ArticleLiterature Review

Beyond the G-spot: Clitourethrovaginal complex anatomy in female orgasm

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Abstract

The search for the legendary, highly erogenous vaginal region, the Gräfenberg spot (G-spot), has produced important data, substantially improving understanding of the complex anatomy and physiology of sexual responses in women. Modern imaging techniques have enabled visualization of dynamic interactions of female genitals during self-sexual stimulation or coitus. Although no single structure consistent with a distinct G-spot has been identified, the vagina is not a passive organ but a highly dynamic structure with an active role in sexual arousal and intercourse. The anatomical relationships and dynamic interactions between the clitoris, urethra, and anterior vaginal wall have led to the concept of a clitourethrovaginal (CUV) complex, defining a variable, multifaceted morphofunctional area that, when properly stimulated during penetration, could induce orgasmic responses. Knowledge of the anatomy and physiology of the CUV complex might help to avoid damage to its neural, muscular, and vascular components during urological and gynaecological surgical procedures.

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... clitoral bulb). Med vagino in dvojnim lokom je sečnica (Jannini et al., 2014). ...
... Dinamična ehografija je pokazala, da je kompleks CUV raztegnjen in med spolnim odnosom tudi stimuliran s penisom. Ta ugotovitev kaže, da bi takšna stimulacija kompleksa CUV lahko prispevala k doseganju vaginalno aktivnega orgazma (Jannini et al., 2014). ...
... Ob vaginalni stimulaciji pa je prišlo do gibanja gobastega tkiva v telesu klitorisa skupaj s rafom, ki je potisnil glavico klitorisa naprej in navzgor. S penetracijo se koren klitorisa približa distalnemu delu sprednje vaginalne stene, kar izboljša stik med vaginalno steno in klitorisom ter poveča prekrvavitev v tem predelu (Levin, 2015;Jannini et al., 2014). Velja pripomniti, da to področje potrebuje še poglobljena raziskovanja. ...
... Women have selfreported achieving orgasms through vaginal, clitoral, and blended vaginal/clitoral stimulation as well. The clitourethrovaginal complex comprises the clitoris, urethra, and anterior vaginal wall, and has been described as an area highly prevalent for orgasmic function [15]. Disrupting these anatomical structures with surgical intervention for SUI or POP may interfere with orgasmic function in women. ...
... In the context of POP surgical repair, dyspareunia may be more common overall (as compared to MUS surgery) due to possible vaginal canal narrowing or shortening, especially with extensive placement of transvaginal mesh. In MUS surgery a much smaller piece of mesh is utilized overall, however the axis of the vaginal canal in relation to the periurethral, anterior vaginal wall tissue may change with sling placement [2,4,15]. The pudendal nerve serves both sensory and motor capabilities in the female genitalia; the dorsal nerve of the clitoris and perineal nerve carry sensation from the female perineum, vulva, and labia, and serve as the two endbranches of the pudendal nerve [2]. ...
... The pudendal nerve serves both sensory and motor capabilities in the female genitalia; the dorsal nerve of the clitoris and perineal nerve carry sensation from the female perineum, vulva, and labia, and serve as the two endbranches of the pudendal nerve [2]. Any interruption in these neural pathways with surgical dissection or mesh placement can account for increased discomfort or dyspareunia during sexual activity or even orgasmic function during sexual activity [15,16]. ...
Article
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Purpose of Review The evolution of vaginal mesh has had a large positive impact on quality of life for patients with stress incontinence and pelvic organ prolapse; for instance, the mid-urethral sling is considered the gold standard treatment for stress incontinence. There are unique side effects, however, for the use of mesh in surgical implantation, including infection, erosion, extrusion, and changes in urinary habits as well. Recent Findings A side effect that may be overlooked in these women undergoing vaginal mesh surgery is sexual dysfunction; while the surgery itself may strongly improve quality of life, there can be some detrimental sexual side effects that may hinder the patient’s quality of life or sexual function overall. Changes in sexual function can be encountered in anywhere from 5 to 20% of all women undergoing surgery for stress incontinence or vaginal prolapse, and the scope of these changes vary from positive to negative. These changes can be broken down by sub-topics explored in the FSFI including dyspareunia or pain, overall function, lubrication, and orgasm. Summary Sexual function is an often overlooked and underdiscussed topic in the medical field and between clinicians and patients overall. It is imperative that clinicians discuss any and all possible complications of mesh surgery with patients preoperatively, including any effects, both positive and negative, in regard to sexual function.
... 9(07), 258-266 260 The full scale or total FSFI score ranges from 2 to 36 and is the sum of all the scores in the six domains. Scores morethan 26.55 considered satisfactory and those below this figure considered having sexual dysfunction [10,11] The following questionnaires were administered before the PRP administration in the 1st, 2nd, 3rd month follow up by female sexual function index FSFI . ...
... PRP injection is effective in mesh erosion through better wound healing, increased synthesis of collagen 3, and neovascularization that enhance re-epithelialization and augment the integrity of the submucosa to be in batter state (7)(8)(9)(10)(11). ...
... It is known that increased blood flow through the clitoris is correlated with improved sexual function in women (11). Accordingly, we administered four injections to the clitoris and its surroundings. ...
Article
Objective:To investigate the effect of platelet-rich plasma (PRP) injection to the lower one-third of the anterior vaginal wall on sexual function, orgasm, in women with sexual dysfunction by scoring with FSFI. Materials and Methods:Three sessions of PRP (platelet rich human autologous plasma) were administered to the anterior vaginal wall of fiftyfemale patients with sexual dysfunctiondiagnosed by FSFI scoring card obtained in JAM clinic in Benha city Egypt and orgasmic disorder. Female Sexual Function Index (FSFI) total score ≤26 orgasmic subdomain score ≤3.75 were considered having sexual dysfunction and recruited in the study. Results:Following the application of the PRP, the total FSFI score was observed as 27.7±4.5 and the total score was 26 and above in patients having sexual dysfunction (p<0.001). Orgasm subdomain scores were found as 2.2±1.2 before the PRP treatment and 4.4±1.06 at the third dose after (p<0.001). Conclusion:PRP administration to the distal anterior vaginal wall improved female sexuality with high satisfaction by using multiple sessions (three month).
... 23 It has also been suggested that by considering the location of nerves within this erogenous vaginal region, clinicians could possibly avoid damage to these nerves during urological procedures. 7 The present study focuses on characterizing the sensory and autonomic nerves present within the AVW-FPT, where mid-urethral slings are implanted, and whether this innervation may be impacted by the MUS procedure. ...
... Accordingly, a discussion of the concepts of nomenclature and the hypothesized functional roles of these glandular structures in women is warranted, especially in connection to female ejaculation, and the purported Gr€ afenberg spot, or G-Spot. 22,7,66 With this acknowledgement, it is pertinent to begin considering the mechanism of male prostate-associated orgasm, which is due to activation of autonomic and visceral sensory nerves that innervate the tissue. 6 It is well recognized that surgical injury to the male prostate after treatment for lower urinary tract symptoms (LUTS) have been reported to result in male orgasmic dysfunction. ...
Article
Background: Female sexual dysfunction, including female orgasm disorder, has been reported following mid-urethral sling (MUS) surgery to treat bothersome stress urinary incontinence. Anterior vaginal wall-female periurethral tissue (AVW-FPT) likely contains autonomic and sensory innervation involved in the female sexual response, and injury to these nerves may result from MUS implantation. Aim: To characterize, using fresh cadaveric tissue, autonomic and sensory nerves in AVW- FPT using immunohistochemistry (IHC), and to assess their proximity to an implanted MUS. Methods: AVW-FPT was excised following careful dissection from four fresh cadavers. Prior to dissection, one cadaver underwent simulation of the MUS procedure by a urogynegologist, using a fascial sling. All samples were paraffin embedded, sectioned, and stained with hematoxylin. Serial sectioning and IHC were performed to identify nerves. IHC markers were used to characterize the sensory and autonomic innervation. Outcomes: IHC localization of autonomic and sensory nerve markers consistent with neural tissue within the region of MUS implantation. Results: IHC of AVW-FPT using protein gene product 9.5 (PGP9.5), a general nerve stain, revealed innervation throughout the region targeted by the MUS implantation. More specifically, immunoreactivity for both autonomic (tyrosine hydroxylase, TH) and sensory (Nav1.8 and S100ß) nerves were found in close proximity (<1 mm) to the implanted MUS. In addition, a subset of S100ß positive nerves also showed immunoreactivity for calcitonin gene-related peptide (CGRP). Combining the IHC findings with the surgical simulation of the MUS implantation revealed the potential for damage to both autonomic and sensory nerves as a direct result of the MUS procedure. Clinical translation: The identified autonomic and sensory nerves of the AVW-FPT may contribute to the female sexual response, and yet are potentially negatively impacted by MUS procedures. Given that surgeries performed on male genital tissue, including the prostate, may cause sexual dysfunction secondary to nerve damage, and that urologists routinely provide informed consent regarding this possibility, urogynaecologists are encouraged to obtain appropriate informed consent from prospective patients undergoing the MUS procedure. Strengths & limitations: This is the first study to characterize the sensory and autonomic innervation within the surgical field of MUS implantation and demonstrate its relationship to an implanted MUS. The small sample size is a limitation of this study. Conclusion: The present study provides evidence of potential injury to autonomic and sensory innervation of AVW-FPT as a consequence of MUS implantation, which may help explain the underlying mechanisms involved in the reported post-operative female sexual dysfunction in some women. Giovannetti O, Tomalty D, Gaudet D, et al. Immunohistochemical Investigation of Autonomic and Sensory Innervation of Anterior Vaginal Wall Female Periurethral Tissue: A Study of the Surgical Field of Mid-Urethral Sling Surgery Using Cadaveric Simulation. J Sex Med 2021;XX:XXX-XXX.
