficial vertical incision was made to remove the ball of the retained barbell safely. In conclusion, among patients with retained genital piercing, outpatient removal of embedded jewelry is feasible. While the practice of female genital piercing is not regulated, piercing of the glans of the clitoris is associated with increased injury to the nerves and blood supply of the clitoris structures leading to future fibrosis and diminished function compared to piercing of the clitoral hood.