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Digest of recent discussions on ISSM mail (January - June 2003)
Hussein Ghanem MD
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Several cases and topics were recently discussed on ISSIR List. Dr. Paulo H. Egydio inquired about techniques for foreskin reconstruction. It appears that there is little literature in this area. Foreskin restoration using the
Grip-type penis stretcher which uses a vacuum-suction type attachment to the skin of the distal shaft was suggested by Dr. Sheldon O. Burman.
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The list of topics and responses includes:
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H Ghanem presented a case of a 40 years old female patient, with external female genitals, a clitoris, a blind vaginal pouch of 4 cm, and absent internal female genital organs. Dr. Hartmut Porst�s opnion is that management would depend on what kind of
sexual life she was having. If this woman has never reached a reasonable level of sexual satisfaction then one should go for genital reconstruction. If she was able to have -so far- a reasonably satisfying sexual experience with whatsoever sexual
activities, then it might be safer to proceed in a more conservative way. Dr. Claudio Teloken uses the technique of creating a sigmoid vagina. Dr. Broderick had experience with one similar case that underwent gonadectomy, hormone replacement therapy &
vaginal dilatation.
Dr. Amr Abd El Raheem presented a very challenging case of precocious puberty with hamartoma of the tuber cinereum in a 4-year-old boy. Neurosurgeons advised conservative treatment at present time because surgery at this area would be accompanied by a
high morbidity & mortality rate. The patient was given monthly I.M injections of a long acting GnRH analogue. Periodic follow up will be done including clinical evaluation, serum level of F.S.H, L.H, Testosterone to monitor response to treatment and M.R.I
brain to monitor the rate of tumor growth.
Dr. Ibrahim Fahmy requested to share information with other workers to update the undergraduate & postgraduate curricula in sexual medicine at Cairo University. He was directed to contact Dr. Gorm Wagner who worked extensively in this area.
Dear members,
I have a patient that was circuncised with 6 years-old. Now this patient have 29 years-old and he is totally insatisfied because he wants a foreskin. He is a sucessfull person and have a good psychological condition. He wants to be submitted a foreskin
reconstruction.
My questions are:
Have you had cases like this?
Are there experience with this reconstruction?
In my mind this possible problem is related with the time when the circuncision was made. When is the best time for a children to submit a circuncision that is not urgent to avoid possible psychological problem?
Thanks a lot for your help.
Paulo H. Egydio, MD, PhD
University of Sao Paulo- Brazil
Reply by Dr. Burman:
As it has for thousands of years, circumcision is best done in early infancy. Foreskin restoration can be done using the Grip-type penis stretcher which uses a vacuum-suction type attachment to the skin of the distal shaft and provides traction. Used
faithfully the traction on the skin elongates it to the desired length. It may require several months of stretching, but it does work.
Sheldon O. Burman, M.D.
Reply by Dr. CostaNeto:
I am quite sure that Dr. Kaufman a retired surgeon from UCLA Los Angeles, had published a paper regarding circuncision recostruction. I think you could find out on Medline.
Best regards,
Dr. Francisco Costa Neto
Andrologista
Dear colleagues,
I would like to obtain your advise about a 40 years old female patient. She has external female genitals with a clitoris, a blind vaginal pouch of 4 cm, and absent internal female genital organs (by ultrasound). She is 180 cm tall (about 5 foot 10).
She describes herself as having a very high sexual desire, and divorced her husband because he had a very low sex interest. Their sexual activity was limited to mutual masturbation on rare occasions during their 3 years of marriage. Currently she is
single and practices regular masturbation but suffers from guilt feelings. She believes that her ideal husband would be a highly educated man with severe ED but intact desire. She also mentioned that she is desperate in her search for such a man as she is
very lonely. Otherwise she is successful at work as a lecturer in a major University in Cairo.
I didn't advise karyotyping or hormonal studies to confirm the possible syndrome of complete androgen resistance (Testicular Feminization), which is characterized by a 46,XY karyotype, bilateral testes, female-appearing external genitalia, a blind vaginal
pouch, and absent mullerian derivatives. I am concerned that the finding of an XY karyotype would depress her more while not altering the management plan. She was reared as a female and has a stable female gender identity. I am referring her to a
reproductive endocrinologist (gynecologist) to assess the need for estrogen treatment.
My questions are: Should I encourage her to undergo vaginal reconstructive surgery so that she could broaden her choices for a mate? What are the success rates & morbidity with such surgeries? Would she be better off with her current choice of limiting
her sexual activities to mutual masturbation, if she finds a husband meeting her criteria? Is exploration & removal of gonads -if found- indicated due to the increased risk of gonadal neoplasms, or would regular follow ups be enough (ultrasound, CT or MR
imaging).
Hussein Ghanem, M.D.
Professor of Andrology, Sexology & STDs
Cairo University, Cairo, Egypt.
Reply by Dr. Porst
Dear Dr. Ghanem,
in order to advise you reasonably one should have more knowledge about the sexual life of this woman in the past.In particular what happened before her marriage ,what kind of sexual life she has had before this and of more importance how was the level of
satisfaction with her sexual possibilities so far.
