BMJ Best Practice Guide Ambiguous Genitalia in Neonates

Ambiguous
genitalia in neonates
The right clinical information, right where it's needed
Last updated: Aug 27, 2019

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Etiology 4
Pathophysiology 7
Prevention 10
Primary prevention 10
Screening 10
Diagnosis 11
Case history 11
Step-by-step diagnostic approach 11
Risk factors 16
History & examination factors 16
Diagnostic tests 17
Differential diagnosis 20
Treatment 21
Step-by-step treatment approach 21
Treatment details overview 23
Treatment options 26
Follow up 37
Recommendations 37
Complications 37
Prognosis 38
Guidelines 39
Diagnostic guidelines 39
Treatment guidelines 39
References 40
Images 43
Disclaimer 50
Summary
◊ Ambiguous genitalia (i.e., a genital phenotype that is neither clearly male nor female) are caused
by the atypical development of chromosomal, gonadal, or anatomical sex. The complex group of
disorders that cause ambiguous genitalia are called disorders of sex development (DSD).
◊ DSD are congenital conditions that most commonly present in the newborn period.
◊ DSD can be classified as sex chromosome DSD, 46,XY DSD, or 46,XX DSD .
◊ Sex chromosome DSD results from the atypical complement of sex chromosomes, and includes
syndromes such as Turner syndrome (45,X with one absent sex chromosome) and Klinefelter
syndrome (XXY with one additional X chromosome). Mosaicism occurs when more than one type of
chromosomal arrangement is present (e.g., 45,X/46, XY).
◊ 46,XX DSD are conditions characterized by excess exposure to androgens. Over 95% of causes of
ambiguous genitalia with a 46,XX genotype are due to congenital adrenal hyperplasia secondary to
21 hydroxylase deficiency.
◊ 46,XY DSD can be due to several etiologies and usually requires a more extensive diagnostic
evaluation.
◊ The initial management of a neonate with ambiguous genitalia is a social and clinical emergency.
The local team has a key role in coordinating the initial assessment and investigations, and
supporting parents. It is important there is early discussion with a more specialist multidisciplinary
team with expertise in pediatric endocrinology, genetics, and surgery, and with appropriate
psychiatric/psychological support. For many DSDs, long-term surgical and psychosexual outcomes
remain uncertain.
Ambiguous genitalia in neonates Basics
Definition
Disorders of sex development (DSD) are congenital conditions in which development of chromosomal,
gonadal, or anatomical sex is atypical.[1] A subset of children with DSD present at birth with ambiguous
BASICS
genitalia (i.e., a genital phenotype that is neither clearly male nor clearly female) and without other
dysmorphic features. Many causes have a genetic basis. A very rare exception may occur when there is
virilization of a 46,XX fetus by maternal virilizing tumors or maternal exposure to androgenic drugs.
This topic addresses the initial approach to neonates with ambiguous genitalia who are not identified
as having a specific chromosomal syndrome in which ambiguous genitalia may be one of a number of
presenting features.
Epidemiology
The overall incidence of all disorders of sex development (DSD) has been estimated at 1.7%, but this
includes conditions that usually do not present with ambiguous genitalia at birth, such as Turner syndrome,
Klinefelter syndrome, and complete androgen insensitivity syndrome.[2] The incidence of DSD presenting
with ambiguous genitalia at birth is estimated at 0.018% (1.8 per 10,000 live births).[3] The incidence of
46,XY DSD is estimated at 1 in 20,000 live male births.[4] In babies with unilateral or bilateral nonpalpable
gonads and hypospadias, up to 50% have an underlying genetic cause .[5]
In one study, 52% of patients had 46,XY DSD, 35% had 46,XX DSD, and 14% had a disorder of gonadal
development.[6] Overall, in 46,XY DSD patients, a genetic diagnosis was made in less than 50% of
patients.[4] This contrasts with 46,XX DSD, where classic congenital adrenal hyperplasia accounts for over
95% of cases.
Etiology
In normal development, sex development is governed by two consecutive processes: sex determination
followed by sex differentiation. Sex determination is the formation of a testis or ovary from a bipotential gonad
and is driven by the sequential expression of a number of genes. Sex differentiation is the development of
internal and external physical characteristics brought about by gonadal hormone action on target tissues.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Aug 27, 2019.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2019. All rights reserved.
BASICS
Examples of genes that control different stages of sex determination;
ovarian determining genes are the subject of ongoing research
Davies JH, Cheetham T. Recognition and assessment of atypical and ambiguous
genitalia in the newborn. Arch Dis Child. 2017 April [epub ahead of print].
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Aug 27, 2019.
5
BASICS Ambiguous genitalia in neonates Basics
Schematic representation of sex differentiation. Glossary: 5 alpha-

reductase (5α-R), anti-Müllerian hormone (AMH), dihydrotestosterone (DHT)
A variety of disorders with an underlying genetic basis cause disorders of sex development (DSD) and
present with ambiguous genitalia in the neonate. These result from atypical sex determination or sex
differentiation. In rare instances, virilization of a 46,XX fetus may occur due to maternal virilizing tumors.
Sex chromosome DSD:
• Individuals may present with ambiguous genitalia due to meiotic or mitotic gain or loss of a sex
chromosome, or due to chimerism (which is rare). 45,X/46,XY mixed gonadal dysgenesis is due to
postmeiotic errors, leading to loss of a Y chromosome in one cell lineage. 46,XX/46,XY chimerism
results from the fusion of two zygotes.
46,XY DSD:
• Gonadal dysgenesis may be due to mutations in one of several genes that are involved in testicular
development.[7] Defects in some of these genes (e.g., sex-determining region Y [SRY]) can also
cause ovotesticular DSD.
• Disorders of androgen biosynthesis include mutations in genes involved in the pathway of testosterone
synthesis that either are common to the adrenal gland and the testes, and thus may also cause
deficiencies of glucocorticoids and/or mineralocorticoids (with some forms of congenital adrenal
hyperplasia [CAH]), or are just found in the testes and thus only lead to defects in testosterone
biosynthesis. Examples are 17 alpha-hydroxylase, 20-22 lyase deficiency due to mutations in
CYP17, 3 beta-hydroxysteroid dehydrogenase (HSD) deficiency due to mutations in HSD3B2,
and steroidogenic acute regulatory (StAR) protein deficiency. These are all autosomal-recessive
conditions.
BASICS
• Partial androgen insensitivity syndrome is due to mutations in the androgen receptor on Xq11, and is
an X-linked recessive condition.[8]
• Congenital hypogonadotropic hypogonadism can be due to one of several gene defects and may be
isolated or associated with other pituitary hormone deficiencies.[9] [10]
46,XX DSD:
• Classic CAH due to 21 hydroxylase deficiency (CYP21A2 on chromosome 6p21.3) is the cause of
ambiguous genitalia in more than 95% of cases. It is an autosomal-recessive condition. Other causes
of 46,XX DSD include 11 beta-hydroxylase deficiency (CYP11B1 on chromosome 8q21) and 3 beta-
HSD deficiency (HSD3B2).
• Ovotesticular DSD may be caused by a number of gene defects, including translocation of an SRY
gene onto an X chromosome or by duplication of the SOX9 region.[11]
Pathophysiology
An example of a sex chromosome disorder of sex development (DSD) is mixed gonadal dysgenesis, which is
characterized by asymmetrical development of the gonads and internal genital ducts. There is a dysgenetic
testis and thus poorly developed Wolffian ducts on one side and a streak gonad (ovary) on the other side.
Variable degrees of external genital ambiguity are found. The lack of a Y chromosome, and thus lack of the
sex-determining region Y (SRY) gene, on one side leads to the dysgenetic testis that produces insufficient
testosterone for normal male virilization. The degree of virilization depends on the degree of functioning of
the testes.
In 46,XY DSD presenting as ambiguous genitalia, the degree of virilization depends on the amount of
residual functioning of the testes, the amount of testosterone synthesized, or the degree of androgen
insensitivity.
In 46,XX DSD with congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the degree of virilization
depends on the residual activity of the 21 hydroxylase gene. In the absence of any 21 hydroxylase activity
(null mutations on both alleles), cortisol precursors are shuttled to androgen production leading to elevated
androgen levels and virilization. This is usually associated with salt wasting.[12]
7
BASICS Ambiguous genitalia in neonates Basics
Selected examples of abnormal testosterone production (red) or testosterone action (purple) in 46,XY
disorders of sex development. Glossary: 3 beta-hydroxysteroid dehydrogenase deficiency (3β-HSD), 17
alpha-hydroxylase deficiency (17α-HSD), 17 beta-hydroxysteroid dehydrogenase deficiency (17β-HSD),
androgen receptor (AR), complete androgen insensitivity (CAIS), partial androgen insensitivity (PAIS)
BASICS
Selected examples of causes of androgen excess in 46,XX disorders of sex development
9
Ambiguous genitalia in neonates Prevention
Primary prevention
If parents are known to be carriers of a particular disorder, such as in autosomal-recessive and X-linked
recessive conditions, genetic counseling can be offered to discuss options such as prenatal diagnosis,
termination, and preimplantation genetic diagnosis. Although the effects of virilization on an affected 46,XX
female fetus with congenital adrenal hyperplasia due to 21 hydroxylase deficiency may be diminished by the
use of prenatal maternal dexamethasone, this intervention remains controversial and should be undertaken
in the setting of a clinical trial as the long-term safety profile is unknown.[13] [14]
Screening
Newborn screening
Serum 17-hydroxyprogesterone (17-OHP) is included in the newborn screening panel in the US but is not
available in many other countries. A markedly elevated 17-OHP level in a neonate with ambiguous genitalia
and impalpable gonads confirms congenital adrenal hyperplasia due to 21 hydroxylase deficiency. 17-OHP
levels may also be normally elevated in preterm babies, so clinicians should familiarize themselves with local
PREVENTION
17-OHP screening cut-off levels.
Ambiguous genitalia in neonates Diagnosis
Case history
Case history #1
A 3.2 kg baby is born by vaginal delivery to a 29-year-old gravida 2, para 1 mother after an unremarkable
pregnancy, labor, and delivery. An ultrasound at 18 weeks was "normal," although the genitalia were not
visualized. Immediately after delivery the baby's genitalia are noted to be ambiguous and the baby is
transferred to a tertiary care neonatal intensive unit (NICU) at a pediatric academic medical center. On
examination of the genitals, the baby has unfused labioscrotal folds that are weakly rugated. The right
labioscrotal fold is larger than the left, with a right gonad palpable. There is a perineal urethral meatus,
and the stretched phallus length is 3.2 cm. The baby is not dysmorphic and the remainder of the exam is
unremarkable.
[Fig-1]
Case history #2
A full-term baby is born with a weight of 3.7 kg to a 28-year-old gravida 3, para 2 mother. Delivery is
precipitous with an umbilical cord around the neck, although the baby appears well with normal vital
signs. The baby is noted to have ambiguous genitalia and is transferred to the NICU. The family history is
notable for a maternal female cousin born "looking like a boy." On examination of the genitalia, the phallus
is 3.5 cm in length with a midshaft diameter of 1.2 cm. There is a small patent urogenital opening at the
base of the phallus, the labioscrotal folds are hyperpigmented and rugated, and no gonads are palpable.
The rest of the physical exam is unremarkable.
[Fig-2]
Step-by-step diagnostic approach