... It is therefore expected that this way of sexual intercourse will lead to orgasm faster than stimulating only one part of the female body. However, some women report that stimulation of the clitoris stimulates them more quickly and gives them more intense orgasms, which are usually not as satisfying as those experienced by penis-vaginal sexual intercourse [6][7][8][9] . ...
... type of orgasm is caused by direct stimulation of the external clitoris without any vaginal stimulation, called a clitorally activated orgasm (CAO). Another form of orgasm is described as the orgasm reached during vaginal penetration without direct stimulation of the external clitoris, vaginally activated orgasm (VAO) 8,12 . ...
Article
Full-text available
Background: Female sexual function comprises variable and multi-layered conditions that incorporate complex interactions of physiological, psychological, and interpersonal components. Despite the progress in understanding the neurobiology of sexual response, the definition of normal sexual response in women remains unresolved. Normal female sexual function differs from individual to individual and depends on the culture, ideology, beliefs, and other factors. Methods: We used a case report, the purpose of which is to justify further investigation into the effectiveness of hypnosis for the treatment of cervical pain during penetration, as well as orgasm disorder. Results: An orgasm was reached by masturbation performed on her by her partner, but without an orgasm by penile-vaginal penetration. The frequency of sexual intercourse has increased (3-4 times/week) in comparison to prior to therapy (once/ 2 months). Orgasm does not occur by self-and by partner masturbation every time, but sporadically; however, more frequently than before therapy. Success has been achieved with the orgasm by penile-vaginal penetration. Conclusions: Hypnotherapy may be a promising co-intervention or intervention per se for both physical and psychological symptoms. The results of hypnotherapy demonstrate that symptoms were significantly alleviated and, consequently, the quality of life improved. Symptoms of pain during sexual intercourse were not eliminated, but the patient had achieved significant control over those symptoms.
... The mechanisms of interaction between the external and internal clitoris and the anatomical structures that contribute to the formation of the orgasmic platform have been described [1]. However, there is also a larger area involved in sexual stimulation, called the clitourethrovaginal (CUV) complex [15][16][17], a variable, multifaceted morpho-functional area that, when properly stimulated during penetration, could induce orgasmic response. ...
... Moreover, since the female orgasm is a complex product of physical, emotional, cognitive and relational factors, it is reasonable to suppose that the "best" orgasm in women is yet to come. Factors such as anatomy [7,8,16,17,[42][43][44], hormonal levels [45], age and sexual experience [46], selfawareness [11,47,48], sexual autonomy (i.e. the extent to which one feels that one's sexual behaviors are self-determined) [49], ability to lose control during sexual activity [50] and partner-related sexual dysfunctions [51] are closely linked with orgasmic function. However, lacking so far a specific and dedicated psychometric tool, all these studies are not showing qualitative data on female orgasm. ...
Article
Full-text available
The female orgasm represents one of the most complex functions in the field of human sexuality. The conjunction of the anatomical, physiological, psycho-relational and socio-cultural components contributes to make the female orgasm still partly unclear. The female orgasmic experience, its correlates and the relation with sexual desire, arousal and lubrication as predictors are highly debated in scientific community. In this context, little is known about the impact of female sexual dysfunction (SD) on sexual pleasure expressed by subjective orgasmic intensity, and there are no suitable psychometric tools suited to investigate this dimension. Thus, we validate, in female subjects, a Visual Analogue Scale (VAS) that we named Orgasmometer-F, to verify if SD is accompanied by a lower perceived orgasmic intensity. A total of 526 women, recruited through a web-based platform and from sexological outpatient clinic, were enrolled in the study. They were divided into, on the basis of the Female Sexual Function Index (FSFI) score in two groups: 1) 112women suffering from SD, (SD Group); and 2) 414 sexually healthy women (Control Group). The participants were requested to fill out the Orgasmometer-F, recording orgasmic intensity on a Likert scale from 0 (absence of orgasmic intensity) to 10 (maximum orgasmic intensity experienced). Women with SD experienced significantly lower orgasmic intensity than controls, as measured by the Orgasmometer-F (p < 0.0001). Interestingly, masturbatory frequency was positively correlated with orgasmic intensity, as were the lubrication, orgasm and sexual satisfaction domains of the FSFI. The Orgasmometer-F was well understood, had a good test-retest reliability (ICC = 0.93) and a high AUC in differentiating between women with and without sexual dysfunction (AUC = 0.9; p < 0.0001). The ROC curve analysis showed that a cut-off <5 had 86.5% sensitivity (95% CI 82,8–89,6), 80.4% specificity (95% CI 71.8–87.3), 75.4% positive predictive value (PPV) and 89.5% negative predictive value (NPV). In conclusion, the Orgasmometer-F, a new psychometrically sound tool for measuring orgasmic intensity in female population, demonstrated that SD impair orgasmic intensity.
... The most sensitive point to stimulus in the female body is the genital area (6) . In the vagina, the lower one-third of the anterior region has been proved to have more nerves immunohistochemically (7)(8)(9) and it is known that the response of the distal anterior vaginal wall to contact and to pressure is higher than the other part of the vagina, in penis-vagina penetration (6,10) . PRP treatment has the potential to be part of a surgical and non-hormonal approach in patients with sexual dysfunction with regenerative changes by increasing collagen formation and neovascularization in the anterior vaginal wall. ...
... The name G-spot, G-spot neurovascular complex, anterior wall erogenous complex, clitorovaginal-urethrovaginal complex, or whichever term it is called, is the female distal anterior vaginal wall, which is known to be more sensitive. The response of the distal anterior vagina, which is more sensitive, to penisvagina penetration is higher (6,10,27) . Based on this, we planned to adminster our injections more commonly in the distal anterior one-third vagina region. ...
Article
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Objective: To investigate the effect of platelet-rich plasma (PRP) injection to the lower one-third of the anterior vaginal wall on sexual function, orgasm, and genital perception in women with sexual dysfunction. Materials and methods: Four sessions of PRP were administered to the anterior vaginal wall of 52 female patients with sexual dysfunction and orgasmic disorder [Female Sexual Function Index (FSFI) total score ≤26 orgasmic subdomain score ≤3.75]. Prior to the PRP administrations in each session, the FSFI validated in Turkish, the Female Genital Self-Image Scale (FGSIS), the Female Sexual Distress Scale-Revised (FSDS-R), and Rosenberg's Self-Esteem Scale were used and in the final follow-up, and the Patient Global Impression of Improvement (PGI-I) was performed and the results were analyzed. Results: Following the application of the PRP, the total FSFI score was observed as 27.88±4.80 and the total score was 26 and above in 50% of the patients (p<0.001). Orgasm subdomain scores were found as 2.11±1.20 before the PRP treatment and 4.48±1.14 afterwards (p<0.001). A significant change was observed in all sub-domains after PRP and it was observed that this change started after the first administration (p<0.001). A statistically significant increase was determined in FGSIS genital perception scores, which was significant between the 1st and 2nd months (p<0.001). The FSDS-R scores showed a minimal increase in stress scores as the application number increased, but a statistically significant decrease was observed in the 4th administration (p<0.001). No statistically significant difference was found in Rosenberg Scale scores before and after treatment (p=0.389). High satisfaction was found in PGI-I scores. Conclusion: As a minimally invasive method, PRP administration to the distal anterior vaginal wall may improve female sexuality with high satisfaction.
... While the study denies the existence of a distinct, vascular, and erectile structure as a concrete spot, on the other hand, it corroborates the idea that a deep interrelation exists among the clitoris, vagina, and urethra with its glands, but not denying the existence and the role of an "erotogenic zone", using Ernst Gräfenberg's wording [28]. Both the urethral orifice and distal urethra indeed are surrounded by the erectile tissue of the clitoral bulbs, providing evidence for the existence of a "clitoral complex" [44], or "clitoral urethral complex" (CUC) [48], and, lastly, in a more complete manner encompassing all the anatomical structures involved, "clitourethrovaginal complex" (CUV) [49], namely the terms which have been coined to denote this area in women. Despite the apparent plethora of anatomical studies, a consensus has not yet been reached on this topic; however, a functional correlation of CUV anatomy to sexual function is supported by the claims of a number of scientists and by the mentioned findings. ...
