III Methodology
Basic principles
The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and
requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a
set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a
structural consensus-based subclass (S2k). The highest S3 class combines both approaches. This guideline was classifed as: S2k .
Grading of recommendations
The grading of evidence based on the systematic search, evaluation, and synthesis of an evidence base which is then used to grade the recommendations is not envisaged for S2k guidelines.
The individual statements and recommendations are only differentiated by syntax, not by symbols ([Table 3 ]).
Tab. 3 Grading of recommendations (based on Lomotan et al., Qual Saf Health Care 2010).
Description of binding character
Expression
Strong recommendation with highly binding character
must/must not
Regular recommendation with moderately binding character
should/should not
Open recommendation with limited binding character
may/may not
Statements
Expositions or explanations of specific facts, circumstances, or problems without any direct recommendations for action included in this guideline are referred to as “statements.” It is
not possible to provide any information about the level of evidence for these statements.
Achieving consensus and level of consensus
At structured NIH-type consensus-based conferences (S2k/S3 level), authorised participants attending the session vote on draft statements and recommendations. The process is as follows. A
recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is
another round of discussions, followed by another vote. Finally, the extent of consensus is determined based on the number of participants ([Table 4 ]).
Tab. 4 Level of consensus based on extent of agreement.
Symbol
Level of consensus
Extent of agreement in percent
+++
Strong consensus
> 95% of participants agree
++
Consensus
> 75 – 95% of participants agree
+
Majority agreement
> 50 – 75% of participants agree
–
No consensus
< 51% of participants agree
Expert consensus
As the term already indicates, this refers to consensus decisions taken relating specifically to recommendations/statements issued without a prior systematic search of the literature (S2k)
or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical
consensus point” (CCP). The strength of the recommendation is graded as previously described in the section “Grading of recommendations”, i.e., purely semantically (“must”/“must not” or
“should”/“should not” or “may”/“may not”) and without the use of symbols.
IV Guideline
1 Preoperative preparation
1.1 Planning the surgery
Surgical planning is based on the symptoms and disorders described by the patient and the clinical findings, supported by additional diagnostic measures. Conservative and alternative
options as well as the limits of what is surgically possible must be explained to the patient beforehand. This chapter contains no statements or recommendations.
1.2 Preoperative diagnosis
Consensus-based recommendation 1.E1
Expert consensus
Level of consensus +++
Physical and psychological trauma, particularly to paediatric or adolescent patients, must be avoided when carrying out clinical examinations and diagnostic procedures.
Consensus-based recommendation 1.E2
Expert consensus
Level of consensus +++
A urological or paediatric urological consultation, which can include further diagnostic investigations (e.g., ultrasound of the urinary tract), should be carried out if the
urinary system is also involved.
1.3 Diagnoses where the cost assumption by the patientsʼ insurance is indicated
Consensus-based recommendation 1.E3
Expert consensus
Level of consensus +++
No aesthetic surgical procedures of the female genitalia must be carried out if body dysmorphic disorder is suspected. In this case, the patient should be transferred to a
suitable department for specific evaluation.
1.4 Patient information
Consensus-based statement 1.S1
Expert consensus
Level of consensus +++
In addition to the standard surgical risks such as complications of bleeding, infections, wound healing disorders with scarring, skin/
Consensus-based recommendation 1.E4
Expert consensus
Level of consensus +++
Prior to all procedures carried out affecting the female genitalia, the patient must be informed in detail about the specific risks such as infections, changes in sensitivity,
dyspareunia, adhesions and scarring, and changes which can affect the patientʼs sexuality.
1.5 Documentation requirements
The patientʼs complete medical history on which the indication is based or which triggered the patientʼs independent wish to undergo reconstructive or aesthetic surgery of the female
genitalia must be documented in written form. The clinical findings, diagnostic results, and consultations involving other medical specialties must be documented. The consequences of these
investigations must be transparent [1 ]. The patient should also be specifically questioned about symptoms and problems which existed preoperatively.
Consensus-based recommendation 1.E5
Expert consensus
Level of consensus +++
The extensive information on which the diagnosis is based and the patientʼs consent to the procedure and acceptance of the risks of the surgical intervention must be
individually documented in written form with time and date by the responsible physician.
