Differential diagnostics of female Bsexual^fluids: a narrative review
Received: 9 October 2017 /Accepted: 24 November 2017
#The International Urogynecological Association 2017
Introduction and hypothesis Women expel various kinds of fluids during sexual activities. These are manifestations of sexual
arousal and orgasm or coital incontinence. This study is aimed at suggesting a diagnostic scheme to differentiate among these
Methods Web of Science and Ovid (MEDLINE) databases were systematically searched from 1950 to 2017 for articles on
various fluid expulsion phenomena in women during sexual activities, which contain relevant information on sources and
composition of the expelled fluids.
Results An ultra-filtrate of blood plasma of variable quantity, which is composed of transvaginal transudate at sexual stimulation,
enables vaginal lubrication. Female ejaculation (FE) is the secretion of a few milliliters of thick, milky fluid by the female prostate
(Skene’s glands) during orgasm, which contains prostate-specific antigen. Squirting (SQ) is defined as the orgasmic transurethral
expulsion of tenths of milliliters of a form of urine containing various concentrations of urea, creatinine, and uric acid. FE and SQ
are two phenomena with different mechanisms. Coital incontinence (CI) could be classified into penetration and orgasm forms,
which could be associated with stress urinary incontinence or detrusor hyperactivity.
Conclusion Squirting, FE, and CI are different phenomena with various mechanisms and could be differentiated according to
source, quantity, expulsion mechanism, and subjective feelings during sexual activities.
Keywords Female ejaculation .Squirting .Coital incontinence .Female prostate .Vaginal lubrication
Women expel various kinds of fluids during sexual activi-
ties . The prevalence is around 10–54% [2–5], and the
quantity of the fluid ranges from 0.3 to 900 mL [5–10].
Expulsion may be manifested by the feelings of wetness,
secretion, discharge, or massive fluid emission.
Controversial opinions on the fluids’origin, quantity, com-
position, and expulsion mechanism exist , and discrep-
ancy in terminology, inaccurate characteristics, and unclear
understanding. Most often, the fluids are described as fe-
male ejaculation because of its similarity to male ejacula-
tion. Previous research reported that Skene’s paraurethral
glands (the female prostate) are the source of expulsion
[2–6,12,13]. Moreover, discrepancy in the amount of
expelled fluid [2–5,9] and the prevalence of various ex-
pulsions [5–9] were associated with the erroneous assump-
tion that the fluids expelled were identical and from the
same source. Currently, the expelled fluids could be related
to various phenomena [10,14,15]. A smaller volume of
fluids may be expelled by the female prostate [7,8,10,13,
16–21], vagina , or Bartholin’sglands. A larger
volume could originate from the urinary bladder [6,7,10,
14,15]. Fluid emission could be a common and desirable
manifestation of sexual arousal (vaginal lubrication), a
physiological sexual response (squirting, SQ; female ejac-
ulation, FE), a result of coital incontinence (CI), or a com-
bination of various fluids.
The aim of our review was to identify the sources of
fluids expelled during sexual activities; compare their
volume, biochemical composition, and expulsion
Obstetrics and Gynecology Department, 2nd Faculty of Medicine,
University Hospital Motol, Charles University, Prague, V Úvalu 84,
Prague 5, Czech Republic
National Institute of Mental Health, Klecany, Czech Republic
Institute of Sexology, 1st Faculty of Medicine, Charles University,
Prague, Czech Republic
International Urogynecology Journal
mechanism; create a scheme based on their characteris-
tics for differential diagnostics of similar but physiolog-
ically different phenomena; and distinguish pathological
conditions from physiological manifestations of sexual
Materials and methods
We conducted a comprehensive and systematic search of
the international databases Web of Science and Ovid
(MEDLINE). These databases were searched for the peri-
od 1950 to 2017. The search was performed in June 2017
with the following terms: Bfemale ejaculation^AND
Borgasm,^Bfemale ejaculation^AND Bfemale prostate,^
Bsquirting^AND Borgasm,^Bvaginal lubrication^OR
Bsecretion^AND Borgasm,^and Bcoital incontinence^
AND Borgasm.^The search was then refined to Bhuman^
and Bwomen.^In addition, we performed a manual search
and scanned the reference list of selected articles. To ob-
tain appropriate articles related to a comparison between
male and female prostates and their secretion capacity, we
search for Bmale prostate^AND Bsperm^OR Bsemen^
Selection of studies and data analysis
EndNoteOnline(ClarivateAnalytics, Philadelphia, PA,
USA) was used for the preparation of the reference list.
