General Medical Information

Non-Newborn Surgical Options

Mark R. Feneley and John P. Gearhart

Intersex patients who require feminine reconstruction of the perineum can be divided into two groups: (i) females with extreme masculinization of the external genitalia (the adrenogenital syndrome and female pseudohermaphroditism), and (ii) others with incomplete masculinization of the sexual structure (male pseudohermaphrodites, mixed gonadal dysgenesis, and some forms of true hermaphroditism (1B).

Surgical repair of these infants who are to be reared as females includes phallic reduction (clitoroplasty), creation of labia majora and minora (labioplasty), and exteriorization of the vagina, if present, or complete reconstruction, if not present (vaginoplasty). Gonads that are inappropriate for gender assignment and gonadal tissue with high potential for malignant transformation will require removal. Formerly, the enlarged clitoris or diminutive penis was managed by clitorectomy, and the entire structure was excised. This approach was superseded by more conservative procedures that included excision of the corporeal bodies without removal of the glans and symmetric wedge resection of the tunica albuginea to shorten the corpora. More recently, methods that preserve innervation to the glans with resection of the entire corporeal body have been developed. A modified approach to phallic reconstruction described by Kogan and Smey has been popularized by other groups. Feasibility of one-stage surgical correction of the high vaginal takeoff has since been demonstrated. Using a modification of the sagittal transanorectal approach of Pena and Devries, accurate positioning of the vaginal introitus and good cosmetic results can be achieved.