Clitoris Research Articles

Could Hormone Levels Impact the Severity of Clitoral Phimosis?

ABSTRACT Introduction Clitoral adhesions (CA) occur when the prepuce adheres to the glans clitoris. CA can be classified as mild, moderate, or severe, based on if more than 75%, 25% to 75%, or less than 25% of the glans clitoris is exposed. Symptoms of CA include pain, difficulty with arousal, and muted or absent orgasm. There is a paucity of information on how hormone levels may contribute to the formation of CA. We hypothesize that patients with lower levels of free and total testosterone, and higher levels of the blood transport protein sex hormone binding globulin (SHBG) could have more severe adhesions. Higher free and total testosterone can yield more oily skin, which may break up or prevent adhesions. Additionally, with higher SHBG, there is less free testosterone available to be used by tissues in the body. Objective To determine if patients with lower free and total testosterone, and higher SHBG have more severe adhesions. Methods Charts of females with CA who underwent the non-surgical lysis procedure at one sexual medicine practice were considered for this study. 24 charts contained information on the severity of phimosis before lysis, total and free testosterone levels, as well as SHBG levels around the time of lysis. The study group consisted of patients with mild (n=9), moderate (n=8), or severe (n=7) CA. Results The average calculated free testosterone among patients with mild, moderate, and severe CA was 0.23ng/dL, 0.35ng/dL, and 0.14ng/dL. The average total testosterone among patients with mild, moderate, and severe CA was 24.79ng/dL, 27.81ng/dL, and 20.26ng/dL. The average SHBG among patients with mild, moderate, and severe CA was 98.69nmol/L, 95.76nmol/L, and 109.40nmol/L. Conclusions We predicted that patients with more severe adhesions would have lower levels of free and total testosterone, as well as higher levels of SHBG, yet this trend did not appear overall in this data among patients with mild, moderate, or severe adhesions. Additional studies with larger sample sizes are needed to explore the potential impact of free and total testosterone, as well as SHBG levels on the development and severity of CA. Studies could also compare levels of these hormones in patients with and without adhesions, or consider patients with recurrence of adhesions. Insight into a hormonal etiology could be important to patients with altered levels of these hormones - for example, patients with medical conditions such as PCOS, patients taking medications such as oral contraceptive pills, and menopausal women on oral estrogen (as increased estrogen raises levels of SHBG) could be at an increased risk for developing CA. Further studies could also consider if the clitoides of transgender males on gender-affirming hormone therapy with testosterone have lower incidences of CA. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

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

Improvement in the Ability to Orgasm after the Non-Surgical Lysis Procedure for Clitoral Adhesions

ABSTRACT Introduction Clitoral stimulation is an essential component of the orgasm experience for many women during sexual intercourse. Stimulating the clitoris indirectly stimulates other parts of the genital area, including the vagina, and ultimately affects the ability to have an orgasm experience. In a 2017 study looking at women's experiences with genital touching, sexual pleasure, and orgasm by Herbenick et al, 36.6% of women noted clitoral stimulation was necessary for orgasm and another 36% of women indicated that even though clitoral stimulation was not required it did make orgasms feel better. Clitoral adhesions (CA) can be associated with the inability to reach orgasm with clitoral stimulation. CA occur when the prepuce adheres to the glans clitoris leading to discomfort, hypersensitivity/hyposensitivity, and chronic vulvodynia. Two lysis of CA treatment modalities exist - one surgical procedure and one non-surgical office-based procedure that stretches the preputial tissue open. There are no studies that explore the ability of the non-surgical lysis of CA procedure to improve a woman's ability to achieve orgasm with external clitoral stimulation. Objective The aim of this study is two-fold: 1) to evaluate the characteristics of women who were not able to orgasm with external clitoral stimulation prior to the non-surgical lysis of CA procedure and 2) to evaluate patient satisfaction and outcomes of the non-surgical lysis of CA procedure in these same women. 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 an IRB-approved retrospective chart review. An online survey was sent to these patients to evaluate the efficacy of the procedure in improving pain and sexual functioning, as well as patient satisfaction with the procedure. Results 41 women participated in the study (67% response rate) and 16 (39%) of them could not achieve orgasm with external clitoral stimulation prior to the non-surgical lysis of CA procedure. Of those 16 women who could not achieve orgasm from external clitoral stimulation, 6 (38%) were able to do so after the non-surgical lysis of CA procedure. Of these 6 women prior to the procedure, 67% had a diagnosis of vulvodynia/vestibulodynia, 67% reported discomfort or pain during sexual activity that involves physical touch of the vulva, and 83% reported lack of clitoral sensation. Unfortunately, 50% of these women who were able to orgasm with clitoral stimulation after the procedure did lose this ability over time. Nonetheless, 83% were extremely satisfied with the procedure and 100% would recommend it to a friend who also had CA. Conclusions The non-surgical lysis of CA procedure may be a worthwhile option for women who are unable to achieve orgasm with external clitoral stimulation. Of note, many of these women with CA who were unable to orgasm with clitoral stimulation also had pain or discomfort with sexual intercourse which may exacerbate the problem. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Clitoral Phimosis Should Have its own Diagnostic and Procedural Codes