The approach to a neonate with ambiguous genitalia involves a multidisciplinary team of pediatric
DIAGNOSIS
subspecialists.[15] This usually includes a pediatric endocrinologist, a geneticist, a urologic or general
surgeon, a psychologist/psychiatrist, and a neonatologist. Ongoing communication with the family is crucial,
as well as communication with the primary care physician.[16] The following concepts should guide the
diagnostic evaluation of neonates with ambiguous genitalia:[1] [17]
• Sex assignment. A sex is not assigned until the evaluation has been completed. The child is referred
to as "baby," not boy or girl. The family should be encouraged to delay naming the baby until the sex
has been assigned. Sex assignment may be undertaken even if an underlying genetic or endocrine
diagnosis is not apparent.[18]
• Following the initial assessment and investigations the baby should be evaluated at a center with
multidisciplinary expertise in the evaluation of neonates with ambiguous genitalia.
• Ideally, discussions with the family are led by one professional from the team, usually the pediatric
endocrinologist. It is useful to gain the parents' agreement to discuss the initial results of investigations
collectively, rather than informing them when each result comes through, as parents may place undue
emphasis on the result of a karyotype or testosterone level and not appreciate the extent to which
these should be interpreted in the light of results of other investigations.[18]
11
• The needs, background, culture, and expectations of the parents must be understood and respected.
Parents should be reassured that children with a disorder of sex development (DSD) can live
successful lives and function well in society. Decisions regarding sex assignment are undertaken
by the DSD multidisciplinary team with the parents. A discharge management plan will be agreed.
Informing the parents regarding expected sexual development is also important, as this helps
anticipate issues early.[18]
History
A family history may identify family members with similar problems indicating an autosomal-recessive
or X-linked inheritance. This includes specific enquiry into a history of consanguinity, genital surgery,
infertility, maternal virilization during pregnancy (e.g., voice change or hirsutism), virilization of a female
at puberty (5 alpha-reductase deficiency), or other children born with ambiguous genitalia. Unexplained
neonatal death in a family member could indicate an undiagnosed DSD associated with adrenal
insufficiency.
Most genetic causes of ambiguous genitalia are due to autosomal-recessive conditions, such as
congenital adrenal hyperplasia (CAH), 5 alpha-reductase deficiency, and other defects in testosterone
biosynthesis. X-linked recessive inheritance could suggest androgen insensitivity (the androgen receptor
gene is on the X chromosome). The prenatal history should include questions regarding maternal
exposures to androgens or medications and signs of virilization in the mother during pregnancy.
Physical exam
Although different disorders may present with similar findings on physical exam, there are often aspects of
the exam that are crucial and will help guide the initial investigations.
• General exam: as some causes of DSD are associated with adrenal insufficiency, it is important
to confirm that vital signs (blood pressure, capillary refill, and heart rate) and blood glucose are
normal with arrangements for appropriate monitoring in place. The presence of dysmorphic
features and/or other congenital anomalies may suggest a syndrome that includes ambiguous
DIAGNOSIS
genitalia (e.g., Smith-Lemli-Opitz syndrome).

• Gonads: the presence of one or two gonads rules out 46,XX DSD secondary to 21 hydroxylase
deficiency. Rarely, 46,XX ovotesticular DSD may present with inguinal gonads. The presence of two
gonads is more likely to be from a cause of 46,XY DSD. The presence of only one palpable gonad
could also suggest a diagnosis of mixed gonadal dysgenesis.
• Phallus length: for a term male infant, a normal stretched penile length ranges from 2.5 cm to
4.5 cm and for a term female infant a normal clitoral length ranges from 0.2 cm to 0.85 cm with
variation between ethnic groups.[18]
• Neonates with 46,XX DSD due to 21 hydroxylase deficiency may have hyperpigmented labioscrotal
folds.
• The external masculinization score can be a useful adjunct to the clinical exam as a guide for the
local clinician.[19] [20]
External masculinization score

Created by the BMJ Knowledge Centre based on Davies JH, Cheetham T. Recognition and assessment
of atypical and ambiguous genitalia in the newborn. Arch Dis Child. 2017 April [epub ahead of print].
• Urethral opening: hypospadias occurs when a urethral opening is not present at the tip of the
phallus. Hypospadias associated with separation of scrotal sacs or undescended testis may
suggest an underlying DSD. If the urethral opening is at the base of the phallus, it could be a
urogenital sinus in a virilized female. This occurs when the urethral and vaginal openings are
DIAGNOSIS
connected internally and exit at the perineum through a common opening.
• Other signs to note include:[18]
• Midline defects (e.g., cleft palate)

• Excess pigmentation (e.g., areolar pigmentation)
• Cardiac or skeletal abnormalities.
Key clinical presentations

