Clitoral Arteries Research Articles

The Role of 3-D Ultrasonography in the Evaluation of Menstrual Cycle-Related Vascular Modifications of the Clitoris. A Prospective Pilot Study

Clitoral functional modifications occur during the menstrual cycle. To prospectively evaluate, by the three-dimensional (3-D) Doppler flow analysis, the hemodynamic clitoral blood flow variations during the menstrual cycle. METHODS. Fourteen young (18-35 years), eumenorrheic (menstrual cycle of >25 and <35 days) women in a stable heterosexual relationship (>1 year) and without any sexual dysfunction (as resulted from the two-factor Italian McCoy female sexuality questionnaire > or =35) were submitted, in the early follicular (day 3-5) and in the periovulatory (day 12-14) phases of the menstrual cycle, to bi- and tridimensional ultrasonographic and color Doppler analyses of the clitoral structures. On the same days, the circulating estradiol values were assayed. MAIN OUTCOMES MEASURES. Two-dimensional ultrasonographic evaluation of follicular diameter and color Doppler evaluation of the dorsal clitoral arteries; 3-D power Doppler analysis of the clitoral body volume and of the indices of clitoral vascularization and blood flow; estradiol assay. The mean virtual organ computer-aided analysis (VOCAL) volume of the clitoral body was lower in the follicular (0.79 +/- 0.19 mL) phase with respect to the periovulatory phase (0.98 +/- 0.22 mL; P < 0.001); the clitoral arteries demonstrated a significant decrease of the pulsatility index (PI) from the follicular (1.75 +/- 0.18) to the periovulatory phase (1.26 +/- 0.21; P = 0.002); the 3-D power Doppler histogram analysis showed significant changes of the indices of vascularization and blood flow (vascularization index [VI] = 2.239 +/- 1.201 vs. 3.302 +/- 1.305, P = 0.001; flow index = 27.290 +/- 2.454 vs. 33.620 +/- 1.712, P < 0.001; vascularization flow index = 0.578 +/- 0.573 vs. 1.091 +/- 0.461; P = 0.001) between the follicular and the periovulatory phase of the menstrual cycle. The relationship between the different parameters evidenced that estradiol is positively correlated with the VOCAL clitoral body volume (r = 0.512; P = 0.033) and inversely correlated with the dorsal clitoral artery PI (r = -497; P = 0.048) and with VI (r = 0.622; P = 0.011). During the normal menstrual cycle, the estrogens may, probably, influence the clitoral anatomic and vascular structures and the 3-D ultrasonography may easily and precisely demonstrate these modifications.

ORIGINAL RESEARCH—ANATOMY/PHYSIOLOGY: Periovulatory Morphometric and Vascular Modifications of the Clitoris in Young Adult and Middle-Aged Women. A Pilot Study

A decline in sexual activity has been reported as women age. To compare, in young adult and middle-aged women, the clitoral volumetric and vascular modifications during the periovulatory phase of the menstrual cycle, and to analyze their relationship with circulating hormones, nitric oxide levels, and with questionnaires on sexuality, relationship, and depression. Fifteen young (18-25 years; Group I), and 16 middle-aged (35-45 years; Group II) eumenorrheic women were submitted, on day 14 of their menstrual cycle, to utero-ovarian and clitoral ultrasonographic analysis, and to color Doppler evaluation of the uterine and dorsal clitoral arteries. On the same day, hormonal parameters and plasma concentrations of nitrites/nitrates were assayed, and the two-factor Italian McCoy female questionnaire and the Beck's Depression Inventory questionnaire were administered. Utero-ovarian and clitoral ultrasonographic analysis, color Doppler evaluation of the uterine and dorsal clitoral arteries; evaluation of hormonal and nitrites/nitrates plasma concentrations; administration of the two-factor Italian McCoy Female Sexuality Questionnaire and the Beck's Depression Inventory questionnaire. RESULTS. The plasma levels of estradiol, testosterone, sex hormone binding globulin, and nitrites/nitrates were similar in both groups. Neither the ultrasonographic assessment of the clitoral body volume (0.82 +/- 0.24 mL vs. 0.73 +/- 0.26 mL) nor the Doppler analysis of the dorsal clitoral artery [pulsatility index (PI) = 1.35 +/- 0.31 vs. PI = 1.36 +/- 0.19] evidenced any significant differences in either Group I or Group II. The two-factor Italian McCoy Female Sexuality Questionnaire and the Beck Depression Inventory questionnaire gave the same results in Group I and Group II. The relationship between the different parameters evidenced that the NO(2-)/NO(3-) circulating levels are inversely correlated with uterine artery (r = -0.4611; P = 0.008) and dorsal clitoral artery (r = -0.331; P = 0.041) PIs. Furthermore, estradiol resulted inversely correlated with depression (r = -0.332; P = 0.045). The two sections (sexuality and partnership) of Italian McCoy Female Sexuality Questionnaire were positively correlated (r = 0.849; P < 0.0001) between each other. In eumenorrheic young adult and middle-aged women, the periovulatory clitoral anatomic and vascular modifications similarly occur.