ABSTRACT Introduction Clitoral phimosis occurs when the prepuce adheres to the glans clitoris. Similarly, penile phimosis occurs when the prepuce adheres to the glans penis. Symptoms of clitoral phimosis can include pain, difficulty with arousal, and muted or absent orgasm. While previous studies on the prevalence of clitoral phimosis in a group of 589 college students in a health clinic was 33%, and in a population of 614 patients with sexual dysfunction, it was 23%. There are no diagnosis codes (ICD codes) or procedure codes (CPT codes) for clitoral phimosis or the lysis procedure for clitoral phimosis. Proper codes ensure that patients receive adequate treatment and are charged appropriately for medical services. Objective To determine the efficacy and patient satisfaction of the office-based lysis of clitoral phimosis procedure and to demonstrate that clitoral phimosis should have its own diagnosis and procedure codes. Methods To evaluate the efficacy and patient satisfaction of the lysis procedure, survey responses from 41 females who underwent the lysis procedure for clitoral phimosis from one sexual medicine practice were analyzed. The survey was sent to 61 patients and 41 responded (67% response rate). Results Among participants who reported pain as a symptom of phimosis (n=25), 76% saw an improvement in pain, with 44%, 28%, and 4% reporting significantly, moderately, or slightly reduced pain. Among those who reported difficulty with arousal before the procedure (n=40), 62.5% saw improvement, with 25%, 25%, and 12.5% considering it to be significantly, moderately, or slightly easier to become aroused. Among those who reported difficulty achieving orgasm before the procedure (n=39), 64% saw improvement, with 25.6%, 17.9%, and 20.5% reporting that they found it significantly, moderately, or slightly easier to achieve orgasm. All women who reported the ability to orgasm from external clitoral stimulation maintained this ability after the procedure (n=24). Of the women that could not orgasm before the procedure (n=16), 6 were able to afterward. 92.7% would recommend the procedure to a friend who had phimosis. Conclusions These findings show that most patients reported improvement in their pain and sexual function, and no patient reported a loss of functioning or worsening of symptoms. The lysis procedure should be recognized as a treatment for pain and sexual dysfunction associated with clitoral phimosis. The routine management of clitoral phimosis in clinical practice should be reflected in diagnosis and procedure codes, which currently do not exist. The lack of proper codes creates a barrier to diagnosis and treatment of clitoral phimosis. If doctors use the ICD code for phimosis, it is rejected by insurance - the codes for “phimosis” and “balanitis” are only designated for male patients. Proper codes support the importance and medical necessity for performing the lysis procedure, and would help communicate a patient's health to other healthcare providers, specialists, insurance payers, and data registries. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout, Absorption Pharmaceuticals

Patient Satisfaction of the Non-Surgical Lysis Procedure for Clitoral Adhesions in Patients with and without Lichen Sclerosuas

ABSTRACT Introduction Lichen sclerosus (LS) is a chronic, inflammatory skin disorder in the anogenital region typically found in prepubertal or postmenopausal women that causes skin thinning, whitening, wrinkling, itching, and pain. LS is an established risk factor for the development of clitoral adhesions (CA). CA occur when the prepuce adheres to the glans clitoris leading to discomfort, hypersensitivity/hyposensitivity, difficulty reaching orgasm, and chronic vulvodynia. However, CA can also occur in the absence of LS. Two lysis of CA treatment modalities exist - one surgical procedure and one non-surgical, office-based procedure that stretches the preputial tissue open. Previous studies explored LS patient satisfaction with surgical lysis or dorsal-slit surgery but not with the non-surgical approach. The non-surgical office-based procedure has also never been studied in patients without LS. Objective The aim of this study is two-fold: to evaluate patient satisfaction and outcomes of the non-surgical lysis of CA procedure in women with LS and to compare the efficacy of the procedure in patients with and without LS. 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 retrospective chart review. An online survey was sent to these patients to evaluate the efficacy of the procedure in improving pain and sexual functioning, as well as patient satisfaction with the procedure. Results 41 women participated in the study (67% response rate) and 5 had a diagnosis of LS that was optimally treated with high-potent steroids. In terms of procedure satisfaction, there was no significant difference in patient satisfaction (80% vs 83%) or the likelihood of recommending the procedure to a friend who also had CA (80% vs. 94%) among women with and without LS. In regards to improving sexual functioning, there was no significant difference in the procedure's ability to improve sexual arousal (80% vs. 60%), ability to orgasm (80% vs. 62%), and sexual satisfaction (60 vs. 72%) between women with and without LS. Finally, there was no significant difference in reporting the procedure was painful (40% vs. 25%) or the incidence of recurrence of adhesions (40% vs. 51%). Conclusions This study demonstrates high patient satisfaction and improvement in sexual functioning associated with the non-surgical lysis procedure for CA in women with and without LS. CA should not be considered as an adjunct side-effect of LS but as an independent pathology. Physicians should examine the clitoris in women with and without LS in order to determine if a patient has CA. Once diagnosed, the non-surgical lysis procedure has similar efficacy and patient satisfaction in women with and without LS and could be considered as a treatment option for improving sexual function in women. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Clitoral Dysesthesia Following Suprapubic Liposuction: A Case Report of Injury to the Nerves Adjacent to the Clitoris

