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Although congenital adrenal hyperplasia (CAH) is the most common cause of genital ambiguity, its surgical treatment remains controversial and often times difficult, especially in cases of high urethro-vaginal confluence. Many aspects are still uncertain, such as the timing of feminizing genitoplasty and type of surgical technique. The objective of this study is to provide a thorough review of the surgical management of children with CAH, discussing the evolution of feminizing genitoplasty and its different techniques, and also to critically appraise the available literature on the timing of surgical intervention and gender reassignment. Prospective long-term studies evaluating the results of modern feminizing genitoplasty techniques are needed as current evidence is based on outdated operations that are no longer used. To date, there have been no studies comparing early and delayed feminizing genitoplasty with regard to psychological outcomes. All families should be counseled regarding the controversies and treatment options, including the watchful waiting approach., (Copyright Georg Thieme Verlag KG Stuttgart . New York.)

Background: The entrance to the scrotum, or the so-called "third inguinal ring" (3rd IGR), was thought to be an important finding and etiological factor for cryptorchidism at the beginning of the 20th century. Historical reports of its association with undescended testis suggest that it was considered by many to be a true anatomical entity. As the understanding of testicular descent has changed, the description of this anatomical passage has vanished from textbooks and publications. In order to evaluate the findings that led to its original report, we sought to assess the patency of the expected testicular path of descent into the scrotum in children with unilateral cryptorchidism., Methods: Two hundred consecutive children who underwent unilateral orchidopexy were prospectively evaluated at the time of surgery to determine the anatomical patency of the area thought to represent the 3rd IGR. We also evaluated its association with the patient's age at surgery, the affected side, position of the undescended testis, macroscopic epididymal anomalies (MEA), and the patency of the processus vaginalis (PV)., Results: The mean age at surgery was 5.2 +/- 3.0 years, ranging from 1 to 13 years. The 3rd IGR was closed in 118 boys (59.0 %) and open in 82 (41.0 %). A closed 3rd IGR was found significantly more frequently in patients with intra-abdominal testes (p < 0.01). No significant association was observed between patency of the 3rd IGR and other evaluated factors., Conclusion: Our results suggest that the so-called 3rd IGR may represent the passage point of the testicle into the scrotum, which was not patent during the intraoperative examination in (2/3) of children with unilateral cryptorchidism. This observation by surgeons at the beginning of the 20th century may represent an anatomical curiosity rather than an important factor in the pathogenesis of cryptorchidism.