Clitoromegaly in a 5-Year-Old: Evaluation and Management
A 5-year-old with clitoromegaly requires immediate referral to a multidisciplinary team including pediatric endocrinology and pediatric urology/surgery to establish the underlying diagnosis before any treatment decisions are made. 1
Immediate Physical Examination Findings to Document
- Measure clitoral width after retracting the clitoral hood (normal is <10 mm width) 1
- Assess Tanner stage and document any virilization signs: pubic hair development, body odor, acne 1
- Evaluate hymenal patency and configuration 1
- Document skin changes, inflammation, or pigmentary abnormalities 1
Critical Differential Diagnosis to Consider
The presence of an enlarged clitoris indicates elevated androgens from either ovarian or adrenal sources 1. The key diagnoses to rule out include:
- Androgen-secreting ovarian or adrenal tumors (potentially life-threatening) 1
- Congenital adrenal hyperplasia (can be life-threatening if undiagnosed) 2
- Premature adrenarche with pathologic androgen excess 1
- Exogenous androgen exposure (e.g., from paternal testosterone gel transfer) 3
- Disorders of sex development 2
Mandatory Specialist Referral
Do not attempt imaging studies (ultrasound or other modalities) prior to referral, as these rarely assist in decision-making and delay appropriate care. 2
Given the patient's age of 5 years, referral should be to:
- Pediatric endocrinology (essential for hormonal workup) 1
- Pediatric urology or pediatric surgeon (patients ≤5 years requiring surgical care should be managed by pediatric surgical specialists) 2
- Genetics consultation if indicated by initial evaluation 1
Management Framework
The multidisciplinary team must establish the underlying diagnosis before making any treatment decisions. 1 This is critical because:
- Different etiologies require different management approaches
- Some causes (like androgen-secreting tumors or congenital adrenal hyperplasia) require urgent medical intervention
- Surgical decisions are highly individualized and controversial 1
Surgical Considerations (If Indicated)
Surgical intervention for clitoromegaly is controversial and should only be performed by surgeons with specific training and experience in disorders of sex development. 1
Key principles include:
- The 2006 Chicago Consensus shifted away from universal surgery, favoring individualized care 1
- 52% of European centers now perform fewer clitoroplasties in less severe cases 1
- Surgical decisions must be individualized based on underlying diagnosis, degree of virilization, and family preferences after comprehensive counseling 1
- Comprehensive family education with open communication is essential throughout the process 1
Common Pitfalls to Avoid
- Never order imaging studies before specialist referral - they delay care without adding value 2
- Never dismiss clitoromegaly as benign - it can reveal life-threatening conditions or significantly impact quality of life 4
- Never rush to surgical decisions - establish diagnosis first and involve family in decision-making with full disclosure 1
- Never assume congenital adrenal hyperplasia is ruled out without proper endocrine evaluation, as this can be life-threatening 2