ABSTRACT Introduction Clitorodynia is a bothersome genito-pelvic dysesthesia characterized by atypical sensations such as burning, stinging, and/or sharp pain confined to the glans clitoris, common clitoral shaft and/or prepucial (hood) area that may be constant, intermittent or occurring only when provoked. Clitorodynia, like other genito-pelvic dysesthesia conditions, may result from a trigger in the end organ (clitoris), pelvic/perineum (pudendal/pelvic nerve neuropathy), cauda equina (Tarlov cyst, annular tear), spine, or brain. While the primary sensory nerve of the clitoris is the dorsal nerve, there are sensory nerves adjacent to the clitoris in the suprapubic area. A 55 year old woman who presented to our sexual medicine clinic for evaluation of clitoral dysesthesia following a suprapubic liposuction in May 2016. She described a 5 year history of unusual, unwanted, unrelenting sensations that felt weird, electrical, uncomfortable, and "nervy", were located to the left side of her clitoris/upper left inner labia, were present all the time at a minimum 5/10 intensity increasing to 7-8/10 that prevented her from focusing on tasks, including sexual activity. Objective We herein describe our evaluation and management of this patient with clitoral genito-pelvic dysesthesia. Methods The evaluation involved a detailed biopsychosocial assessment including: medical history; psychologic assessment; hormone assessment; vulvoscopy with cotton-tip swap testing; neurogenital testing for assessment of the integrity of the pudendal and sciatic nerves; and left clitoral/left inner labia anesthesia testing to assess for clinically significant symptom reduction. Results History was positive for diabetes mellitus, hypercholesterolemia, hypertension, abdominoplasty surgery (2007) and L5-S1 fusion (2010). Physical examination using vulvoscopy with cotton-tip swab testing revealed a focal region of dysesthesia (∼ 4 cm long, ∼2 cm wide) to the left of the clitoris and left upper inner labia associated with significant tenderness (7/10). Pudendal nerve integrity testing was normal. Sciatic nerve integrity testing was abnormal consistent with her previous spine surgery. Cotton-tip swab testing after focal anesthesia of the region of dysesthesia with benzocaine 20%, lidocaine 8% and tetracaine 6% revealed a clinically significant symptom reduction to pain free (0/10). Conclusions Clitoral dysesthesia can occur from injury to the nerves adjacent to the clitoris. This is a case of clitoral genito-pelvic dysesthesia in the end organ following a liposuction procedure to the suprapubic area. The most likely trigger was iatrogenic neuropathic injury of the left anterior labial branch of the genital branch of the genitofemoral nerve and/or left anterior labial branch of the ilioinguinal nerve. These latter nerves course in the suprapubic area and do not innervate the clitoris itself. Nerve testing of the clitoris, innervated by the dorsal nerve branch of the pudendal nerve, was unremarkable. Proposed management of the clitoral dysesthesia will focus on treating the iatrogenic peripheral neuropathy in the end organ and include perineural 5% dextrose injections, low intensity shockwave treatments, platelet rich plasma injections, and/or steroid injections. Disclosure No

Clinical Presentation of Clitorodynia associated with Clitoral Adhesions and Keratin Pearls