2 Anatomy and nomenclature of female genitalia
This chapter contains no statements or recommendations. This chapter presents basic information about the anatomy of the external female genitalia, the structure of the female pelvic floor
as well as the nerves and blood supply of the female pelvic floor ([Figs. 1 ], [2 ] and [3 ]).
Abb. 1 External genitalia and anal region. Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]
Abb. 2 Structure of the female pelvic floor. Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]
Abb. 3 Nerves and vasculature of the female pelvic floor. Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]
2.1 External female genitalia
See [Fig. 1 ].
2.1.1 Vascularisation, innervation and lymphatic circulation
See [Fig. 2 ].
2.2 Female internal genitals – vagina
See [Fig. 3 ].
3 Reconstructive and aesthetic surgeries of the female genitalia
3.1 Introduction
Reconstructive and aesthetic surgeries of the external female genitalia include a wide range of diagnoses and treatment options which, because of the existing range of options, are still
not very standardised/have not been standardised. It is therefore important to be informed about the current status of different surgical options and possibilities to be able to offer
individualised therapy to patients. The aim must be to achieve anatomically oriented results and the technique must be selected accordingly.
3.2 Medical history
When taking the patientʼs medical history, both the existing morphological disorders/changes as well as any possibly existing psychosexual interactions should be determined to optimally
tailor the diagnosis to the expected healing/therapeutic success.
3.3 Indications and contraindications
Reconstructive and aesthetic surgeries of the female genitalia include the restoration or approximation of the form and function of the vulva after partial or total resection, in cases
with congenital and/or acquired disorders or disease- and age-related changes or where the patient has a specific idea of what the outcome should look like. Contraindications proceed from
medical-ethical considerations or age-related limitations.
3.3.1 Ritual circumcision (female genital mutilation)
Female circumcision or FGM (female genital mutilation) is a culturally rooted ritual practice which is widely prevalent in certain countries. In Germany and Austria, FGM constitutes an
act of actual bodily harm and therefore contravenes the right to physical integrity and self-determination as defined by law (German constitution). [Table
5 ] outlines the primary and secondary complications after female genital mutilation.
Tab. 5 Primary and secondary complications following female genital mutilation (FGM).
Primary complications
Somatic
Psychological
Secondary complications
Somatic
dysuria
scar-related menstrual problems
recurrent infections
epidermoid/clitorial cysts
neuroma of the dorsal nerve of the clitoris
urinary retention, urinary stones
incontinence, urinary urgency, hyperactive bladder, etc.
dysmenorrhoea
hematocolpos
hematometra
dyspareunia
fistula
dystocia
neonatal outcome
higher episiotomy rate/higher rate of perineal tears
higher rate of caesarean sections
gynaecological diagnosis/catheterisation more difficult/impossible
Psychological
post-traumatic stress disorders, visual intrusions/flashbacks/hyperarousal
sexual dysfunction
anxiety disorder/depression
Consensus-based statement 3.S2
Expert consensus
Level of consensus +++
Female genital mutilation (FGM) has been included in the ICD system (International Classification of Diseases) since 2013 and has been recognised and defined as physical and
mental suffering.
Consensus-based statement 3.S3
Expert consensus
Level of consensus +++
Each of the listed forms of female genital mutilation (FGM) justifies the diagnosis that medical therapy is required if the corresponding physical and/or mental complaints and
impairments are present.
Consensus-based recommendation 3.E6
Expert consensus
Level of consensus +++
An interdisciplinary approach should be used when treating girls and women affected by female genital mutilation (FGM). This can be provided in a standardised form either
centrally (centre-based infrastructure) or locally (cooperation infrastructure).
Because of the differences in the severity of FGM, the differences in how the ritual practice was experienced, and the changes in physical and mental development of the individual
affected women and girls, the somatic and psychological symptoms and complaints also differ.
Consensus-based statement 3.S4
Expert consensus
Level of consensus +++
Especially women with Type III FGM have a higher risk of sustained health problems affecting the urogenital region such as traumatic obstetric and vestibular-perineal
complications and secondary fistula formation.
Defibulation is a surgical procedure which improves overall functionality with regards to urination, the passage of menstrual blood, sexual penetration, and vaginal delivery [2 ], [3 ] ([Table 6 ]).
Tab. 6 Obstetric defibulation after FGM type III.