Bilateral impalpable gonads in an apparent male baby
• A neonate with bilateral impalpable gonads with an external male phenotype may in fact have a
46,XX karyotype with clitoral enlargement from excess androgen production in utero. These babies
should not be discharged until CAH secondary to 21 hydroxylase deficiency has been excluded.
Inguinal herniae in an apparent female baby
13
• A neonate may still have an underlying 46,XY karyotype and this presentation may occur in, for
example, complete androgen insensitivity, 17 beta-hydroxysteroid dehydrogenase deficiency, and 5
alpha-reductase deficiency.
Asymmetric genitalia
• Sex chromosome mosaicism (e.g., 45,X/46,XY) may cause asymmetric genitalia. At laparoscopy,
a streak gonad and hemiuterus are typically identified on the side contralateral to the descended or
palpable gonad.
Micropenis
• For a term male infant, a normal stretched penile length ranges from 2.5 cm to 4.5 cm.[18] A
length of <2.5 cm is considered abnormal in a full-term male baby, especially in the presence of
undescended testes or other abnormalities.[18] There is variation in normal penile size between
ethnic groups.
• In preterm infant males, the penis is shorter and the length should be plotted on a centile chart
available for preterm male babies.[21]
• Disorders of testosterone biosynthesis or testosterone action may lead to micropenis (e.g., partial
androgen insensitivity and 5 alpha-reductase deficiency).
Clitoral enlargement
• A normal clitoral length in a term female infant ranges from 0.2 cm to 0.85 cm, with variation
between ethnic groups.[18] CAH secondary to 21 hydroxylase deficiency is the commonest cause
of cliteromegaly.
Hypospadias
• Severe hypospadias may be associated with ambiguous genitalia. Severe hypospadias may have
an underlying genetic cause in 40% of cases including partial androgen insensitivity and 5 alpha-
reductase deficiency.[19] The neonate with hypospadias but with impalpable gonads has CAH
DIAGNOSIS
secondary to 21 hydroxylase deficiency until proven otherwise.
Approach to a patient with ambiguous genitalia

Following undertaking a detailed history and exam (which must include palpation for gonads), the next
step is to organize specific investigations. At initial presentation, regular electrolytes, prefeed glucose
concentrations, and regular blood pressure monitoring should be undertaken. Urgent chromosome
analysis (karyotype) should be requested, with imaging in the first 48 hours and hormone studies after 48
hours of age. In those with no palpable gonads, a 17-OHP and other hormone studies should be taken
after 48 hours of age. An ultrasound is useful to define the presence of a uterus (a Müllerian structure),
presence of adrenal glands, and morphology of gonads. A urine protein-creatinine ratio should also be
requested.
Chromosomal analysis
On initial evaluation, a chromosomal analysis should be performed with at least 30 metaphases to assess
for mosaicism. Results can usually be obtained within 72 hours. A formal karyotype can take many
days to perform and a more rapid result may be obtained by requesting an urgent fluorescence in situ
hybridization (FISH) or quantitative polymerase chain reaction (PCR) of the sex-determining region Y
(SRY) gene. Other genetic studies can be performed when a specific diagnosis is being considered.[4]
Imaging
A pelvic and abdominal ultrasound scan (USS) is performed to determine whether a uterus (a Müllerian
structure) is present. In an infant, maternal estrogens enhance the ability to view the uterus on ultrasound
in the first few weeks of life. Ovaries and fallopian tubes are often not visible on ultrasound. A USS is also
useful to detect renal anatomy, adrenal anatomy (as adrenal glands are relatively large in the neonatal
period), gonad site, and morphology.[22]
Hormonal studies
These investigations are usually undertaken after 48 hours of age. Although certain clinical presentations
of ambiguous genitalia make some diagnoses more likely, the clinician should be aware that a definitive
diagnosis cannot be made from clinical exam alone as there are varied presentations in many DSD.
No palpable gonads
• In the absence of palpable gonads, CAH secondary to 21 hydroxylase deficiency must be excluded
as it is the most likely diagnosis.
• 17-hydroxyprogesterone (17-OHP) levels should be obtained and will be markedly elevated in 21
hydroxylase deficiency.
• Electrolytes should be obtained and monitored closely, as salt wasting may take a few days to
develop, typically in the second week of life in 21 hydroxylase deficiency. Renin and aldosterone
measurement will help assess mineralocorticoid activity.
• If CAH is suspected and 17-OHP levels are not markedly elevated, adrenal precursors should
be further evaluated to look for rarer causes of CAH, including 11 deoxycortisol and 11-
deoxycorticosterone to rule out 11 beta-hydroxylase deficiency. A urine steroid profile is helpful in
this scenario.
Gonad(s) palpable
DIAGNOSIS
• Testosterone and dihydrotestosterone (DHT): a high testosterone-to-DHT ratio suggests a 5 alpha-
reductase deficiency. A low testosterone-to-androstenedione ratio suggests 17 beta-hydroxysteroid-
dehydrogenase deficiency.
• Luteinising hormone (LH) and follicle-stimulating hormone (FSH): these help evaluate the
hypothalamic-pituitary-gonadal axis. Low levels in the first week of life may not necessarily
indicate hypogonadotropic hypogonadism; however, an assessment at 2 to 4 months may be more
revealing when there is a physiological increase in LH and FSH levels.
• Adrenocorticotropic hormone (ACTH) stimulation test: this test is used in selected cases to
investigate abnormalities of glucocorticoid synthesis in some forms of DSD.
• Human chorionic gonadotropin (hCG) stimulation test: this assesses the ability of Leydig cells
of the testes to respond to hCG (an LH receptor analog) and produce testosterone. The ratio of
testosterone to DHT after hCG stimulation is used to ascertain the presence of 5 alpha-reductase
deficiency. The hCG stimulation test can also identify a block in the testosterone biosynthetic
pathway such as 17 beta-hydroxysteroid-dehydrogenase deficiency, where the ratio of testosterone
to androstenedione would be low.
15
• Mullerian-inhibiting substance (MIS) or anti-mullerian hormone (AMH): MIS is now commonly
referred to as AMH. This can be obtained to assess testicular (Sertoli cell) function in a baby with a
suspected 46,XY DSD and in chromosomal DSD. MIS levels are age- and sex-dependent.
Risk factors
Strong
family history
• A family history of consanguinity, genital surgery, infertility, neonatal death, virilization of a female at
puberty (e.g., 5 alpha-reductase deficiency), or other children born with ambiguous genitalia could
suggest a diagnosis.
• Most causes of disorders of sex development have an autosomal-recessive inheritance, such as
congenital adrenal hyperplasia, 5 alpha-reductase deficiency, and defects in testosterone biosynthesis.
History & examination factors

Key diagnostic factors
ambiguous genitalia with no palpable gonads (common)
• Although impalpable gonads are more suggestive of a 46,XX disorder of sex development (DSD), an
underlying 46,XY DSD is still possible.
ambiguous genitalia with one palpable gonad (common)

• Presence of one gonad makes 46,XX disorder of sex development (DSD) less likely, as ovaries
are less likely to descend into the inguinal region. 46,XY DSD, mixed gonadal dysgenesis, and
ovotesticular DSD should be considered.
ambiguous genitalia with bilaterally palpable gonads (common)

DIAGNOSIS
• Presence of both gonads makes 46,XX disorder of sex development (DSD) less likely and a 46,XY
DSD more likely.
penile length <2.5 cm in a phenotypic male (common)

• For a term male infant, a normal stretched penile length ranges from 2.0 cm to 2.5 cm.[18] A length of
<2.5 cm is considered abnormal in a full-term male baby, especially in the presence of undescended
testes or other abnormalities.[18] There is variation in normal penile size between ethnic groups.
• In preterm infant males, the penis is shorter and the length should be plotted on a centile chart
available for preterm male babies.[21]
clitoris >1 cm in a phenotypic female (common)

• A normal clitoral length in a term female infant ranges from 0.2 to 0.85 cm, with variation between
ethnic groups.[18]
hypospadias and undescended testes or separation of scrotal sacs (common)

• Hypospadias is a urethral opening not present at the tip of the phallus.
• Presence in combination with separation of scrotal sacs or only one or no palpable gonads suggests a
disorder of sex development.
urethral opening at base of phallus (common)
• If there are no palpable gonads, the presence of a single urogenital sinus versus a separate vaginal
introitus and urethra in a female is more likely to be a 46,XX disorder of sex development (DSD),
although a cause of 46,XY DSD is still a possibility.
• This occurs when the urethral and vaginal openings exit at the perineum through a common opening.
Other diagnostic factors

hypotension and vomiting (common)
• Signs of salt wasting (from mineralocorticoid deficiency), including hypotension, weight loss, and
vomiting, suggest primary adrenal insufficiency, and congenital adrenal hyperplasia secondary to
21 hydroxylase deficiency is the commonest cause. These infants may have hypoglycemia from
glucocorticoid deficiency.
dysmorphic facial features (uncommon)