We assessed the quality of the studies; confirmed the eli-
gibility of the titles, abstracts, and full texts; and indepen-
dently selected the titles and abstracts twice. To define the
differential diagnosis of FE and SQ, manuscripts without
exact information about the quantity, composition, and flu-
id expulsion mechanism were excluded. Studies that
assessed the previously mentioned phenomena based on
women’s subjective feelings or on research questionnaire
were not included. Only reviews containing a comprehen-
sive analysis were included. In the case of CI, articles
showing no correlations with urine leakage during sexual
activities and in which the type of urinary incontinence
was not verified by urodynamic investigation were exclud-
ed. We read the full text of the articles and made the selec-
tion based on the aforementioned eligibility criteria.
Because of the small number of studies and patients and
the studies’heterogeneity, we could not use meta-
analytical methods. Hence, this review was based on a
descriptive analysis of selected articles; our study is pre-
sented as a narrative synthesis of selected studies. We used
semi-quantitative characteristics of the phenomena for
higher variability of the results and better compre
Fig. 1 The selection process
Int Urogynecol J
Characteristics of selected studies
Our search yielded 622 citations, of which 75 studies
were retrieved (in full text). Fifty-three studies published
from 1950 to 2017 were included in the list. Five book
chapters and two reports by the World Health
Organization (WHO) and International Urogynecological
Association (IUGA) were added. Figure 1shows the se-
A total of 63 studies with relevantinformation (FE, 27; SQ,
4; female prostate, 15; vaginal lubrication, 15; CI, 13; male
prostate and semen parameters, 7; Table 1)wereincludedin
the review. Some of the studies reported on several topics
simultaneously, and the information overlapped.
Women may expel fluids during sexual activities from the
vagina, urinary bladder, and female prostate (Fig. 2).
Lubrication fluid (LF) originates from the vagina; urinary
bladder is the source of the fluids expelled at SQ or CI.
FE originates from the female prostate; female prostate
secretion may also contaminate other fluids, especially
The fluids differ from each other according to the source,
expulsion mechanism, volume, color, density, chemical com-
position (prostate-specific antigen [PSA], uric acid, urea, cre-
atinine, sodium, potassium, chloride), pH, manifestations, and
Vaginal lubrication fluid
Lubrication fluid is an ultra-filtrate of blood plasma. Blood flow
in the genital area is increased during sexual arousal, and LF
from the vaginal venous plexus enters the vaginal lumen
transvaginally [25,32,36]. The vaginal fluid may also contain
peritoneal and follicular fluid, uterine fluid, cervical fluid, and
secretions from Bartholin’sandSkene’sglands. The daily
production is approximately 6 g . LF is characterized by
high potassium and low sodium concentrations compared with
plasma  and has an average pH of 4.7 (range, 3.4–6.4) .
The mean vaginal discharge quantity is 1.5 g/8 h (maximum at
mid-cycle, 2.0 g/8 h), although the amount varies significantly
between the different days of the cycle; low mean values may
be observed on days 7 and 26 (1.4 g/8 h) . During sexual
stimulation, LF production is increased to 0.7 mL/15 min ,
and both sodium and chloride ion concentrations also increase
. Kinsey et al. assumed that vaginal fluid may be forced out
by the contractions of the perivaginal muscles; thus, it resem-
bles fluid expulsion .
Female ejaculation and female prostate
ABreal^FE is the secretion of an extremely scanty (few
milliliters), milky fluid by the female prostate [7,10,15],
which was described by de Graaf in 1762 and later de-
scribed as Skene’s paraurethral glands [11,38]. The fe-
male prostate is an exocrine organ of variable size and
location and contains cellular equipment for neuroendo-
crine activity [33,39]. According to various authors, it
exists in only two-thirds of women , 1 in 2 women
, or in 6 out of 7 women . It weighs 2.6 to 5.2 g,
consists of a maximum of one tenth to one quarter of the
male prostate (23.7 g), and consists of glands, ducts, and
musculofibrous tissues. Compared with the male prostate,
it has more musculofibrous tissues and ducts, but substan-
tially fewer glands (Table 3).
