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Management of Females with Congenital Adrenal Hyperplasia. Management of the enlarged clitoris, because of its import for sexual function, has been and remains one Milf split clitoris the most controversial topics in pediatric Milf split clitoris. 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.

The clitoris, like the penis, consists of two corpora cavernosa. "Milf split clitoris"

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While not having a defined corpora spongiosum, the clitoris does have the male equivalent of the glans, which consists of spongiosal tissue. These arteries course ventrally and are Milf split clitoris the medial aspect of the bifurcated corpora, where they then course dorsally along the phallic shaft 1. Innervation governing tumescence and sensation are also similar to that observed in the penis.

Most important to the discussion of clitoral surgery is the anatomic course of the nerves that provide sensation to the glans. The clitoral neurovascular bundles ascend along the ischiopubic rami and meet as paired bundles that course along the dorsal surface and then pass largely intact into the glans.

In considering the anatomy of the clitoris, one should also be versed in the anatomy of neighboring structures. If clitoroplasty surgery is undertaken, it is done so with the intent Milf split clitoris providing an appearance that aims to closely resemble the typical female phenotype.

Regression of the glans clitoris, with creation of a labia minora and clitoral hood to properly conceal the glans, requires a good understanding of these later structures. A recent study of non-CAH females revealed that the labia minora converge under the clitoral glans, separate to the clitoral hood. Variability exists with regard to the morphology of the clitoral hood. The four recognized morphologies include horseshoe, trumpet, coffee bean, and tent 4.

There are a limited number of clinical entities that result in clitoromegally. A number of enzymatic defects in the production of cortisol can cause a shunting of cortisol precursors to an alternate metabolic pathway, which results in Milf split clitoris excess production of adrenal androgens i. Females with classic CAH, whether salt-losing or non-salt-losing, present at birth with an enlarged phallus due to in utero exposure to excess fetal adrenal androgens.

The overall worldwide incidence of classic CAH is one in 15, live births of which two-thirds are salt wasting 5. InLawson Wilkins demonstrated that it was possible to suppress adrenal androgen production by providing these individuals with cortisone. With the ability to abrogate ongoing hormonal stimulation of the phallus, it was no longer deemed necessary to reconstruct these children as males. A far less common condition that can cause enlargement of the phallus in the genetic female is exogenous in utero androgen exposure.

This can either be due to the pregnant mother suffering from masculinizing tumors such as arrhenoblastoma [Ovarian Sertoli-Leydig cell tumors SLCTs ] of the ovary or exogenous intake of androgenic hormones 6 — 8. A number of Disorders of Sex Development DSD possessing a cell line with a Y chromosome can "Milf split clitoris" in a child with an enlarged phallus who may be assigned the female gender role.

This choice should only be undertaken Milf split clitoris extensive multidisciplinary assessment and counseling of the parents. In ovotesticular DSD previously labeled true hermaphroditismfunctional ovarian Milf split clitoris testicular tissues are both identifiable.

In both conditions, the phallus will undergo some degree of enlargement due to endogenous testosterone production. While it is beyond the scope of this manuscript to describe the process of assigning gender to these individuals, if a female gender role is selected then surgery to render the phallus more clitoral in appearance may be entertained Rare cases of females with clitoromegally secondary to pelvic plexiform neurofibroma have also been reported This is felt most likely due to fetal programming causing a surge in LH and the overactivation of the pituitary—gonadal axis At present, the decision to perform genital surgery in children with clitoromegally is intensely debated.

As "Milf split clitoris" all reconstructive surgery for patients with Disorders of Sex Development DSDthree specific reasons for intervening are typically considered: Since the only known function of the clitoris itself is to provide sexual pleasure, the later goal "Milf split clitoris" the only one that is relevant to the discussion of clitoroplasty. The primary concern in performing surgeries that address clitoral enlargement is that the procedure may reduce innervation to the clitoris.

To this point, it is important to note that when compared to controls, sexually mature females who have undergone surgery in childhood frequently report reduced sensation and decreased ability to achieve orgasm 15 — In cases of moderate and severe virilization, both guidelines recommended that clitoroplasty be considered as long as an experienced surgeon performs it. Most clitoral surgery is performed Milf split clitoris conjunction with a vaginoplasty. The advantage of performing both procedures simultaneously is that the common urogenital sinus can be used for a host of reconstructive purposes If vaginoplasty is not undertaken simultaneously, one should always use the sinus tissue to create a more female-like vulva.

Prior to embarking on major surgery such as clitoroplasty, the patient must be in optimal physiologic condition. In that the majority of patients who present with clitoromegally are patients with CAH, an understanding of proper endocrine management in these patients is imperative.

As a general rule, there is high concordance between genotypic CYP21A2 mutations and phenotype In the most severe form, concomitant aldosterone deficiency leads to salt loss. The three clinical phenotypes are typically classified Milf split clitoris classic salt-losing most severeclassic non-salt-losing simple-virilizingor non-classic mild or late-onset. In childhood, treatment is geared toward optimizing growth and pubertal development. Once adult height is achieved, treatment should be focused on optimizing fertility and quality of life and minimizing the side effects of glucocorticoid therapy.

Treatment of the classic or severe form of CAH requires suppression of adrenal androgen overproduction and replacement of cortisol and aldosterone. Non-classic CAH is a milder form of the disease. Although the same gene, CYP21A2, is involved in both the severe and mild forms, genetic mutations typically associated with non-classic CAH result in substantially less impairment of hydroxylase activity. Thus, patients with non-classic CAH do not have cortisol deficiency but instead may have manifestations of hyperandrogenism, later in childhood or in early adulthood.

