What are the treatment options for a female-to-male (FTM) transgender patient experiencing clitoral pain?

Management of Clitoral Pain in FTM Transgender Patients

For an FTM transgender patient with clitoral pain, begin by evaluating for testosterone-induced clitoral priapism and treat with oral pseudoephedrine (60mg every 6 hours) combined with imipramine if priapism is confirmed, as this represents a medical emergency requiring prompt intervention. 1, 2

Immediate Assessment and Differential Diagnosis

Rule Out Clitoral Priapism First

• Clitoral priapism is a rare but recognized complication in FTM patients on testosterone therapy, presenting as persistent, painful clitoral engorgement that does not resolve spontaneously 2
• Testosterone-induced clitoromegaly appears to be a risk factor for venous outflow obstruction, though the exact mechanism remains unclear 2
• Physical examination should assess for persistent engorgement, duration of symptoms, and whether the pain is constant or intermittent 2

Infectious Etiologies

• Obtain urethral swab or first-void urine for gonorrhea and chlamydia testing if the patient is sexually active, particularly with urethral involvement or dysuria 1
• Initiate empiric treatment with ceftriaxone and doxycycline if urethritis or sexually transmitted infection is suspected while awaiting culture results 1

Dermatologic Conditions

• Screen for lichen sclerosus, which causes genital pain, scarring, and can affect individuals with vulvar anatomy regardless of gender identity 1
• Perform biopsy if lichen sclerosus is suspected and initiate ultra-potent topical corticosteroids if confirmed 1

Traumatic Neuroma

• Consider post-traumatic clitoral neuroma if there is history of genital surgery or trauma, presenting as localized, severe neuropathic pain 3
• This may be palpable on examination as a discrete painful mass 3

Treatment Algorithm

For Clitoral Priapism (Most Urgent)

• Administer oral pseudoephedrine 60mg every 4-6 hours around-the-clock as first-line therapy 4, 2
• Add imipramine (dosing per standard protocols) for additional adrenergic effect if pseudoephedrine alone is insufficient 2
• Provide analgesics for pain control during treatment 4
• Symptoms should resolve within 24-48 hours with appropriate treatment; if not, consider urologic consultation 2

For Testosterone-Induced Vaginal Atrophy

• Prescribe vaginal estrogen therapy as first-line treatment for vaginal dryness and painful intercourse caused by testosterone-induced atrophy 1
• This local therapy does not interfere with masculinizing effects of systemic testosterone 1

For Lichen Sclerosus

• Initiate ultra-potent topical corticosteroids (clobetasol propionate 0.05%) once diagnosis is confirmed by biopsy 1
• Long-term management requires ongoing dermatologic follow-up 1

For Traumatic Neuroma

• Surgical excision is the definitive treatment for symptomatic clitoral neuroma and effectively ameliorates pain 3
• This can be performed as a standalone procedure or during clitoral reconstruction if desired 3

Gender-Affirming Care Considerations

Trauma-Informed Approach

• Use the patient's preferred terminology when discussing anatomy (e.g., some FTM patients may prefer terms other than "clitoris") 5
• Conduct examination with explicit permission, allowing the patient to guide contact and maintain control 5
• Offer chaperone services and ensure appropriate pain control procedures 5

Hormone Therapy Effects on Pain

• Testosterone therapy can modulate pain perception, with some FTM patients reporting improvement in pre-existing pain conditions after starting testosterone 5, 6
• However, testosterone may also create new pain in some individuals, including clitoral pain from clitoromegaly 5, 6
• Gender identity appears to play a more significant role in pain sensation than sex assigned at birth 5

Adjunctive Management

Psychosocial Support

• Address psychosexual concerns, as chronic genital pain significantly impacts quality of life and sexual functioning 1
• Screen for comorbid anxiety, depression, and substance use, which are more prevalent in transgender populations and affect pain management 5
• Affirming the patient's gender identity reduces psychological distress and improves pain outcomes 5

Specialist Referral

• Consider referral to a sexual health specialist for comprehensive management when pain persists despite initial interventions 1
• Urology consultation may be needed for refractory priapism or consideration of surgical interventions 2, 3

Critical Pitfalls to Avoid

• Do not dismiss clitoral pain as a minor complaint—it may represent priapism requiring urgent treatment 2
• Do not recommend discontinuing testosterone without thorough evaluation, as this may worsen gender dysphoria and overall quality of life 5
• Avoid making the patient remove gender-affirming garments (like chest binders) unnecessarily during examination, as this triggers dysphoria 5
• Do not undertreat pain in transgender patients—there is documented bias and undertreatment of pain in this population 5