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correction of genitalia
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Feminizing Feminizing genitoplastygenitoplasty
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Normal Sexual Differentiation has 3 Normal Sexual Differentiation has 3 stages:stages:
1.1.Establishment of chromosomal sexEstablishment of chromosomal sex
2.2.Development of the undifferentiated Development of the undifferentiated gonadsgonads
3.3.Differentiation of internal ducts & Differentiation of internal ducts & genitaliagenitalia
IntroductionIntroduction
Normal Sexual Normal Sexual DifferentiationDifferentiation
Genital Ridge
Bipotential Gonad
SF-1
SF-1Ovary
Follicular Cells
Theca Cells
Follicles
Mullerian Duct
Female Genitalia
Leydig Cells
Sertoli Cells
SF-1
SF-1
Testosterone
AMH
Testis
Mullerian Duct Regression
Wolffian Duct
GenitalTubercle
UrogenitalSinus
MaleInternal Genitalia
PenisProstate
DHT
The Big PictureThe Big Picture……
Ovarian cords develop in the absence Ovarian cords develop in the absence of SRYof SRY2 X Chromosomes are necessary for 2 X Chromosomes are necessary for normal development (ovarian normal development (ovarian dysgenesis in 45 XO)dysgenesis in 45 XO)They appear to differentiate granulosa They appear to differentiate granulosa cells into the protective granulosa cell cells into the protective granulosa cell layerlayerGerm cells undergo exhaustive mitosis Germ cells undergo exhaustive mitosis creating 20 million cells by 20 weekscreating 20 million cells by 20 weeks
Ovarian DifferentiationOvarian Differentiation
Oestrogen synthesis is Oestrogen synthesis is detectable at 8 weeksdetectable at 8 weeksOestrogens are NOT necessary Oestrogens are NOT necessary for normal female differentiation for normal female differentiation but in males, they can inhibit the but in males, they can inhibit the effects of MIS on Mullerian tissue effects of MIS on Mullerian tissue
Gonadal Function - OvaryGonadal Function - Ovary
It all starts with the Y chromosomeIt all starts with the Y chromosome……
FemaleFemaleWolffian ducts regress due to lack of testosteroneWolffian ducts regress due to lack of testosteroneMullerian ducts grow in the absence of MISMullerian ducts grow in the absence of MISCephalic end forms Fallopian tubesCephalic end forms Fallopian tubesCaudal end fuses to form the UterusCaudal end fuses to form the UterusMeets the Urogenital sinus to form the Uterovaginal Meets the Urogenital sinus to form the Uterovaginal plate and ultimately the vaginal lumenplate and ultimately the vaginal lumen
Phenotypic DifferentiationPhenotypic Differentiation
FemaleFemale
Genital tubercle develops into the clitorisGenital tubercle develops into the clitorisGenital swellings become the labia majoraGenital swellings become the labia majoraUrethral folds become the labia minoraUrethral folds become the labia minoraThe Introitus develops between the urethral The Introitus develops between the urethral foldsfolds
Phenotypic DifferentiationPhenotypic Differentiation
Abnormal Sexual DevelopmentAbnormal Sexual Development
Virilised FemalesVirilised Females 46 XX, normal ovaries, internal genitalia46 XX, normal ovaries, internal genitalia Varying degrees virilisation Varying degrees virilisation –– depends on time, depends on time,
amount of androgen exposureamount of androgen exposure Early Early –– retention of urogenital sinus, retention of urogenital sinus,
labioscrotal fusionlabioscrotal fusion Later Later –– clitoral hypertrophy clitoral hypertrophy MMüüllerian duct differentiationllerian duct differentiation normalnormal CAUSESCAUSES::
Fetal androgens - Congenital Adrenal Hyperplasia Fetal androgens - Congenital Adrenal Hyperplasia (CAH)(CAH)
Maternal androgens Maternal androgens –– anabolic steroids, Danazol, anabolic steroids, Danazol, ovarian / adrenal tumoursovarian / adrenal tumours
Syndromes Syndromes ––Beckwith-WiedemannBeckwith-Wiedemann IdiopathicIdiopathic
Congenital Adrenal Hyperplasia (CAH)Congenital Adrenal Hyperplasia (CAH)
Constitutes 60% of Constitutes 60% of allall intersex cases in literature (however intersex cases in literature (however in South Africa true hermaphroditism is dominant)in South Africa true hermaphroditism is dominant)
Possible medical emergencyPossible medical emergency Results from block in steroid synthesis pathway Results from block in steroid synthesis pathway –– excess of excess of
precursors, deficiency of end-productprecursors, deficiency of end-product Decreased negative feedback Decreased negative feedback –– increased ACTH increased ACTH –– adrenal adrenal
hyperplasia, pigmentationhyperplasia, pigmentation Manifestations depend on level of blockManifestations depend on level of block 90% of cases 90% of cases –– 21 Hydroxylase deficiency 21 Hydroxylase deficiency
Salt-wasting, hyperkalaemia, hypotension, vascular collapseSalt-wasting, hyperkalaemia, hypotension, vascular collapse Autosomal recessiveAutosomal recessive
An approach to the newborn An approach to the newborn DSDDSD
History & Physical examinationHistory & Physical examination
Biochemical studiesBiochemical studies
ElectrolytesElectrolytes
1717 OH progesteroneOH progesterone
Genetic evaluationGenetic evaluation
KaryotypeKaryotype
FISH for SRY geneFISH for SRY gene
Radiographic studiesRadiographic studies
U/SU/S
GenitogramGenitogram
LaparoscopyLaparoscopy
Gonadal biopsyGonadal biopsy??
