Clitoral Body Research Articles

Somatic and autonomic nerve density and distribution within the clitoris: an immunohistochemical study in adult female cadavers.

Knowledge of clitoral neuroanatomy is critical to vulvar surgery. We sought to characterize the density and distribution of autonomic and somatic nerves supplying the clitoris. Pelvic tissue harvested from female cadavers was sectioned axially at three anatomic levels: the proximal aspect of the clitoral body (CB), the distal CB, and the glans. The CB, glans, and the surrounding connective tissue (dorsal, lateral, and ventral) were outlined microscopically. An area containing large nerve bundles dorsal to the CB, referred to as the dorsal nerve subregion, was analyzed separately. Double-immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image-segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and βIIIT and MBP respectively. Comparisons were made using nonparametric Friedman tests. Seven cadavers, aged 22-81, were examined. Somatic (mean 4.42%, SD ± 1.97) and autonomic (2.14% ± 2.42) nerve density was highest in the dorsal nerve subregion and dorsal region at the distal CB level. Compared with the CB, somatic density was higher in proximal (0.05% ± 0.03 vs 1.27% ± 0.69, p = 0.03) and distal (0.29% ± 0.25 vs 1.09% ± 0.41, p = 0.05) dorsal regions. Somatic density was greater in the glans than in the surrounding lateral (0.78% ± 0.47 vs 0.43% ± 0.23, p = 0.03) and ventral (0.78% ± 0.47 vs 0.52% ± 0.2, p = 0.03) regions. Autonomic density was greater than somatic in all areas, except for the dorsal nerve subregion. Somatic and autonomic nerve density were greatest in a well-defined region dorsal to the CB. Surgical preservation of this region is critical for maintaining nerve supply to the clitoris.

(001) How many Nerve Fibers Innervate the Human Clitoris? A Histomorphometric Evaluation of the Dorsal Nerve of the Clitoris

Abstract Introduction It is frequently quoted in mainstream media that the clitoris has “8000 nerve endings”. However, no study has yet quantified the number of nerve fibers (axons) innervating the human clitoris. The dorsal nerve of the clitoris (DNC) is the primary source of somatic clitoral innervation. Reporting the number of axons in the DNC is an important step in our understanding of clitoral innervation and sexual response with implications for many fields of medical practice. Reconstruction following iatrogenic injuries to the dorsal clitoral nerve and restoration following cases of genital mutilation will benefit from a better understanding of the DNC. This knowledge will also be an important factor contributing to the optimization of nerve selection and sensory outcomes in gender-affirming genital surgery. Objective The purpose of this study is to quantify the number of nerve fibers in the human dorsal nerve of the clitoris (DNC) and report the approximate number of nerve fibers that innervate the human clitoris. Methods Following institutional approval and informed consent, dorsal clitoral nerve samples were obtained from 7 transmasculine patients undergoing gender-affirming phalloplasty surgery. In phalloplasty one of the two dorsal clitoral nerves is used to coapt to a sensory nerve in the phallus in order to provide for erogenous phallic sensation. At the time of nerve coaptation, a small excess of dorsal clitoral nerve (5 mm) was collected for analysis at the proximal level of the clitoral body, just after appearance of the dorsal clitoral nerve from underneath the pubic symphysis. The samples were placed into 3% glutaraldehyde fixative, post-fixed in 1% osmium tetroxide and serially dehydrate in ethanol and toluene. They were then embedded in araldite, sectioned on ultramicrotome into 1 μm cross sections and counter-stained with 1% toluidine blue. Histomorphometric evaluation was performed at 1000x magnification using a Leitz Laborlux S microscope and image analysis software (Clemex Vision Professional, Longueuil, Quebec) in order to obtain a nerve fiber count from each dorsal clitoral nerve specimen. Descriptive statistics were performed to yield a mean and range of the number of nerve fibers in the DNC. Assuming anatomic symmetry between bilateral DNC, the total number of somatic nerve fibers innervating the human clitoris was obtained by doubling the mean count of the DNC. Results 7 samples of the DNC were collected. The mean number of nerve fibers in the human dorsal clitoral nerve was 5140 with a range of 4926 to 5543. The mean number of myelinated nerve fibers innervating the human clitoris was 10281 (range 9852 to 11086). Conclusions This study is the first to report the number of myelinated nerve fibers in the human dorsal clitoral nerve and approximate the number of nerve fibers innervating the human clitoris. Findings demonstrate high and consistent myelinated axon counts and density. When taking into account the presence of uncounted unmyelinated axons, it is clear that far more than 8000 fibers innervate the human clitoris. Disclosure No

