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Concept: Sex organ

149

Superovulation induced by exogenous gonadotropin treatment (PMSG/hCG) increases the number of available oocytes in humans and animals. However, Superovulatory PMSG/hCG treatment is known to affect maternal environment, and these effects may result from PMSG/hCG treatment-induced oxidative stress. 2-Cys peroxiredoxins (2-Cys Prxs) act as antioxidant enzymes that protect cells from oxidative stress induced by various exogenous stimuli. Therefore, the objective of this study was to test the hypothesis that repeated PMSG/hCG treatment induces 2-Cys Prx expression and overoxidation in the reproductive tracts of female mice. Immunohistochemistry and western blotting analyses further demonstrated that, after PMSG/hCG treatment, the protein expression levels of 2-Cys Prxs increased most significantly in the ovaries, while that of Prx1 was most affected by PMSG/hCG stimulation in all tissues of the female reproductive tract. Repeated PMSG/hCG treatment eventually leads to 2-Cys Prxs overoxidation in all reproductive organs of female mice, and the abundance of the 2-Cys Prxs-SO2/3 proteins reported here supports the hypothesis that repeated superovulation induces strong oxidative stress and damage to the female reproductive tract. Our data suggest that excessive oxidative stress caused by repeated PMSG/hCG stimulation increases 2-Cys Prxs expression and overoxidation in the female reproductive organs. Intracellular 2-Cys Prx therefore plays an important role in maintaining the reproductive organ environment of female mice upon exogenous gonadotropin treatment.

Concepts: Human, Reproduction, Molecular biology, Antioxidant, Organ, Reproductive system, Sexual reproduction, Sex organ

81

Compelling evidence from many animal taxa indicates that male genitalia are often under postcopulatory sexual selection for characteristics that increase a male’s relative fertilization success. There could, however, also be direct precopulatory female mate choice based on male genital traits. Before clothing, the nonretractable human penis would have been conspicuous to potential mates. This observation has generated suggestions that human penis size partly evolved because of female choice. Here we show, based upon female assessment of digitally projected life-size, computer-generated images, that penis size interacts with body shape and height to determine male sexual attractiveness. Positive linear selection was detected for penis size, but the marginal increase in attractiveness eventually declined with greater penis size (i.e., quadratic selection). Penis size had a stronger effect on attractiveness in taller men than in shorter men. There was a similar increase in the positive effect of penis size on attractiveness with a more masculine body shape (i.e., greater shoulder-to-hip ratio). Surprisingly, larger penis size and greater height had almost equivalent positive effects on male attractiveness. Our results support the hypothesis that female mate choice could have driven the evolution of larger penises in humans. More broadly, our results show that precopulatory sexual selection can play a role in the evolution of genital traits.

Concepts: Sexual selection, Penis, Charles Darwin, Physical attractiveness, Sex organ, Human penis size, Secondary sex characteristic, Baculum

39

Despite 30 years of advocacy, the prevalence of non-therapeutic female genital alteration (FGA) in minors is stable in many countries. Educational efforts have minimally changed the prevalence of this procedure in regions where it has been widely practiced. In order to better protect female children from the serious and long-term harms of some types of non-therapeutic FGA, we must adopt a more nuanced position that acknowledges a wide spectrum of procedures that alter female genitalia. We offer a revised categorisation for non-therapeutic FGA that groups procedures by effect and not by process. Acceptance of de minimis procedures that generally do not carry long-term medical risks is culturally sensitive, does not discriminate on the basis of gender, and does not violate human rights. More morbid procedures should not be performed. However, accepting de minimis non-therapeutic f FGA procedures enhances the effort of compassionate practitioners searching for a compromise position that respects cultural differences but protects the health of their patients.

Concepts: Human, Gender, Culture, Anthropology, Clitoris, Sex organ, Sexual differentiation, Genital modification and mutilation

33

It is well known that sexual selection is the main driving force of substantial diversity of genitalia found in animals. However, how it facilitates the diversity is still largely unknown, because genital morpho/physical features and motions/functional morphology of the structures in sexual intercourse are not linked for the vast majority of organisms. Here we showed the presence of material gradient and numerically studied an effect of stiffness gradient of the beetle penis during its propulsion through the female duct. We found that stiffness gradient on the penis essentially affects its propulsion. Microscopic investigation suggests the possibility that the tip of the hyper-elongated penis is softer than the rest of it, and our numerical model confirms that this type of distribution of stiffness gradient aids in faster propulsion than other types. This result indicates that previously ignored physical properties of genital materials are of crucial importance in evolutionary studies of genitalia.

Concepts: Sexual intercourse, Sex, Penis, Scrotum, Vulva, Sex organ, Secondary sex characteristic, Sex organs

29

Male genital satisfaction is an important aspect of psychosocial and sexual health. The Index of Male Genital Image (IMGI) is a new scale that measures perceptions of male genitalia. We aim to characterize genital satisfaction using the IMGI and correlate dissatisfaction with sexual activity. We conducted a nationally representative survey of non-institutionalized adults aged 18-65 years residing in the U.S. In total, 4198 men completed the survey and 3996 (95.2 %) completed the IMGI. Men reported highest satisfaction with the shape of their glans (64 %), lowest satisfaction with the length of their flaccid penis size (27 %), and neutrality with the scent of their genitals (44 %). No demographic characteristics (age, race, sexual orientation, education, location, and income) were significantly associated with genital dissatisfaction. Men who were dissatisfied with their genitals were less likely to report being sexually active (73.5 %) than those who were satisfied (86.3 %). Penetrative vaginal sex (85.2 vs. 89.5 %) and receptive oral intercourse (61.0 vs. 66.2 %) were reported less by dissatisfied men. Overall, most U.S. men were satisfied with their genitals; however, a subset (14 %) report low genital satisfaction, which included men of all ages, races, and socioeconomic groups. Low genital satisfaction is associated with a decrease in sexual activity. These results provide clinicians and health educators a baseline of genital satisfaction to provide education and reassurance.