ORIGINAL RESEARCH—WOMEN'S SEXUAL HEALTH: Ultrasonographic and Doppler Findings of Subclinical Clitoral Microtraumatisms in Mountain Bikers and Horseback Riders

Repeated microtraumas in horseback riders and mountain bikers are, in males, associated with perineal and scrotal lesions. No data are reported in the females. To report five cases of clitoral microcalcifications, diagnosed by ultrasonography, in six healthy, eumenorrheic athletes, and to verify the clinical and sexual impact of the ultrasonographic findings. Translabial ultrasonographic evaluation of the clitoris, Doppler analysis of dorsal clitoral arteries, and the two-factor Italian McCoy Female Sexuality Questionnaire (MFSQ) METHODS: The patients were assessed with a detailed history, and were submitted, in the periovulatory phase of the cycle (day 14), to clitoral ultrasonographic analysis and color Doppler evaluation of the dorsal clitoral arteries. The women were not sexually aroused. On the same day, in a separate room--and prior the ultrasound and Doppler examinations took place--the subjects completed the two-factor Italian MFSQ. All the patients were completely asymptomatic but reported a past history of intermittent perineal tenderness or discomfort. In five out of the six subjects, the ultrasonographic assessment of the clitoris evidenced a disseminated clitoral microlithiasis. Only the youngest (18 years old) biker showed a normal pattern of the clitoral structures. A normal clitoral body volume (0.68 +/- 0.21 mL) and a normal mean dorsal artery pulsatility index (PI) was found (PI = 1.75 +/- 0.32) in all the patients. The two-factor Italian MFSQ showed a mean value of 42 +/- 4 (range 37-45). The chronic traumatisms may be responsible, especially in well-trained riders, for microhematomas, inflammation, and/or degenerative processes at level of the clitoral structure. Further studies should be undertaken to determine the clinical significance of the described disseminated clitoral microlithiasis.

Menstrual Cycle‐Related Morphometric and Vascular Modifications of the Clitoris

The evaluation of clitoral anatomy and function is of paramount importance to understand the physiology and pathology of clitoral function. To prospectively evaluate the clitoral volumetric and vascular modifications during the menstrual cycle, and analyze their relationship with circulating hormones and nitric oxide levels. Thirty healthy eumenorrheic women were studied in different phases of the menstrual cycle (day 3, 10, 14, 20, and 27). They were submitted to ultrasonographic (US) and Doppler analyses, and to hormonal and biochemical evaluations. Transvaginal US evaluation of uterus, ovaries, and clitoris; Doppler analysis of uterine and dorsal clitoral arteries; and measurement of plasma luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol, androstenedione, testosterone, and nitrites/nitrates concentration. Sex hormone binding globulin was assayed, and free androgen index was calculated. During the menstrual cycle, FSH, LH, and estradiol changed as expected, whereas androgens did not show any significant change. The US assessment of the clitoral body volume evidenced a progressive increase with significant modifications during the periovulatory phase, after which it remained stable until day 20. Subsequently, the clitoral body volume decreased into the premenstrual phase (day 27), reaching values similar to those observed on cycle day 3. A comparable trend was observed in the nitrite/nitrate circulating values. The uterine and clitoral arteries presented significant modifications with reduced resistances in the periovulatory period. Estradiol levels resulted positively correlated with the clitoral body volume and inversely correlated with the dorsal clitoral artery pulsatility index (PI). Furthermore, the dorsal clitoral artery PI was inversely and significantly correlated with the nitrite/nitrate circulating values and the clitoral body volume. Clitoral anatomic and vascular modifications are observable during the normal menstrual cycle.

