Ambiguous genitalia: diagnosis, evaluation, and treatment

Does preoperative genitography in congenital adrenal hyperplasia cases affect surgical approach to feminizing genitoplasty?

PURPOSE

Genitography has traditionally been an imperative part of radiographic evaluation in females born with congenital adrenal hyperplasia before surgical reconstruction. We evaluated the role of preoperative genitogram in surgical reconstruction planning and how it correlates with intraoperative findings.

MATERIALS AND METHODS

We retrospectively reviewed the records of 40 patients with congenital adrenal hyperplasia who underwent feminizing genitoplasty at our institution between 2003 and 2009. Preoperative genitogram findings were recorded and correlated with operative findings.

RESULTS

A total of 42 preoperative genitograms were available for review in 40 patients with congenital adrenal hyperplasia who underwent feminizing genitoplasty. Genitography revealed complete anatomy of the urogenital sinus in 30 cases (72%) while bladder filling alone was present in 9 (21%) and vaginal filling was noted in 2 (5%). The urogenital sinus could not be catheterized in 1 patient (2%). Vesicoureteral reflux was identified in 6 patients (15%) with a mean grade of 2. Vaginoplasty was done with a flap technique in 37 patients (more than 90%) while the remaining 3 underwent pull-through vaginoplasty. In no case did genitogram reveal anatomy that was not visible via endoscopy or at reconstruction. The vaginoplasty technique was based on endoscopic and intraoperative findings, and not on genitogram.

CONCLUSIONS

Genitography during preoperative evaluation in females with congenital adrenal hyperplasia undergoing feminizing genitoplasty did not reveal urogenital sinus anatomy completely in 25% of the patients in our series. Preoperative genitogram did not influence the surgical approach. Its value as preoperative imaging in patients with congenital adrenal hyperplasia may be limited.

Intersex: four cases in one family

Intersex presents a unique challenge to modern medicine. Generally, patients with ambiguous genitalia present in the neonatal period. Due to functional failure of the assigned gender role, some patients may be discovered later in life, as in the presented cases. The four patients, all members of the same family and aged 23, 15, 13 and 4 years, presented with ambiguous genitalia. The family history revealed parental consanguinity and one additional case of genital ambiguity. The eldest two patients had developed gynaecomastia during puberty. Examination of the genitalia revealed penoscrotal hypospadias and bifid scrotum in all the four. Gonads were palpable bilaterally in three of the patients, but in the fourth only one gonad was palpable. Buccal smear was negative for sex chromatin in all the cases. On abdominal ultrasound Müllerian structures were found in the two eldest patients. The karyotype in all four cases was determined as 46XY. Gonadal biopsies revealed immature testicular tissue and azoospermia, as sometimes seen in cryptorchidism. We conclude that these cases should be classified as dysgenetic male pseudohermaphrodites, a rare variety of ambiguous genitalia. In agreement with the patients and their parents, they were assigned the male gender and surgery was performed accordingly. We stress the need for active involvement of patient and parents in the process of gender assignment and awareness of hasty decision making.

Imaging techniques to assess the pelvis in young females

This article is designed to help the nonradiologist to form a logical imaging plan when presented with a diagnostic dilemma involving the pelvis of a young female. Common presenting problems are grouped under the categories of fetus, neonate and infant, child, and adolescent. Ultrasound is frequently the initial, and sometimes the only, examination indicated. The appropriateness of other modalities, such as plain radiography, genitography, computed tomography, and magnetic resonance imaging, is described. Details of examination performance and interpretation are beyond the scope of this discussion, but can be gleaned from the references cited.

Ambiguous genitalia: comparative role of pelvic ultrasonography and genitography

Ambiguous genitalia represents a true medical and social emergency which needs a multi-disciplinary team approach for elucidation. The paediatric radiologist plays an important role in defining the genital anatomy which remains one of the most important factors in sex determination. Aiming to compare the predictive value of pelvic ultrasonography and genitography in sex determination in patients with ambiguous genitalia, we retrospectively reviewed the medical records of 69 patients, 53 females and 16 males, where both procedures were employed. In female pseudohermaphroditism, the presence of a uterus with or without vagina was predicted in 46 (86.8%) patients by ultrasound compared with 44 (83%) patients in whom a genitogram revealed a vagina +/- uterus. In six (11.3%) patients, a genitogram revealed a male-type urethra. The combination of ultrasound and genitogram, however, was more sensitive and predicted the presence of a uterus with or without vagina in 52 (98.1%) patients. In male pseudo-hermaphroditism, there was no false positive by ultrasound, and a genitogram revealed a male-type urethra in 12 (75%) patients. In conclusion, although real time pelvic ultrasonography is less invasive than genitography, its yield in elucidating genital anatomy is comparable. The combination of both procedures is more informative and has a better yield.

Role of MRI in the evaluation of ambiguous genitalia

Diagnostic accuracy of magnetic resonance imaging (MRI) interpretation was assessed prospectively in patients with ambiguous genitalia or intersex problems. MRI depiction of the uterus was possible in 93%, the vagina in 95%, the penis in 100%, the testis in 88%, and the ovary in 74% of patients. The strength of MRI lies in the multiplanar capability and tissue characterization by means of T1- and T2-weighted sequences. MRI contributes to accurate morphologic evaluation of müllerian duct structures, the gonads, and the development of the phallus, all of which are essential for appropriate gender assignment and planning of surgical reconstruction.