• Presence of dysmorphic features and/or other congenital anomalies suggests a syndromic cause of
ambiguous genitalia. Further hormonal studies may not be necessary if a malformation syndrome is
diagnosed.
Diagnostic tests
1st test to order
Test Result
chromosome analysis (karyotype) may be normal or show
evidence of mosaicism
• On initial evaluation, should be performed with at least 30
metaphases to assess for mosaicism. Results can usually be
obtained within 72 hours.
DIAGNOSIS
• A rapid result may be obtained using a fluorescence in situ
hybridization (FISH)/polymerase chain reaction (PCR) for sex-
determining region Y (SRY).
serum electrolytes and glucose low sodium/high
potassium in salt-wasting
• May be deranged due to aldosterone deficiency and glucocorticoid
forms of congenital
deficiency.
adrenal hyperplasia;
typically not abnormal
before day 4 of life
17
Test Result
pelvic ultrasound presence or absence of
• Will determine presence of Müllerian structures (uterus). Ovaries and uterus or undescended
testes; this result may
fallopian tubes often not visible on ultrasound.
give an indication of
• May also help locate site and morphology of gonads.
• Adrenal glands are usually relatively large in the neonatal period. Sertoli cell function
or responsiveness to
Müllerian-inhibiting
substance/anti-mullerian
hormone; adrenal glands
may have a heterogeneous
‘cerebriform’ pat tern in
21-hydrox ylase deficiency
Other tests to consider
Test Result
serum 17 hydrox yprogesterone markedly elevated in 21
hydrox ylase CAH
• Levels should always be obtained, especially in the absence of
palpable testes, as the most likely diagnosis is congenital adrenal
hyperplasia (CAH) secondary to 21 hydroxylase deficiency.
• Is part of the newborn screen.
• Test after 48 hours of age.
plasma renin activity elevated in salt-wasting
CAH
• High activity in the setting of salt-wasting. Congenital adrenal
hyperplasia (CAH) due to 21 hydroxylase deficiency and other causes
of salt wasting cause elevated levels.
serum 11 deox ycortisol and 11 deox ycorticosterone elevated in CAH due
to 11 beta-hydrox ylase
• In 46,XX congenital adrenal hyperplasia (CAH) not due to 21
deficiency
hydroxylase deficiency, measurement of additional adrenal
DIAGNOSIS
precursors may lead to a diagnosis. 11 beta-hydroxylase deficiency

is the second most common cause of CAH after 21 hydroxylase
deficiency.
serum testosterone low levels will be
observed in testosterone
• Low testosterone level in a 46,XY baby with ambiguous genitalia
biosynthetic and
should be followed up with a human chorionic gonadotropin (hCG)
testicular function
stimulation test to further assess testicular function.
defects; elevated in
• An elevated ratio of testosterone to dihydrotestosterone is
5 alpha-reductase
characteristic of 5 alpha-reductase deficiency.
• A reduced testosterone/androstenedione ratio is observed in 17 beta- deficiency or 21
hydrox ylase deficiency,
hydroxysteroid dehydrogenase deficiency.
11 beta-hydrox ylase
deficiency
serum dihydrotestosterone low in 5 alpha-reductase

deficiency
• Elevated ratio of testosterone to dihydrotestosterone is characteristic
of 5 alpha-reductase deficiency.
Test Result
serum LH and follicle-stimulating hormone (FSH) low or normal in
hypogonadotropic
• Levels indicate activity of the hypothalamic-pituitary-gonadal axis,
hypogonadism
although low levels in the first week of life do not necessarily indicate
hypogonadotropic hypogonadism. Assessment at 2 to 4 months
of life may be more revealing when LH and FSH levels increase
physiologically.
adrenocorticotropic hormone (ACTH) stimulation test low cortisol levels
observed in some forms
• May reveal abnormalities of glucocorticoid synthesis.
of congenital adrenal
hyperplasia and disorders
of adrenal development
human chorionic gonadotropin (hCG) stimulation test low testosterone with

• Helps assess the ability of the Leydig cells of the testes to respond to testosterone biosynthetic
and testicular function
hCG and produce testosterone.
defects; high testosterone
to dihydrotestosterone
ratio in 5 alpha-reductase
deficiency; low ratio
of testosterone to
androstenedione in 17
beta-hydrox ysteroid-
dehydrogenase deficiency
Müllerian-inhibiting substance (MIS) or antiMüllerian hormone MIS/AMH levels are age-

(AMH) and sex-dependent
• Can be a useful indicator of testicular Sertoli cell function in a 46,XY
DSD and in chromosomal DSD.
urine steroid profile a number of key defects
will be teased out by this
• Helps assess disorders of adrenal steroidogenesis.
investigation including 21
DIAGNOSIS
• Spot sample should be taken before treatment with glucocorticoids.
hydrox ylase and 11 beta-
• Sample analysis takes at least several days and so treatment should
hydrox ylase deficiency,
not be delayed if congenital adrenal hyperplasia is suspected.
beta-hydrox ysteroid-
dehydrogenase
deficiency, and 17 alpha-
hydrox ylase deficiency;
will not identify a defect
in 17 beta-hydrox ysteroid-
dehydrogenase; will only
tease out a defect in 5
alpha-reductase after
approximately 2–3 months
of age
19
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Micropenis due to another • Isolated micropenis suggests • Requires investigation for
cause inadequate testosterone abnormalities of congenital
production. hypopituitarism and
• Some cases are due disorders of testosterone
to hypogonadotropic biosynthesis.
hypogonadism (patients
may also present later with
delayed puberty and no
ambiguity of the genitals),
growth hormone deficiency
(short stature, poor growth),
or a genetic syndrome (e.g.,
Prader-Willi syndrome).
• Patients typically have
normal testes palpable, no
hypospadias, and a normal
46,XY karyotype.
Unilateral undescended • Patients with isolated • Clinical diagnosis.

testis (cryptorchidism) unilateral undescended • Ultrasound abdomen/pelvis
testis have no micropenis, no may be used to locate the
hypospadias, and a normal testes.
46,XY karyotype. • No further hormonal
• Extremely common in normal evaluation is indicated if this
boys, especially preterm is an isolated finding.
infants.
• Bilateral abdominal testes
are not common and further
evaluation is indicated.
DIAGNOSIS
Ambiguous genitalia in neonates Treatment
Step-by-step treatment approach

The initial management of a neonate with ambiguous genitalia is a social and clinical emergency. The local
team has a key role in coordinating the initial assessment and investigations, managing a clinical emergency,
and supporting parents. It is important there is early discussion with a more specialist multidisciplinary team
(MDT) if at all possible.
Management of a neonate with ambiguous genitalia should involve an MDT of pediatric subspecialists,
including a pediatric endocrinologist, a psychologist/psychiatrist, a geneticist, a urologic or general
surgeon, and a neonatologist.[15] Ongoing communication and support for the family is crucial, as well as
communication with the primary care physician.[16] [24]
The following principles should guide the management of a neonate with ambiguous genitalia:[1] [17] [25]
[26]
• Sex assignment. This should be undertaken by a specialist disorders of sex development (DSD) MDT.
The child is referred to as "baby," not boy or girl. The family is encouraged to delay naming the baby
until the sex has been assigned.
• If at all possible, the baby should be managed at a center with multidisciplinary expertise in the
evaluation of neonates with ambiguous genitalia.
• The needs, background, culture, and expectations of the parents must be understood and respected.
It is important that parents are kept fully informed throughout the investigative process by the clinical
team. Regular clear communication and information updates are important.
Sex assignment
The specialist DSD MDT must take into account many factors when considering sex assignment,
including:
• Underlying diagnosis if known

• Appearance of the external genitalia
• Surgical reconstructive options
• Need for hormonal replacement therapy
• Potential for future fertility
• Culture and preferences of the family
• Exposure of high levels of testosterone on brain development
• Potential for future sexual function
• Potential future gender identity.
Sex chromosome DSD

Gonadal dysgenesis
• Sex assignment is based on likelihood of fertility, degree of virilization, presumed gonad function in
TREATMENT
puberty based on hormonal tests, and risk of gonadal malignancy.

