The clitoral index: a bio assay of androgenic stimulation: The clitoral Index

Acquired non-hormonal clitoromegaly is a rare condition and is due to benign or malignant tumours and sometimes idiopathic. Few cases of clitoral abscesses have been reported after female circumcision. We hereby report a case of clitoral abscess causing acquired clitoromegaly following an obstetrical surgery.

The glans clitoris is a target organ that is responsive to androgenic stimuli and enlarges throughout life. The size of the glans clitoris can be quantitated by determining the clitoral index (CI), which is the product of the sagittal and transverse diameters of the glans. Four hundred ten patients, ranging in age from 17 to 35 years, were examined. Ninety-five percent of 249 normal women had a CI less than 35 ^mm2. Of 85 patients with clitoromegaly (CI greater than 35 mm2) in addition to at least 1 other clinical sign of excess androgenic stimulation, 53 (62%) had abnormally high values for either or both total serum testosterone and 17-ketosteroid levels. The CI is a useful bioassay for the clinical recognition of excess androgenic stimulation. Clitoromegaly is defined as a measure of the clitoral index (width × length in mm) more than 35mm² .

It can be congenital or acquired. Congenital causes are-congenital adrenal hyperplasia due to enzyme deficiency, babies of mothers having ingestion of androgens or drugs having androgenic actions i.e. norethisterone/danazole etc. during pregnancy, luteomas, theca-lutein cysts, virilizing adrenal or ovarian tumour during pregnancy.

Acquired causes are PCOS, hyperthecosis ovarii, arrehanoblastoma, drugs induced and adrenal tumours. Various benign and malignant tumours of clitoris can also present as clitoromegaly .. Metastasis from distant organs can also cause clitoromegaly. Sometimes pseudoclitoromegaly can be found in girls as a result of masturbation. It can also be idiopathic.

Acquired clitoromegaly.

 clitoral abscess as a cause of acquired clitoromegaly . However, few cases of periclitoral abscess have been reported presenting as labial swelling and extending till clitoral region or swelling near the clitoral region.

 epidermal inclusion cysts to be a common complication, in countries where female circumcision (Female Genital Mutilation/FGM) is common . Among the 32 cases of clitoral cysts, only 1 was infected and the clitoral abscess was drained.

In our case the clitoral abscess appeared to have formed in an infected haematoma. The diagnosis of urethral stenosis while being referred at tertiary care hospital, history of onset of pain in perineal region aggravated by micturition in the immediate postpartum period, suggests that there must have been some difficulty in insertion of urethral catheter and probably some injury might have happened in the clitoral region. This injury had led to the formation of a haematoma which later became infected to form an abscess causing clitoromegaly. However, an idiopathic cause of the clitoral abscess cannot be ruled out. Urine routine examination was normal. Urine culture was sterile after 24 hours. Her total testosterone level was 24.67ng/dL, DHEA-S was 102.3 mcg/dL (reference range for females of 18-29 years : 44-332mcg/dL)