PCOS, Sexuality, and Clitoral Vascularisation: A Pilot Study

In polycystic ovarian syndrome (PCOS) women, the changes in body appearance (mainly obesity and hirsutism) may influence the feminine identity of the patients with consequent depression and sexual disturbances. To evaluate if lean PCOS patients present an increased incidence of depression and sexual dysfunction in comparison with controls and if clitoral volume and vascularization are influenced by circulating androgens levels. 25 lean PCOS women (Group I) and 18 healthy nonhirsute volunteers (Group II) were submitted, on day 3-5 of the cycle, to ultrasonographic and Doppler analyses, and to hormonal and biochemical evaluations. Utero-ovarian and clitoral ultrasonographic analysis, and color Doppler evaluation of the uterine, stromal ovarian, and dorsal clitoral arteries. Hormonal and nitrites/nitrates plasma concentrations were analyzed. Each woman filled in the 2-factor Italian McCoy female questionnaire (MFSQ) and the Beck's Depression Inventory questionnaire (BDI). Androgens resulted, as expected, more elevated in PCOS patients than in controls. However, the ultrasonographic (US) assessment of the clitoral body volume evidenced no significant differences between PCOS (0.72+/-0.41 mL) and control (0.62+/-0.20 mL) patients. The resistances registered at the level of the dorsal clitoral artery did not show any difference between Group I (PI=1.55+/-0.40) and Group II (PI=1.79+/-0.38). The 2-factor Italian MFSQ and the BDI did not show any difference between PCOS women and controls. In PCOS women, probably, the moderate hirsutism and hyperandrogenism do not induce the sense of loss of feminine identity and have no impact on sexual self-worth and sexual satisfaction.

Effect of Hormone Replacement Therapy on Clitoral Artery Blood Flow in Healthy Postmenopausal Women

Aging and the decline of ovarian hormonal secretion during menopause may alter libido, and sexual response and functioning. The effects of hormone replacement therapy (HRT) on the genital vascular hemodynamics have been widely studied. However, there is a lack of knowledge about the effect of HRT on basal clitoral blood flow. The aims of this study were to measure clitoral artery blood flow and to determine whether HRT has a significant effect in clitoral artery blood flow in postmenopausal women. Doppler sonography of clitoral arteries was performed in 25 postmenopausal women aged 51.3 +/- 4.5 years who had been using a continuous combined HRT (0.625 mg of conjugated equine estrogens plus 2.5 mg medroxyprogesterone acetate, in 1 tablet daily) for 2.0 +/- 1.1 years, and the clitoral artery peak systolic velocity, resistance index (RI), and pulsatility index (PI) were measured. Thirty-five postmenopausal women aged 50.0 +/- 4.2 years who had not used HRT served as a control group. Assessment of clitoral blood flow with color Doppler ultrasonography by measuring the peak systolic velocity, RI, and PI. Clitoral artery circulation was easily detectable by the color Doppler sonography. The clitoral artery peak systolic velocities were significantly higher in postmenopausal women taking HRT compared with the control group (11.8 +/- 5.2 cm/second vs. 15.0 +/- 5.4 cm/second, P = 0.025). HRT improves blood flow to the clitoris. A clitoral blood flow evaluation may be proposed as a potential tool to assess the impact of HRT on the genital tissues and to investigate female sexual response disorders in postmenopausal women.

T01-O-08 Effects of surgery for stress urinary incontinence on the clitoral blood flow

Objectives To study the effects of the mini-invasive surgery using the tension free vaginal tape (TVT) procedure and the transobturator tape (TOT) procedure in modifying clitoral blood flow in women affected by stress urinary incontinence (SUI). Methods The setting of the prospective open clinical study was the Urogynecologic Service. Forty-two women (mean age 52.8 ys) and 63 women (mean age 53.9 ys) were treated with TVT and TOT, respectively. Each woman underwent translabial color Doppler sonography to measure the resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV) and end diastolic velocity (EDV) of clitoral arteries, before and 6 months after surgery treatment. Results In the TVT women the mean PI and the mean PSV were significantly lower, and the mean RI was significantly higher compared with pre treatment values (p Conclusions The different vaginal approach for both of the surgical methods influence the clitoral blood-flow. Our data stimulate to study the sexual aspects after incontinence treatment, particularly, the possible impact of clitoral flow changes on sexual function.

Clitoral Blood Flow Changes After Surgery for Stress Urinary Incontinence: Pilot Study on TVT Versus TOT Procedures

To study the effects of mini-invasive surgery using the tension-free vaginal tape (TVT) procedure and the transobturator tape (TOT) procedure in modifying clitoral blood flow in women affected by stress urinary incontinence. The setting of the prospective open clinical study was the Urogynecologic Service of the Department of Microbiological and Gynecological Science, University of Catania School of Medicine (Catania, Italy). A total of 105 women underwent surgery; 42 (mean age 52.8 years) and 63 (mean age 53.9 years) were treated with TVT and TOT, respectively. Each woman underwent translabial color Doppler ultrasonography to measure the resistance index, pulsatility index, peak systolic velocity, and end-diastolic velocity of the clitoral arteries, before and 6 months postoperatively. In the TVT group, the mean pulsatility index and mean peak systolic velocity were significantly lower and the mean resistance index was significantly greater compared with the pretreatment values (P <0.5). In the TOT group, each color Doppler measurement was similar to that obtained at baseline (P = NS). The different vaginal approach for these two surgical methods influenced clitoral blood flow. Our data could add new information about sexual behavior after incontinence treatment, particularly the impact of clitoral blood flow changes.