PD06-04 THE SUB SYMPHYSEAL APPROACH TO THE BLADDER NECK FOR CHILDREN BORN WITH INCONTINENT EPISPADIAS

You have accessJournal of UrologyCME1 Apr 2023PD06-04 THE SUB SYMPHYSEAL APPROACH TO THE BLADDER NECK FOR CHILDREN BORN WITH INCONTINENT EPISPADIAS Moneer Hanna, Mohammed El Menshawy, and Ashraf Fahmy Moneer HannaMoneer Hanna More articles by this author , Mohammed El MenshawyMohammed El Menshawy More articles by this author , and Ashraf FahmyAshraf Fahmy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003230.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To review the outcome of a less invasive surgical approach for plication/ reconstruction of the bladder neck to treat urinary incontinence which may be combined with partial penile disassembly in boys born with epispadias. METHODS: Between 2010 and 2022 a total of 9 children, 6 boys born with penopubic epispadias and 3 girls with incontinent epispadias, all had no prior surgery were operated via the sub symphyseal approach. Their age varied between 3 and 11 years. In boys the urethral plate was first dissected and lifted from the corporal bodies down to the glans penis distally and the wide bladder neck proximally i.e partial penile disassembly. In girls the skin wedge between the crura of the clitoral bodies was raised and tabularized to be used for retraction and further proximal dissection behind the pubic symphysis. The urethra was tubularized over 10 French catheter 10 French catheter, and the bladder neck was plicated over the catheter in 6 children using non absorbable sutures. In 3 children (one boy and 2 girls) the bladder neck was too wide, and a triangular wedge of tissue was excised followed by 2-layer closure with long lasting absorbable sutures around the catheter. The bladder was filled with saline and the water tightness of the suture line and/or the competence of the plicated bladder neck were tested. The corporal bodies are rotated and sutured together to correct the dorsal chordee and the penis is resurfaced by skin. In girls the crural bodies are approximated followed by monsplasty. RESULTS: The follow up ranged between 6 months and 5 years. All boys and 2 girls who were incontinent achieved dryness for 3+ hours and achieved volitional voiding over 6 months postoperatively. One girl exhibited stress incontinence which improved considerably following periurethral injection of bulking agent. The bladder capacity increased from 50- 120 ml preoperatively to 150-230 ml. post-surgery with gradual increase of the bladder capacity over the years. 6/18 renal units showed vesicoureteral reflux (Grade II-III) prior to surgery and were all corrected successfully by endoscopic bulking agent injections. CONCLUSIONS: The sub symphyseal exposure to achieve continence by plicating and/or reconstructing the bladder neck provides a safe and effective surgical approach for children born with incontinent epispadias. Furthermore, in boys it can be combined with penile disassembly. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e156 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Moneer Hanna More articles by this author Mohammed El Menshawy More articles by this author Ashraf Fahmy More articles by this author Expand All Advertisement PDF downloadLoading ...

Anatomic relationships of the clitoral body, bulbs of the vestibule, and urethra

Although recent studies have enhanced our understanding of the anatomy of the clitoris and its somatic innervation, less emphasis has been placed on the anatomic relationships of the clitoris to its surrounding structures. This study aimed to further characterize the gross and histologic relationships of the clitoris, vestibular bulbs, and urethra. Detailed dissections were performed in 30 unembalmed female cadavers. In 23 specimens, gross dissections were performed, and relationships of the clitoris, vestibular bulbs, and urethra were annotated. Histologic evaluation was performed in 7 specimens, in which tissues were harvested within 24 hours from death. Descriptive statistics were used for data analyses. The clitoral body consisted of 2 components, the proximal body and the distal body. The distal body was oriented ≤90° from the proximal body, forming an outer and inner angle at the inflection point. A "septumlike" arrangement of fibroconnective and vascular tissues was noted between the inner angle of the clitoral body and the urethra. Neurovascular bundles coursed laterally along the clitoral body and the surfaces of the crura and vestibular bulbs. The vestibular bulbs approached each other over the ventral surface of the urethra, at the commissure of the vestibular bulbs. Each bulb was separated by fibrous tissue and did not merge along the midline. The vestibular bulbs approximated the clitoral body, but the erectile tissue of the vestibular bulbs was separated from the corpora cavernosa of the clitoral body by the tunica albuginea. The erectile tissue of the vestibular bulbs abutted the ventrolateral walls of the urethra but was separated from the urethral mucosa by an indiscrete layer of erectilelike tissue with dense stroma. This study provided gross and histological confirmation of the relationships of the clitoris, vestibular bulbs, and urethra. Detailed knowledge of the anatomy of the clitoris is crucial for reducing surgical complications associated with periclitoral and distal urethral procedures, which may adversely affect sexual arousal and sexual function.