... Despite all these reasons, it seems evident that the questions about the existence of the G-spot have not yet been definitively answered, as well as the question of the nature of FE and the existence of more than one female orgasm. However, it is important that the topic is finally addressed in a scientifically appropriate way, as the most recent studies [49] have improved our understanding of the complex anatomy and physiology of the female sexual response. On the other hand, the other aspects influencing the perception and the orgasmic experience connected to the G-spot remain in most cases anecdotal or understudied. ...
Article
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In the field of female sexuality, the existence of the so-called “G-spot” represents a topic still anchored to anecdotes and opinions and explained using non-scientific points, as well as being overused for commercial and mediatic purposes. Purpose of Review The scope of this review is to give an update on the current state of information regarding the G-spot and suggesting potential future directions in the research field of this interesting, albeit controversial, aspect of human sexual physiology. Recent Findings From evolutionary, anatomical, and functional points of view, new evidence has rebutted the original conceptualization of the G-spot, abandoning the idea of a specific anatomical point able to produce exceptional orgasmic experiences through the stimulation of the anterior vaginal wall, the site where the G-spot is assumed to be. From a psychological perspective, only few findings to date are able to describe the psychological, behavioral, and social correlates of the pleasure experience by G-spot-induced or, better, vaginally induced orgasm (VAO). Summary Recent literature suggests the existence of a G-spot but specifies that, since it is not a spot, neither anatomically nor functionally, it cannot be called G, nor spot, anymore. It is indeed a functional, dynamic, and hormone-dependent area (called clitorourethrovaginal, CUV, complex), extremely individual in its development and action due to the combined influence of biological and psychological aspects, which may trigger VAO and in some particular cases also female ejaculation (FE).
... As engorgement increases, the prepuce of the clitoral hood retracts and vaginal length and diameter, especially in the distal two thirds, increase. Similar to erectile dysfunction (ED) in men, diseases such as hypertension, diabetes, and atherosclerosis can lead to smooth muscle fibrosis in the vaginal wall and clitoris that can lead to symptoms of vaginal dryness and painful intercourse [2][3][4][5]. ...
... All of the female genital organs play a role in sexual arousal and are all uniquely designed and positioned for optimization of sexual stimulation and enhancement of arousal and pleasure [3][4][5]. Gaining familiarity with female sexual anatomy, and how the female genital organs respond during sexual arousal, will enable health care professionals to better evaluate and treat female patients with sexual function complaints. ...
Article
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Purpose of Review There is a growing body of evidence-based research in the area of female sexual arousal that has led to improved understanding of the female sexual arousal response and the development of FDA-approved treatments for female sexual dysfunction. The purpose of this paper is to review the existing literature on female sexual arousal and response with a focus on local genital arousal and the mechanisms underlying vaginal lubrication. Recent Findings From May 2000 to May 2020, PubMed and Cochrane databases were reviewed and manuscripts selected, based on keywords, content, references, and relevance to the topic. Vaginal lubrication occurs due to vasodilation of the major branches of iliohypogastric and pudendal arterial beds. The increase in intravascular and vaginal wall pressure forces fluid to pass through the vaginal intraepithelial gap junctions, forming a transudate of plasma. The fluid coalesces to form water-like droplets that lubricate the entire vaginal canal, allowing for ease of penetration during sexual intercourse. Vaginal lubrication is a fundamental component of female sexual arousal and directly correlates with subjective levels of satisfaction and enjoyment. Summary The female sexual arousal response is a complex reflex involving multiple organs and bodily functions. There are numerous age-related, metabolic, environmental, hormonal, and other factors that can negatively impact female sexual arousal and vaginal lubrication. As women age, vaginal lubrication declines due to declining genital blood flow and serum hormone levels. Concomitant reduction in physical activity and other medical comorbidities can also negatively impact vaginal blood flow and lubrication. The new and evolving treatment modalities for female sexual arousal disorder are directed toward optimizing vaginal health, function, and lubrication.
... 58 The term clitourethrovaginal (CUV) complex has been proposed to describe this concept, in reflection of the recognized erotogenic nature of several regions of the tissues found within the AVW. 13 This includes the glandular tissue (female prostate), the urethra, the AVW itself, and clitoral tissues. 13,66 This complex of erotogenic tissues is considered to have a common pelvic innervation of sensory and autonomic nerves. ...
... 58 The term clitourethrovaginal (CUV) complex has been proposed to describe this concept, in reflection of the recognized erotogenic nature of several regions of the tissues found within the AVW. 13 This includes the glandular tissue (female prostate), the urethra, the AVW itself, and clitoral tissues. 13,66 This complex of erotogenic tissues is considered to have a common pelvic innervation of sensory and autonomic nerves. Several reports have discussed the location and distribution of the innervation of these pelvic structures that is, vagina, 67,68 urethral sphincter, 69 clitoris, 70−72 and periurethral tissue. ...
Article
Introduction: There is evidence of glandular tissue within the region of the anterior vaginal wall-female periurethral tissue (AVW-FPT) having similar morphology and immunohistochemistry to the prostate in men and having physiological roles in the female sexual response (FSR). Whether this tissue should be called a prostate in women has been debated. Iatrogenic injury to structures of the AVW-FPT, including these glands and the associated neurovasculature, could be a cause of female sexual dysfunction (FSD). Objectives: To consolidate the current knowledge concerning the glandular tissue surrounding the urethra in women, evidence was reviewed to address whether: (i) these glands comprise the prostate in women, (ii) they have specific functions in the FSR, and (iii) injury to the AVW-FPT and prostate has sexual dysfunction as a likely outcome. Methods: A literature review was conducted using keywords including female prostate, Skene’s/paraurethral glands, periurethral tissue, Gr€afenberg (G)-spot, female ejaculation, mid-urethral sling (MUS), and sexual dysfunction. Results: Histological and immunohistochemical studies of the glandular tissue surrounding the urethra support the existence of prostate in women. Evidence suggests this tissue may have physiologically and clinically relevant autonomic and sensory innervation, and during sexual arousal may contribute to secretions involved in ejaculation and orgasm. Gaps in knowledge relating to the functional anatomy, physiological roles, and embryological origins of this tissue have impeded the acceptance of a prostate in women. Injury to the innervation, vasculature, and/or glandular tissue within the surgical field of MUS implantation suggests iatrogenic sexual dysfunction is plausible. Conclusions: Continuing to advance our understanding of the morphology, histochemistry, and physiologic capacity of this glandular tissue will clarify the characterization of this tissue as the “prostate” involved in the FSR, and its role in FSD following surgical injury.
... Although locoregional discrepancies in the innervation of the human vagina are still debated, immunohistochemical studies reported that a greater number of fibers is detectable in distal regions of the vaginal wall compared with the proximal 23 and that the distal anterior vaginal wall is markedly thicker than the proximal. 24 Furthermore, following the studies of O'Connell et al, 25 suggesting that the distal vagina and the urethra display a close spatial, morphological, and functional proximity to the erectile tissue of the bulbs and cavernous bodies of the clitoris and based on dynamic imaging techniques, Jannini et al 26 proposed the existence of a clitourethrovaginal complex, defined as a morphofunctional area stimulated by vaginal penetration and involved in triggering sexual arousal and vaginally activated orgasm. ...
Article
Introduction Androgens have been shown to exert beneficial effects on vaginal physiology, at least partially independent of their aromatization to estrogens. Androgen deficiency in the vagina and in the other genitourinary tissues contributes to the development of vulvovaginal atrophy and genitourinary syndrome of menopause, resulting in impaired arousal and lubrication and dyspareunia. Objectives To summarize the role of testosterone in modulating vaginal structure and function. Methods A qualitative review of the relevant literature on the topic was performed using the PubMed database. We present a summary of preclinical and clinical evidence supporting the involvement of testosterone (T) in vaginal physiopathology and discuss it in terms of the role of the vagina in female sexual response. Results Androgens are important in the differentiation of the vagina and in maintaining trophic and functional actions in postnatal life, as suggested by the detection of the androgen receptor and of the key enzymes involved in androgen synthesis. T is essential for the integrity of vaginal tissue structure (including non-vascular smooth muscle thickness and contractility and collagen fiber compactness) and for the complex neurovascular processes that regulate arousal and lubrication (vascular smooth muscle relaxation via the NO/cGMP/PDE5 pathway, nerve fiber density and neurotransmission). T has also been reported to modulate nociception, inflammation, and mucin secretion within the vagina. Available and potential androgen-based treatments for vulvovaginal atrophy/genitourinary syndrome of menopause and for other conditions leading to female genital arousal disorder and dyspareunia are presented. Conclusions The vagina is both an androgen-target and synthesis organ. Preclinical and clinical data consistently suggest that T plays an important role in maintaining vaginal health and genital sexual function. Maseroli E, Vignozzi L. Testosterone and Vaginal Function. Sex Med 2020;XX:XXX–XXX.