• If the patient is raised female, surgical separation of the urethral and vaginal openings may be
required. Clitoral reduction may be indicated in cases of severe virilization. Bilateral gonadectomy
is usually undertaken before puberty to avoid virilization during puberty and to eliminate the risk of
21
gonadal malignancy. Exogenous estrogen will be needed at puberty to allow pubertal development.
Further genitoplasty in adolescence may be required.
• If raised male, surgical correction of hypospadias or chordee is usually required. Testosterone
replacement may be required at puberty if there is gonadal failure or if bilateral gonadectomy has
previously been undertaken.
45,X/46,XY mixed gonadal dysgenesis
• Sex assignment can be challenging, as the phenotype is variable. Factors that should be
considered include future prospects of fertility, genital appearance, size of phallus, presumed
testicular function in puberty based on hormonal tests, gonadal development, and malignancy
risk (see section on sex assignment above). The risk of gonadal malignancy is highest in mixed
gonadal dysgenesis when there is Y chromosomal material in those with an intra-abdominal
(undescended) gonad.
• For individuals assigned male, hypospadias or chordee, if present, may require surgical
correction. Testes are at increased risk of malignancy. Testes present in the scrotum should
be monitored clinically and, if there are concerns, a biopsy may be required. A streak ovary,
if present, should be removed because of the risk of malignant change. If there is gonadal
failure, testosterone replacement will be required at puberty. Müllerian structures should be
be removed in individuals raised male.[11]
• For individuals assigned female, surgical separation of the urethral and vaginal openings
may be necessary. Clitoral reduction may be indicated in cases of severe virilization.
Gonadectomy should be performed early in life to prevent malignancy[27] and to avoid risk
of virilization during puberty. Estrogen will be needed at puberty for pubertal development.
Further genitoplasty in adolescence may be necessary. Those with a uterus will need
treatment with cyclic progesterone once breakthrough bleeding occurs.
46,XX DSD
Congenital adrenal hyperplasia (CAH) secondary to 21 hydroxylase deficiency[28]
• These individuals are typically assigned a female sex, as fertility is preserved in CAH. Surgical
management is sometimes required.
• Glucocorticoids (usually hydrocortisone) are typically required to replace cortisol. If there is salt
wasting, fludrocortisone is required to replace aldosterone, and salt supplements may be required
in the first 1 to 2 years of life and then discontinued. Corticosteroid treatment is commenced as
soon as the diagnosis is confirmed and is continued lifelong.
• Separation of the urethral and vaginal openings may be required. Clitoral reduction may be
indicated in cases of severe virilization. Further genitoplasty in adolescence may be necessary.
More recently, some centers opt to not undertake genital surgery until the affected individual is old
enough to make an informed decision about whether to proceed with surgical intervention.
46,XY DSD
TREATMENT
Testosterone biosynthetic defects
• Neonates are usually (but not always) assigned a male sex, which has the potential to preserve
future fertility. However, debate continues as to the optimal strategy for sex assignment,
gonadectomy, and surgical intervention. Many factors are considered by the MDT before a final
decision is made.[29]
• Individuals with defects that are common to the adrenal gland and the testes may have
deficiencies of glucocorticoids and/or mineralocorticoids. Treatment with glucocorticoids and/or
mineralocorticoids in these patients is commenced as soon as the diagnosis is confirmed and
continued lifelong.
• If hypospadias or chordee is present, surgical correction is usually required. Gonadectomy may be
considered if the neonate is assigned female sex.
• Testosterone replacement may be required at puberty, particularly if there is evidence of gonadal
failure or poor virilization.
5 alpha-reductase deficiency
• Individuals with 5 alpha-reductase deficiency have a high degree of phenotypic variability

and have been raised male or female. Debate continues as to the optimal strategy for sex
assignment, gonadectomy, and surgical intervention. A decision regarding sex of rearing will
involve an MDT discussion with the parents and will be informed by age at diagnosis, degree of
virilization, and other factors (see section on sex assignment above). If an early diagnosis is made,
some favor male sex assignment as the penis and scrotum are likely to respond to exogenous
dihydrotestosterone. If hypospadias or chordee is present, surgical correction is usually required.
• If raised male, affected individuals may not need hormonal replacement in puberty as
further virilization may occur spontaneously. 5 alpha-reductase converts testosterone into
dihydrotestosterone in the peripheral tissues, including the genital skin, and the rise in testosterone
levels at the onset of puberty may be sufficient to induce the development of secondary sexual
characteristics, either through low-level expression of 5 alpha-reductase or via alternative
pathways.
• If raised female, bilateral gonadectomy may be considered.[29]
Partial androgen insensitivity
• Some individuals are raised male, although in those with severe partial androgen insensitivity
adequate virilization at puberty will not occur and female sex of rearing may be more
appropriate.[29]
• If raised male, surgical correction of hypospadias or chordee is usually required. Testosterone
replacement may be needed at puberty, particularly if testosterone levels remain low. The response
to exogenous testosterone is variable.
• If raised female, surgical separation of the urethral and vaginal openings may be required. Clitoral
reduction may be indicated in cases of severe virilization. Bilateral gonadectomy is considered
before puberty to avoid further virilization at puberty and because of the risk of malignant change
in the gonad (particularly if it is outside the scrotum). If gonads are removed, exogenous estrogen
will be needed at puberty for pubertal development. Further genitoplasty in adolescence may be
required. Removal of gonads will mean the individual will be infertile, so the decision for female sex
assignment needs to be considered carefully.
TREATMENT
Treatment details overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
23
Initial ( summary )
all neonates presenting with
ambiguous genitalia
1st multidisciplinary approach
Acute ( summary )
46,XX: congenital adrenal
hyperplasia secondary to 21
hydrox ylase deficiency (at
presentation)
1st multidisciplinary consultation + probable

female sex assignment
plus glucocorticoid replacement
adjunct surgical correction
adjunct mineralocorticoid replacement
46,XY
with testosterone 1st sex assignment after multidisciplinary

biosynthetic defects consultation
adjunct glucocorticoid replacement if adrenal

insufficiency
adjunct mineralocorticoid replacement if adrenal

insufficiency
with 5 alpha-reductase 1st sex assignment after multidisciplinary

deficiency consultation
adjunct topical dihydrotestosterone (DHT)
with partial androgen 1st sex assignment at birth after

insensitivity multidisciplinary consultation
with gonadal dysgenesis 1st sex assignment at birth after

multidisciplinary consultation
with 45,X/46,XY mixed 1st sex assignment at birth after

TREATMENT
gonadal dysgenesis multidisciplinary consultation
adjunct surgical correction at puberty
Ongoing ( summary )
Ongoing ( summary )
hydrox ylase deficiency (following sex
assignment)
1st lifelong glucocorticoid replacement
adjunct lifelong mineralocorticoid replacement
raised as males 1st monitoring for spontaneous puberty ±

testosterone supplementation
adjunct lifelong glucocorticoid replacement
raised as females 1st bilateral gonadectomy
plus estrogen supplementation at puberty

plus testicular monitoring ± biopsy
adjunct bilateral gonadectomy
adjunct cyclic progesterone
TREATMENT
25
Treatment options
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Initial
all neonates presenting with
ambiguous genitalia
1st multidisciplinary approach
» Initial management is a social and clinical

emergency.
» The child should be referred to as "baby," not

boy or girl.
» Members of the local team have key roles

in coordinating the initial assessment and
investigations, managing the clinical emergency,
and supporting parents.
» Discuss the patient with a more specialist

multidisciplinary team if at all possible.
» The multidisciplinary team should include

a pediatric endocrinologist, a psychologist/
psychiatrist, a geneticist, a urologic or general
surgeon, and a neonatologist.[15]
» Communicate frequently with the family and

primary care physician.[16] [24]
Acute
hydrox ylase deficiency (at
presentation)
1st multidisciplinary consultation + probable

female sex assignment
» Sex assignment should be undertaken by

a specialist disorders of sex development
multidisciplinary team.
» Patients are typically assigned a female sex,

as fertility is preserved.
» Some require surgical management.