How many nerve fibers innervate the human glans clitoris: a histomorphometric evaluation of the dorsal nerve of the clitoris.

It is frequently quoted in mainstream media that the clitoris has "8000 nerve endings." However, no study has yet quantified the number of nerve fibers (axons) innervating the human clitoris. The dorsal nerves of the clitoris (DNCs) are the primary source of sensation and somatic clitoral innervation. Therefore, reporting the number of axons in the DNCs is an important step in our understanding of clitoral innervation and sexual response with implications for many fields of medical practice. The purpose of this study is to quantify the mean number of axons in the human DNCs and to report the approximate mean number of nerve fibers that innervate the human glans clitoris. DNC samples were obtained from 7 transmasculine patients undergoing gender-affirming phalloplasty surgery. At the time of nerve coaptation, a small excess of the DNC (5 mm) was collected for analysis at the proximal level of the clitoral body, just distal of the emergence of the DNCs from underneath the pubic symphysis. Samples were placed into 3% glutaraldehyde fixative, postfixed in 1% osmium tetroxide, and serially dehydrated in ethanol and toluene. Samples were then embedded in araldite, sectioned on an ultramicrotome into 1-μm cross sections, and counterstained with 1% toluidine blue. Histomorphometric evaluation was performed at 1000x magnification with a Leitz Laborlux S microscope and image analysis software (Clemex Vision Professional) to obtain an axon counts. Descriptive statistics were performed to yield a mean and standard deviation of the number of axons in the DNCs. Assuming anatomic symmetry between bilateral DNCs, mean total number of somatic nerve fibers innervating the human glans clitoris was obtained by doubling the mean count of the DNCs. Seven sample DNCs were collected. Of those, 5 were analyzed as 2 did not have sufficient nerve tissue present. The mean number of nerve fibers in the human DNCs was 5140 (SD = 218.4). The mean number of myelinated nerve fibers innervating the human clitoris was 10,281 (SD = 436.8). This study is the first to report the number of axons in the human DNC, at a mean 5140. Given the bilateral nature of clitoral innervation and symmetry of anatomic structures, the approximate mean number of myelinated axons that innervate the human glans clitoris is 10,280. When the uncaptured unmyelinated fibers and contributions from the cavernosal innervation are accounted for, it is clear that far Moree than 8000 axons innervate the human clitoris.

Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions

ABSTRACT Introduction In clitoral adhesions (CA), a closed compartment of space under the clitoral hood can lead to accumulation of squamous cells and smegma, irritation, erythema, and infection. This causes the prepuce to adhere to the glans clitoris and prevents the corona, a ridge of tissue between the glans clitoris and the clitoral body, from being visualized. CA can cause discomfort, hypersensitivity or hyposensitivity, difficulty reaching orgasm, and chronic vulvar pain including clitorodynia. One treatment for CA is a non-surgical lysis procedure that is minimally invasive and stretches the preputial tissue open, yet there is a paucity of data on its effectiveness in treatment of symptoms and restoration of function. Objective To evaluate patient-reported outcomes of the non-surgical lysis procedure in order to determine if this procedure is an appropriate treatment for symptomatic CA that can be performed in the office-based setting. Methods 61 women who have been treated for CA using the non-surgical lysis procedure at one sexual medicine practice from 2017-2021 were identified using a chart review and an online survey was sent to patients to evaluate the efficacy of the procedure in improving pain and sexual functioning, as well as patient satisfaction with the procedure. Results There were 41 survey responses (67% response rate). All women that reported the ability to achieve orgasm from external clitoral stimulation maintained this ability after the procedure (n=24), and of the women that could not do so before the procedure (n=16), 6 were able to afterwards. 76% of respondents reported improvement in pain with 44%, 28%, and 4% reporting significant, moderate, and slight improvement. 63% reported improvement in sexual arousal with 25%, 25%, and 13% reporting significant, moderate, and slight improvement. 64% reported improvement in their ability to achieve orgasm with 26%, 18%, and 21% reporting significant, moderate, and slight improvement. 71% reported improvement in their satisfaction with sex with 27%, 17%, and 27% reporting significant, moderate, and slight improvement. 80% of respondents reported they could have comfortable physical/sexual stimulation within one month of the procedure, and 31% of respondents reported that it took one week or less. 93% of participants would recommend the procedure to a friend who also had CA. 65% and 18% of respondents reported being extremely and mostly satisfied with their decision to have the procedure. Conclusions These findings indicate that most patients reported improvement in their pain and sexual functioning, and no participants reported worsening in their pain, sexual arousal, or ability to achieve orgasm. 6 of 16 patients that could not achieve orgasm from external clitoral stimulation prior to the procedure were able to afterwards. Thus, the non-surgical lysis procedure could be considered as a treatment for pain and sexual dysfunction associated with CA. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raliegh, NC), Absorption Pharmaceuticals