If this woman has never reached a reasonable level of sexual satisfaction with those possibillities (masturbation,oral etc.) then one should go for genital reconstruction.In this perspective it is of particular interest whether she has experienced any
satisfaction by vaginal intercourse although this is limited due to the anomaly described.If she was able to have so far reasonably satisfiying sexual experience with whatsoever sexual activities then I would proceed with her in a more conservative way.
Best regards
Prof.Porst,Hamburg,Gremany
Reply by Dr. Teloken
Dear Hussein
We have good results and high satisfaction rate with sigmoid vagina. Since the patient has been evaluated by Psychiatry Section, is our option.
The Procedure can be carried out laparoscopically.
There is no mortality so far and the mortbidity is quite low.
Best Regards
Claudio Teloken, MD, PhD
Adj Professor of Urology
Fund Fac Federal Ciencias Medicas
cep 90480-003
phone 55 51 33285 410 fax 55 513 328 1975
Porto Alegre - Brazil
Reply by Dr. Gregory Broderick
Hussein: excellent case for discussion.
I have had experience with only one adult.
She was a native of China who emigrated to San Francisco.
She presented to the ER at UCSF with right lower quadrant pain.
She was engaged to be married and sexually active; she and her husband were quite content:
She did have pelvic ultrasound to evaluate her gonads; she was operated on by Gyn to remove the gonads, and she was started on hormones. She also had a series of vaginal dilations under sedation to stretch vagina. We did not have her see Psychiatrist as
her gender identity was quite normal (female). The Psych felt there would be more harm to discussing the 'gender identity issues' and recommended we focus on the infertility/adoption issues with the couple.
Greg
Reply by Dr. Ghanem
Thank you Dr. Porst, Dr. Teloken, Dr. Broderick for your advice.
Regarding Dr. Porst's questions, the patient didn't have any premarital sexual relations (cultural / religious reasons). During her marriage vaginal intercourse wasn't possible, however she describes masturbation as extremely pleasurable & reaches orgasm
very easily despite her guilt feelings. She practiced masturbation regularly during her marriage & continues after her divorce. Although the reconstructive surgeons I consulted appeared very interested, yet the patient remains worried about the outcome of
the surgery & will probably continue with conservative therapy.
Best regards,
Hussein Ghanem
A 4-year-old boy came to our clinic presenting with manifestations of puberty that began at the age of one. There was no history of previous illness, medical treatment or previous surgery, no positive consanguinity orfamily history of similar
condition, no history of abnormal behavior, seizures or manifestations of increased intracranial pressure. Examination revealed normal mental state and behavior for age, height of 117cm, span of 113cm, sparse facial hair, acne, absent axillary hair,
sparse body hair, pubic hair was dense around the penis but not extending to the inner thigh or umbilicus, voice of an adult male, both testes were 4x2.5cm,the penis was 14 cm.
Serum level of sex hormones was normal for an adult male F.S.H: 1.6 n (1.5-13) mIU/ml, L.H: 1.4 n (0.8-7.6) mIU/ml, Prolactin: 8.2 n (2.5-17) ng/ml, Testosterone: 3.4 n (2.86-11) ng/ml.
Scrotal U/S showed the testes with normal echogenicity, no focal lesions or calcifications, the right testis measuring 22.7x20.9x32.6mm (volume=8ml), the left testis measuring 28x19x30.9mm (volume=8.7ml). Post contrast CT examination of the suprarenal
glands was free. M.R.I of the brain showed a small rounded well defined space occupying lesion in midline of the supra sellar cistern measuring 1cm in diameter which was impressive of hamartoma of tuber cinereum. Pelvic U/S showed the prostate with normal
echogenicity
measuring 3x1.9x2cm (volume=6ml), both seminal vesicles with normal echogenicity, the right measuring 1.01x0.68cm and the left measuring 1.18x0.63cm.
Plain X-RAY of both hands revealed that the epiphysis were not closed with an estimated radiological bone age of 9 years (greulich pyle method).
The patient was diagnosed as true precocious puberty due to hamartoma of
tuber cinereum.
The neurosurgery department was consulted and advised conservative treatment at present time because surgery at this area would be accompanied by a high morbidity & mortality rate. The patient will be given monthly I.M injections of a long acting GnRH
analogue (the first dose was given at 18-2-03). Periodic follow up will be done including clinical evaluation, serum level of F.S.H, L.H, Testosterone to monitor response to treatment and M.R.I brain to monitor the rate of tumor growth.
We would appreciate any suggestions & advise in the medical, surgical, psychological management, as well as avoiding early closure of the epiphysis in this unfortunate child.
A picture of the case �courtesy of Dr. Osama Shoier, Assistant Lecturer of Andrology, Cairo University - may be seen on:
http://www.issir.org/prod/data/issirlist/precocious_puberty.jpg
Dr. Amr Abd El Raheem
Resident of Andrology, Sexology & STDs
Cairo University, Cairo, Egypt
amraheem@hotmail.com
Last update : 07/24/2003
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