The female prostate’s secretion contains a high concentra-
tion of PSA, prostatic-specific acid phosphatase, fructose, and
glucose (Table 2)[8,19]. It histomorphologically resembles
themaleprostatebeforepuberty. According to Zaviačič
et al., the prostatic (paraurethral) ducts penetrate into the lu-
men of the urethra along its whole length . Dwyer argues
that single or multiple orifices are on the sides of the urethral
meatus . The role of the female prostate is unclear; some
Table 1 Articles according to
topic, character of the collected
information, and the type and
number of publications used for
Female ejaculation 11 14 2 0 0 27
Squirting 2 1 1 0 0 4
Female prostate 11 3 0 1 0 15
Vaginal lubrication 11 1 0 3 0 15
Coital incontinence 10 2 0 0 1 13
Male prostate and semen
41 011 7
Int Urogynecol J
studies assume that prostate secretions have an antimicrobial
or protective effect against urinary tract infections .
Squirting is the involuntary expulsion of a substantial amount
of urine during sexual activity . Until recently, most or-
gasmic emissions have been erroneously called the FE [10,
14,19,37]. Currently, such massive gushes at orgasm are
referred to as squirting (gushing) [10,14]. The biochemical
composition of this fluid could be identical to urine orits
diluted form . The volume of massive gushes (which
could be recurring) usually ranges from 15 to 110 mL (medi-
an, 60 mL), and the color is most frequently described as
Bclear as water^[7,9,14]. The fluid may be contaminated
by the female prostate secretion and may contain a small con-
centration of PSA [7,10]. Squirting occurs during sexual stim-
ulation of the clitoro-urethro-vaginal complex [10,14].
Women and their partners consider squirting to be a positive
phenomenon that improves their sexual life .
Fig. 2 Sources of fluids expelled during sexual activities
Table2 Summary of fluids compared according to source, expulsion mechanism, volume, density, chemical composition, color, manifestations, and
Vaginal lubrication Female ejaculation Squirting (gushing) Coital incontinence
Source [6,7,10,14,15,24–37] Vagina Female prostate Urinary bladder Urinary bladder
Expulsion mechanism [7,10,14,15,
Glands secretion Transurethral
Vol u m e [7,10,14,15,26,30] +/++ + ++/+++ ++/+++
Density [10,30–32] +/++ ++/+++ + +
Prostate-specific antigen [7,10,14,15,33] −/+ +++ +/++ −/++
Uric acid [10,14]––+/+++ +++
Urea [10,14]––+/+++ +++
Creatinine [10,14]––+/+++ +++
Sodium [10,14,19,24,25,28,29]+ + ++/+++ +++
Potassium [10,14,19,24,25,28,29] +/++ + ++/+++ +++
Chloride [10,14,19,24,25,28,29] + + ++/+++ +++
Glucose [10,33]–+++ −/+ –
Fructose [10,33]–+++ −/+ –
pH (acidity) [7,27,33]+++ –−/+ +
Urodynamic examination  Normal finding Normal finding Normal finding Signs of stress incontinence
Color [7,10,14,15,24,25,28–32] Clear, transparent Whitish, milky Clear, yellowish Yellow
of transparent fluid
Involuntary leakage of urine
Subjective feelings  Sexual arousal,
Orgasm, satisfaction Orgasm, satisfaction Humiliation, shame,
+++ large quantity, ++ moderate quantity, + small quantity, −no presence or no parameters available
Int Urogynecol J
Coital incontinence is manifested by an involuntary leakage of
urine during sexual intercourse and could be classified into
penetration and orgasm forms . The prevalence of CI in
women with urinary incontinence (UI) ranges from 10 to 67%
[51–55]. Compared with women with detrusor overactivity
(DOA), women with stress urinary incontinence (SUI) more
frequently report CI [53,55]. Women with CI always have
abnormal urodynamic parameters, unlike women with ejacu-
lation orgasm (FE or SQ) without CI . Some studies cor-
relate penetration CI with the diagnosis of SUI and orgasmic
CI with DOA [51,55]; other studies in this regard are rather
Female ejaculation, SQ, and CI are three completely different
phenomena. Understanding their mechanisms may help to
differentiate them according to their manifestations, subjective
feelings, and biochemical composition of the expelled fluid.