The Suspensory Ligament of the Clitoris: A New Anatomical and Histological Description

The importance of the clitoris as an organ has been neglected by doctors and anatomists over the centuries. Its central role in female sexuality is widely recognized and respected. Although multiple studies have been conducted on the fundiform ligament of the penis, the literature concerning the suspensory ligament of the clitoris is extremely poor. The possibility to describe its complex structure may help us understand female orgasm and sexuality. Carrying out an anatomical and histological study about the supporting ligaments of the clitoris and in particular the suspensory ligament of the clitoris. A total of 10 female cadavers were dissected specifically for this study. All the supporting structures of the clitoris were studied, photographed and measured. A histological study of these structures was also carried out. The suspensory ligament of the clitoris is a multidimensional structure consisting of three anatomically and histologically distinct components. The superficial layer originates from the anterior abdominal wall, it is the anatomical extension of the fascia superficialis of the abdomen. It mainly consists of loosely organized elastic fibers, fibroblasts and few loosely organized collagen fibers. The intermediate component also originates from the anterior abdominal wall through the extensions of the abdominal aponeurosis that reach the body of the clitoris. It completely encloses the clitoral body and sends lateral extensions to the labia majora. Histologically, this layer mainly consists of well-organized collagen fibers as well as fibroblasts. The deep component is shorter and extends from the pubic symphysis to the knee of the clitoris and also connects the two crus to the pubic symphysis. It almost exclusively consists of very well organized collagen fibers. The suspensory ligament of the clitoris is a multidimensional structure that extends from the anterior abdominal wall to the clitoris. Unlike previous descriptions of the ligament supporting the clitoris, we observed that this structure consists of three anatomically and histologically distinct layers. These new anatomical considerations must be taken into account for any surgery affecting the subcutaneous tissues of the pubis and the abdomen as well as for reconstructive surgery of the clitoris and metoidioplasty. Botter C, Botter M, Pizza C, et al., The Suspensory Ligament of the Clitoris: A New Anatomical and Histological Description. J Sex Med 2022;19:12-20.

Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair

Worldwide, 200 million girls and women have been subjected to female genital mutilation. To restore the clitoral function and vulvar anatomy, clitoral repair has been performed since the 2000s. Nevertheless, there is a lack of precise and comprehensive data on the clitoral anatomy during surgical repair. This study aimed to precisely describe the terminal anatomies of the dorsal nerve and artery of the clitoris, and the clitoral neurovascular flap advancement for reconstruction in patients with female genital mutilation. This study was performed on seven fresh female cadavers. The site of origin, diameter, length, and trajectory of each nerve and artery were recorded. The clitoral neurovascular flap advancement was measured after a midline transection of the suspensory ligament was performed and after extensive liberation of the dorsal bundles at their emergence from the pubic rami. At the distal point of the clitoral body, the width of the dorsal nerve and artery was 1.9 ± 0.3 mm and 0.9 ± 0.2 mm, respectively. The total length of the dorsal bundles was 6.6 cm (± 0.4). The midpart of the suspensory ligament was sectioned, which allowed a mean anteroposterior mobility of 2.7 cm (± 0.2). Extensive dissection of the neurovascular bundles up to their point of emergence from the suspensory ligament allowed a mean mobility of 3.4 ± 0.2 cm. We described the anatomical characteristics of the dorsal nerve and artery of the clitoris and the mobility of the clitoral neurovascular flap for reconstruction post clitoridectomy. This was done to restore the anatomic position of the glans clitoris while preserving and potentially restoring clitoral function in patients with female genital mutilation.

The Richard Grady Monsplasty: A vertical Z-plasty technique

Classic bladder exstrophy in the female results in an exstrophic bladder and urethra, an anterior introitus with a bifid clitoris and short labia minora. During closure, the lower abdominal wall is closed and the bifid clitori are brought into close apposition, but are often not completely closed to prevent injury to the clitoral bodies, thus leaving a persistent gap between the clitoral bodies that grows over time. We demonstrate a vertical z plasty closure to provide a 2 layer closure of the mons that decreases tension and improves cosmetic appearance by recreating a clitoral hood that provides a more normal appearance of the external genitalia for girls with bladder exstrophy.