ABSTRACT Introduction Clitoral adhesions occur when the clitoral prepuce adheres to the glans clitoris. This can lead to accumulation of desquamated epithelial cells under the prepuce, resulting in the formation of smegmatic pseudocysts and keratin pearls. A keratin pearl is a focus of central keratinization within concentric layers of squamous cells. Presence of these firm, millimeter-sized masses can lead to clitoral pain (similar to a grain of sand in the eye). Although keratin pearls have been described in the literature, there is little known about their clinical presentation or association with female sexual dysfunction (FSD). Objective Explore the clinical presentation of clitoral pain associated with clitoral adhesions and keratin pearls related to concomitant genitopelvic pain conditions and sexual dysfunction. Methods A retrospective chart review was conducted in two metropolitan gynecology clinics specializing in vulvar pain between January 2018 and September 2021. Patients presenting with clitoral pain (clitorodynia) were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed by review of the clinical notes. Adult patients with documented clitoral pain as well as clitoral adhesions (clitoral phimosis) and keratin pearls noted on exam were included in the study. FSD was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Data was presented in means and percentages. Results Forty-one patients met inclusion criteria. Average age at presentation was 35 years (range 19-73 years). Self-reported ethnicity of the study population was 73% White, 5% Hispanic, 5% Asian, 2% Black, with no response from 15% of participants. Vulvar lichen sclerosus was noted in 17% (7/41) of patients, with an average age of 46 years (range 24-73 years). Seventy-six percent (31/41) of patients also had the diagnosis of overactive (hypertonic) pelvic floor muscle dysfunction (PFD), 25% (8/31) had pudendal neuralgia and 10% (3/31) had interstitial cystitis/painful bladder syndrome. Forty-six percent (19/41) of patients had provoked vestibulodynia (PVD) associated with a hormonal factor (hormonal contraceptive use, postpartum/breastfeeding, perimenopause, or menopause). Recurrent vulvar candidiasis or tinea cruris was noted in 5% of patients. Four patients (10%) presented with clitoral pain alone and were not found to have other identified genitopelvic pain conditions. Baseline FSFI and FSDS-R data were available in 35 patients. Mean FSFI score was 13.25, with 91% of patients meeting criteria for FSD (total FSFI score < 26.55). Mean scores for FSFI domains were: desire (2.4), arousal (2.1), lubrication (2.5), orgasm (2.0), satisfaction (2.5), and pain (1.6). Mean FSDS-R score was 29.42, with 89% of patients meeting criteria for FSD (FSDS-R score ³11). Conclusions Clitoral pain associated with clitoral adhesions and keratin pearls occurs in women of all ages. Clitoral adhesions are not confined to patients with vulvar lichen sclerosus. A vast majority of patients with clitoral adhesions and keratin pearls have additional chronic vulvar pain conditions, most commonly overactive PFD, pudendal neuralgia, or hormonally-associated PVD. Clitoral pain with clitoral adhesions and keratin pearls is associated with FSD and sexual distress. Clitorodynia and clitoral phimosis should be identified in the clinical evaluation of genitopelvic pain. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; part-time employee of Dare Bioscience. Received research funding from Dare Science, SST, Endoceutics, The Cellular Medicine Association, and Ipsen for other projects. He is a consultant for Ipsen, SST, and AMAG

A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions

Clitoral adhesions are characterized by adherence of preputial tissue to the glans clitoris and can be managed using a non-surgical approach in order to relieve symptoms of sexual dysfunction. To evaluate efficacy and patient satisfaction associated with the non-surgical lysis procedure in order to determine if it is an appropriate treatment for symptomatic clitoral adhesions. The non-surgical lysis procedure is performed by using a fine Jacobsen mosquito forceps to separate the plane between the prepuce and the glans of the clitoris, removing smegma and/or keratin pearls from underneath the adhesions and allowing for visualization of the entire glans. A chart review of 61 women that were treated for clitoral adhesions using the non-surgical lysis procedure at 1 sexual medicine practice was performed and an online survey was sent to these patients. Encrypted survey responses were used to evaluate patient satisfaction as well as self-reported improvement in sexual functioning and pain before and after the procedure. 41 survey responses were received out of 61 eligible (67% response rate). A large majority reported improvement in pain (76%), sexual arousal (63%), and ability to achieve orgasm (64%) and no participants reported worsening in these symptoms. Of the 16 women that reported the inability to orgasm from external clitoral stimulation prior to the procedure, 6 (38%) were able to do so afterwards. Seventy-one percent of respondents reported improvement in their satisfaction with sex and 83% reported being satisfied with their decision to have the procedure. Ninety-three percent of participants reported that they would recommend this procedure to a friend with clitoral adhesions. The results of this study will help clinicians to recognize the non-surgical lysis procedure as a treatment option for clitoral adhesions. This study is the first of its kind assessing a cohort of patients undergoing the non-surgical lysis procedure for clitoral adhesions. Its limitations include a small sample size from 1 clinic and lack of validated instrument to evaluate sexual function and pain before and after the procedure. Providers should regularly examine the clitoris of patients with symptoms of sexual dysfunction in order to determine if they have clitoral adhesions. The non-surgical lysis procedure may be a viable therapeutic option for these patients that has demonstrated both satisfaction and symptom relief. Myers MC, Romanello JP, Nico E, et al. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. J Sex Med 2022;19:1412-1420.