TREATMENT
plus glucocorticoid replacement

Treatment recommended for ALL patients in
selected patient group
Primary options
Acute
» hydrocortisone: 10-15 mg/square meter
of body surface area/day orally given in 3-4
divided doses
» Glucocorticoids are required to replace

cortisol. Treatment is commenced as soon as
the diagnosis is confirmed and is continued
lifelong. Hydrocortisone is preferred to other
glucocorticoids because of their greater potential
for adverse effects.
Treatment recommended for SOME patients in
» Surgical separation of the urethral and vaginal
openings may be required. Clitoral reduction
may be indicated in cases of severe virilization.
Some centers consider delaying or avoiding
surgical intervention.
adjunct mineralocorticoid replacement
Primary options
» fludrocortisone: 0.1 to 0.3 mg orally once

daily
» If there is salt wasting, fludrocortisone is

required to replace aldosterone. It usually takes
at least 4 days after birth for serum electrolytes
to become abnormal and if untreated, adrenal
crisis may ensue in the second week of life.
Electrolytes should be carefully monitored during
this period. Treatment is commenced as soon
as the diagnosis is confirmed and is continued
lifelong. Over-treatment must be avoided.
» Additional salt supplementation is usually

required in the first 1-2 years of life.
46,XY
with testosterone 1st sex assignment after multidisciplinary

biosynthetic defects consultation
» Guiding principles for sex assignment:[1] [17]

[25] [26]

TREATMENT

» Encourage the family to delay naming the baby

until the evaluation has been completed and sex
has been assigned.
27
Acute
» Sex assignment is based on the underlying
diagnosis if known, appearance of external
genitalia, surgical reconstructive options, need
for hormonal replacement therapy, potential for
future fertility, culture/preferences of the family,
exposure of high levels of testosterone on brain
development, potential for future sexual function,
and gender identity.
» Understand and respect the needs,

background, culture, and expectations of the
parents.
adjunct glucocorticoid replacement if adrenal
insufficiency
Primary options
» hydrocortisone: 10-15 mg/square meter

of body surface area/day orally given in 3-4
divided doses
» Patients with defects that are common to

the adrenal gland and the testes (i.e., defects
early in the steroid biosynthetic pathway)
may also have deficiencies of glucocorticoid
deficiency. Treatment is commenced as soon
as the diagnosis is confirmed and is continued
adjunct mineralocorticoid replacement if adrenal
insufficiency
Primary options
» fludrocortisone: 0.1 to 0.3 mg orally once

daily
» If there is salt wasting in addition to

glucocorticoid deficiency, fludrocortisone is
required to replace aldosterone. It may take
up to 4 days after birth to become apparent
and electrolytes should be carefully monitored.
Treatment is commenced as soon as the
diagnosis is confirmed and is continued lifelong.
TREATMENT

» Hypospadias or chordee may require surgical
correction.
Acute
with 5 alpha-reductase 1st sex assignment after multidisciplinary
deficiency consultation

[25] [26]


has been assigned.


parents.
adjunct topical dihydrotestosterone (DHT)
» For the infant who is sex assigned male,
topical DHT cream can be applied to the external
genitalia to improve virilization. This product may
need to be compounded by a pharmacist.
» Hypospadias or chordee may require surgical
correction.
with partial androgen 1st sex assignment at birth after
insensitivity multidisciplinary consultation
» Most are raised male. Female sex assignment

may be considered in those with severe under
masculinization as further virilization will not
occur at puberty. In these cases the gonads
would be removed to avoid any possibility of
further virilization. Removal of gonads will mean
the individual will be infertile, so the decision for
TREATMENT
female sex assignment needs to be considered

carefully.

[25] [26]
29
Acute

has been assigned.


parents.
» In those assigned male, hypospadias or
chordee, if present, may require surgical
correction.
» In those assigned female, surgical separation

of the urethral and vaginal openings may be
required.
» The risk of gonadal malignancy is high in

nonscrotal gonads and bilateral gonadectomy
should be considered.
with gonadal dysgenesis 1st sex assignment at birth after
multidisciplinary consultation
» In partial gonadal dysgenesis, sex assignment

may be based on the likelihood of fertility.
» Patients with complete gonadal dysgenesis will

be infertile.
» However, in those with a uterus it may be

possible to carry a pregnancy by the use of egg
donation.

[25] [26]

TREATMENT


has been assigned.
Acute

parents.
» In those sex assigned male, hypospadias
or chordee, if present, may require surgical
correction.
» In females, surgical separation of the urethral

and vaginal openings may be required. Clitoral
reduction may be indicated in cases of severe
virilization. Some centers delay or avoid genital
surgery.
» As risk of gonadal malignancy is high,

consideration should be given to early bilateral
gonadal malignancy.
with 45,X/46,XY mixed 1st sex assignment at birth after
gonadal dysgenesis multidisciplinary consultation
» Sex assignment can be challenging.
» Special consideration should be given to future

risk of gonadal malignancy.

[25] [26]


has been assigned.

TREATMENT

31
Acute
parents.
» In those assigned male, hypospadias or
chordee, if present, may require surgical
correction.
» In those assigned female, surgical separation

of the urethral and vaginal openings may be
required. Clitoral reduction may be indicated in
cases of severe virilization. Some centres delay
or avoid genital surgery.
Ongoing
hydrox ylase deficiency (following sex
assignment)
1st lifelong glucocorticoid replacement

Primary options
» hydrocortisone: children: 10-15 mg/square

meter of body surface area/day orally given
in 3-4 divided doses; adults: 25-30 mg/day
orally given in 2-3 divided doses
» Glucocorticoids are required to replace

cortisol. Treatment is commenced as soon as
the diagnosis is confirmed and is continued
» Further genitoplasty in adolescence may be
necessary.
TREATMENT
Primary options
» fludrocortisone: children: 0.1 to 0.3 mg

orally once daily; adults: 0.1 to 0.2 mg orally
once daily
Ongoing
» If there is salt wasting, fludrocortisone is
required to replace aldosterone. Treatment
is commenced as soon as the diagnosis is
confirmed and is continued lifelong.

» Males with testosterone biosynthetic

defects, partial androgen insensitivity, and
gonadal dysgenesis may require testosterone
supplementation at puberty, particularly if there
is poor virilization and/or evidence of gonadal
failure.
» Patients with 5 alpha-reductase deficiency

typically may not need hormonal replacement
during puberty. Testosterone levels may
be sufficient to permit the development of
secondary sexual characteristics despite a
lack of the more potent dihydrotestosterone.
Individuals tend to develop less facial and body
hair than unaffected males.
» If additional testosterone is required, consult

specialist for guidance on dose.
adjunct lifelong glucocorticoid replacement
Primary options
» hydrocortisone: children: 10-15 mg/square

meter of body surface area/day orally given
in 3-4 divided doses; adults: 25-30 mg/day
orally given in 2-3 divided doses
» Patients with testosterone biosynthetic defects

that are common to the adrenal gland and the
testes may have glucocorticoid deficiency.
Treatment with glucocorticoids is commenced
as soon as the diagnosis is confirmed and is
continued lifelong.
Primary options
» fludrocortisone: children: 0.1 to 0.3 mg

TREATMENT
orally once daily; adults: 0.1 to 0.2 mg orally

once daily
» If there is salt wasting in addition to

glucocorticoid deficiency, fludrocortisone is
required to replace aldosterone. Treatment
33
Ongoing
is commenced as soon as the diagnosis is
confirmed and is continued lifelong.
» In sex assigned females with gonadal

dysgenesis or partial androgen insensitivity,
gonadectomy is recommended early in life to
eliminate the risk of malignancy and prevent
virilization at puberty.
» In sex assigned females with complete

androgen insensitivity, gonadectomy may
be postponed until after puberty to allow
aromatization of endogenous testosterone
to estrogen, which will promote breast
development.
» There is a low risk of malignant change in

gonads in complete androgen insensitivity.
» Estrogen is needed at puberty to allow
pubertal development, including secondary
sexual characteristics. An exception to this is
complete androgen insensitivity. If gonadectomy
has been postponed until after puberty,
aromatization of endogenous testosterone to
estrogen will promote breast development.
» Transdermal or oral estradiol can be given,

starting with a low dose and increasing every 6
months up to a normal female adult dose, while
monitoring the effect on pubertal development.
Consult specialist for guidance on dose.
necessary.