Anatomy of the bulbus vestibuli: A cadaveric study

BackgroundTo describe the BV anatomy in detail, to compare previous BV descriptions and illustrations to the current study’s findings and photograms, to show the BV topographic relation of the BV to the urethral meatus, to document the BV anatomy using photograms. MethodsTen fresh human female adult cadavers were used. Stratum-by-stratum anatomical dissections in sagittal, transverse, and coronal planes were performed. The BV was dissected-off from the original location of the posterior-distal vaginal wall and the anterior anal wall. ResultsThe BV was located within the posterior-distal vagina and composed of two vertical legs, which fused to one another. The inferior pars intermedia fused both descending legs to the anterior-proximal perineal urethral wall, and BV embraced the anterior-proximal urethra. The superior pars intermedia connects the BV to the posterior-distal clitoral body. The BV legs traversed parallel to and aside from the vaginal introitus and the lateral urethra and not crossing the anterior-distal urethra. The tile-end was a tapered end which terminates in the vicinity of Bartholin glands. Laterally, the BV legs outspread to the medial labia minora and attach to the ischiopubic ramus. The anatomical site-specific defect (s) occurs within the BV. ConclusionsThe present study resolves the BV anatomical controversy and shows that the BV runs parallel to and aside from the anterior-distal urethra and the BV. The site-specific defect(s) can occur within the BV. This study provides important information for anatomy educators and surgeons.

Distance Between Reproductive Structures and the Insertion Point of the Retrograde Pubic Ramus Screw.

To identify the distance between the guidewire for a retrograde pubic ramus screw and critical reproductive structures in men and women. Twenty hemipelves from 10 fresh-frozen cadavers (pelvis to distal femur) were studied. The mean (±SD) age was 77 ± 6 years for the 5 male cadavers and 71 ± 9 years for the 5 female cadavers. A 2.8-mm guidewire for a cannulated screw was inserted from the parasymphyseal bone using fluoroscopic guidance. The soft tissue was dissected and measurements performed by the first author. In men, we measured the closest distances from the guidewire entry point to the contralateral spermatic cord and corpus cavernosum. In women, we measured the closest distances from the guidewire entry point to the base of the clitoral body and clitoral glans. In male cadavers, mean distances were 8.8 ± 4.2 mm to the spermatic cord and 13 ± 6.7 mm to the corpus cavernosum. The guidewire did not penetrate these structures in any specimen. In female cadavers, mean distances were 12 ± 5.7 mm to the base of the clitoral body and 40 ± 8.2 mm to the clitoral glans. The guidewire also did not penetrate these structures. The contralateral spermatic cord and corpus cavernosum in men and the base of the clitoral body in women are close to the pathway of the retrograde ramus screw guidewire. Careful identification of the entry point and avoidance of multiple attempts of guidewire insertion may reduce the risk of injury to these structures.

V09-09 THE RICHARD GRADY MONSPLASTY

INTRODUCTION AND OBJECTIVE: Classic bladder exstrophy in the female results in an exstrophic bladder and urethra, an anterior introitus with a bifid clitoris, and short labia minora. During closure, the lower abdominal wall is closed and the bifid clitori are brought into close apposition, but are often not completely closed to prevent injury to the clitoral bodies. The lower abdominal wall is often under tension, leading to gradual spreading of the distance between the clitoral bodies. We demonstrate a vertical z plasty closure to provide a 2-layer closure of the mons that decreases tension and improves cosmetic appearance of the female external genitalia by creating a clitoral hood. METHODS: This technique was developed as part of an international collaboration focused on the repair of bladder exstrophy and epispadias. After closure of the lower abdominal fascia, 2 lateral incisions are made just superior to the clitoral bodies. The inferior edges of these incisions are re-approximated in the midline in a subcuticular fashion with absorbable monofilament suture, thus forming the deep, posterior ledge of the skin closure. Next, the superior cut edges are re-approximated in a similar fashion, creating the superior/outer ledge of the mons. This closure is then extended and joined with the abdominal skin closure. RESULTS: This technique has been used as an adjunct in newborn primary closures and in older patients who present for cosmetic revision. The extension of the mons to create a clitoral hood eliminates the appearance of a protruding bifid clitoris. There have been no wound infections, skin breakdowns, or early clitoral separations. CONCLUSIONS: The vertical Z-plasty closure of the mons creates a more normal appearance of the external genitalia of girls with bladder exstrophy and epispadias by developing a clitoral hood, while also providing a robust, multi-layer closure that decreases tension and the risk of wound dehiscence. Source of Funding: None

Anatomical Dissection of the Dorsal Nerve of the Clitoris.