Launching Bsquirting^as a term in the scientific literature in
2011 stopped the use of Bfemale ejaculation^as a Buniversal^
label for all kinds of fluids emitted by women during sexual
Main differential diagnosis criteria for clinical practice
In clinical practice, the diagnosis of emitted fluids is based
mainly on quantity, appearance, and subjective feelings.
Transurethral gushes of tens to hundreds of milliliters of trans-
parent fluid that is not considered by women without UI at
orgasm as urine is SQ [10,14]. These women, who have no
disorder related to urine leakage , usually experience in-
tensive sexual arousal and reach orgasm (even repeatedly)
without any problem. At fluid expulsion, they feel substantial
sexual catharsis and consider the fluid different from urine in
smell, taste, and appearance . In women with SUI or DOA,
CI can be observed. During penile penetration or at orgasm,
they experience unwanted leakage of urine. Consequently,
they feel frustrated and the sexual activity is rather unpleasant
for them because of CI. During FE, a small amount of thick
and milky fluid mixed with lubrication fluid is expelled by the
female prostate, which in turn makes differentiation challeng-
ing. BReal^FE often occurs without noticing a leakage of a
larger fluid volume (unlike SQ). FE is perceived mainly as the
feeling of wetness due to increased lubrication during orgasm.
Moreover, a greater quantity of fluid from the vagina may be
forced out by a one-time pulse emission . It may occur
primarily after penis withdrawal or after coitus, and it is most-
ly a discharge (not gush) of accumulated LF, which is possibly
mixed with sperm.
Table 3 Comparison of
morphological and functional
parameters of the mal e and female
Male prostate Female prostate
Morphological structures [21,33] Prostatic glands (+++)
Musculofibrous tissue (++)
Prostatic glands (+)
Musculofibrous tissue (+++)
Average size of the prostate (cm)
Ave rag e weight (g) [21,33]23.7 2.6–5.2
Average volume prostatic
secretion (mL) [10,41–48]
0.2–2.3 0.89 ± 0.52
Physiological function [40–49] Increase in ejaculation semen volume,
facilitation of reproduction
Character of the emission [10,46] Expulsion, discharge during orgasm Secretion during orgasm
Localization [21,33,47] Surrounding the prostatic part of the
Glucose [21,33] + +++
Fructose [21,33] + +++
Potassium + +
Sodium + +
Chloride + +
+++ large quantity, ++ moderate quantity, + small quantity
Int Urogynecol J
Sources, volume, and mechanism of expelled fluids
The fluid expelled at SQ has a definite origin (the urinary
bladder) [7,10,14], which may accumulate hundreds of mil-
liliters of fluid; the contractions of musculus detrusor vesicae
facilitate the massive expulsions. When we assessed previous
research, we found that most of the orgasmic expulsions,
which are currently most likely referred to as SQ, are de-
scribed as FE [2,6,13,17,20,23]. The authors considered
all female orgasmic expulsions analogous to male ejaculation
 and noted that the female prostate is the main source of
the fluids . The female prostate may produce fluid bio-
chemically comparable with the male prostate secretion; how-
ever, the quantity squirted at an orgasm differs .
Transurethral expulsion and their origin in the urinary bladder
were confirmed by catheterizing the urinary bladder orby
ultrasound bladder examination before and after SQ .