Revision Clitorolabiaplasty and Urethroplasty After Gender-Affirming Vaginoplasty

ABSTRACT Introduction Gender-affirming vaginoplasty was historically a two-stage procedure with secondary labiaplasty after the initial vaginoplasty. Techniques have evolved into what is now generally a single stage procedure, however some patients may still require revision surgery for cosmetic or functional reasons. Additionally, as with any urethral procedure, patients may develop issues with their urinary stream requiring repeat surgery. Objective The patient is a 51-year-old transgender woman. She underwent robotic-assisted peritoneal flap vaginoplasty in the summer of 2020. Her post-operative course was complicated by recurrent infections. Once the infections had settled and the surgical site was well healed, she had persistent complaints of flat labia majora, overly exposed clitoris causing hypersensitivity, as well as spraying of her urinary stream. We aimed to demonstrate that minor revisions with urethroplasty to relocate the urethral meatus inferiorly as well as securing the clitoris in a more inferior position and bringing the labia together in the midline can provide coverage for the clitoris, more aesthetic appearance of the vulva, and an excellent functional outcome. Methods We first performed the urethroplasty. We began with cystoscopy to identify the level of the external sphincter which was marked externally on the skin. We then incised the skin in the midline starting at the level of the current urethral meatus and extending inferiorly for approximately 2cm. Skin flaps were mobilized off of the urethra bilaterally. The urethra was spatulated ventrally for approximately 1.5cm. The edges were oversewn with 3-0 Vicryl for hemostasis. The superior part of the spatulated urethra was sutured to the surrounding skin to form the lower edge of the vestibulum and provide further definition to the labia minora. The lower edge of the spatulation was sutured to the surrounding skin to become the new urethral meatus. We then turned our attention to the clitoroplasty and labiaplasty. The patient's clitoris was sitting high, over-exposed, and somewhat prolapsed after her initial vaginoplasty and post-operative infections. We started by making a circumferential degloving incision at the level of the glans clitoris. The skin was then carefully mobilized off of the clitoris. A midline incision was made inferior to the clitoris and the clitoris was secured to the vestibulum. A double Z-plasty was performed, in order to bring the labia majora together in the midline to provide better coverage for the clitoris. Results The procedure lasted 4 hours. There was minimal bleeding and no intra- / post-operative complications were encountered. She was discharged home on post-operative day one in good condition. The Foley catheter was left in place until post-operative day five. One month post-operatively, the patient reported resolution of urinary spraying, improved cosmesis, and better coverage for the clitoris. Conclusions Patients may not be satisfied with the cosmetic and functional results following gender-affirming vaginoplasty even if the vaginal canal itself is of adequate dimensions. Minor revisions can provide significant rewards in terms of improvements to the cosmetic appearance of vulva and lower urinary tract symptoms. Disclosure No

Mapping a Danger Zone of the Dorsal Nerve of the Clitoris: Implications in Female Cosmetic Genital Surgery.

The literature regarding the route of the dorsal nerve of the clitoris is sparse and lacks surgical focus. With an increasing number of procedures being performed on the labia, it is important to elucidate the route and note any variation from normal of the nerve. Fifty-one cadavers were dissected to yield 97 dorsal nerve of the clitoris samples. Measurements were taken from (1) the dorsal nerve of the clitoris penetration point of the perineal membrane to the urethra, (2) the nerve's penetration point of the perineal membrane to the pubic bone, (3) the angle of the clitoris to the branch point of the dorsal nerve of the clitoris, and (4) the branch point of the nerve to the distalmost point of the glans clitoris. Any anomalous branching patterns of the dorsal nerve of the clitoris were recorded and classified. The means and standard deviations of each measurement were used to create a surgical danger zone. The mean of each measurement was (1) 34.63 mm, (2) 5.74 mm, (3) -3.07 mm, and (4) 30.40 mm, respectively. In addition, six distinct branching patterns were observed, organized, and classified based on the location and number of branches observed. The dorsal nerve of the clitoris has multiple branching patterns and typically travels along the same course in most women. Further investigation of the course and three-dimensional position of the dorsal nerve of the clitoris is warranted to preserve sexual sensation as the frequency of procedures involving the female pudendum increases.