The clitoris is the primary somatosensory organ of female sexual response. Knowledge of its neural anatomy and related landmarks is essential for safe genital surgery. The aim of this study was to describe the distal course of the dorsal nerves of the clitoris and associated structures. Clitorises of 10 fresh cadavers were dissected. Measurements of the dorsal nerves, suspensory ligament, clitoral body, clitoral hood, and clitoral glans were obtained. The course of the dorsal nerves was examined. The dorsal nerves of the clitoris were larger than expected, ranging from 2.0 to 3.2 mm in diameter, on average, along their course in the clitoral body. In 9 of 10 specimens, the dorsal nerves could be traced to within 6 mm of the glans. They traveled deep to a superficial clitoral fascia but superficial to the tunica albuginea, were variably located between 10 and 2 o'clock, and were separated by the deep suspensory ligament (DSL) of the clitoris. The mean length of the descending clitoral body, from the angle to the base of the glans, was 37.0 mm. The mean distance from the pubic rim to the DSL was 37.7 mm. The clitoral body is substantial in length, mostly lying superficially under the clitoral hood and mons pubis. The dorsal nerves of the clitoris are large and superficial, terminating at or near the base of the clitoral glans. Knowledge of this anatomy is critical prior to performing surgery near the clitoris.

Anatomy, histology, and nerve density of clitoris and associated structures: clinical applications to vulvar surgery

A precise understanding of structures comprising the female external genitalia is essential in obstetric and gynecologic practice. To further characterize the anatomy, histology, and nerve density of the clitoris and associated structures, and to provide clinical correlations to vulvar surgery. Unembalmed female cadavers were examined. The length and width of the body, glans, and crura of the clitoris were measured. Distances from the glans to the urethra and from the dorsal surface of the clitoral body to the mid pubic arch were recorded. The path of the dorsal nerve of the clitoris was examined, and the nerve width was measured as it emerged from the lateral surface of crura and at the distal clitoral body. Distances from where the dorsal nerve emerged from the perineal membrane to the posterior surface of the membrane and to mid pubic arch were measured. Connective tissue layers associated with the clitoris were examined. Tissue was harvested from additional unembalmed cadavers, and nerve density of the labia minora, glans, and clitoral body were analyzed. Histological examination was performed on vulvar structures to clarify tissue composition. Descriptive statistics were used for data analyses. A total of 27 cadavers (aged 48-96 years) were examined, 22 grossly and 5 histologically. The median length and width of clitoral body were 29 mm (range, 13-59 mm) and 9 mm (range, 5-14 mm), respectively. The glans was 8 mm (range, 5-12 mm) long and 4 mm (range, 3-10 mm) wide. The length of the crura was 50 mm (range, 25-68 mm), and the width at the anterior portion was 9 mm (range, 2-13 mm). The closest distance from the glans to the urethra was 25 mm (range, 14-37 mm) and from the clitoral body to the mid pubic arch was 29 mm (range, 14-46 mm). The widths of the dorsal nerve at the lateral crura and at the distal clitoral body were 3 mm (range, 2-4 mm) and 1 mm (range, 1-2 mm), respectively. The distance from the dorsal nerve as it emerged from the perineal membrane to the mid pubic arch was 34 mm (range, 20-48 mm) and to the posterior surface of the membrane was 20 mm (range, 8-31 mm). The dorsal nerve and artery of the clitoris coursed adjacent to the medial surface of the inferior pubic ramus surrounded by a dense fibrous capsule adherent to the periosteum. The nerve and artery then coursed deep to dense connective tissue layers, which were contiguous with the suspensory ligament and fascia of the clitoris. Histologic examination revealed the presence of erectile tissue in the clitoral body, crura, and vestibular bulbs, but such tissue was absent in the glans and labia minora. Nerve density analysis revealed statistically significant greater density in the dorsal compared with ventral half of the clitoral body. Although not statistically significant, there was increased nerve density in the distal compared to the proximal half of the labia minora. Precise knowledge of clitoral anatomy and associated neurovascular structures is essential to safely complete partial vulvectomies, clitoral and vulvar reconstructive procedures, anti-incontinence surgeries, and repair of obstetric lacerations. Understanding the range of anatomic variations and awareness of the areas of increased nerve density is important during counseling and surgical planning. Although the dorsal nerve of the clitoris courses deep to dense connective tissue layers, inadvertent injury may occur in the setting of deep dissection or suture placement. The dorsal nerve seems most vulnerable with surgical entry or lacerations that extend from the midline of the prepuce to the inferior pubic rami.