With the bladder’s capacity (around 500 mL), expulsions
with an average volume of 60 mL during sexual stimulation
may be repeated [9,14]. Schubach assumed that during sexual
excitation (increased blood pressure, faster glomerular filtra-
tion, changes in hormonally conditioned reabsorption mecha-
nisms in the kidneys), the bladder is filled more rapidly with
less concentrated urine . Such a premise could explain why
some authors (Schubach, 8 respondents; Rubio-Casillas and
Jannini, 1 respondent) reported that SQ is composed of diluted
urine, which contains muchless uric acid, urea, and creatinine
[7,10], whereas others claim that the fluid at SQ is identical in
biochemical composition to urine (Salama, 7 women; our un-
published study, 1 woman) . Moreover, Wimpissinger
et al. proved that in two women, using their expelled fluid,
which they considered FE, a high PSA and glucose content
(without volume data), unlike voided urine . Goldberg
et al. showed that the fluid emitted in six patients is chemically
similar to urine . The chemical analysis (prostatic acid
phosphatase [PAP], urea, creatinine, glucose) in a previous
case report involving one patient indicated that the expulsion
fluid was not urine . Neither Goldberg et al. nor
Addiego et al.  provided the exact volumes of the emitted
fluid. Nevertheless, most likely, the volume of the bladder
content and urine concentration immediately before initiating
sexual activity and the possible dilution during sexual stimu-
lation play asubstantial rolein the composition of the expelled
fluid at SQ. The concentration of the emitted fluid may be
influenced by other factors, such as water intake, surrounding
temperature, physical activity, metabolic condition, hormonal
activity, overall health condition, and psychogenic aspects.
Previous studies with a small number of women with SQ
(16 respondents) had contradictory conclusions and thus
could not establish a clear mechanism of the creation of the
expelled fluid [7,10,14]. The function of the bladder sphinc-
ter, which should be closed during sexual arousal and orgasm,
remains to be clearly identified . However, according to
Khan et al., involuntary bladder contraction and relaxation of
the sphincter during female orgasm are possible .
Earlier studies described most fluid expulsions as FE, and
the female prostate was considered to be the main source ,
releasing 3–50 mL of fluid (Bullough et al., 3–12 mL;
Goldberg et al., 3–15 mL; Zaviačičet al., 1–5 mL; Heath,
30–50 mL; Belzer, 10 mL) [5,6,8,17,20]. The main evi-
dence of the female prostate as the origin of the fluid was the
presence of PSA (or PAP) in the emission. Although PSA is
the main marker of female prostate secretion, PSA may also
be found in lower concentrations in the fluids expelled from
other sources, such as the vagina and urinary bladder, which
could be associated with contamination by the female prostate
secretion during simultaneous expulsions from the other
sources. According to Rubio-Casillas and Jannini, a decreas-
ing PSA concentration is observed in the following: female
ejaculate > urine > squirting > vaginal secretion .
However, a previous study demonstrated that the female pros-
tate could not be the source of massive expulsions considering
its size, structure, and secretion capacity. On average, it
weighs 2.6 to 5.2 g and it is four to five times smaller than
the male prostate. Moreover, the glandular and ductal compo-
nents are in reverse ratio tothose of the male prostate . The
average volume of male ejaculate is 3.6 mL (1.2–7.6), of
which 15–30% is from the male prostate; the secretion volume
[43–46]. The secretion volume of the female prostate is
around 1 mL [10,19]. Hence, the female prostate could not
be the main source of the massive fluid expulsions.
Differential diagnostic criteria of expelled fluid
according to biochemical analysis and examination
using a device
The expelled fluids could be indicatively differentiated ac-
cording to their manifestations; however, the precise diagnosis
is based on a biochemical analysis or examination using a
device (ultrasound, urodynamic examination, magnetic reso-
nance imaging). Biochemical analysis of FE revealed high
concentrations of PSA, glucose, and fructose, whereas the
fluid at SQ, unlike FE, has higher concentrations of uric acid,
urea, creatinine, and sodium; has a substantially lower density;
and contain practically no fructose or glucose [7,9,10].
Biochemical differentiation of expelled fluids during orgasmic
incontinence at CI and orgasm at SQ is more difficult to per-
form. The quantity and appearance of the fluid may be similar.
The exact diagnosis is based on the fact that continent women
with ejaculation orgasm (SQ) show neither high detrusor ac-
tivity nor any other abnormal urodynamic parameters unlike
women with CI, who have urodynamic evidence of SUI or
DOA . Differentiation based on biochemical markers
characteristic of urine (uric acid, urea, creatinine, chloride,
potassium) could be misleading; although some authors
Int Urogynecol J
provided evidence of lower quantity of these markers at SQ
(SQ is a diluted fluid from the urinary bladder) , others
found no differences (SQ is voided urine) . Future studies
should investigate whether substantial urine dilution occurs at
SQ, resulting from sexual arousal and increased renal activity,
or whether the fluid at SQ is just urine. Differentiation of
lubrication fluid from other fluids is not usually difficult, as
the former is a desired and common sexual response. Massive
fluid emissions from the vagina are considered discharge of
accumulated LF rather than gushes of fluid. Women with lu-
brication problems are at a disadvantage in terms of sexual
satisfaction, and a prevalence of lubrication disorders of 5.8 to
19.7% among fertile women was reported .