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 role of clitoral topography in sexual arousal and orgasm: transperineal ultrasound study

The clitoris has a critical pivotal role in female orgasm and arousal. The aim of this cross-sectional study was to evaluate topographic measurements of the clitoris, as well as to explore potential relationships between the clitoral complex and the orgasm domain of female sexual function, combining transperineal ultrasound with morphometric measurements. In sexually active, heterosexual, premenopausal women, three-dimensional transperineal ultrasound imaging was used to measure the subpubic angle, the anterior triangle area (ATA) of the genital hiatus, the levator urethra gap, and the anteroposterior and transverse diameters of the genital hiatus. Mons pubis thickness, clitoris-urethra distance (CUD), clitoris-fourchette distance, and fourchette-perineal body distance were measured using a caliper. Comparison of measurements and correlation with orgasm score were performed. Among the 108 sexually active women, 30 (27.7%) reported a low orgasm domain score. There were statistically significant differences between the low orgasm group and the control group in the ATA (4.05 vs 3.64cm2 respectively; p = 0.03), CUD (21mm; p = 0.04 vs 16.1mm; p = 0.04), and volume of the glans clitoris (947.7mm3 vs 1081mm3; p = 0.02). There was a moderate and inverse correlation between clitoris-urethra distance and orgasm (r = -0.53, p < 0.001), and arousal (r = -0.42 p < 0.001). Broader ATA (OR = 0.47; 95% CI = 0.23-0.99; p = 0.04) and longer CUD (OR = 0.57; 95% CI = 0.44-0.73; p < 0.001) were identified as the only independent predictors of orgasm problems. Longer glans clitoris-urethra distance and broad space for the deep structures of the clitoris is related to difficulty in reaching orgasm and arousal problems.

A Cadaveric Study of the Dorsal Nerve of the Clitoris: Mapping a 3D Danger Zone for Female Cosmetic Genital Surgery

Introduction The Dorsal Nerve of the Clitoris (DNC) innervates the clitoris and plays a major role in female sexual arousal. However, little research investigating the location of its terminal branches places them at risk of being severed during surgical procedures. For instance, the most common labiaplasty approach begins with an incision into the prepuce surrounding the glans clitoris. This area may house terminal branches of the DNC, leading to damage if severed. In this study we measured the distances of distal DNC branches from important surgical landmarks, as well as created a three-dimensional “danger zone,” which can be used by surgeons performing female cosmetic genital surgery. Methods A total of 19 female preserved cadavers were examined, yielding 38 DNC. The DNC was located by first making a shallow vertical incision from the pudendal cleft superiorly through the mons pubis. The body of the clitoris was located and the fascia surrounding the crura within the labia minora was carefully dissected to expose the DNC. The DNC was followed to its deepest point at the penetration of the perineal membrane, and was also followed superficially over the angle of the clitoris and toward the glans. The distal branches were carefully dissected to reveal the location at which the nerves penetrate the clitoris. Care was taken to not disturb the natural position and course of the nerves. Photographic evidence of each nerve was obtained, and various depth measurements were taken with Mitutoyo Absolute IP-67 digital calipers. Statistical analysis was conducted in Microsoft Excel. Results The distance from the distal-most DNC branch to the edge of the prepuce surrounding the clitoris was the most important and surprising measurement we obtained in this study. The mean distance was 10.80 mm (SD 5.31 mm). These terminal branches extend into the subcutaneous tissue of the prepuce (Figure 1), which serves as the initial incision point in the most common approach to the labiaplasty procedure. Without the ability to visualize the small distal DNC branches, surgeons operating in this area have a high risk of severing the nerves that provide sensation to the clitoris. As such, this reveals that surgeons performing surgeries in this region should avoid techniques involving excision of the clitoral hood. Another important measurement was the mean distance of the DNC as it passed over the angle of the clitoris to the edge of the labia minora, which was 30.35 mm (SD 6.44 mm). This measurement provides an understanding of the depth that the DNC travels within the labia minora, which is also relevant to labia excision in the labiaplasty procedure. Conclusion This study demonstrates that the most distal branches of the DNC extend further than expected, and terminate subcutaneously within the prepuce of the clitoris. This study also reveals the depth at which the DNC travels compared to the labia minora, which is an important depth for surgeons performing procedures in this region. While there is still much to be understood about the course of the DNC, these measurements are an important beginning to increasing the awareness of this region for female sexual health.

New method for early evaluation of clitoris innervation using clitoro-perineal reflex after feminizing genitoplasty in early childhood: a pilot-study

