What initial testing should be done for a female-to-male transgender patient experiencing clitoral pain?

Initial Testing for Female-to-Male Transgender Patient with Clitoral Pain

Begin with a detailed history using the patient's preferred anatomical terminology, followed by a trauma-informed physical examination with explicit permission, and obtain targeted laboratory testing based on clinical presentation—specifically screening for infectious causes if sexually active and evaluating for medication-related priapism if applicable. 1, 2

History Taking Approach

Essential Components

• Conduct an organ inventory to provide medically appropriate care uncoupled from gender identity, documenting current anatomy regardless of gender presentation 1, 3
• Use the patient's preferred terminology when discussing anatomy (e.g., asking what terms they use for genital structures) to reduce psychological distress and improve pain outcomes 1, 2
• Document pain characteristics systematically: onset (sudden vs. gradual), duration, quality (sharp, burning, throbbing), severity, and whether pain is constant or episodic 3, 4
• Assess relationship to testosterone therapy: duration of use, dosage, timing of clitoral growth, and temporal relationship between hormone therapy and pain onset 2, 5

Critical History Elements

• Medication review: Specifically ask about antidepressants (trazodone, bupropion, SSRIs), antipsychotics, or any medications with alpha-adrenergic blockade properties, as these are associated with clitoral priapism 6, 7, 8
• Sexual history: If sexually active, obtain details about partners, practices, symptoms of urethritis (dysuria, discharge), and timing of last sexual contact 2
• Gender-affirming practices: Ask about binding, tucking, or other practices that might cause mechanical trauma, using a non-judgmental harm reduction approach 2
• Screen for comorbid conditions: Anxiety, depression, substance use, and other chronic pain conditions, which are more prevalent in transgender populations and affect pain management 1, 2, 4

Physical Examination Protocol

Trauma-Informed Approach

• Obtain explicit permission before each step of the examination, allowing the patient to guide contact and maintain control throughout 1, 2
• Offer a chaperone of the patient's choosing, as transgender patients may have experienced past discrimination or trauma in healthcare settings 1, 2
• Avoid unnecessary removal of gender-affirming garments, as this triggers dysphoria 2
• Ensure adequate time is allotted; if the patient is not tolerating the examination, stop and reschedule rather than forcing completion 1

Specific Examination Findings to Document

• Clitoral assessment: Measure clitoral width after retracting the hood (normal <10mm in cisgender females, but testosterone-induced clitoromegaly is expected in FTM patients) 1, 5
• Evaluate for priapism: Assess for persistent engorgement, swelling, tenderness, and erythema of the clitoris suggesting venous outflow obstruction 6, 5, 7, 8
• Inspect for dermatologic conditions: Look for hypopigmentation (lichen sclerosus), erythema, lesions, or scarring 1, 2
• Assess surrounding structures: Examine for urethral discharge, Bartholin gland swelling (4 and 8 o'clock positions), Skene gland erythema (lateral to urethra), and any masses or nodularity 1

Laboratory and Diagnostic Testing

First-Line Testing Based on Clinical Presentation

If sexually active or urethral symptoms present:

• Obtain urethral swab or first-void urine for nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia 2
• Consider urinalysis to evaluate for urinary tract infection if dysuria is present 2

If priapism suspected (persistent painful engorgement):

• No specific laboratory tests are indicated initially; diagnosis is clinical based on examination findings of prolonged clitoral engorgement 6, 5, 7, 8
• Review medication list for causative agents rather than ordering labs 7, 8

If dermatologic condition suspected:

• Perform biopsy of any suspicious lesions to confirm diagnosis of lichen sclerosus or other dermatoses 2

Imaging Considerations

• Imaging is generally not indicated for initial evaluation of clitoral pain in FTM patients unless there is concern for mass, abscess, or other structural abnormality requiring surgical intervention 2
• Doppler ultrasound could theoretically assess clitoral blood flow in cases of suspected priapism, though this is not standard practice and literature is limited to case reports 5, 8

Differential Diagnosis Framework

Most Likely Etiologies in FTM Patients

1. Testosterone-related clitoral sensitivity or priapism: Androgen-induced clitoromegaly may predispose to venous outflow obstruction 5
2. Medication-induced priapism: Antidepressants with alpha-adrenergic blockade (trazodone, buprolion, SSRIs) 6, 7, 8
3. Sexually transmitted infections: Gonorrhea, chlamydia, or other pathogens causing urethritis or localized inflammation 2
4. Lichen sclerosus: Causes pain, scarring, and dyspareunia in individuals with vulvar anatomy 2
5. Localized vulvodynia (clitorodynia): Can be provoked or unprovoked, often comorbid with other chronic pain conditions 4

Critical Pitfalls to Avoid

• Do not assume pain is "normal" from testosterone therapy without thorough evaluation, as this represents bias and undertreatment documented in transgender populations 1, 2
• Do not force examination if the patient is experiencing significant distress; this can cause trauma and prevent future care-seeking 1
• Do not discontinue testosterone without thorough evaluation, as this may worsen gender dysphoria and overall quality of life without addressing the underlying cause 2
• Do not overlook infectious etiologies in sexually active patients, as STIs can present with localized genital pain 2
• Do not delay treatment of priapism if suspected, as prolonged engorgement can lead to tissue damage similar to penile priapism 5, 8