Physical examinationPhysical examination
• •Measurement of genitaliaMeasurement of genitalia- Micropenis: <2 cm- Micropenis: <2 cm
Clitoromegaly: >1 cmClitoromegaly: >1 cm - -
- Gonad palpation- Gonad palpation
FedermanFederman’’s rule: a palpable gonad below the inguinal s rule: a palpable gonad below the inguinal ligament is testes until proven otherwisligament is testes until proven otherwis
Physical examinationPhysical examination
Bilateral palpable, descended gonadsBilateral palpable, descended gonadsmost likelymost likely hypospadias hypospadias
Unilateral nonpalpable testesUnilateral nonpalpable testesmost likelymost likely gonadal dysgeneis gonadal dysgeneis
Bilateral nonpalpable gonadsBilateral nonpalpable gonadsmost likelymost likely CAH CAH
DSD Team ParticipantsDSD Team Participants
Medical GeneticsMedical Genetics
Pediatric UrologyPediatric Urology
Pediatric EndocrinologyPediatric Endocrinology
NeonatologistNeonatologist
Pediatric GynecologyPediatric Gynecology
Pediatric PsychologyPediatric Psychology
NurseNurse
Medical EthisicitMedical Ethisicit
Social WorkerSocial Worker
Prader ClassificationPrader Classification
Preoperative preparationPreoperative preparation
Hormonal treatment and endocrine Hormonal treatment and endocrine consultationconsultation
Genitography Genitography Endoscopy either before or at the Endoscopy either before or at the
time of definitive repair:time of definitive repair:Length of the urogenital sinusLength of the urogenital sinusIntroduction of urethral and vaginal Introduction of urethral and vaginal
catheterscatheters
ENDOSCOPYENDOSCOPY
surgerysurgery
AgeAge
What is the proper time for repair?What is the proper time for repair?3-9 months (1st year of life)3-9 months (1st year of life)
Do we wait till puberty?Do we wait till puberty?Controversial issueControversial issue
CLITOROPLASTYCLITOROPLASTY
- Corporeal body excisionCorporeal body excision- Neurovascular bundle conservationNeurovascular bundle conservation- Ligation of both proximal ends of Ligation of both proximal ends of
erectile tissueerectile tissue- Excision of a ventral wedge for Excision of a ventral wedge for
reduction glanuloplastyreduction glanuloplasty
LabioplastyLabioplasty
Surgical correction of low Surgical correction of low confluenceconfluence
Cutback vaginoplasty:Cutback vaginoplasty:- Performed in patients with labial Performed in patients with labial
fusionfusion- Incision of the skin in midline Incision of the skin in midline
posteriorly to the perineum to posteriorly to the perineum to expose the vaginal orificeexpose the vaginal orifice
- The incised lateral edges are The incised lateral edges are oversewnoversewn
Flap vaginoplasty:Flap vaginoplasty:- In low confluence UGS- Inverted U skin incision- Sutured to the vagina after opening
the UGS posteriorly- Alone, not a solution- Should be ass. With mobilization
Surgical correction of the Surgical correction of the high confluencehigh confluence
Pull-through vaginoplasty- Inverted U incision- Dissection till vaginal catheter is
encountered- Division of the vagina at its entrance
to the sinus& mobilized extensively- Closure of UGS & used as a
functional urethra
Monfort transtrigonal approachMonfort transtrigonal approach- Midline incision in the posterior wall Midline incision in the posterior wall
of the urinary bladderof the urinary bladder- In very high lesionsIn very high lesionsPosterior sagittal approachPosterior sagittal approach- In cloacal anomaliesIn cloacal anomalies- High UGS High UGS
COMPLEX FLAPSCOMPLEX FLAPS
Gonzalez:Gonzalez:- Flaps of phallic skin to construct the Flaps of phallic skin to construct the
distal vaginadistal vaginaPassereni:Passereni:- Distal UGS anteriorly opened to Distal UGS anteriorly opened to
construct the distal vaginaconstruct the distal vaginaRink:Rink:
- Lateral incision of UGS with spiral - Lateral incision of UGS with spiral construction of the distal vaginaconstruction of the distal vagina
Total UGS mobilizationTotal UGS mobilization
Vaginal replacement
Skin graft:Skin graft:- From thighFrom thigh- ContractureContracture- Needs lubricantNeeds lubricant- Split thickness or full thicknessSplit thickness or full thickness- Daily dilatationDaily dilatation
Rotational flaps:Rotational flaps:- Gracilis myocutaneous flapsGracilis myocutaneous flaps- Pudendal thigh flapsPudendal thigh flaps- Labia minora flapsLabia minora flaps- Flaps after tissue expantionFlaps after tissue expantion
Bowel vaginaBowel vagina- Better than skinBetter than skin- Sigmoid colon is preferedSigmoid colon is prefered- May use ileumMay use ileum
Medico legal aspectMedico legal aspect