Neoclitoris:Integration part 2
by M. Italiano
In my previous article (1), I made several points:
1) The sensate pedicle clitoroplasty technique was developed by Ulrich T. Hinderer in 1974 for use in persons with ambiguous genitalia, and subsequently used in transsexuals in the 1980's by several respected surgeons.
2) This represented an improvement over using just corpus spongiosa tissue or just using fused, shortened corpora cavernosa stumps as previously used by some surgeons.
3) That neither of these techniques have demonstrated a greater capacity for attaining orgasm amongst the limited studies performed.
4) That despite claims that total removal of the corpora and crura are necessary to avoid pain, there is evidence to the contrary-even that the preservation of the crura and corpora cavernosa tissue may be a source of pleasure, and that the NV bundle, crura, and corpora can all be successfully used.
5) That the sensate pedicle technique actually cuts and damages many nerves, and although good for the 1980's, is in no way state of the art today.
Further integration, with an exposition as to why the sensate pedicle technique is archaic, is presented.
As previously mentioned (1), lifting the dorsal nerve off of the tunica albuginea, even from 11 to 1 O'Clock, WILL cut nerves which extend around the lateral and ventral sides. Besides the references for such cited in my previous article (1), an additional report by Baskin (2) found that "the neuroanatomy was analogous in male and female patients, revealing an extensive network, not only at the 11 and 1 O'Clock position, but completely surrounding the ventral aspect of erectile bodies."
Thus, it is irrelevant, if the sensate pedicle technique is performed on transssexuals or intersexuals. If the author warns of cutting nerves in minor procedures, such as straightening the penis, how much more nerve cutting and nerve damage occurs in transsexuals and intersexuals? Cheryl Chase, director of ISNA, writes "there really is no such thing as a 'neurovascular bundle'...See the following article for an accurate anatomy."(3) Furthermore, the ventral mid-glans is also innervated by the dorsal neurovascular bundle (4), which is cut off by the sensate pedicle technique. It is not surprising that some of the NV bundle is often present in tissue samples after surgery. Lastly, not only the dorsal nerve innervates the glans, but it is also innervated by a branch of the perineal nerve.(4)
Thus, it is bad enough to use the sensate pedicle technique. However, it is even worse for those, who in addition, insist on removing the corpora cavernosa and the crura.
A recent report by Colombel et. al. (5), demonstrates that the dorsal nerves are in direct communication with the branches of cavernous nerves of the penis. Andersson et. al. (6) also demonstrate a "rich sympathetic, adrenergic innervation of the CC and the vasculature. The pelvic nerve plexus has parasympathetic and sympathetic roots. This ends in cavernous nerves which anastamose in 70% of the cases with the pudendal nerve in the penile root." Benoit et. al. (7) state, "Thus, there are two neurovascular pathways destined for the penis that are topographically distinct. One is located in the pelvis and the other in the perineum." The functional balance between these remains unknown. In any event, the removal of cavernosal nerves interferes with the pelvic and/or with the pudendal nerve. Thus the total removal of the cavernosa is indefensable. Furthermore, the corpora cavernosa and prepuce are the only two features common to all primate genitalia. (8) THE CRURA The removal of the crura, may be even more harmful than the removal of the corpora. In a very recent report (8), Akman et. al. studied the nerve distribution under the pubic arch and the relationship of the nerves to the crural bodies, corporeal bodies, and urethra of the penis. Previous studies were only based on the penis distal to the pubic arch without total inclusion of the crural bodies. Beneath the pubic arch, the nerves to the penis were an extension of the dorsal neurovascualar bundle of the prostate. The nerves formed 2 bundles following a path just under the pubic arch in close proximity to the bone, superior to the urethra and medial to the origin of the crural bodies. The nerve bundles joined the corporeal bodies at the proximal origin, where the 2 crural bodies fused together. At this point perforating branches from the cavernosal nerves were documented. As the dorsal nerves joined the dorsal aspect of the corporeal bodies, they immediately began to fan out along the surface of the corporeal tissue to the junction of the urethral spongiosum. The authors state that a precise understanding of penile anatomy beneath the pubic arch and at the origin of the crural bodies is important for preserving