Concepts: Sexual intercourse, Oral sex, Human sexual behavior, Human sexuality, Penis, Foreplay, Sex organ, Human penis size

28

INTRODUCTION: Penile girth enhancement by the injection of Vaseline is an existing practice. Many cases develop severe complications that need surgery. AIM: To report on the reconstructive surgical solutions of the complications of Vaseline self-injection and the outcomes. To develop a modification of a one-step reconstruction method involving the use of pedicled scrotal flaps. MAIN OUTCOME MEASURES: The complications and their surgical solutions were classified as regards severity and difficulty. The outcomes were observed and a newly introduced one-step surgical method was investigated. METHODS: Seventy-eight consecutive patients (87.2% of them with a history of imprisonment) were divided into three groups. In group A, aesthetic penile defects or phimosis caused by the Vaseline necessitated circumcision or local excision. In group B, the whole penile skin was involved, and total skin removal and two- or (a newly modified) one-step reconstructive surgery were performed. In group C, both the whole penile skin and the scrotum were involved: complete skin removal and skin grafting or skin pedicled flap transplantation were carried out. RESULTS: In five cases in group B, postoperative skin necrosis made a second operation necessary. There was one intraoperative urethral injury, where a urethral fistula developed and a second urethral reconstruction was performed. There was no major complication with the newly developed one-stage pedicled flap procedure. At the end of the therapy, all the cases were healed. All of the patients reported successful sexual intercourse after the operations and 91% were satisfied with the result. CONCLUSIONS: The complications depend mainly on the amount of Vaseline injected, the hygienic circumstances, and the personal tolerability. In the worst cases, only radical skin removal and skin transplantation can solve the problem. The newly developed one-step arterial branch-preserving scrotal skin flap reconstruction appears to be a suitable and cost-effective solution for these patients.

Concepts: Surgery, Plastic surgery, Necrotizing fasciitis, Reconstructive surgery, Penis, Scrotum, Sex organ, Erogenous zone

28

We describe a rare case of clitoromegaly due to a large clitoral cyst that occurred spontaneously without any declared previous female genital mutilation. The cyst was excised successfully with good cosmetic results.

Concepts: Reproductive system, Female reproductive system, Clitoris, Epidermoid cyst, Vulva, Sex organ, Female genital cutting, Clitoromegaly

27

Female genital mutilation (FGM) involves the partial or complete removal of the external female genitalia and/or other injury to the female genital organs whether for cultural or other nontherapeutic reasons.

Concepts: Uterus, Clitoris, Penis, Vulva, Sex organ, Female genital cutting, Genital modification and mutilation

27

BACKGROUND: We present a rare case involving severe hypertrophy of the labia majora. This 39-year-old married woman developed a clinically noticeable bilateral lipodystrophy of her labia majora following the administration of chronic antiretroviral therapy. Different combination drug regimens that included drugs like Crixivan(®), Epivir(®), and Zerit(®) were administered to the patient from 1998 to 2005. The patient is currently on a single drug regimen of Atripla(®) with the disease under control and no other comorbidities. The severity of the pubic protuberance created an appearance resembling male genitalia, even when covered by underwear. This anatomical abnormality obviously impaired her social life and forced her to avoid wearing tight pants, swimming garments, and tight clothes in general. She also avoided any sexual activity. METHODS: Her pubic hair was shaved. Crural creases and vulvar mucosa were marked in order not to be violated. The estimated amount of skin and fat to be removed was marked. Intraoperative tailor-tacking suturing was used to mark the extent of the resection of the labia majora. Sutures were left in place to verify the accurate tension of the remaining skin. The procedure was performed with the patient under general anesthesia. Labial skin resection was performed by sharp dissection. Electrocautery was then used to excise the lobulated fat accumulation. Two layers of 3/0 Vicryl(®) sutures were used in the lax subcutaneous tissue. 4/0 Vicryl(®) rapide was used on the skin to approximate wound edges. Suction drains were left in place for 48 h to reduce the dead space and to manage postoperative bleeding. The patient was instructed to keep ice and compression pads on the area for the first 24 h and to keep the area clean. This was followed by the application of antibiotic ointment two times a day on the wounds to avoid blood crust formation and to keep the skin soft. RESULTS: Stitches were removed on POD 14 after an overall uneventful postoperative course. The sensitivity of the labia majora’s interior aspect was preserved, even initially. With the legs slightly open, the labia majora just covered the entrance to the vagina. The clitoris and labia minora became visible again, restoring a normal anatomical appearance. Moderate edema was observed for 4 weeks after surgery. CONCLUSION: The surgical technique used provided an excellent result according to the patient, who regained her self-confidence and started having a normal sexual life again. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Concepts: Evidence-based medicine, Clitoris, Vagina, Vulva, Sex organ, Labia majora, Labia minora, Pubic hair

25

Cloacoscopy and cystoscopy are simple, noninvasive to minimally invasive techniques that provide excellent visualization, and result in fast recovery. General or intrathecal anesthesia is sufficient. They can be performed in free-ranging turtles under field conditions. Cloacoscopic gender identification of external genitalia is not reliable because of the high degree of misinterpretation between phallus and clitoris, especially in juveniles. However, saline-infusion or air insufflation cystoscopy through the urinary bladder (or accessory vesicles/bladders) is often effective for the visualization of gonads and to identify the sex. Visualization of gonads is feasible through the urinary bladder or accessory vesicle wall in many species.

Concepts: Uterus, Urinary incontinence, Urinary bladder, Urethra, Reproductive system, Minimally invasive, Penis, Sex organ