... Anatomic and tissue investigations identified different sensations perceived through sexual stimulation, solely by the vagina, solely by the clitoris, and simultaneously 2,[9][10][11] . Sexual stimulation and consequently sexual satisfaction not only correlate with the method of orgasm induction, but, also, with psychological and emotional states 8,9,[12][13][14][15][16][17] . Some evolutionists have argued that female orgasm does not represent an adaptive function, because women respond differently to male representatives 18 . ...
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Background: The purpose of the study was to evaluate the correlations between demographic variables and claims from the Female Sexual Function Index (FSFI), and questions from Semantic Differential Items of Female Sexual Function (SDIFSF). Data were collected through an online survey. Methods: Based on the Kolmogorov-Smirnov and Sha-piro-Wilk test on six claims of FSFI, a non-parametric statistical analysis with the Spearman correlation coefficient and χ2-test were used. Statistical significance was set at p<0.05 Results: The sample consisted solely of female participants, aged from 18 to 89 years. Most of the participants (n=287; 66.9%) were in a relationships (but not married), were still students (n=178; 41.5%) and were Catholic (n=267; 62.2%). Conclusions: The youngest participants expressed the highest level of satisfaction after sexual intercourse and mostly take the initiative for sexual intercourse. However, they mostly experienced pain after sexual intercourse. Married participants had the highest level of experiencing an orgasm (in any way), were pleasantly aroused during and had feelings of satisfaction after sexual intercourse. The higher the level of education, the more positive effects were present during (expe-riencing an orgasm, lubrication) and feelings of satisfaction after sexual intercourse. However, at the same time, participants felt pain during and after sexual intercourse, were concerned whether their partners like them, and were concerned about not being mentally present (e.g. daydreaming or fantasising about being with someone else) during sexual intercourse. Participants with one sexual partner in the previous year experienced an orgasm during and felt satisfied after sexual intercourse but felt pain during sexual intercourse. With the increasing number of sexual partners, lubrication increased, as did pleasant arousal during sexual intercourse, and a feeling of satisfaction. Furthermore, pain was present during and after sexual intercourse.
... Among women, the vagina, clitoris, and urethra are so closely connected that they are termed the clitoral complex. Stimulation of one of these parts often affects the others due to the heightened sensitivity of nerve-endings during arousal and the internal tension of pelvic floor muscles putting pressure on the bladder/urinary tract (Vaccaro, 2014; see also Jannini et al., 2014;Puppo & Puppo, 2015). The urethra in women is surrounded by erectile tissue, and when women are sexually stimulated the urethra tends to enlarge and swell (Grafenberg, 1950). ...
Article
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Increased urination urgency has been shown to facilitate impulse control in cognitive domains, but its effects in other areas are unknown. We examined whether inhibitory spillover effects would replicate and extend to close relationships-specifically, influencing decision making related to sexual risk-taking. Across three studies, we either measured (Studies 1 and 3) or manipulated (Study 2) participants' bladder pressure and assessed sexual self-control using a questionnaire of sexual risk-taking intentions (Study 1) or a simulated semi-behavioral sexual risk-taking (Choose Your Own Sexual Adventure) task (Studies 2 and 3). Study 1 (N = 44 men, 59 women) showed greater urination urgency was associated with greater sexual risk-taking. Study 2 (N = 65 men, 91 women) showed that increasing urination urgency led to greater sexual risk-taking, but only among men. Study 3 (N = 86 men, 183 women) showed elevated urination urgency was associated with an increase in sexual arousal, which accounted for the greater sexual risk-taking.
... La mancanza della tunica albuginea e del meccanismo veno-occlusivo rende ragione del fatto che i corpi cavernosi del clitoride vanno incontro a una tumescenza e non a una vera e propria erezione. Sulla base delle interazioni anatomiche e dinamiche che si instaurano tra clitoride, uretra e parete vaginale anteriore, evidenze scientifiche supportano l'esistenza di un complesso "clitorido-uretro-vaginale" (CUV), un'area morfo-funzionale coinvolta nell'innesco del piacere [13,14]. Come detto in precedenza, anche nella donna le vie di trasduzione dell'NO mediano la vasodilatazione endotelio-dipendente dei vasi vaginali e clitoridei: rispetto a ciò che accade nell'uomo, i vasi genitali femminili differiscono sostanzialmente solo per il diametro inferiore, con una conseguente risposta emodinamica minore. ...
Article
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Sommario Nella donna non è stata ancora chiaramente dimostrata un’associazione tra disfunzione sessuale (Female Sexual Dysfunction, FSD) e rischio cardiovascolare, come è avvenuto nel maschio. Nel corso degli anni la sessualità femminile e le relative problematiche sono state valutate utilizzando parametri poco oggettivabili, mentre solo recentemente si è posto l’accento sul ruolo della componente vascolare e sul fatto che i fattori di rischio cardiovascolare possono influenzare negativamente la sessualità della donna. In questa rassegna forniremo alcuni spunti di riflessione in merito al dimorfismo di genere che caratterizza questo ambito di studio e alla fisiopatologia della componente vascolare dell’eccitazione sessuale femminile, con un breve accenno alle metodiche strumentali oggi a disposizione dello specialista.
... The local administration of androgens could be the future: some double-blind, placebo-controlled clinical trials have demonstrated that local vaginal DHEA may improve SD in post-menopause, such as moderate to severe dyspareunia (88). The rationale of the use of the weak androgen DHEA in the menopausal vagina is probably to be found in the bona fide androgen-dependence of the anatomical structures named clit-urethra-vaginal (CUV) complex, which is the trigger of sexual pleasure during the vaginal penetration (89). Moreover, having made clear that the clitoris itself, differently from the penis, maintains its full responsivity to testosterone at all ages of the woman (90), we are currently exploring the use of low doses of testosterone gel on the postmenopausal clitoris with preliminary encouraging results. ...
Article
Sexual function is an important component of either general health and quality of life in both genders. Many studies have focused on the different risk factors for sexual dysfunctions, proving an association with several medical conditions. Endocrine disorders have been often mentioned in the pathogenesis of female and male sexual dysfunctions; however, particularly in women, sexual function is rarely addressed during clinical, in general, and endocrinological, in particular, consultations. As a thorough diagnosis is required in order to provide an adequately tailored treatment, knowing how each endocrine dysfunction can impair sexual health is of the utmost importance, also considering the high prevalence of conditions such as disorders of pituitary, thyroid, adrenal, gonads as well metabolic disorders. We performed a thorough review of existing literature on the different mechanisms involved in the pathogenesis of female sexual dysfunctions secondary to endocrine disorders in order to provide an up-to-date reference.
... During onset-that is, before any 'deep' penetration occurs-special attention is given for some time to the clitoral complex. (On the conception of the clito-urethro-vaginal complex, seeO'Connell et al. 2008;Foldès and Buisson 2009;Jannini et al. 2014;Mazloomdoost and Pauls 2015;Levin 2018.) In *He yinyang he takes the penis or 'jade whip' to 'hit upwards' (shang zhen 上揕) without penetration in order to cause her bodily flows to arrive (zhi qi 致氣), producing 'warmth' (slips 108-9). ...
Preprint
Full-text available
The sexual body techniques of early and medieval China are treated heuristically to form a sexual scenario for non-same-sex partners that is discussed in (1) textual sources dating from approximately 200 BCE to 1000 CE. These sources were transmitted and reformulated throughout this period as part of the wider sexual knowledge culture of imperial China (Wells and Yao Ping 2015; Yao Ping 2018). Minimal referential series of short extracts from such sources will be presented in historical order to illustrate some fairly consis¬tent basic ideas, concepts, theories and practical advice documented therein. This concise review will discuss (2) general aspects of the sexual scenario in which gender-specific roles during the sexual encounter must be emphasised. As ‘essence’ is considered to be the most precious generative fluid in the human body, men are advised to (3) deal with male essence as a scarce good, and thus learn to avoid emission and ejaculation during a sexual encounter. In stark contrast to this male preoccupation with containment, women are thought to be a superior source of nourishment. Repeated (4) female ejaculation provides the ‘female essence’ that can be absorbed by the man. (5) Performing a sexual encounter means mutual stimulation to this end during foreplay and onset phase, followed by a series of penetrative ‘advances’ with ‘intermissions’, and culminating in a ‘grand finale’.
... Female sexual dysfunction is not unusual and can have a significant negative impact on the quality of life of affected female and their partners [1]. Vaginal lubrication is an indicator of female genital sexual arousal and is a complex physiologic process that is not clearly understood [2]. Vaginal mucosal epithelial cells have been reported to have an important role in the mechanism of vaginal lubrication [3]. ...
