True hermaphrodite - a rare case for hysterectomy

One apparently healthy male patient reported at the Urology outpatient department, Bangabandhu Sheikh Mujib Medical University, Bangladesh, with the history of cyclical bleeding per urethra. He started bleeding from the age of 10. The bleeding lasted for 2-3 days. He also had cyclical lower abdominal pain, which remained unexplained. Menstruation occurred every 3-4 months. Left testis was normal but there was a separate soft palpable mass from its lower pole. Chromosomal analysis showed translocation of X and Y chromosome 45(t X/Y). Ultrasonography revealed normal kidneys with well-filled urinary bladder that appeared regular in outline. Left testis was normal in size, measuring about 2.73 × 1.72 cm. Its echotexture was finely homogenous with no evidence of collection or mass. There was a multiloculated cystic mass in the right half of scrotum. Right testis was not visualised along the line of descent. Surprisingly, uterus was found to be present and normal in size and anteverted in position. Fluid collection was noted in the uterine cavity. No ovarian outline was noted. FSH level was almost four times the normal level for males (31.74 IU). The LH level was slightly raised (16.17 IU). The testosterone, Estradiol and Prolactin level were within normal male range, being 3.5 microgram/L, 24 pg/L, and 13.54 microgram/L respectively. Semen analysis revealed azoospermia but the amount of semen was normal. After discussion with the patient, a total abdominal hysterectomy with right-sided salpingo-oophorectomy and left salpingectomy was performed under general anaesthesia. True hermaphrodites must be distinguished from a false one, they have both male and female gonadal tissue, false hermaphrodites are unisexual, but their sex organs resemble those of the opposite sex. This particular patient raised great interest because true hermaphrodites are rare. Attempts were made to make his life normal as a male. If he had the opportunity to have easy access to medical treatment, would he be raised as a female? Controversies are paramount. In this patient, subsequent surgery was done by urologists to correct the chordee and the hypospadias. The overall life of this patient is still a dilemma to us. It was a rare case of hysterectomy done, from the gynaecologist's point of view.