|
|
Genital Function and Sensitivity Following Feminizing Surgery« Back to Volume 24, Issue 2, November 2008 - Table of Contents Like other disorders of sex development (DSD), congenital adrenal hyperplasia (CAH) in 46,XX can be associated with ambiguous genitalia at birth. Clinical management commonly involves surgery performed during infancy and childhood to feminize the appearance of genitals. However, it has been suggested that surgery to the clitoris potentially disrupts neurological pathways and compromises erotic sensation and pleasure. In a cross-sectional investigation, Crouch and colleagues investigated the genital sensitivity of women with CAH and 10 healthy controls (23 to 38 years old). Sensitivity thresholds for the clitoris and upper vagina were measured using a GenitoSensory Analyzer and sexual function by standardized self-report questionnaire including 7 subscales assessing sexual anorgasmia, satisfaction, sensuality, communication, vaginal penetration difficulties, frequency of intercourse and avoidance. Thirty-two of 56 eligible women with CAH (17 to 39 years of age) agreed to participate: 25 with classic CAH, 4 with non-salt losing CAH, and 3 with late-diagnosed CAH. A total of 28 of 32 women participated in sensory testing, including 4 who had not undergone prior genital surgery. The sample is heterogeneous with regard to the type of genital surgery (clitoridectomy versus clitoral reduction and with or without surgery to the lower vagina), age at surgical procedures, and number of surgical procedures. Clitoral sensation (temperature) testing indicated relative impairment for those who underwent clitoridectomy. As anticipated, clitoral sensation was not impaired in those with CAH who had not undergone surgery. In comparison with control group participants, women who had undergone clitoral reduction had a higher median threshold for warmth detection and a lower median threshold for cold. Vaginal sensitivity (vibratory) testing could not be assessed in some participants due to introital vaginal stenosis which prevented insertion of the vaginal probe. In addition, some control group participants chose not to undergo vaginal testing. For those who did, no difference was observed in vaginal sensation between the CAH group and control group participants (regardless of prior vaginal surgery). Assessment of sexual function also proved to be challenging in this study; only 19 of 32 CAH participants adequately completed the questionnaire because of lack of sexual activity upon which responses depended. Those women with CAH who had undergone surgery reported worse scores on the intercourse frequency, vaginal penetration difficulties, and anorgasmia (p=0.065) subscales compared with healthy controls and women with CAH who had not undergone surgery. Scores on global sexual dysfunction and avoidance were similar in women with CAH with and without surgery (Table). Significant correlations were detected between self-reported global sexual dysfunction and clitoral sensitivity impairment (Figure). The authors concluded that surgery is associated with a loss of sensitivity, and that impaired clitoral sensitivity is a result of surgical damage to the innervation of the clitoris. The authors further concluded that surgery is associated with sexual difficulties, citing a moderate but significant linear relationship between impaired clitoral sensitivity and the severity of sexual difficulties. Editor’s CommentThese findings support previous research1,2 suggesting an association between sexual dissatisfaction and genital surgery. This study goes beyond earlier research, however, by providing evidence for a mechanism mediating this association. Several challenges to interpretation of these data are worthy of note. Detailed operative records were available for only 15 women. This number is too small to enable comparisons of the effects of different surgical techniques. In addition, a significant number of women were unable to undergo vaginal testing due to proximal vaginal stenosis. On one hand, this difficulty provides important information, as the participants had reportedly undergone previous vaginoplasty to overcome penetration difficulties, yet penetration challenges clearly remain. A similar problem was seen in the effort to assess sexual function. Nineteen of 32 participants were unable to complete the questionnaire, citing lack of sexual experience necessary to complete questionnaire items. It can be argued that clitoridectomy is rarely performed these days, and as such, numbness associated with this operation does not apply to the types of techniques currently performed. However, the authors indicated that only a third of the women in their sample who had undergone a more conservative technique, clitoral reduction, reported normal clitoral sensitivity. Most participants in this study underwent surgery in the early 1980s. The authors indicated that most of the clitoral procedures these participants experienced were based on the dorsal neurovascular bundle preservation approach described in 1981 by Mollard,3 a procedure the authors noted that has been widely used after 1985 and which has become the basis of current practice. If the findings from this study are replicated in future studies, important issues need be carefully considered. Genital feminizing surgery for patients with CAH is typically performed prior to the age of consent. It is an unanswered question whether most women with CAH would knowingly sacrifice genital function for appearance. The difficult decision of opting for surgery (or not) is often left to parents/caregivers. As such, at the time of consent, they should be armed with clear information relating to the possibility of impairment of genital sensitivity and function. As noted by the authors, “informed consent should be based not just on the technical aspects of surgery and risks, but on a developed understanding and appreciation of potential implications for future sexual lives.” David E. Sandberg, PhD References - (linked to
|
Volume 26 Number 1
September 2010
www.GGHjournal.com
ISSN 1932-9032
)