Article
Full-text available
Purpose: The expression of epithelial progenitor cells (EPCs) in rat vagina was recently reported. The aims were to investigate the effects of estrogen on vaginal EPCs in the oophorectomized female rat model. Materials and methods: Female Sprague-Dawley rats (230-240 g, n=30) were divided into 3 groups: control (n=10), bilateral oophorectomy (OVX, n=10), and bilateral OVX followed by subcutaneous injections of 17β-estradiol (50 μg/kg/day, n=10). After 4 weeks, the expression of EPC-specific markers (CD44, estrogen receptor alpha [ERα], and progesterone receptor) were evaluated by immunohistochemistry and Western blot. Results: The CD44/ERα double-labeled cells were mainly expressed in basal cell layers and suprabasal layers as shown by confocal immunofluorescence. Confocal microscopy revealed that the number of CD44+/ERα+ cells decreased in the OVX group compared with the controls but was similar to control levels in rats receiving estrogen replacements. The protein expression of CD44 and ERα decreased after OVX and was restored to control levels after estrogen supplementation. Conclusions: Markers of EPCs were expressed in the vagina, and the expression of resident EPCs was regulated by estrogen. These findings imply that resident EPCs may have an important role in the regeneration of vaginal mucosa by estrogen replacement.
... Both the vaginal epithelium and the smooth and striated musculatures of all portions of the vagina were positive for TR a1-2 and b 1 . Notably, the positive immunostaining for all TR isoforms are found in smooth muscle cells of the corpus cavernosum of the clitoris and the epithelial cells of the Skens's gland, both involved in the female pleasure (Jannini et al., 2014). This finding is interesting because it reveals an additional connection between male and female genitalia. ...
... The clitoris plays a critical, pivotal role in female orgasm and arousal [3][4][5]. Despite the important role of the clitoris, we have learned about its detailed anatomy from cadaveric dissections over only the last two decades [6]. ...
Article
Introduction and hypothesisThe 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.Methods 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.ResultsAmong 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 3.64 cm2 respectively; p = 0.03), CUD (21 mm; p = 0.04 vs 16.1 mm; p = 0.04), and volume of the glans clitoris (947.7 mm3 vs 1081 mm3; 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.Conclusions 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.
... Levin 23 termed this region the anterior vaginal wall complex, an inclusive description consisting of the urethra, clitoral tissue, and Halban fascia. Further, this is consistent with the concept of the clitourethrovaginal complex as favored by Jannini et al 24 and corroborates a prior description by O'Connell et al. 15 It was noted during our dissections that the embalmed tissue was significantly easier to work with, because tissue integrity and gross anatomic detail could be maintained to a satisfactory degree. The tissue quality among cadavers displayed minimal discernable anatomic variation in the underlying structures, even among the range of ages. ...
... The anatomical relationships and the dynamic interaction among clitoris, urethra, and anterior vaginal wall, as evidenced through ultrasound imaging during coitus, made evident the need of an improvement in the nomenclature. The term clito-urethro-vaginal complex was coined to identify a multifaceted morpho-functional area (Figure 13.1), which, when properly stimulated during penetration, can induce vaginally-activated orgasm in some women [2,63]. Vaginally-activated orgasm involves the pumping effect on the Kobelt plexus, while the root of the clitoris is particularly stretched by the penis and compressed against the anterior vaginal wall, the pubic symphysis and the urethra with the surrounding exocrine glands and erectile tissue. ...
Chapter
Full-text available
The clitoris and the clito‐urethro‐vaginal complex are responsive to ovarian hormones and are the main peripheral structures that, with significant individual differences, provide the genital peripheral afferent component of female sexual pleasure. In the central nervous system during orgasm, essentially all of the major brain systems are activated, including the brainstem, limbic system, cerebellum, and cortex. In a symphony of integration, these peripheral and central systems mediate the sensory, cognitive, autonomic, and motor events of orgasm.
... 8 Based on the anatomic relations and dynamic interactions among the clitoris, urethra, and anterior vaginal wall, an area of especially high nerve density in the vagina, some lines of evidence support the concept of a clitoral-urethral-vaginal complex, a multifaceted morphofunctional area involved in triggering pleasure. 9,10 It is well established that the same molecular mechanisms regulate the relaxant and contractile response in these structures as in the male corpus cavernosum. 11 Indeed, preclinical and human histologic studies have constantly indicated that the nitric oxide-cyclic guanosine monophosphatephosphodiesterase type 5 pathway plays a key role in modulating blood flow and smooth muscle relaxation not only in the clitoris, 12 but also in the vagina 13 (see also "Proposed mechanisms providing the pathophysiologic bases of female vasculogenic sexual dysfunction syndromes" in part I 6 ). ...
Article
Introduction: Although basic science and clinical research indicate that the vascular physiopathology of male and female sexual dysfunction (FSD) is similar, to date the association between FSD and cardiovascular (CV) diseases has been only marginally explored. Aim: To discuss the potential reasons for differences in the role of CV diseases and risk factors in sexual function in women vs men in the 2nd part of a 2-part review. Methods: A thorough literature search of peer-reviewed publications on the topic was performed using the PubMed database. Main outcome measures: We present a review of the main factors that could account for this gap: (i) actual physiologic discrepancies and (ii) factors related to the inadequacy of the methodologic approach used to investigate CV risk in patients with FSD. A summary of the available methods to assess female sexual response, focusing on genital vascularization, is reported. Results: The microanatomy and biochemistry of the male and female peripheral arousal response are similar; in contrast, there are differences in the interplay between the metabolic profile and sex steroid milieu, in the relative weighting of cardiometabolic risk factors in the pathogenesis of CV disease, and their clinical presentation and management. CV diseases in women are under-recognized, leading to less aggressive treatment strategies and poorer outcomes. Moreover, evaluation of hemodynamic events that regulate the female sexual response has thus far been plagued by methodologic problems. Conclusion: To clarify whether sexuality can be a mirror for CV health in women, the female genital vascular district should be objectively assessed with standardized and validated methods. Studies designed to establish normative values and longitudinal intervention trials on the effect of the treatment of CV risk factors on FSD are urgently needed. Maseroli E, Scavello I, Vignozzi L. Cardiometabolic Risk and Female Sexuality-Part II. Understanding (and Overcoming) Gender Differences: The Key Role of an Adequate Methodological Approach. Sex Med Rev 2018;X:XXX-XXX.
... Indeed, it may oppose the entry of calcium ions through the L-type channels, which are located in the plasma membrane of the smooth muscle cells surrounding microvessels [14]. Targeting the clitourethrovaginal (CUV) complex with a local vasoactive product can facilitate sexual response upon adequate sexual stimulation [18], given the evidence that type 5 phosphodiesterase (PDE5) is expressed in the human vagina [19]. Even though it is known that vulvar congestion does not always translate into subjective arousal [20], vasoactive drugs, such as PDE5 inhibitors, have been tested in specific populations of premenopausal women suffering from well-established medical conditions, such as type I diabetes [21], interfering with genital neurovascular substrates. ...
Article
PurposeThe aim of this pilot, double-blind, randomized, placebo-controlled study, was to evaluate both the efficacy and the tolerability of a formulation for vulvar application containing Visnadine, a natural extractive substance with vasoactive properties, (ReFeel® spray, IDI Integratori Dietetici Italiani S.r.l., Italy) in women self-reporting sexual symptoms. Methods Sixty women (age range 18–60 years) volunteered to test the product against placebo (PL): Two puffs in the vulvar area, 10 min before sexual stimulation, for 30 days and for a minimum of six times. The main outcome measure was the improvement of the Female Sexual Function Index (FSFI) score (cut-off ≤ 26.55 for female sexual dysfunction [FSD]). Secondary outcomes were sexual satisfaction and tolerability with the product. ResultsPL group (n = 28) and Visnadine group (n = 30) were comparable for age, sexual function and rate of FSD at baseline (T0). After 1 month (T1), women in Visnadine group scored from 25.0 ± 3.8 to 27.9 ± 2.4 (p < 0.001), whereas no changes were evident in PL group (from 25.4 ± 5.0 to 25.6 ± 4.7). Statistically significant differences at T1 were reported in women with a positive (p < 0.001) or a negative FSD diagnosis (p < 0.01) using active treatment. Women with FSD reported significantly more improvement in satisfaction with their sexual function when treated with Visnadine spray compared to PL (p < 0.001), as well as more excitation (p < 0.001), pleasure (p < 0.001) and less time to reach orgasm (p < 0.003). No significant side effects were evident in both groups. Conclusions On demand, 1-month use of Visnadine spray displayed positive effects on sexual function in women with and without FSD and it was well tolerated. Topical Visnadine may not only be part of multimodal strategies to manage clinically relevant sexual symptoms but also simply to help women to enhance their subjective impaired perception of sexual response.