Antepartum defibulation
reduces urogenital complications, such as
allows diagnostic workup prepartum, including
inspection
microbiological smears
cytology
vaginal ultrasound
Intrapartum defibulation
reduces patientʼs surgical stress
Consensus-based recommendation 3.E7
Expert consensus
Level of consensus +++
During pregnancy, defibulation may be performed before (antepartum) or during (intrapartum) birth. Antepartum defibulation should be carried out from the second trimester of
pregnancy. Intrapartum defibulation should be carried out during the first stage of labour to make it easier to monitor the birth process and carry out bladder catheterisation
if required.
3.3.2 Dysplasia of the vulva and vagina (VIN, VaIN)
Consensus-based recommendation 3.E8
Expert consensus
Level of consensus +++
If the patient has dysplasia of the cervix, vulva and vagina, the diagnosis, therapy and follow-up of the patient must be carried out in accordance with the relevant
S3-guidelines “Prevention of Cervical Cancer” (AWMF registry number 015-027OL) and “Diagnosis, Therapy and Follow-up in Patients with Cervical Cancer” (AWMF registry number
032-033OL) and the S2k-guidelines “Diagnosis, Therapy and Follow-up of Vaginal Cancer and Its Precursors” (AWMF registry number 032-042) and “Diagnosis, Therapy and Follow-up
of Vulvar Cancer and Its Precursors” (AWMF registry number 015-059).
3.3.3 Pagetʼs disease of the vulva
Extramammary Pagetʼs disease is a very rare entity with a prevalence of 1% of all vulvar malignancies. The primary therapy for vulvar Pagetʼs disease is based on surgical removal of the
lesion.
3.3.4 Lichen sclerosus/lichen ruber planus
Lichen sclerosus and lichen ruber planus are inflammatory skin diseases of the anogenital area which are underdiagnosed. Symptoms include pain, burning, itching, sexual dysfunction,
dysfunction of the urinary tract as well as atrophy and sclerosis of the labia and/or the vaginal introitus with introitus stenosis. Local therapy consists of treatment with
corticosteroid cream (methylprednisolone aceponate or clobetasol propionate) combined with regular lubrication or moisturising care [4 ].
3.3.5 Benign tumours of the vulva
Benign tumours of the vulva include syphilis chancre, Behcetʼs disease, folliculitis, condyloma and granulomas, abscesses, Bartholin gland cysts (see chapter 3.3.7), and cysts.
3.3.6 Birth trauma and episiotomy
Keloid formation after birth trauma or suture granulomas (e.g., following the increased use of suture materials) can lead to symptoms such as dyspareunia or pain when sitting or moving
[5 ]. Surgical revision may be considered if the symptoms still persist after three to six months.
3.3.7 Bartholin gland cyst and vulvar abscess
Bartholin glands can develop cysts or abscesses. Treatment consists of an incision with placement of a catheter or marsupialisation. The cyst or gland may be excised following
recurrence of the cyst or abscess [6 ].
3.3.8 Gender incongruence
Readers are referred to the S2k-guideline “Surgical Gender Reassignment Measures for Gender Incongruence and Gender Dysphoria” (registry number 043-052) which is currently being
revised.
4 Surgeries listed according to topographic anatomy
4.1 Mons pubis
This chapter contains no statements or recommendations. Deformities in the region of the mons pubis are classified into four grades ([Table 7 ]). The
grades and their treatment are shown in [Table 7 ].
Tab. 7 Classification of deformities of the mons pubis and appropriate recommended form of treatment.
Classification
Treatment
Grade 1: slight protrusion with minimal/no coverage of the labia majora
Liposuction
Grade 2: moderate protrusion with partial coverage of the labia majora
Panniculectomy with liposuction
Grade 3: significant protrusion with complete coverage of the labia majora
Panniculectomy with liposuction, dermal-fascial suspension suture, poss. vertical wedge resection
Grade 4: no protrusion, strong ptosis with partial or complete coverage of the labia majora
Panniculectomy with dermal-fascial suspension suture and vertical wedge resection
4.2 Vulva/labia majora
Consensus-based recommendation 4.E9
Expert consensus
Level of consensus +++
A big volume reduction of the clitoris and the tissue around the clitoris must be avoided, as this leads to painful exposure of the clitoris.
Consensus-based statement 4.S5
Expert consensus
Level of consensus +++
Too thin or too small labia majora in very slim patients who have lost a lot of weight or who have experienced age-related involution/atrophy may be perceived as inaesthetic and
may be associated with dyspareunia requiring treatment.