» Testosterone replacement may be required

at puberty, particularly if there is evidence of
TREATMENT
gonadal failure.
» The dose of testosterone can be increased

over 2 years while monitoring testosterone levels
and the effect on pubertal development. Once
puberty is completed, a testosterone patch or
Ongoing
gel may be offered instead of intramuscular
injections. Consult specialist for guidance on
dose.
plus testicular monitoring ± biopsy
» Risk of gonadal malignancy is highest in
mixed gonadal dysgenesis and in those with an
intra-abdominal (undescended) testis. Risk of
malignancy in a scrotal testis is not clear but may
also be increased. The testis should be carefully
monitored and a biopsy during puberty may be
indicated if there are clinical concerns.
adjunct bilateral gonadectomy
» The gonads may need to be removed if there
is any risk of malignancy on clinical suspicion or
biopsy specimens.
» Risk of gonadal malignancy is highest in

mixed gonadal dysgenesis, where there is Y
chromosomal material present and in those
with an intra-abdominal (undescended) gonads.
Bilateral gonadectomy is indicated in this
situation.
» Estrogen is required for development of
secondary sexual characteristics at puberty and
maintenance of bone mass.
» Transdermal or oral estradiol can be given,

starting with a low dose and increasing at 6-
monthly intervals up to a normal female adult
dose. Consult specialist for guidance on dose.
necessary.
» As risk of gonadal malignancy is high,

TREATMENT
consideration should be given to early bilateral

gonadal malignancy.
adjunct cyclic progesterone
35
Ongoing
» Patients with a uterus need treatment with
cyclic progesterone once breakthrough bleeding
occurs. Consult specialist for guidance on dose.
TREATMENT
Ambiguous genitalia in neonates Follow up
Recommendations
Monitoring
FOLLOW UP
Individuals with a disorder of sex development (DSD) should have their growth and development
monitored.
In children with congenital adrenal hyperplasia (CAH), follow-up every 3 to 4 months is recommended.
Adequacy of treatment is monitored using growth parameters, blood pressure, bone age, serum
electrolytes, and renin measurements to guide aldosterone replacement, and suppression of serum
androgens to guide corticosteroid replacement. In addition, 24-hour profiles of 17 hydroxyprogesterone
(17-OHP) may be indicated to assess the adequacy of glucocorticoid replacement throughout the day.
Those with other DSD should be carefully monitored to evaluate whether they spontaneously enter
puberty or require intervention with exogenous hormone replacement. This will be largely dependent on
their underlying diagnosis, prior surgery, and treatment in early childhood.
In those who spontaneously enter puberty, the progression and potential need for supplemental hormonal
treatment should be routinely evaluated at a minimum of 6-monthly intervals.
Patient instructions
The potential for psychological concerns, such as gender identity disorder, depression, sexual aversion,
and lack of intimate relationships, should be assessed. It is important for people with a disorder of sex
development (DSD) to have access to a psychologist/psychiatrist with experience in DSD.
Those taking hydrocortisone supplementation should be aware of the importance of long-term compliance
and management during intercurrent illness, and that they should not to stop the medication suddenly.
They should be given written instructions for "sick day rules" for increasing their oral dosage during times
of stress and illness or administering an emergency intramuscular hydrocortisone injection.
Complications
Complications Timeframe Likelihood

surgical complications short term low
There may be general complications from surgical procedures to reconstruct the genitalia such as
bleeding, infection, dysuria, and obstruction to menstrual flow.
infertility long term medium
In congenital adrenal hyperplasia secondary to 21 hydroxylase deficiency, the likelihood of infertility is

increased especially in those noncompliant with treatment and who have an increased weight.
In other disorders of sexual development, fertility may or may not be maintained.
Bilateral gonadectomy will result in infertility. In mixed gonadal dysgenesis, testicular function is variable.
37
Ambiguous genitalia in neonates Follow up
Complications Timeframe Likelihood

short stature long term medium
FOLLOW UP
In congenital adrenal hyperplasia secondary to 21-hydroxylase deficiency, inadequate treatment or poor

compliance leading to excess androgens can cause the epiphyses to fuse prematurely, with resultant short
stature. Treatment with glucocorticoids and monitoring of serum androgen levels on treatment can help
attain a greater final height and prevent precocious puberty.
gender identity disorder long term low
Individuals with a disorder of sex development are at higher risk of developing a gender identity disorder
and this must be taken into consideration and evaluated during follow-up.
gonadal malignancy long term low
The risk of gonadal malignancy is highest in mixed gonadal dysgenesis where there is Y chromosomal
material present and in an intra-abdominal (undescended) gonad. The risk of malignancy in a scrotal
testis may also be increased. The testis should be carefully monitored and a biopsy during puberty may be
indicated if there are clinical concerns.
adrenal crises long term low
Adrenal crisis can result if individuals with primary adrenal insufficiency are not compliant with
glucocorticoid and/or mineralocorticoid replacement, and is characterized by cardiovascular collapse,
shock, and, if untreated, death.
Prognosis
Information on the long-term outcome is lacking in many disorder of sex development (DSD) conditions.
46,XX DSD
Girls with congenital adrenal hypeplasia (CAH) secondary to 21 hydroxylase deficiency may have a varied
outcome. Fertility may be impaired. If glucocorticoids and fludrocortisone are taken as prescribed (lifelong
treatment) and monitoring of growth in childhood is adhered to, adequate height is achieved and adrenal
crises can be avoided.
46,XY DSD and sex chromosomal DSD

The outcome depends on the underlying disorder and the treatment and is the subject of ongoing study. Sex
steroids may be required. Psychological counseling is helpful. Further surgical treatment may be indicated.
Ambiguous genitalia in neonates Guidelines
Diagnostic guidelines
International
Global disorders of sex development update since 2006: perceptions,

approach and care [1]
Published by: Global DSD Update Consortium Last published: 2016
Consensus statement on management of intersex disorders [11]

Published by: International Consensus Conference on Intersex Last published: 2006
Guidelines on paediatric urology [23]

Published by: European Association of Urology; European Society for Last published: 2019
Paediatric Urology
UK guidance on the initial evaluation of an infant or an adolescent with a
GUIDELINES
suspected disorder of sex development [19]
Published by: Society for Endocrinology (UK) Last published: 2015
(reaffirmed 2018)
Treatment guidelines
International
Global disorders of sex development update since 2006: perceptions,

approach and care [1]
Published by: Global DSD Update Consortium Last published: 2016
Consensus statement on management of intersex disorders [11]

Published by: International Consensus Conference on Intersex Last published: 2006
Guidelines on paediatric urology [23]

Published by: European Association of Urology; European Society for Last published: 2019
Paediatric Urology
UK guidance on the initial evaluation of an infant or an adolescent with a

suspected disorder of sex development [19]
Published by: Society for Endocrinology (UK) Last published: 2015
(reaffirmed 2018)
39
Ambiguous genitalia in neonates References
Key articles
• MacLaughlin DT, Donahoe PK. Sex determination and differentiation. N Engl J Med. 2004 Jan
REFERENCES
22;350(4):367-78. Abstract
• Lee PA, Houk CP, Ahmed SF, et al. Consensus statement on management of intersex disorders:
International Consensus Conference on Intersex. Pediatrics. 2006 Aug;118(2):e488-500 Abstract
• Lambert SM, Vilain EJ, Kolon TF. A practical approach to ambiguous genitalia in the newborn period.
Urol Clin North Am. 2010 May;37(2):195-205. Abstract
• Davies JH, Cheetham T. Recognition and assessment of atypical and ambiguous genitalia in the
newborn. Arch Dis Child. 2017 Apr 25 [Epub ahead of print]. Abstract
• Chavhan GB, Parra DA, Oudjhane K, et al. Imaging of ambiguous genitalia: classification and
diagnostic approach. Radiographics. 2008 Nov-Dec;28(7):1891-904. Abstract
• Brain CE, Creighton SM, Mushtaq I, et al. Holistic management of DSD. Best Pract Res Clin
Endocrinol Metab. 2010 Apr;24(2):335-54. Full text Abstract
• Mieszczak J, Houk CP, Lee PA. Assignment of the sex of rearing in the neonate with a disorder of sex
development. Curr Opin Pediatr. 2009 Aug;21(4):541-7. Abstract
References
1. Lee PA, Nordenström A, Houk CP, et al. Global disorders of sex development update since 2006:
perceptions, approach and care. Horm Res Paediatr. 2016 Jan 28;85(3):158-80. Full text Abstract
2. Blackless M, Charuvastra A, Derryck A, et al. How sexually dimorphic are we?: review and synthesis.
Am J Hum Biol. 2000 Mar;12(2):151-166. Abstract
3. Sax L. How common is intersex?: a response to Anne Fausto-Sterling. J Sex Res. 2002
Aug;39(3):174-8. Abstract
4. Morel Y, Rey R, Teinturier C, et al. Aetiological diagnosis of male sex ambiguity: a collaborative study.
Eur J Pediatr. 2002 Jan;161(1):49-59. Abstract
5. Kaefer M, Diamond D, Hendren WH, et al. The incidence of intersexuality in children with
cryptorchidism and hypospadias: stratification based on gonadal palpability and meatal position. J
Urol. 1999 Sep;162(3 Pt 2):1003-6; Abstract
6. Siklar Z, Berberoglu M, Adiyaman P, et al. Disorders of gonadal development: a broad clinical,