... Of the female sexual organs, the clitoris is the pivotal anatomical structure involved in the physiologic changes that occur during sexual arousal and orgasm [5][6][7]. The clitoris is a complex organ comprised of internal and external components, including the glans, body, bulbs, and crura, and lies in close proximity to the distal vagina [8][9][10]. ...
Article
Introduction and hypothesis: We present a 3D computational approach for automated clitoral measurements. We hypothesized that computationally derived measurements would be comparable and less variable than reported manual measures. Methods: In this retrospective study, MRIs of 22 nulliparous women age 20-49 years with normal vaginal and clitoral anatomy were collected. Manual segmentations were performed to reconstruct 3D models of the whole clitoris (glans, body, crura, and bulbs) and vagina. The length, width, and volume of the clitoral structures and the distance between the vagina and clitoral structures were calculated. Computed clitoral morphometrics (length, width) were compared to median [range] values from a previously published cadaver study (N = 22) using the median test and Moses extreme reaction test. Calculated distances were compared to mean (± SD) reported by a 2D MRI study (N = 20) using independent t-test and Levene's test. Results: Overall, computed clitoral morphometrics were similar to manual cadaver measurements, where the majority of length and width measures had ~1-2 mm difference and had less variability (smaller range). All calculated distances were significantly smaller and had smaller SDs than manual 2D MRI values, with two-fold differences in the means and SDs. Large variation was observed in clitoral volumetric measures in our cohort. Conclusions: The proposed 3D computational method improves the standardization and consistency of clitoral measurements compared to traditional manual approaches. The use of this approach in radiographic studies will give better insight into how clitoral anatomy relates to sexual function and how both are impacted by gynecologic surgery, where outcomes can assist treatment planning.
... Indeed, genital arousal consists of clitoral tumescence and vaginal vasocongestion and swelling, which result from relaxation of endothelial SMCs [37]. It is also well known that clitoris is an androgens-responsive organ, throughout the entire life spectrum [40], both in its external and inner part, or clitourethrovaginal (CUV) complex [41]. For instance, during embryogenesis, androgens are fundamental for the development and morpho-functional regulation of genital organs [42,43]. ...
Article
Introduction Preclinical studies show that, in the clitoris, testosterone (T) is necessary to maintain a functional contractile and relaxant machinery, which represents the underlying mechanism of the peripheral arousal response. Although there is clinical evidence suggesting that T treatment significantly improves multiple domains of sexual functioning, the vascularization of clitoral tissue and its regulation by sex steroids are still under-investigated. Objective To explore the effects of 6-month systemic T administration on clitoral color Doppler ultrasound (CDU) parameters in women with female sexual dysfunction (FSD). Methods 81 women with FSD were retrospectively recruited. Data on CDU parameters at baseline and after 6 months with four different treatments were available and thus further longitudinally analyzed: local non-hormonal moisturizers (NH group), n=37; transdermal 2% T gel 300 mcg/day (T group), n=23; local estrogens (E group), n=12; combined therapy (T+E group), n=9. Patients underwent physical, laboratory, and genital CDU examinations at both visits and completed different validated questionnaires, including the Female Sexual Function Index (FSFI). Results At 6-month visit, T therapy significantly increased clitoral artery peak systolic velocity (PSV) when compared to both NH (p < 0.0001) and E (p < 0.0001) groups. A similar increase was found in the T + E group (p = 0.039 vs. E) (Fig.1). In addition, T treatment was associated with significantly higher FSFI desire, pain, arousal, lubrication, orgasm and total scores at 6-month visit vs. baseline. Similar findings were observed in the T + E group. No significant differences in the variations of total and high-density lipoprotein-cholesterol, triglycerides, fasting glycemia, insulin and glycated hemoglobin levels were found among the four groups. No adverse events were observed. Conclusions In women complaining for FSD, systemic T administration, either alone or combined with local estrogens, was associated with a positive effect on clitoral blood flow and a clinical improvement in sexual function, showing a good safety profile. Disclosure Work supported by industry: no.
... During onset -that is, before any 'deep' penetration occurs -special attention is given for some time to the clitoral complex. (On the conception of the clito-urethro-vaginal complex, see O' Connell et al. 2008;Foldès and Buisson 2009;Jannini et al. 2014;Mazloomdoost and Pauls 2015;Levin 2018.) In *He yinyang, he takes the penis or 'jade whip' to 'hit upwards' (shang zhen 上揕 ) without penetration in order to cause her bodily fows to arrive (zhi qi 致氣 ), producing 'warmth' (slips 108-9). ...
Chapter
Full-text available
The sexual body techniques of early and medieval China are treated heuristically to form a sexual scenario for non-same-sex partners that is discussed in textual sources dating from approximately 200 BCE to 1000 CE. These sources were transmitted and reformulated throughout this period as part of the wider sexual knowledge culture of imperial China. Minimal referential series of short extracts from such sources will be presented in a historical order to illustrate some fairly consistent basic ideas, concepts, theories and practical advice documented therein. This concise review discusses general aspects of the sexual scenario in which gender-specific roles during the sexual encounter must be emphasised. As ‘essence’ is considered to be the most precious generative fluid in the human body, men are advised to deal with male essence as a scarce good, and thus learn to avoid emission and ejaculation during a sexual encounter. In stark contrast to this male preoccupation with containment, women are thought to be a superior source of nourishment. Repeated female ejaculation provides the ‘female essence’ that can be absorbed by the man. Performing a sexual encounter means mutual stimulation to this end during foreplay and onset phase, followed by a series of penetrative ‘advances’ with ‘intermissions’, and culminating in a ‘grand finale’.
... Levin 23 termed this region the anterior vaginal wall complex, an inclusive description consisting of the urethra, clitoral tissue, and Halban fascia. Further, this is consistent with the concept of the clitourethrovaginal complex as favored by Jannini et al 24 and corroborates a prior description by O'Connell et al. 15 It was noted during our dissections that the embalmed tissue was significantly easier to work with, because tissue integrity and gross anatomic detail could be maintained to a satisfactory degree. The tissue quality among cadavers displayed minimal discernable anatomic variation in the underlying structures, even among the range of ages. ...
Article
Full-text available
Background: Controversy exists in the literature regarding the presence or absence of an anatomic "G-spot." However, few studies have examined the detailed topographic or histologic anatomy of the putative G-spot location. Aim: To determine the anatomy of the anterior vaginal wall and present detailed, systematic, accessible findings from female cadaveric dissections to provide anatomic clarity with respect to this location. Methods: Systematic anatomic dissections were performed on 13 female cadavers (32-97 years old, 8 fixed and 5 fresh) to characterize the gross anatomy of the anterior vaginal wall. Digital photography was used to document dissections. Dissection preserved the anterior vaginal wall, urethra, and clitoris. In 9 cadavers, the vaginal epithelial layer was reflected to expose the underlying urethral wall and associated tissues. In 4 cadavers, the vaginal wall was left intact before preservation. Once photographed, 8 specimens were transversely sectioned for macroscopic inspection and histologic examination. Outcomes: The presence or absence of a macroscopic anatomic structure at detailed cadaveric pelvis dissection that corresponds to the previously described G-spot and gross anatomic description of the anterior vaginal wall. Results: Deep to the lining epithelium of the anterior vaginal wall is the urethra. There is no macroscopic structure other than the urethra and vaginal wall lining in the location of the putative G-spot. Specifically, there is no apparent erectile or "spongy" tissue in the anterior vaginal wall, except where the urethra abuts the clitoris distally. Clinical implications: The absence of an anatomic structure corresponding to the putative G-spot helps clarify the controversy on this subject. Strengths and limitations: Limitations to this study include limited access to specimens immediately after death and potential for observational bias. In addition, age, medical history, and cause of death are not publishable for privacy reasons. However, it is one of the most thorough and complete anatomic evaluations documenting the anatomic detail of the anterior vaginal wall. Conclusion: The G-spot, in its current description, is not identified as a discrete anatomic entity at macroscopic dissection of the urethra or vaginal wall. Further insights could be provided by histologic study. Hoag N, Keast JR, O'Connell HE. The "G-Spot" Is Not a Structure Evident on Macroscopic Anatomic Dissection of the Vaginal Wall. J Sex Med 2017;14:1524-1532.
... Indeed, genital arousal consists of clitoral tumescence and vaginal vasocongestion and swelling, which result from relaxation of endothelial SMCs [37]. It is also well known that clitoris is an androgens-responsive organ, throughout the entire life spectrum [40], both in its external and inner part, or clitourethrovaginal (CUV) complex [41]. For instance, during embryogenesis, androgens are fundamental for the development and morpho-functional regulation of genital organs [42,43]. ...