4.3 Labia minora
Hypertrophy of the labia minora may be acquired (e.g., varicosis, inflammation, culture-related lengthening/elongation) or congenital [7 ]. If a patient
suffers from disproportionately large labia minora, an aesthetically satisfactory appearance may be achieved by resecting the excessive skin [8 ]. The
following images show excision techniques to reduce the labia minora and different types of flap-plasty procedures ([Figs. 4 ], [5 ] and [6 ]).
Abb. 4 Excision techniques to reduce hypertrophic labia minora (based on [7 ]). Source: Jörg Pekarsky with the kind permission of Prof. M. W.
Beckmann. [rerif]
Abb. 5 Planning and implementation of a VY-flap plasty. Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann. [rerif]
Abb. 6 Planning and implementation of a lotus petal flap procedure (lotus petal/Singapore flap). Source: Jörg Pekarsky with the kind permission of Prof. M. W. Beckmann.
[rerif]
4.4 Clitoral prepuce
This chapter contains no statements or recommendations. Reconstruction of the vulva after FGM also plays an important role (see chapter 5). For example, the “omega domed” flap procedure
(OD flap) is a specially developed local flap-plasty procedure to reconstruct the prepuce.
4.5 Vagina
The diagnosis and treatment of female genital prolapse should be based on the guideline “Diagnostics and treatment of the pelvic organ prolaps”, AWMF registry number 015-006, as at April
2016. The diagnosis and treatment of female incontinence should be based on the guideline “Diagnosis and therapy of female urinary incontinence”, AWMF registry number 015-005, which is
currently being revised. The diagnosis and therapy of female genital malformations should be based on the guideline “Female Genital Malformations”, AWMF registry number 015-052, as at
March 2020.
4.6 Vaginal introitus
Hymen reconstruction plays a special role in those cultural regions where moral significance is attached to female virginity or, rather, the integrity of the hymen edges. The diagnosis
and treatment should be based on the guideline “Female Genital Malformations”, AWMF registry number 015-052, as at March 2020.
As with hymen reconstruction, it is also possible to reconstruct the vaginal introitus. The diagnosis and treatment should also be based on the guideline “Female Genital Malformations”,
AWMF registry number 015-052, as at March 2020.
4.7 G-spot
Injecting the G-spot with autologous fat or a filler is not a medically indicated procedure as defined in the German Social Code, Book V (SGB), which means that health insurance companies
will not cover the costs of this procedure.
5 Female genital mutilation
5.1 Basic facts
Ritual cutting of the external female genitalia (female genital mutilation/FGM) is a global phenomenon which is especially prevalent in Africa, Asia, and South America. According to
estimates by the WHO, around 200 000 000 girls and women are affected globally [9 ]. The WHO categorises the forms of FGM into four different types: I – IV
([Table 8 ]).
Tab. 8 Forms of female genital mutilation (FGM) based on the classification by the World Health Organisation (WHO), 1997.
Type I
Partial or total removal of the clitoral glans and/or the prepuce/clitoral hood
Type Ia
Removal of the clitoral hood
Type Ib
Removal of the clitoris and the clitoral hood
Type II
Partial or total removal of the clitoris and the labia minora, with or without removal of the labia majora (excision)
Type IIa
Removal of the labia minora
Type IIb
Partial or complete removal of the clitoris and the labia minora
Type IIc
Partial or complete removal of the clitoris, the labia minora and labia majora
Type III
Narrowing of the vaginal opening with creation of a scarred skin covering, through the removal and stitching together of the labia minora and/or labia majora, with or without
removal of the clitoral prepuce/clitoral glans and hood (infibulation)
Type IIIa
Removal and stitching together of the labia minora
Type IIIb
Removal and stitching together of the labia majora
Type IV
All other harmful procedures which injure the female genitalia and serve no medical purpose, for example: pricking, piercing, incising, scraping, cauterising, chemically
burning
5.2 Reconstruction procedures
Reconstructive surgical procedures of the external female genitalia include many indications and treatment options, few of which are standardised. As regards the technique, there are
several standardised flap-plasty techniques which can be used for vulva reconstruction, each of which has different advantages and disadvantages [10 ], [11 ], [12 ], [13 ], [14 ], [15 ], [16 ]. Inadequate transfer of tissue has a negative effect on vulva reconstruction, e.g., through the creation of excessive volume with unnatural
projection, tissue rigidity, deformation, and functional limitations. The choice of flap-plasty technique must be balanced very carefully.