A major complication of feminizing genitoplasty in children is the loss of clitoral sensation with serious impact at adult life. We suggest a new method to evaluate the surgical results during childhood based on the bulbocavernosus or clitoro-perineal reflex (CPR). The afferent pathway of CPR implies the intact sensory receptors on the clitoral glans. Girls with congenital adrenal hyperplasia who were followed-up medically without surgery or who underwent feminizing genitoplasty with or without clitoroplasty were included (2002–2018). All clitoroplasties were standardized reduction clitoroplasty with preservation of neurovascular bundles associated with vaginoplasty and vestibuloplasty. Standardized examinations were prospectively performed including the CPR starting at one year postoperatively. The reflex was triggered by gentle touch of the glans by a cotton swab. Contraction of the perineal muscles was considered positive. Thirty-two children were operated at a median age of 8.6 months (5.8–12.1). Median follow-up (FU) was 3.9 years (1.3–6.4). Twenty-four patients had clitoroplasties: 17 were tested for CPR at one-year FU, and all had a positive test. Eight girls had genitoplasty without clitoral surgery, two of them were tested and were positive. Ten patients were managed without surgery, two of them were tested for the CPR and were positive. The reflex was always triggered easily and repeated at least twice during the FU. The clitoro-perineal reflex is a simple, non-invasive and reproducible test in early childhood and may serve as an early evaluation tool of clitoral innervation after feminizing genitoplasty. These results need to be confirmed at long term and completed at adult life.

Are you in pain if you say you are not? Accounts of pain in Somali-Canadian women with female genital cutting.

As a rite of passage to womanhood, 2 million girls undergo female genital circumcision (FGC)-the tradition of cutting, and often removing parts of the vulva-every year. The current study is the first to focus on the connection between peripheral nerve damage and chronic neuropathic pain in women with FGC. We used mixed methods-quantitative, qualitative, and physiological-to study chronic pain in Somali-Canadian women (N = 14). These women have the most extensive form of FGC, which includes removal of the glans clitoris, labia minora, medial portion of the labia majora, and stitching together the remaining parts of the labia majora. Our results indicate a multifaceted pain experience in women with FGC. Although they report good overall health and very low pain levels on the short form of the McGill Pain Questionnaire, pressure-pain quantitative sensory testing of the vulvar region applied through vulvalgesiometers shows pain thresholds consistent with those reported by women with chronic vulvar pain. Furthermore, qualitative interviews reveal a considerable amount of often debilitating pain in daily life. These results challenge the use of assessment tools offering elicited verbal pain language and highlight the importance of culturally sensitive ways of conceptualizing, measuring, and managing pain.

Mapping a Danger Zone of the Dorsal Nerve of the Clitoris: Implications in Female Cosmetic Genital Surgery

OBJECTIVE: Complications following labiaplasty procedures are understudied and underreported1 and could possibly include loss of sensation in the female pudendum.2 As the number of procedures each year increase,3 it is important to continue to explore ways to ensure positive outcomes for patients. The aim of this study was to determine variability in the course and branching of the dorsal nerve of the clitoris (DNC) and to generate a surgical safe zone. METHODS: Ninety-seven Cadavers from the University of Nebraska Medical Center, Creighton University, and Kansas City University anatomy labs were examined for this study. A shallow vertical incision was made from the pudendal cleft superiorly through the mons pubis. The glans clitoris was identified and used as a landmark while the fascia surrounding the body of the clitoris was carefully removed. The DNC was located where it pierces the perineal membrane and traced distally. The following measurements were taken: (1) from the point where the DNC pierces the perineal membrane to the urethra, (2) from the point where the DNC pierces the perineal membrane to the pubic bone, (3) from the angle of the clitoris to where the nerve branches on the dorsum of the body of the clitoris, and (4) from that branch point to the distal most portion of the glans clitoris. A subset of the population (n = 72) cadavers were examined for abnormal branching patterns, which were noted and characterized. All statistical data analyses were conducted through IBM SPSS. RESULTS: Thirty-five DNCs were characterized as anomalous in the branching pattern analysis. Type 1 was the typical DNC branching pattern (splits once into two terminal branches). Type 2 was distinguished by the presence of an early branch near where the DNC pierces the perineal membrane. Types 3–6 corresponded to the number of branches the DNC had (type 3 had 3 branches, etc). Finally, the measurements that were taken were used to generate a surgical safe zone, which can be used to avoid injury to the DNC during procedures involving the female pudendum. CONCLUSIONS: The findings of this study allowed the investigators to map out a surgical safe zone for procedures involving the female pudendum to avoid injury to the DNC and identify and classify anomalous branching patterns. This information should be useful to physicians performing procedures near the DNC to increase patient satisfaction and safety. Further research should be done into the DNC and outcomes of labiaplasties and other surgeries that could impact this nerve. REFERENCES: 1. Goodman MP. Outcomes. In: Goodman MP, ed. Female Genital Plastic and Cosmetic Surgery. First. John Wiley & Sons, Ltd.; 2016:206–211. 2. Runacres SA, Wood PL. Cosmetic labiaplasty in an adolescent population. J Pediatr Adolesc Gynecol. 2016;29:218–222. 3. Vieira-Baptista P, Almeida G, Bogliatto F, et al. International Society for the study of vulvovaginal disease recommendations regarding female cosmetic genital surgery. J Low Genit Tract Dis. 2018;22:415–434.

Do external female genital measurements affect genital perception and sexual function and orgasm?