Article
Full-text available
Purpose To explore the effects of 6-month systemic testosterone (T) administration on clitoral color Doppler ultrasound (CDU) parameters in women with female sexual dysfunction (FSD). Methods 81 women with FSD were retrospectively recruited. Data on CDU parameters at baseline and after 6 months with four different treatments were available and thus further longitudinally analyzed: local non-hormonal moisturizers (NH group), n = 37; transdermal 2% T gel 300 mcg/day (T group), n = 23; local estrogens (E group), n = 12; combined therapy (T + E group), n = 9. Patients underwent physical, laboratory, and genital CDU examinations at both visits and completed different validated questionnaires, including the Female Sexual Function Index (FSFI). Results At 6-month visit, T therapy significantly increased clitoral artery peak systolic velocity (PSV) when compared to both NH ( p < 0.0001) and E ( p < 0.0001) groups. A similar increase was found in the T + E group ( p = 0.039 vs. E). In addition, T treatment was associated with significantly higher FSFI desire, pain, arousal, lubrication, orgasm, and total scores at 6-month visit vs. baseline. Similar findings were observed in the T + E group. No significant differences in the variations of total and high-density lipoprotein-cholesterol, triglycerides, fasting glycemia, insulin and glycated hemoglobin levels were found among the four groups. No adverse events were observed. Conclusion In women complaining for FSD, systemic T administration, either alone or combined with local estrogens, was associated with a positive effect on clitoral blood flow and a clinical improvement in sexual function, showing a good safety profile. Trial registration number NCT04336891; date of registration: April 7, 2020.
Article
Full-text available
Objetivo: revisar la literatura presente, respecto a la evidencia científica existente, en relación al punto “G”. Materiales y métodos: Se realizó una búsqueda bibliográfica en diferentes bases de datos electrónicas para identificar literatura relevante EBSCO, Elsevier, Interscience, Medline, Ovid, Pubmed, SciELO, Scopus (1950 al 2016), Cochrane Group (julio 31 del 2016) y libros de texto impresos, así como de revistas de sexología científica indexadas y sociedades sexológicas reconocidas como: Advances in Sexual Medicine, American Journal of Sexuality Education, British Journal of Sexual Medicine (BJSM), European Journal of Sexual Health, Sexology and The Journal of Sexual Medicine; tratando de encontrar la mejor evidencia científica existente en relación al punto “G”. Resultados: Se revisaron 75 títulos, de los cuales 65 cumplían con nuestros criterios de selección, correspondientes a artículos de revisión, diseños de tipo transversal, casos y controles. El termino Punto “G”, no es un término usado en la anatomía humana; y no existen imágenes anatómicas ni ecográficas de dicho punto, por lo tanto, el punto “G” no existe; y a pesar de ser ampliamente aceptado entre las mujeres, los estudios anatómicos, bioquímicos e histológicos no han demostrado su existencia. Conclusiones: La literatura muestra que la vagina no tiene ninguna estructura anatómica que pueda desencadenar un orgasmo; y así como las teorías que afirmaban la existencia del punto “G”, por más de treinta años tuvieron su auge, hoy por hoy, la evidencia de su no existencia, también está cogiendo eco.
Article
Introduction: Despite its frequency, recognition and therapy of vulvovaginal atrophy (VVA) remain suboptimal. Wet mount microscopy, or vaginal pH as a proxy, allows VVA diagnosis in menopause, but also in young contraception users, after breast cancer, or postpartum. Intravaginal low dose estrogen product is the main therapy. Ultra-low-dose vaginal estriol is safe and sufficient in most cases, even in breast cancer patients, while hyaluronic acid can help women who cannot or do not want to use hormones. Areas covered: The authors provide an overview of the current pharmaceutical treatment for vulvovaginal atrophy and provide their expert opinions on its future treatment. Expert opinion: The basis of good treatment is a correct and complete diagnosis, using a microscope to study the maturity index of the vaginal fluid. Minimal dose of estriol intravaginally with or without lactobacilli is elegant, cheap and can safely be used after breast cancer and history of thromboembolic disease. Laser therapy requires validation and safety data, as is can potentially cause vaginal fibrosis and stenosis, and safer and cheaper alternatives are available.
Article
Introduction: Female sexual dysfunction (FSD) is a highly prevalent, yet commonly underdiagnosed and undertreated condition. This paper reviews the diagnostic terminology for FSD, and basic sexual physiology in women. The Food and Drug Administration (FDA) approved drugs for FSD are discussed, followed by investigational drugs for FSD currently in phase 2 or 3 clinical trials, reasons for failure of drug development, and potential future drug targets. Areas Covered: A literature review was conducted for available treatments for FSD: flibanserin, estrogen, ospemifene and prasterone. Potential treatments are assessed, as was the Pharmaprojects database which includes clinical trial information. Testosterone, bremelanotide, bupropion-trazodone, PDE-5 inhibitors, prostaglandins, tibolone and combination therapies, and the theoretical basis of potential drug targets are discussed. Expert opinion: The lack of established endpoints for phase 3 studies of FSD has impeded approval of new treatments, and required additional studies for validation, resulting in proposed changes to the FDA draft guidance for FSD clinical trials in October 2016. Current DSM-5 diagnostic nosology also fails to capture the full range of symptomology. Several promising compounds have shown no movement for several years limiting women’s options. Overcoming socio-cultural bias against women’s sexual and reproductive health will be critical in the approval of new treatments for FSD.
Chapter
Sexual arousal is a physiological response to internal and external stimuli and is mediated by both central and peripheral nervous systems. This chapter focuses specifically on genital arousal, which is characterized by changes in sensation, tissue contractility, vasocongestion, and lubrication. The physiological events of the sexual arousal response in women are related to the structural integrity of genital tissues and the function of vascular, neural, and hormonal systems. The strongest evidence, thus far, indicates that the adrenergic and nitric oxide signaling systems play important roles in acutely regulating genital blood flow but sex steroid hormones are also critical for maintaining genital tissue health. The additive, synergistic or antagonistic interactions of cellular processes will ultimately determine the overall physiological responses manifested as blood flow, lubrication or tissue contractility.
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Although gynaecology is a specialty responsible for women’s health, the field was historically male-dominated and its science remains biased towards male perceptions of women’s health. In light of the changing social climate in our society and the changing gender composition of the specialty, a number of steps can be taken to make gynaecology more women-centred.
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The article consists of 6 sections written by separate authors that review female genital anatomy, the physiology of female sexual function and the pathophysiology of female sexual dysfunction but excluding hormonal aspects. Aim. To review female sexual function - physiology and pathophysiology- especially since 2010 and to make specific recommendations with levels of evidence ( Oxford Centre) where relevant. Conclusion. Despite numerous lab assesssments of female sexual function, genital assessments alone appear insufficient to characterise fully the complete sexual response.
Chapter
Female genital mutilation (FGM), perhaps among the most culturally determined surgical practices in the world today, profoundly impacts quality of life in women. However, in some women who have undergone FGM, sexuality—specifically pleasure and orgasm—might be spared. Such controversial and paradoxical outcomes may be explained by adopting a dutiful sociocultural and historical perspective, allowing the clinician to manage sexual problems related to FGM while also showing respect for a woman’s cultural beliefs, needs, and expectations. While, on the one hand, it is critically important to advocate strongly for the abolition of FGM, on the other, healthcare professionals should understand the impact of FGM on women’s well-being and be trained to assess and treat possible sexual complications with a prejudice-free attitude.
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Introduction The word “haptics” refers to sensory inputs arising from receptors in the skin and in the musculoskeletal system, particularly crucial in sexual economy. Haptic stimuli provide information about mechanical properties of touched objects and about the position and motion of the body. An important area in this field is the development of robotic interfaces for communication through the “haptic channel,” which typically requires a collaboration between engineers, neuroscientists, and psychologists. Many aspects of human sexuality, such as arousal and intercourse, can be considered from a haptic perspective. Objectives To review the current literature on haptics and somatosensation, and discuss potential applications of haptic interfaces in sexual medicine. Methods Articles for this review were collected based on the results of a bibliographic search of relevant papers in Cochrane Library, Google Scholar, Web of Science, Scopus, and EBSCO. The search terms used, including asterisks, were “haptic∗,” “somatosensor∗,” “sexual∗,” and related terms describing the role of touch, technology, and sexuality. Additional terms included “interface∗,” “touch,” and “sex∗.” Results We have provided a functional and anatomical description of the somatosensory system in humans, with special focus on neural structures involved in affective and erotic touch. One interesting topic is the development of haptic interfaces, which are specialized robots generating mechanical signals that stimulate our somatosensory system. We provided an overview on haptic interfaces and evaluated the role of haptics in sexual medicine. Conclusion Haptics and studies on the neuroscience of the somatosensory system are expected to provide useful insights for sexual medicine and novel tools for sexual dysfunction. In the future, crosstalk between sexology and haptics may produce a novel generation of user-friendly haptic devices generating a higher level of realism and presence in providing stimuli. Moscatelli A, Nimbi FM, Ciotti S, et al. Haptic and Somesthetic Communication in Sexual Medicine. J Sex Med 2020;XX:XXX–XXX.