Changes in clitoral blood flow in premenopausal women affected by type 1 diabetes after single 100-mg administration of sildenafil

Objectives To verify whether sildenafil is effective in modifying clitoral blood flow in premenopausal women affected by type 1 diabetes. Methods The setting was a diabetes outpatient clinic in which 30 premenopausal women affected by type 1 diabetes treated with insulin therapy and 39 healthy premenopausal women participated in our prospective open-label clinical study. Each diabetic woman received a single oral dose of 100 mg sildenafil. Translabial color Doppler ultrasonography was used to measure the resistance index, pulsatility index, peak systolic velocity, and end-diastolic velocity of the clitoral arteries 1 and 4 hours after sildenafil intake. Results One hour after the administration of sildenafil, the mean resistance index was significantly lower and the mean pulsatility index, mean peak systolic velocity, and mean end-diastolic velocity of the clitoral arteries were significantly greater compared with baseline and 4 hours after sildenafil ( P <0.05). The baseline clitoral blood flow of the diabetic women was lower compared with that of the control group ( P <0.001). Conclusions Sildenafil seems to improve the clitoral blood flow of premenopausal women with type 1 diabetes.

Sildenafil improves sexual functioning in premenopausal women with type 1 diabetes who are affected by sexual arousal disorder: a double-blind, crossover, placebo-controlled pilot study

To verify whether sildenafil is effective in type 1 premenopausal women affected by sexual arousal disorder (SAD). Double-blind, crossover, placebo-controlled study. Gynecological diabetic outpatient clinic and sexual clinic. Thirty-six type 1 premenopausal diabetic women affected by SAD. Two 8-week periods of sildenafil 100 mg, washout, and placebo, by two possible sequences. Each woman submitted blood samples to measure HbA(1c), and T, free T (FT), and PRL. Efficacy was assessed [1] subjectively by the Personal Experiences Questionnaire based on the 5-point Likert scale, quantifying arousal, desire, orgasm, enjoyment of sexual activities, and frequency of sexual relationships; and [2] objectively by translabial color Doppler ultrasound to measure the resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end diastolic velocity of clitoral arteries. Thirty-two women completed the study. The mean HbA(1c) value was 8.0% +/- 1.8%, and plasma concentrations of T, FT, and PRL were normal. Sildenafil seems to improve arousal, orgasm and sexual enjoyment, and dyspareunia in women affected by type 1 diabetes. However, by flowmetric measurements, the mean RI was significantly lower and both the mean PI and PSV of the clitoral arteries were significantly higher compared with baseline and placebo. Sildenafil seems to improve subjective sexual aspects and can be used to treat objectively genital arousal disorder of premenopausal women with type 1 diabetes.

Clitoral Artery Blood Flow in Healthy Young Women: Preliminary Report on Menstrual Cycle and Hormonal Contraception

The aim of the present study was to measure clitoral artery blood flow throughout the menstrual cycle and in oral contraceptive users. We recruited healthy young women ( n = 19, age range: 21-28 years; body-mass index: 18-23 kg/m 2 ) without sexual dysfunction (Female Sexual Functioning Index criteria; Rosen et al., 2000). Clitoral arterial peak systolic velocity (PSV) in at least two phases of the same ovulatory cycle or during the second week of the pill was measured by doppler ultrasonography. Clitoral arterial PSV measures (cm/s) were superimposable during the follicular and the luteal phase of the menstrual cycle (10.4 - 1.2 versus 10.2 - 1.6), whereas a slight but significant increase (12.2 - 1.2, f = 3.99; p < 0.04) was evident at the time of ovulation. In addition, PSV measures were significantly higher in women taking hormonal contraception compared to women studied throughout the menstrual cycle (14.2 - 2.7 versus 10.8 - 1.5; p < .001). Whether or not these preliminary data may be of any significance to female sexual arousal throughout the menstrual cycle remains to be established.

Clitoral blood flow increases following vaginal pressure stimulation

The vascular responses of clitoral arteries to vaginal pressure stimulation in 10 volunteer women were evaluated by Doppler ultrasonography. Pressure stimulations (20-160 mm Hg) along the lower third of the vagina increased blood velocity and flow into clitoral arteries in 9 of the 10 women. The latency and duration of the Doppler responses ranged from 0.1 to 1.6 sec and from 3.2 to 9.5 sec, respectively, and the response was associated with a blood flow increase of 4 to 11 times the baseline prestimulation level. This response parallels that recorded in the cavernous arteries in men when a similar range of pressure stimulations are applied to the glans penis. Similar responses evoked in the male and female suggest a sexual synergy that may occur during intercourse in that such physiological responses and reflexes may be reciprocally reinforced.