Functional Morphology of the Dolphin Clitoris

Dolphins copulate year‐round despite short estrus periods. Copulation may be pleasurable for female dolphins through clitoral stimulation, as they have large and well‐developed clitorises. Although female mammals possess a clitoris homologous to the penis, the general structure and functional morphology has only been described in a few species. We explore the gross morphology and microanatomy of the common bottlenose dolphin (Tursiops truncatus) clitoris at different developmental stages to assess the potential for erectile tissue to expand during copulation. Excised clitorises were collected opportunistically from eleven post‐mortem dolphins including adults, subadults, and calves. Specimens were subdivided for use in: 1) gross morphology dissections, 2) micro‐computed tomography scans, or 3) paraffin histology and staining (modified Mason's trichrome and hematoxylin and eosin). Erectile tissue was present consistently along the clitoral body that extended from the hood tip to the base. The erectile tissue had a forked shape and similar relative volumes in both the calf and subadult specimens. The erectile tissue was surrounded by a thick layer of smooth muscle along the lateral sides of the crurae, clitoral body, and hood, but not cranially or caudally. Muscle tissue was surrounded by connective tissue. There was a hard bulb with a capsule around it at the root of the clitoris proper that was comprised of dense connective tissue. It appeared to be structural rather than erectile or secretory in nature. Our data provide a baseline for comparisons with other species known to have sex for pleasure (e.g., humans). The consistent shape and relative volumes of erectile tissues between calves and subadults suggest there are few developmental changes except for allometric size increases. Future research that compares the density of connective tissue in cetaceans and other marine and terrestrial mammals may be able to yield insights if the unexpectedly dense tissue of the dolphin clitoris is an adaptation driven by natural selection or sexual selection.Support or Funding InformationThis research was funded by the American Association of Anatomist Short‐term Visiting Scholarship to D.N.O. and a faculty grant from Mount Holyoke College to P.L.R.B.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor

BackgroundThe effects of phosphodiesterase-type 5 (PDE5) inhibitors on the in vivo clitoral structure of women with diabetes have never been investigated. AimTo study the in vivo structural and hemodynamic changes of the clitoris in premenopausal women with type 1 diabetes on PDE5 inhibitors. Methods38 premenopausal women with type 1 diabetes aged 36 -46 years. A randomized 1:1 study design was used: Study Group (group A) on Tadalafil 5 mg daily, and control group (group B). Blood samples were taken from each woman to measure HbA1c, testosterone, and Free Androgen Index. The women underwent microbiopsy of the clitoral body by means of semiautomatic gun during total anesthesia for surgery therapy of a benign gynecological pathology. The tissue removed was processed for electron microscopy. Translabial color Doppler ultrasound was used to measure the peak systolic velocity (PSV), the end diastolic velocity (EDV), and the pulsatility index (PI) of clitoral arteries. Main Outcome MeasuresMicro-ultrastructure observation of clitoral tissue and color Doppler sonography of clitoral blood flow. ResultsOf the 38 women, 13 (68.4%) of group A and 15 (78.9%) of group B completed the study. Group A showed a mean PSV and EDV increase, and a mean PI decrease with respect to baseline (P < .001). Group B did not show any change in both the parameters (P = NS). By a quantitative study in both groups a variable degree of ultrastructural abnormalities of smooth muscle cells (SMCs) was observed, consisting in increased glycogen and lipoic deposits, cytoplasmic vacuoles, and focal increase of electron density of SMCs. Moreover, the mean SMC thickness of group A (1.83 ± 0.68 µm) was larger than that of group B (1.3 ± 0.41 µm) (P = .02). Clinical ImplicationsPDE5 inhibitors could be used to treat diabetic women with genital arousal disorder. Strengths & LimitationsThe study shows a clear effect of PDE5 inhibitors on clitoral SMCs. However, a limit was to not have investigated the sexual function/behavior of women of both groups, this was because of the short time of the study. ConclusionThis study could help to understand in what way PDE5 inhibitors act on the ultrastructural pathophysiological clitoral cavernous tissue of women with diabetes. It could support PDE5 inhibitor usage in women with genital sexual arousal disorder due to metabolic diseases.Caruso S, Cianci A, Cianci S, et al. Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor. J Sex Med 2019;16:375–382.

Novel Observations of Female Genital Anatomy in Classic Bladder Exstrophy Using 3-Dimensional Magnetic Resonance Imaging Reconstruction

Understanding the distinct female anatomy in classic bladder exstrophy is crucial for optimal reconstructive and functional outcomes. We present novel quantitative anatomical data in females with classic bladder exstrophy before primary closure. 3-Dimensional reconstruction was performed in patients undergoing pelvic magnetic resonance imaging, and pelvic anatomy was characterized, including measurements of the vagina, cervix and erectile bodies. We examined magnetic resonance imaging of 5 females (mean age 5.5 months) with classic bladder exstrophy and 4 age matched controls (mean age 5.8 months). Mean distance between the anal verge and vaginal introitus was greater in patients with classic bladder exstrophy (2.43 cm) than in controls (1.62cm). Mean total vaginal length in patients with classic bladder exstrophy was half that of controls (1.64 cm vs 3.39 cm). All 4 controls had posterior facing cervical ora, while 4 of 5 females with exstrophy had anterior facing cervical ora located in the anterior vaginal wall. Lateral deviation of the cervical ora was also seen in all 5 patients with classic bladder exstrophy but in only 1 control. Clitoral body length was comparable in both groups (26.2 mm and 28.0 mm). However, the anterior cavernosa-to-posterior (pelvic rami associated) cavernosa ratio was much greater in patients with classic bladder exstrophy (6.4) compared to controls (2.5). This study uncovers the uniquely novel finding that contrary to their male counterparts, females with classic bladder exstrophy have the majority of the clitoral body anterior to the pelvic attachment. This discovery has surgical and embryological implications.