5.2.1 Reconstruction of the clitoral prepuce
This chapter contains no statements or recommendations. In patients with FGM type I to III, the prepuce has usually been affected and often no longer exists. The anatomical area where
the tip of the clitoris protrudes from the scarred skin may be excised and removed to obtain surgical access to the clitoral stump or it can be used for a local flap-plasty
procedure.
5.2.2 Reconstruction of the clitoral glans
This chapter contains no statements or recommendations. Clitoral reconstruction is a key procedure of vulva reconstruction after FGM, as this procedure aims to restore fundamental organ
integrity for normal sexual functioning.
5.2.3 Reconstruction of the labia majora/minora
This chapter contains no statements or recommendations. Reconstruction of the labia minora and majora after FGM type II and III is usually only possible with tissue grafting due to the
extensive loss of tissue in the area.
5.2.4 Reconstruction of the vaginal vestibule
This chapter contains no statements or recommendations. The flexibility of vulvar tissue often ensures that primary wound closure is still possible despite extensive tissue defects. In
terms of anatomical function, wound closures of such defects may result in restrictions which affect both form and function, for example, deformations, loss of elasticity, and tissue
tension.
5.3 Reconstruction after subsequent secondary injuries and/or changes
The range of reconstructive options after secondary injury and/or changes after FGM is broad and ranges from procedures to improve function such as correction of scarring and fistula
remediation including perineal reconstruction to the removal of tumours and clitoral cysts and even complex tissue transfers [17 ].
Consensus-based recommendation 5.E10
Expert consensus
Level of consensus +++
During reconstruction after FGM (Female Genital Mutilation), also secondary changes and impairments should be recognized anamnestically and clinically and should be classified
accordingly and included in the surgical planning.
6 Other procedures for the reconstruction of female genitalia
6.1 Vaginal lifting using lasers
Consensus-based recommendation 6.E11
Expert consensus
Level of consensus +++
There is no evidence from prospective randomised studies about the clinical efficacy and side effects of vaginal lifting carried out without a medical diagnosis for purely
cosmetic reasons using CO2 lasers or non-ablative erbium-YAG (yttrium aluminium garnet) lasers or radiofrequency therapy. These procedures should therefore only be
offered to patients in the context of clinical studies.
6.2 Vaginal lifting using radiofrequency therapy (RF)
This chapter contains no statements or recommendations. Several prospective studies are reported which describe the effect of radiofrequency therapy on vaginal laxity.
6.3 Vaginal lifting using muscle training
There are currently no prospective randomised studies on remedying vaginal laxity using muscle training. No recommendation can therefore be given. This chapter contains no statements or
recommendations.
7 Postoperative Procedure
Follow-up treatment after surgery of the female genitalia depends on the type and extent of the surgical intervention and the patientʼs physical condition. Most aesthetic procedures should
be carried out on an outpatient basis.
7.1 Postoperative monitoring
This chapter contains no statements or recommendations. The basics of postoperative monitoring are presented.
7.2 Peri- and postoperative medication
This chapter contains no statements or recommendations. The use of local analgesics (creams/sprays) is not recommended to avoid unnecessarily affecting the mucosal milieu. The
prophylactic administration of antibiotics depends on the type of surgical procedure and the patientʼs medical history (see S3-guideline “Strategy for the Rational Use and Administration
of Antibiotics in Hospital”, AWMF registry number 092/001).
7.3 Dressing changes and hygiene
This chapter contains no statements or recommendations. Basic methods to change dressings and maintain hygiene are described as well as other important aspects, for example, the
prevention of adhesions in postoperative wounds.
7.4 Follow-up treatment
This chapter contains no statements or recommendations. Basic postoperative follow-up is described.
8 Complications during reconstructive and aesthetic surgeries of the female genitalia
The complication rate depends on the type of procedure, patient age, and the patientʼs comorbidities. All complications usually associated with surgical procedures may occur [18 ]. Different reporting systems and classification systems (e.g., Clavien-Dindo classification [19 ]) have been developed to
accurately record such complications. Complication rates of 22% of cases and a mortality rate of 0.8% have been reported in literature [20 ]. Careful
preoperative assessment and selection of patients and advance planning can have a positive effect on the complication rate.
