Position: Lithotomy, Trendelenburg, arms at side on armboards
Time: 1-2 hours (average)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: High (7-10)
Maintenance Paralytic: Yes

Blocks: Pudendal

Approach – The anesthetic approach for this case is similar to other urological/gynecological procedures. A paralytic is often used on induction and for maintenance as it is a sensitive area and movement could be detrimental to the patient’s outcome. Maintenance with volatile gas or TIVA. Alternatively, a pudendal nerve block and sedation can be used if the procedure is for small cosmetic changes, such as reducing the size or changing the shape of the clitoris.

Positioning – These procedures are mostly performed in lithotomy position and often with a fair amount of trendelenburg needed for optimal positioning for the surgery team. While positioning the patient, it is important to remember to ensure padding of the back of knees, arms, and lower back. Also expecting blood pressure changes because of positioning, as well as monitoring the patient’s face for edema if prolonged trendelenburg is needed.

PONV – As these cases are typically younger females or intersex patients, the occurrence of PONV is higher, and medications should be administered. Consider placing a scopolamine patch or using a medication like aprepitant in pre-op if the patient is susceptible to nausea. Other medications such dexamethasone, ondansetron, or metoclopramide can be used IV.

Postoperative Considerations – Remember that the clitoris is highly innervated and will be sensitive and painful post operatively. Patient’s will usually have a foley placed for post-op care and post operative pain management is important.

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.

The surgery may be indicated by medical necessity such a congenital adrenal hyperplasia, female genital mutilation repair, or for cosmetic reasons.