neuronal structures. It is clear that the sensate pedicle technique is totally inadequate at preserving nerves in SRS. Furthermore, the total removal of the crura and corpora cavernosa further cut and damage nerves. HOW MUCH ERECTILE TISSUE SHOULD BE REMOVED? Shouldn't erectile tissue be removed to prevent painful erection? At least one SRS surgeon is able to retain some erectile tissue (the crura and some of the corpora) which actually is ranked among the most erotic places in 12 post-operative male to female transsexuals surveyed by this surgeon (discussed in reference 1). This would also be in accord with the recommendation by Baskin (also discussed at some length in reference 1). It is also in accord with the letter by Chase, mentioned above (3). Herein, she states "Finally, the surgery is based on the premise that erectile tissue is unimportant and can be removed. Unlikely to be true." I posed the question of pain associated with not excising all of the erectile tissue directly to Chase. She replied, "Erection is painful if the erectile tissue is surgically relocated, scrunched down with stitches (like the pleats in a quilt), and surrounded with scar tissue." (9) So, the method of retaining erectile tissue is important. In an individual with ambiguous genitalia, a technique was used to preserve the corpora and both the dorsal AND ventral neurovascular pedicles. (10) A co-author of the paper writes, "The corpora still function and erection occurs but I suspect...that there is very little direct vascular communication across the site of excised tissue, nevertheless there is erectile function due to the preserved vascular connections proximal to (and distal to) the site." (11) There was no painful erection in the report listed above (10). Also, it should be mentioned that there is no difference in either nitric oxide synthase localization (12) or the distribution of peptidergic nerve fibers (13) in the normal clitoris as opposed to persons with an ambiguous phallus. Finally, women don't masturbate by manipulating the glans. They do so by manipulating the shaft. (14) WHAT'S IN A GLANS? For over a hundred years, anatomical research has confirmed that both the penile and clitoral prepuce are richly innervated, specific erogenous tissue with specialized encapsulated (corpuscular) sensory receptors, such as Meissner's corpuscles, Krause end bulbs, Ruffini corpuscles, and mucocutaneous corpuscles. (15) These receptors trasmit sensations of fine touch, pressure, proprioception, and temperature. The two primary sensory receptors in primate skin are free nerve endings and encapsulated or corpuscular receptors. Although free nerve nerve endings (itch, pain, and temperature receptors) are found in most skin, the encapsulated receptors are concentrated in regions that require specialized touch sensitivity. These include the external genitalia. (15) They have a capsule and an inner core composed of both neural and non-neural elements with the exception of the pinkus corpuscle, which is nontheless a genital sensory receptor associated with Merkel cells. The capsule of corpuscular receptors is a continuation of the perineurium and the core includes preterminal and terminal nerve fibres surrounded by laminated layers of modified Schwann cells (laminar cells), Meissner's and genital corpuscles have a complex branching of the nerves with the corpuscular core. (15) However, importantly, the Pacinian corpuscle has a single nerve through the core, which is surrounded by laminar cells to form an onion bulb configuration. (15) In humans, the glans penis has FEW corpuscular receptors and predominant free nerve endings, consistent with protopathic sensibility. Protopathic means a low order of sensibility (concioussness of sensation), such as to deep pressure and pain, that is POORLY localized. As a result, the GLANS PENIS HAS VIRTUALLY NO FINE TOUCH SENSATION AND CAN ONLY SENSE DEEP PRESSURE AND PAIN AT A HIGH THRESHOLD. THE PREPUCE HAS TEN TIMES MORE CORPUSCULAR SENSORY RECEPTORS THAN THE GLANS PENIS. (15,16) This is why circumcision has recently been under severe criticism. (15,17) The residual exposed glans mucosa becomes abnormally keratinized with an increase in the number of cell layers in glanular mucosal epithelium.(17) Foreskin restoration DOESN'T regenerate encapsulated receptors, but re-covering of the corona results in a reverting of the epithelium to the normal squamous mucosa of the glans.(17)
The point is that the only area of the human body which is LESS sensitive than the male glans is the sole of the foot!(16,17,18) The clitoral glans has MUCH more sensory receptors than even the male prepuce, which has ten times the amount of the male glans!(15,17) But, in uncircumcised male to female transsexuals, even this tissue has been lost to circumcision.