8.1 Rate of complications
Consensus-based statement 8.S6
Expert consensus
Level of consensus +++
There are currently no official statistics or quality indicators for specific complications associated with reconstructive and aesthetic surgeries of the female genitalia.
8.2 General surgical complications
This chapter contains no statements or recommendations. Surgeries of the female genitalia can cause special complications. These are mentioned within this chapter.
8.3 Complications following procedures using autologous tissue
This chapter contains no statements or recommendations. Procedures using autologous tissue include all flap-plasty procedures. Arterial blood supply and venous drainage are critical for
the survival of the flap and therefore for the success of the surgery.
8.4 Complications following procedures using non-autologous materials
This chapter contains no statements or recommendations. Non-autologous materials basically include all types of silicone implants, non-resorbable suture materials, and acellular dermal
matrix (ADM). The most common complications associated with non-autologous materials are infections and seromas which may require follow-up interventions.
8.5 Revision and follow-up surgeries
The most common indication for acute revision is haemorrhage, which requires immediate intervention. Its urgency depends on the location (arterial or venous) and the severity of the
secondary haemorrhage, the patientʼs general condition, and the lab test results (hemoglobin test).
Surgical revision must be carried out immediately in cases with reduced arterial blood flow or disordered venous drainage. Any delay can cause flap necrosis. Such cases require revision
of the vascular anastomosis.
9 Special aspects affecting children and adolescents
9.1 General information on reconstruction and aesthetic surgery of the female genitalia during childhood
The most important aspects of reconstructive and aesthetic surgical interventions in childhood and adolescence deal with symptoms (see chapter 9.2) and functionality, especially
restrictions in fertility (e.g., in the context of aplasia of the internal reproductive organs as occurs with Müllerian agenesis/Mayer-Rokitansky-Küster-Hauser syndrome [MRKH] and complete
androgen insensitivity syndrome [CAIS]) and diminished functionality with regards to continuity and preservation of continence of the urinary tract and intestinal system. Information on
these points can be obtained from the S2k-guideline “Female Genital Malformations” (AWMF registry number 015/052) [21 ].
Consensus-based recommendation 9.E12
Expert consensus
Level of consensus +++
Non-medically indicated surgeries of the female genitalia must not be carried out during childhood.
9.2 Reconstructive procedures for congenital malformations
For reconstructive procedures to treat congenital malformations, readers are referred to the guideline “Female Genital Malformations”, AWMF registry number 015/052 [21 ].
9.3 Genital (alignment) surgery for variants of sexual development
This chapter contains no statements or recommendations. Formerly, it was the patientʼs guardian who gave their consent to genital surgery in cases with variants of sexual development.
This has now changed fundamentally and the individualʼs right to self-determination is specifically emphasised. The S2k-guideline “Variants of Sexual Differentiation”, AWMF registry number
174/001, is currently being revised with a special focus on this topic.
9.4 Reconstructive surgery of the female genitalia during childhood after previous female genital mutilation
Carrying out a reconstructive procedure during childhood requires a very stringent indication. For this reason, interventions performed in children must only be considered if they are
clearly medically indicated. In addition to urogenital or rectovaginal fistula, which are very rare in Germany, a medical indication will usually only be considered for cases with
infibulation or partial stenosis of the vulva.
Consensus-based statement 9.S7
Expert consensus
Level of consensus +++
The treatment of patients with FGM and its associated problems requires an extensive understanding of the complex sociocultural and medical aspects involved, particularly for
patients who are children or adolescents.
Consensus-based recommendation 9.E13
Expert consensus
Level of consensus +++
Physical and psychological trauma caused by unnecessary and insensitive examinations of patients during childhood and adolescence must be avoided.
10 Psychosomatics
10.1 Sexual dysfunction
This chapter contains no statements or recommendations. Several studies on sexual dysfunction disorders are presented.
10.2 Contraindication: psychological disorders
This chapter contains no statements or recommendations. Body dysmorphic disorder is a contraindication for cosmetic surgeries of the female genitalia because the distortion of reality
associated with this psychological disorder negatively affects their ability to make an informed decision and their capacity to consent.
10.3 Patient satisfaction and quality of life
Consensus-based recommendation 10.E14
Expert consensus
Level of consensus +++
Aesthetic and functional surgical therapy may be considered for patients with body dissatisfaction relating to their genitalia to improve their sexual self-image and sexual
satisfaction.