Objective:To provide baseline data for the anatomy of the external female genitalia and to investigate the correlation between those measurements and sexual function and genital perception.Materials and Methods:This prospective cohort study consisted of 208 healthy premenopausal women. The Female Sexual Function index (FSFI) and the Female Genital Self-image scale (FGSIS) questionnaires were administered. Participants were divided into two groups according to their female sexual dysfunction (FSD) status. External genital measurements and anterior and posterior vaginal length were measured.Results:The external female genital measurements were (cm, mean ± standard deviation): clitoral prepuce length 2.05±0.48; clitoral glans length 0.87±0.21; clitoral glans width 0.60±0.15; clitoris to urethra 2.24±0.55; anterior fornix depth 7.75±0.92; posterior fornix depth 9.25±0.75; labia minora width, right 2.12±0.86, left 2.20±0.96. A weak negative correlation was found between total FGSIS scores and clitoral prepuce length (p=0.01, r=-0.17), whereas a weak positive correlation was seen between total FGSIS scores and anterior-posterior vaginal lengths (p=0.04, r=0.13; p=0.02, r=0.15, respectively). No statistically significant difference was found between the genital measurements of participants with FSD (n=82, 39.4%) and those without FSD (n=126, 60.6%), and the total FSFI scores and orgasm subdomain scores.Conclusion:The female genital measurements were found to be distributed over a wide range. Although the relationship between genital measurements and genital perception varied, no significant relationship was found between genital measurements and sexual functions or orgasm. These findings suggest that a more cautious approach should be taken towards genital surgeries for cosmetic purposes.

The Acton Model: support for women with female genital mutilation

Objectives To identify the presenting characteristics, needs and clinical management of non-pregnant women with female genital mutilation who attended the Sunflower clinic, a midwife-led specialist service. Methods This was a retrospective case series review examining referral patterns, clinical findings and subsequent management between 1 April 2018 and 31 March 2019.The review was conducted at a multi-disciplinary female genital mutilation clinic for non-pregnant women aged 18 years and over in West London. Results There were 182 attendances at the clinic (88 new patients; 94 follow-up appointments). Almost half (52%) had type 3 mutilation, 32% had type 2; 9% had a history of type 3; 5% had type 1; one had type 4 and one declined assessment. A total of 35 women (40%) disclosed at least one psychological symptom (such as depression, anxiety, flashbacks, nightmares) during initial consultation. Conclusions Non-pregnant women attending female genital mutilation services present with a wide range of psychological and physical problems. Holistic woman-centred models of care appear to facilitate access to deinfibulation and counselling, which in turn may reduce long-term costs to the NHS. Safeguarding is an intrinsic part of midwives' work and is sometimes complex. The authors recommend a revision of the World Health Organization classifications to specify partial or total removal of the clitoral glans (rather than the clitoris as a whole) as this is inaccurate and may have a negative psychological impact for women.

Glans clitoris innervation: PIEZO2 and sexual mechanosensitivity.

The clitoris is a leading player in female sexual arousal, if not the main protagonist. Despite this role, studies performed on this structure with specific neuroanatomical techniques are few. This study focuses on glans clitoris innervation, with special emphasis on sensory corpuscles and the presence of the mechanotransducer protein PIEZO2 in these structures. Six glans clitoris samples were obtained at autopsy covering an age spectrum between 52 and 83years old. Several types of nerve terminations including free nerve endings, genital endbulbs as well as Meissner-like corpuscles and Pacinian corpuscles, but not Ruffini corpuscles, were found. Although corpuscular morphology in the glans clitoris was subtly different from the cutaneous digital counterparts, their basic composition was comparable for both Pacinian and Meissner-like corpuscles. Genital endbulbs showed heterogeneous morphology, and the axons usually exhibited a typical "wool ball" or "yarn ball" aspect. Some of them were lobulated and variably encapsulated by endoneurial elements (65%); from the capsule originate septa that divides the genital endbulbs, suggesting that they are found in clusters rather than as single corpuscles. In addition, most corpuscles in the glans clitoris showed axonal PIEZO2 immunoreactivity, thus, suggesting a mechanical role and molecular mechanisms of mechanosensibility similar to those of digital Meissner's corpuscles. Our results demonstrate that sensory corpuscles of the glans clitoris are similar to those of other glabrous skin zones, as most genital organs are characterized by clusters of corpuscles and the occurrence of the mechanoprotein PIEZO2 in the axons. These findings strongly suggest that PIEZO2 participates in erotic and sexual mechanical sensing.

The overlooked reproductive function of the human clitoris-News media responses to the published review.

A brief survey of how the news media reported and misreported on the publication of the review that revealed the overlooked empirical evidence for the reproductive function of the human clitoris.