Although the male glans and female glans may have some overlap in the amount of these receptors (19), only the corona of the glans is rich in these receptors. (15,16) The sensate pedicle technique, or any other which does not use coronal tissue for clitoral glans construction, is simply not based in an accurate understanding of the fact that the human male glans overall (except for the corona and the prepuce and ridged band which is removed at circumcision) is unlike the clitoral glans. In other human primates the male and female glans are comparable in sensory receptors. (15,16) Any male to female technique at clitoroplasty needs to conserve the coronal margin for neoclitoral construction. This would not be in contradiction to the preservation of the entire tunica albuginea, with nerves which fan out laterally and ventrally. It would not be in contradiction to the preservation of all of the crura and some of the corpora, which is necessary for maintaining nerve sensation of all pathways as well as erectile function, although the subalbugineal level, which is absent in the clitoris, may need to be removed, as it is related to the uniqueness of the male erection cycle which includes not only tumescence, but also rigidity.(20)
1) Neoclitoris:Integration (can be viewed at the Gendercare Library, following gendercare.com site: http://gendercare.com/srs_results3.html
2) Baskin, L. (1999) Fetal genital anatomy reconstructive implications. J. of Urology Aug;162 (2):527-529.
3) Personal Communication fro Cheryl Chase, Oct. 31, 2000.
4) Yang, C.C. & Bradley, W.E. (1999) Innervation of the human glans penis. J. of Urol. Jan;161(1):97-101.
5) Columbel, M. et. al. (1999) Caverno-pudendal nervous communicating branches in the penile hilum. Surg. Radiol. Anat. Vol. 21(4):273-276.
6) Andersson, K.E. et. al. (2000) Sympathetic pathways and adrenergic innervation of the penis. Int. J. Impot. Res. Mar;12 Suppl. 1:S pages 5-12.
7) Benoit, G. et. al. (1999) Supra and infralevator neurovascular pathways to the penile corpora cavernosa. J. of Anat. Nov;195 (Pt. 4), 605-615.
8) Akman, Y., et. al. (2001) Penile anatomy under the pubic arch: reconstructive implications. J. of Urol. Jul;166 (1), 225-230.
9) Personal Communication from Cheryl Chase, Nov. 1, 2000.
10) Papageorgiou, T. et. al. (2000) Clitoroplasty with preservation of neurovascular pedicles. Obstet. Gynecol. Vol. 96 (5), Part 2 Nov., 821-823.
11) Personal Communication from James H. Segars, Sept. 17, 2001.
12) Burnett,A.L., et. al.(1997) Immunohistochemical Description Of Nitric Oxide Synthase Isoforms In Human Clitoris J. of Urol. Vol. 158, 75-78.
13) Hauser-Kronberger, C., et. al. (1999) Peptidergic innervation of the human clitoris. Peptides Vol.20 (5):539-543.
14) Kinsey, A. (1953) Sexual Behavior in the Human Female.
15) Cold, C.J. & McGrath, K.A. (1999) ANATOMY AND HISTOLOGY OF THE PENILE AND CLITORAL PREPUCE IN PRIMATES. An evolutionary Perspective of the Specialized Sensory Tissue of the External Genitalia. Chapter 3 in Male and Female Circumcision, edited by Denniston, et. al. Kluwer Academic/Plenum Publishers, New York.
16) Halata Z. & Munger, B.L. (1986) The neuroanatomical Basis for the Protopathic Sensibility of the Human Glans Penis. Brain Research Vol. 371 (2),205-230.
17) Cold, C.J. & Taylor, J.R. (1999) The Prepuce B.J.U. Int. Vol. 83, Suppl. 1, 34-44.
18) von frey, M. (1984) Beitraege zur Physiologie des Schmerzsinns. Zweite Mitt. Akad. wiss. Leipzig Math naturwiss Kl Berlin Vol.46, 283-296.
19) Personal Communication from John R. Taylor Oct. 4, 2000.
20) Toesca, A., et. al. (1996) Immunohistochemical study of the corpora cavernosa of the human clitoris J. of Anat. Vol. 188, 513-520.