Morphometric and Vascular Modifications of the Clitoris During Pregnancy: A Longitudinal, Pilot Study.

During pregnancy, women go through a series of physical and emotional changes that may have an impact on their sexuality. The aim of the study was to examine modifications in sexual function during pregnancy by means of translabial ultrasonography and administration of questionnaires on sexual activity. Eighteen healthy and adult (25-35years) pregnant women without sexual dysfunction and with a stable heterosexual relationship were examined at 10-12, 18-20, and 30-32weeks of gestation. Patients underwent ultrasonographic translabial clitoral volume and labia minora thickness measurements and color Doppler assessment of the dorsal clitoral and posterior labial arteries. On the same day, each patient completed the two-factor Italian McCoy Female Questionnaire (MFSQ) and the Female Sexual Function Index (FSFI). The mean clitoral body volume progressively increased during pregnancy, and color Doppler analysis of the dorsal clitoral artery showed a significant decrease in the pulsatility index from the first to the third trimester. Similarly, the labia minora thickness increased and the posterior labial artery pulsatility index progressively decreased throughout gestation. The MFSQ score for sexuality and partnership and the number of intercourses/week did not significantly change during the study period. However, the MFSQ score for partnership reached the lowest value in the third trimester of pregnancy. Analysis of the FSFI data showed no significant differences throughout pregnancy for the majority of the domains (sexual desire, arousal, orgasm, lubrication, and pain), with the exception of the satisfaction item, which decreased during the third trimester. A significant proportion of women are concerned that changes in their body during pregnancy may have a detrimental effect on sexuality. Despite significant changes in genital morphology and vascularity throughout gestation, these modifications do not seem to have an impact on sexual function in pregnancy.

Female sexual function and the clitoral complex using pelvic MRI assessment

ObjectiveTo report basic measurements of clitoral anatomy, and explore potential relationships between the clitoral complex and female sexual function using MRI assessment. Study designIn this retrospective descriptive study, 20 sexually active women (≥18 years) who had a recent pelvic MRI for various gynecologic concerns were invited to participate. Outcome measures included demographic data, medical and sexual history, quality of life questionnaires: Female Sexual Function Index (FSFI), Body Exposure during Sexual Activities Questionnaire (BESAQ), and Short Form Quality of Life Questionnaire (SF-12). These data were then compared to detailed clitoral MRI measurements and analyzed using the Pearson correlation and Chi square test. ResultsFSFI domains of desire, arousal, lubrication, and orgasm were inversely correlated with clitoral size (p=0.01–0.04), as were SF-12 physical composite scores (p=0.003), suggesting improved sexual function and physical health in women with smaller clitoral structures (specifically the clitoral body and crus). ConclusionSexual function was improved in women with a smaller-sized clitoris, specifically the clitoral body and crus.

Body Imaging and Sexual Behavior in Lean Women with Polycystic Ovary Syndrome

In women with polycystic ovary syndrome (PCOS), changes in body appearance may influence the feminine identity of the patients with possible consequent depression and sexual dysfunction. The study aims to examine the differences in mood, perceived body image, sexual behavior, and clitoral vascularization between lean PCOS patients and healthy eumenorrheic controls. Thirty-three lean PCOS women (Group I) and 22 healthy nonhirsute volunteers (Group II) were submitted, on day 3-5 of the cycle, to ultrasonographic (US) and Doppler analyses, to clinical, hormonal, and biochemical evaluations, and to psychometric tests. Main outcome measures are Ferriman-Gallwey score (FG), clitoral volume, clitoral artery Pulsatility Index, the two-factor Italian McCoy female questionnaire (MFSQ), the Stunkard Figure Rating Scale (FRS), and the Beck Depression Inventory (BDI) questionnaire. The FG score and the androgens resulted, as expected, more elevated in PCOS patients than in controls. However, the US assessment of the clitoral body volume and the resistances registered at the level of the dorsal clitoral artery did not show any difference between Group I and Group II patients. Moreover, the two-factor Italian MFSQ, the FRS, and the BDI were similar in both groups. It seems that in lean PCOS women, the moderate hirsutism and hyperandrogenism do not have any important influence on body image and self-esteem and, as a consequence, on sexual function.