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Treatment of the mild or non-classic form is targeted at controlling excess androgen symptoms and may or may not involve glucocorticoid therapy. Longer-acting glucocorticoids have typically Milf split clitoris avoided in children due to their potential for growth suppression No consensus exists for glucocorticoid dosing in adults. "Milf split clitoris" may use hydrocortisone, prednisone, prednisolone, dexamethasone, or a combination of treatments.

Long-acting glucocorticoids are preferable because they are effective given once or twice daily The specific regiment varies between institutions worldwide. In a survey in the United Kingdom of 30 teaching centers, a variety of different regimens were utilized; hydrocortisone was the most common, followed by dexamethasone and then prednisolone Mineralocorticoid is given in classic cases of CAH.

Fludrocortisone is provided to maintain normal electrolyte and plasma renin activity. The use of fludrocortisone is also recommended in simple-virilizing CAH and allows management with lower doses of glucocorticoid Some clinicians feel that the same daily dose of fludrocortisone given in split doses twice daily is more effective than once daily therapy Overtreatment should Milf split clitoris avoided and may result in hypertension. Levels of hydroxyprogesterone, testosterone, androstenedione, and plasma renin activity are used to evaluate adequacy of therapy and patient compliance.

Adrenal androgen concentrations later in the day and after medication will be lower, and target levels for hormones measured in this manner are unknown; thus, hormones are best measured early in the morning and before medication. The target goal for androstenedione, testosterone, and plasma renin values are to have them within the normal range for age.

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Bone age and somatic growth data are also used to determine the efficacy of the chosen steroid replacement regimen. The physiologic stress that surgery induces requires thoughtful increases in perioperative steroid dosing. The role that clitoral surgery plays in clitoromegally Milf split clitoris strongly debated. In addition, the emotional impact of having a child with clitoromegally will be extremely challenging for most families.

It is for this reason that it is imperative that a multidisciplinary care model be utilized to provide comprehensive care of the child and family. Specific evidenced-based models for multidisciplinary care have been published Evidence supports that laboratory monitoring for appropriate steroid dosing and the provision of mental health care occurs more consistently when Milf split clitoris multidisciplinary models are in place.

Surgical techniques for management of Milf split clitoris can broadly be divided into three categories: Prior tomany prominent surgeons supported the surgical removal of the entire clitoris 28 — "Milf split clitoris" was largely based on the misunderstanding that the clitoris was unnecessary for sexual function The procedure began by placing a Foley catheter in the urethra to avoid injury.

The dorsal vein and suspensory ligaments were then divided. The corpora cavernosa were subsequently dissected proximally to the bifurcation of the crura and each of the crura was then separated from its attachment to the inferior aspect of the ischial rami. Prior to complete removal, a hemostat was carefully placed across the attenuated tip of the corpus to control the clitoral artery. Unlike previous authors who had advocated partial clitoral resection, Gross emphasized the complete removal of all tissues in order to eliminate the painful neuromata, which were reported to occasionally occur in the stump after amputation.

A vulvoplasty would be subsequently performed with the urogenital sinus tissue. This view apparently stems from the belief that the clitoris is necessary for normal sexual function.

From the body (located in...

This contention was later brought into question as reports of patients with sexual inhibition and ambivalence toward sexual activity began to surface Any surgical procedure involving the clitoris carries the risk of disruption of the nerve supply 1633 Techniques to reduce clitoral size have attempted to minimize this risk by preserving the dorsal neurovascular bundles 34 — There is no unanimous consensus as to the best technique for achieving this goal.

Excision of the corporal bodies with preservation of the glans clitoris and attached ventral mucosa was initially described by Goodwin and later expounded upon by others 3238 — In the earliest version of this operation, an incision was made at the dorsal base of the clitoris.

The crura were dissected back to the bifurcation of the crura. The neurovascular bundles were then dissected off of the shaft and the crura were separately mobilized, ligated, and divided. The corporal shaft of the clitoris was then dissected distally to the glans and the corpora excised.

The preserved glans and attached ventral mucosa were the recessed beneath the pubic arch If a vaginoplasty was to be undertaken simultaneously, then it was generally performed using a cut-back procedure or a Fortunoff flap Improved Milf split clitoris of the importance of the dorsal Milf split clitoris bundle for clitoral innervation led Goodwin to modify his technique of reduction clitoroplasty by approaching the dissection from the ventral aspect of the clitoris Management of the enlarged clitoris, because of its import for Milf split clitoris function, sexually mature females who have undergone surgery in childhood .

of the clitoris is split longitudinally and the flaps utilized for construction of. The clitoris is the most important part of female sexuality. While it takes 5Dog Mom Women's Casual Letter Print Short Sleeve Tee. Dog Mom.

From the body (located in front of the urethra), the clitoris splits in half to form the paired crura (these are like the “legs” of the clitoris), and.

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Impaired sexual and reproductive outcomes in women with classical forms of congenital adrenal hyperplasia.

Appropriate preoperative stress steroid dosing is given under the direction of our pediatric endocrinologist. The clitoris is not just the part of your vulva that feels like a tiny button. If supine positioning is chosen, the patient undergoes full circumferential body prep from the nipples down.

Anatomical studies of the human clitoris. Should we question early feminizing genitoplasty for patients with congenital adrenal hyperplasia and XX karyotype?

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