Coital incontinence, its forms, and differential
Whether the fluid expelled at FE (or SQ) is from the
female prostate or the urinary bladder and whether it is
urine has been a major topic of dispute. The fluid at SQ
was (inaccurately) attributed to the female prostate based
on the concentrations of PSA and PAP, which were con-
sidered the main markers for differentiation. Moreover,
the detection of PAP in the urine may be complicated,
as the concentration is small and diagnostic kits primarily
serve to determine the level of phosphatase in the blood
and not in the urine . Women with CI experience leak-
age of urine frequently and involuntarily during the day;
thus, there is no problem with the identification of CI.
They were able to recognize that urine is leaked during
sexual activities, unlike women who are capable of
squirting and do not consider the fluid to be urine .
CI is initiated by various situations, such as increased
abdominal pressure, penile insertion, deep penetration,
high arousal, orgasm, and clitoral stimulation , and
by psychogenic factors as well. Hence, most women
avoid sex or prevent involuntary urine leakage by voiding
before the sexual activity. Determining whether the incon-
tinence is penetration or orgasmic in form is not difficult,
as a woman could identify at which phase of sexual ac-
tivity urine leakage occurs. However, inconsistent opin-
ions are noted for whether penetration incontinence oc-
curs mainly at SUI [51,52,54–58,60] owing to increased
mobility of the urethrovesical junction andwhether
orgasmic incontinence is related to DOA . El-Azab
stated that the reason for urine leakage at orgasm is not
definitely DOA, but an incompetent urethral sphincter or
vaginal prolapse . In a differential diagnosis, we
should take into account the possibility that CI might de-
velop in the course of a woman’slifeorinawomanwith
the ability to squirt, or that a woman with symptoms of UI
might gain the ability to squirt.
Limitations and deficiencies of the study
In our study, articles on the characteristics and the exact com-
position of expelled fluids during sexual activity among wom-
en were lacking, and the groups of respondents were small;
thus, having a statistically significant analysis was not possi-
ble. Only studies with approximately 10 respondents and a
few individual case reports were included in the assessment
[6,7,9,10,13,14,19]. Other previous studies use different
methodological procedures and inconsistent terminology, and
the characteristic of the examined fluids is mostly based on
only the subjective feelings of the respondents [3,4,12,23,
62]. The term Bsquirting^was only used for the first time in
the scientific literature in 2011 . Currently, fluid expul-
sions during sexual activities would not be immediately re-
ferred to as FE only; the expulsions could also be SQ [4–9,11,
13,19,20,23]. Moreover, older studies are focused mainly on
the female prostate, its localization, anatomical composition,
and biochemical analysis of its secretion. Although they
looked into the relationship between orgasm and fluid gushes,
an exact biochemical analysis was not performed, and the
volume was not identified.
Having a larger group of respondents for the study appears
difficult as the topic is extremely sensitive, and full coopera-
tion of women and their partners with the research team is
Importance of further research and its benefit
for clinical practice
Further studies on expelled fluids during sexual activities in
women are warranted to obtain specific knowledge on their
characteristics and biochemical composition. The creation of a
practical algorithm for the differential diagnostics of the phe-
nomena (FE, SQ, CI) for the use of specialists is essential. The
information could be used to prevent erroneous consideration
of FE and SQ as disorder symptoms that require a therapy, as
is required in cases of CI.
We have differentiated among the four types of fluids expelled
during sexual activities in relation to sexual arousal and or-
gasm. Apart from the desired lubrication and involuntary
urine leakage disorder, two different physiological but unusual
phenomena exist: FE and SQ. At FE, a small amount of fluid
is secreted by the female prostate, and at SQ, the fluid similar
to or identical to urine is squirted transurethrally from the
urinary bladder. Further study is necessary considering the
limited number of studies, the small group of respondents,
and the unclear conclusions.
Int Urogynecol J
Compliance with ethical standards
Financial disclaimer/conflict of interest None.
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