Anatomy of the clitoris and its impact on neophalloplasty (metoidioplasty) in female transgenders

Abstract

The current management of female to male transgender surgery is based on the advances in neophalloplasty, perioperative care and the knowledge of the female genital anatomy, as well as the changes that occur to this anatomy with preoperative hormonal changes in transgender population. Since the clitoris plays the main role in female sexual satisfaction, its impact on the outcome in female to male transgender surgery is predictable. Although female genital anatomy was poorly described in majority of anatomical textbooks, recent studies have provided a better insight in important details such as neurovascular supply, ligaments, body configuration, and relationship with urethral/vaginal complex. This article aims to review current state of knowledge of the clitoral anatomy as well its impact on clitoral reconstruction in female to male sex reassignment surgery.

The Clitoral Infrafrenulum Fascial Bundle: The Anatomy and Histology

“…Stojanovic and Djordjevic () reviewed current knowledge of clitoral anatomy and its relevance to clitoral reconstruction in female‐to‐male sex reassignment surgery. Pauls () reported that the clitoris has an intricate anatomy; therefore, understanding the clitoral frenulum as the anatomical structure stabilizing the clitoris is important, since the clitoris is considered to be central to female orgasmic responses.…”

A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the “Ideal” Neophallus an Achievable Goal?

“…10,12,13,18 Metoidioplasty is advantageous for its capacity to yield “like-with-like” glans reconstruction with tactile and erogenous clitoral tissue, sufficient erectile rigidity without a prosthesis, scarring that is limited to the perineum, and shorter operative times. 5,12,13,20,31 The metoidioplasty-constructed neophallus is often shorter and smaller compared with other techniques; as a result, functional limitations can include difficulty with standing micturition and sexual penetration. 12–14,32 Though sometimes touted as a single-stage procedure, a series by Hage and van Turnhout 17 found that, on average, 2.6 procedures were required before a metoidioplasty reconstruction was considered complete.…”

“…5,12,13,20,31 The metoidioplasty-constructed neophallus is often shorter and smaller compared with other techniques; as a result, functional limitations can include difficulty with standing micturition and sexual penetration. 12–14,32 Though sometimes touted as a single-stage procedure, a series by Hage and van Turnhout 17 found that, on average, 2.6 procedures were required before a metoidioplasty reconstruction was considered complete.…”

“…In metoidioplasty, the clitoris is converted to the glans penis, which should supply excellent erogenous sensation. 10,12,13,18 By extension, as the metoidioplasty procedure utilizes local, sensate tissue for reconstruction, one would expect a greater number of patients in the metoidioplasty group (as opposed to the RFFP group) to retain high-quality tactile sensation. Similarly, free flap phalloplasty procedures are often times deliberately performed in multiple stages, giving metoidioplasty an edge in the category of single-stage reconstructions.…”

“…10,12 Metoidioplasty involves the creation of a neophallus from the female clitoris, which is often hypertrophied by the effects of hormonal stimulation. 10,12 Advantages of this technique include “like-with-like” penile reconstruction, a limited local donor site, and the ability to achieve erectile rigidity without a prosthesis. However, the resultant neophallus is often shorter and smaller than in other techniques, potentially compromising sexual function and capacity for standing micturition.…”