cytogenetic and histopathologic spectrum. Pediatr Endocrinol Rev. 2007 Mar;4(3):210-7. Abstract
7. MacLaughlin DT, Donahoe PK. Sex determination and differentiation. N Engl J Med. 2004 Jan
22;350(4):367-78. Abstract
8. Giwercman YL, Svensson J. Androgen insensitivity syndrome [article in Norwegian]. Tidsskr Nor
Laegeforen. 2008 Feb 28;128(5):581-5. Abstract
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Clin Endocrinol Metab. 2005 May;90(5):3122-7. Full text Abstract
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International Consensus Conference on Intersex. Pediatrics. 2006 Aug;118(2):e488-500 Abstract
12. MacGillivray MH, Mazur T. Intersex. Adv Pediatr. 2005;52:295-319. Abstract
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Ambiguous genitalia in neonates Images
Images
IMAGES
Figure 1: Infant presenting with ambiguous genitalia; the history and appearance are most likely consistent
with mixed gonadal dysgenesis
From the personal collection of Dr Ingrid Holm
43
IMAGES Ambiguous genitalia in neonates Images
Figure 2: Infant presenting with ambiguous genitalia; history and appearance are most likely consistent with
congenital adrenal hyperplasia, due to 21 hydroxylase deficiency
From the personal collection of Dr Ingrid Holm
IMAGES
Figure 3: Examples of genes that control different stages of sex determination; ovarian determining genes are
the subject of ongoing research
Davies JH, Cheetham T. Recognition and assessment of atypical and ambiguous genitalia in the newborn.
Arch Dis Child. 2017 April [epub ahead of print].
45
Figure 4: Schematic representation of sex differentiation. Glossary: 5 alpha-reductase (5α-R), anti-Müllerian

hormone (AMH), dihydrotestosterone (DHT)
IMAGES
Figure 5: Selected examples of abnormal testosterone production (red) or testosterone action (purple) in
46,XY disorders of sex development. Glossary: 3 beta-hydroxysteroid dehydrogenase deficiency (3β-HSD),
17 alpha-hydroxylase deficiency (17α-HSD), 17 beta-hydroxysteroid dehydrogenase deficiency (17β-HSD),
androgen receptor (AR), complete androgen insensitivity (CAIS), partial androgen insensitivity (PAIS)
47
Figure 6: Selected examples of causes of androgen excess in 46,XX disorders of sex development
IMAGES
Figure 7: External masculinization score
Created by the BMJ Knowledge Centre based on Davies JH, Cheetham T. Recognition and assessment of
atypical and ambiguous genitalia in the newborn. Arch Dis Child. 2017 April [epub ahead of print].
49
Ambiguous genitalia in neonates Disclaimer
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Group does not advocate or endorse the use of any drug or therapy contained within nor does it diagnose
patients. Medical professionals should use their own professional judgement in using this information and
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This information is not intended to cover all possible diagnosis methods, treatments, follow up, drugs and any
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DISCLAIMER
Contributors:
// Authors:
Justin H Davies, MD, FRCPCH, MRCP

Consultant Paediatric Endocrinologist
Honorary Senior Lecturer, University of Southampton, Southampton, UK
DISCLOSURES: JD is chair of the British Society for Paediatric Endocrinology and Diabetes and a medical
advisor to the Child Growth Foundation. He has received a travel bursary from Novo Nordisk and grants
from the European Society for Paediatric Endocrinology and the Child Growth Foundation.
Gemma Wat ts, BMS, MRCPCH

Specialist Registrar in Paediatric Endocrinology
Department of Paediatrics, University Hospitals Southampton NHS Trust, Southampton, UK
DISCLOSURES: GW declares that she has no competing interests.
// Acknowledgements:
Dr Justin Davies and Dr Gemma Watts would like to gratefully acknowledge Dr Ingrid A. Holm, a previous
contributor to this topic. IAH declares that she has no competing interests.
// Peer Reviewers:
Paul Saenger, MD, MACE

Professor of Pediatrics
Department of Pediatrics (Endocrinology), Montefiore Medical Center, Albert Einstein College of Medicine,
New York, NY
DISCLOSURES: PS declares that he has no competing interests.
Mary M. Lee, MD
Professor of Pediatrics and Cell Biology
Vice-Chair of Academic Affairs in Pediatrics, Pediatric Endocrine Division, UMass Medical School,
Worcester, MA
DISCLOSURES: MML declares that she has no competing interests.
Patricia Y. Fechner, MD
Associate Professor Pediatrics
Pediatric Endocrinology, University of WA, Medical Director of DSD Program, Seattle Children’s Hospital,
Seattle, WA
DISCLOSURES: PYF declares that she has no competing interests.

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Ambiguous

The right clinical information, right where it's needed

Last updated: Aug 27, 2019

Schematic representation of sex differentiation. Glossary: 5 alpha-

Sex chromosome DSD:

17-OHP screening cut-off levels.

Step-by-step diagnostic approach

genitalia (e.g., Smith-Lemli-Opitz syndrome).

External masculinization score

• Midline defects (e.g., cleft palate)

Key clinical presentations

secondary to 21 hydroxylase deficiency until proven otherwise.

Approach to a patient with ambiguous genitalia

History & examination factors

ambiguous genitalia with one palpable gonad (common)

ambiguous genitalia with bilaterally palpable gonads (common)

penile length <2.5 cm in a phenotypic male (common)

clitoris >1 cm in a phenotypic female (common)

hypospadias and undescended testes or separation of scrotal sacs (common)

Other diagnostic factors

dysmorphic facial features (uncommon)

Other tests to consider

precursors may lead to a diagnosis. 11 beta-hydroxylase deficiency

serum dihydrotestosterone low in 5 alpha-reductase

human chorionic gonadotropin (hCG) stimulation test low testosterone with

Müllerian-inhibiting substance (MIS) or antiMüllerian hormone MIS/AMH levels are age-

Condition Differentiating signs / Differentiating tests

Unilateral undescended • Patients with isolated • Clinical diagnosis.

Step-by-step treatment approach

• Underlying diagnosis if known

Sex chromosome DSD

puberty based on hormonal tests, and risk of gonadal malignancy.

Testosterone biosynthetic defects

• Individuals with 5 alpha-reductase deficiency have a high degree of phenotypic variability

Treatment details overview

1st multidisciplinary approach

1st multidisciplinary consultation + probable

plus glucocorticoid replacement

adjunct surgical correction

adjunct mineralocorticoid replacement

with testosterone 1st sex assignment after multidisciplinary

adjunct glucocorticoid replacement if adrenal

adjunct mineralocorticoid replacement if adrenal

adjunct surgical correction

with 5 alpha-reductase 1st sex assignment after multidisciplinary

adjunct topical dihydrotestosterone (DHT)

adjunct surgical correction

with partial androgen 1st sex assignment at birth after

adjunct surgical correction

with gonadal dysgenesis 1st sex assignment at birth after

adjunct surgical correction

with 45,X/46,XY mixed 1st sex assignment at birth after

gonadal dysgenesis multidisciplinary consultation

adjunct surgical correction at puberty

1st lifelong glucocorticoid replacement

adjunct surgical correction at puberty

adjunct lifelong mineralocorticoid replacement

raised as males 1st monitoring for spontaneous puberty ±