Article
Vaginal atrophy caused by the aging process and perineal trauma has a negative impact on women. A new vaginal atrophy treatment is injection of materials into the vaginal wall, including platelet-rich plasma (PRP), autogenous fat graft (AFG), hyaluronic acid (HA), botulinum toxin (BTX), and collagen, but to date their efficacy has not been reviewed. Vaginal wall injection is available only for mild cases of vaginal atrophy or as an adjunct to vaginal surgery. PRP is used mainly to restore vaginal function, and multiple injections are needed to achieve good results in vaginal atrophy. HA, AFG, and collagen are used mainly to augment the vaginal wall. BTX injection can inhibit vaginal muscle spasm and reduce pain during sexual intercourse in patients with vaginismus. Injection of most of these materials into vaginal wall is effective and relatively safe. Vascular embolisms are the most serious complication of vaginal injection and should be prevented. In addition, there has been no randomized double-blind placebo-controlled trial or discussion of methods to avoid serious complications resulting from vaginal injection. Therefore, further studies of the injection of materials into the vaginal wall to treat vaginal atrophy are required, and the procedures should be standardized to benefit more patients. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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For sexologists, physicians, psychologists, gynecologists etc., it is a duty to update their knowledge. Female and male orgasm-sexuality, free pdf with 36 Pubmed-full text Dr Vincenzo Puppo-New Sexology Project: Eur J Obstet Gynecol, Eur Urol, Clin Anat, BJOG, J Urol, Int Urogynecol J, J Sex Med, BJU Int, J Pediatr Adolesc Gynecol, ISRN Obstet Gynecol, Gynecol Obstet Fertil, Maturitas, Int J Urol, etc. Sexual pleasure/orgasm, (clitoris, labia minora and vestibular bulbs, exist in all women) is a source of physical and psychological wellbeing that contributes to human happiness. Female sexual anatomy is not has been a neglected area of study and the existing terminology is accurate from centuries... The key to female orgasm are the female erectile organs of the vulva (external organs)... Female orgasm is possible in all women, always, with effective stimulation of the female erectile organs... female sexual dysfunctions are popular because they are based on something that does not exist, i.e. the vaginal orgasm... Female sexual satisfaction is based on orgasm: sexologists must define having sex/love making when orgasm occurs for both partners, always, with or without vaginal intercourse (definition for all human beings)... the duration of penile-vaginal intercourse is not important for a woman’s orgasm: premature ejaculation is not a male sexual dysfunction... Website http://www.vincenzopuppo.altervista.org/articoli.html Free video: clitoris/labia minora erection in woman https://www.researchgate.net/publication/273966598_Flaccid_Erect_Clitoris_Labia_minora_in_woman_Clin_Anat_2013 Free video: orgasms in all women https://www.researchgate.net/publication/343851657_Video_Female_orgasms_in_all_women_always_with_stimulation_clitoris-labia_minora_with_fingers https://www.youtube.com/watch?v=Pm_Qg2b4kKI
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Introduction The G-spot, a putative erogenous area in the anterior vaginal wall, is a widely accepted concept in the mainstream media, but controversial in medical literature. Aim Review of the scientific data concerning the existence, location, and size of the G-spot. Methods Search on Pubmed, Pubmed Central, Cochrane, clinicaltrials.gov and Google Scholar from inception to November 2020 of studies on G-spot's existence, location and nature. Surveys, clinical, physiological, imaging, histological and anatomic studies were included. Main Outcome Measure Existence, location, and nature of the G-spot. Results In total, 31 eligible studies were identified: 6 surveys, 5 clinical, 1 neurophysiological, 9 imaging, 8 histological/anatomical, and 2 combined clinical and histological. Most women (62.9%) reported having a G-spot and it was identified in most clinical studies (55.4% of women); in 2 studies it was not identified in any women. Imaging studies had contradictory results in terms of its existence and nature. Some showed a descending of the anterior vaginal wall, that led to the concept of clitourethrovaginal complex. In anatomic studies, one author could systematically identify the G-spot, while another group did not find it. Studies on innervation of the vaginal walls did not systematically identify an area with richer innervation. Conclusion The different studies did systematically agree on the existence of the G-spot. Among the studies in which it was considered to exist, there was no agreement on its location, size, or nature. The existence of this structure remains unproved. Vieira-Baptista P, Lima-Silva J, Preti M, et al. G-spot: Fact or Fiction?: A Systematic Review. Sex Med 2021;XX:XXXXXX.
Article
Knowledge of the actual anatomy and function of the clitoris has been underrepresented for a long time. Anatomical descriptions and illustrations existed but were scientifically disregarded for centuries. Even now anatomy books and textbooks are still dominated by incorrect depictions and inadequate functional descriptions of the clitoris, even though the knowledge about this complex organ is essential for the clinical practice in gynecology, obstetrics, urology and other specialist disciplines. From a special gynecological perspective, the sociocultural and medical history are presented, including misunderstandings and misconceptions. The correct anatomy and physiology are closely related to the rediscovery of the clitoris in research and practice as well as in the social perception. The relevance of the clitoris for contemporary medicine regarding sexuality, self-awareness, self-determination and therefore gender equity can be seen as a fundamental and also political issue.
Article
Masturbation is one of the most common sexual behaviors in humans. It is also a phylogenetically widespread trait of various other mammalian and some non-mammalian species. Several hypotheses have been proposed aiming to explain the function of masturbation in primates and other species. These were mainly based on observations of nonhuman primates such as rhesus macaques or bonobos and rodents such as African ground squirrels. Based on these observations various scholars suggested that masturbation improves ejaculate quality, decreases the risk of contracting sexually transmitted infections or is merely a by-product of sexual arousal and thus an alternate outlet to copulation. While these theories may explain some facets of masturbation in some species, they do not explain why masturbation is so widespread and has developed in various species as well as our hominid ancestors. Moreover, the research on which these theories are based is scarce and heavily focused on male masturbation, while female masturbation remains largely unexplored. This sex difference may be responsible for the one-sided theorizing that attributes a specific biological benefit to masturbation. We propose that the widespread prevalence of masturbation in the animal kingdom may be better explained by viewing masturbation as a primarily self-reinforcing behavior that promotes pleasure both in human and in nonhuman species.
Article
Background Vaginal laxity, usually accompanied with prolapse symptoms, affects women’s sexual satisfaction and quality of life. Vaginal tightening surgery aims to reinforce the peri-vaginal muscle strength and restore the normal vaginal anatomy. Objectives The objective of this study was to introduce a new surgical approach with vaginal tightening using acellular dermal matrix (ADM). Methods In this retrospective study, we analyzed data from 80 patients with vaginal laxity who underwent surgery from April 2017 to April 2021. Three-dimensional transvaginal ultrasound (3D-TVS) and the Female Sexual Function Index (FSFI) were evaluated among the patients. Results The mean age of the patients was 44.6 years. The mean patient follow-up was 13.2 months. No infection, rectovaginal fistula, or implant explantation occurred. 3D-TVS demonstrated a significant reduction of introital diameter on a maximum Valsalva maneuver (2.3 cm vs. 4.1 cm; p<0.05) and the reconstruction of acute vaginal angulation. FSFI orgasm subscore increased significantly. Conclusions Vaginal tightening with ADM is a minimally invasive surgery with safety and efficacy for patients with vaginal laxity.
Article
Objective To compare sexual function and outcomes of quality of life of patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome after vaginal dilation and surgical procedures. Study Design Cross-sectional study from January 2019 to June 2019. Setting Tertiary teaching hospital. Patient(s) Women with MRKH syndrome treated with vaginal dilation (n = 88) or surgical procedures (n = 45). Intervention WeChat-based questionnaires were distributed to every group member in our MRKH support group. Main Outcome Measure(s) Sexual functional were assessed by means of the Female Sexual Function Index (FSFI). Outcomes of quality of life were assessed by means of the 12-item World Health Organization Disability Assessment Schedule 2 (WHODAS2). Vaginal length was defined as the maximum depth of the placement of the vaginal mold. Result(s) The FSFI scores were similar between the dilation (24.49 ± 4.51) and surgery (23.79 ± 3.57) groups. Except for the higher orgasm score in the dilation group (9.96 ± 3.60 vs. 8.20 ± 2.67), the other dimensions of the FSFI were not significantly different between the groups. No significant differences were found in the WHODAS2 scores between the dilation group (median 8.33 [interquartile range 4.17–15.62]) and the surgery group (6.25 [2.08–14.58]). However, the vaginal length was significantly shorter in the dilation group (6.5 ± 2.04 cm) than in the surgery group (8.1 ± 1.59 cm). Conclusion(s) Although the vaginal length was shorter in the dilation therapy group than in the surgical therapy group, sexual function and quality of life were similar between these two groups. Vaginal dilation should be proposed as the first-line therapy for MRKH patients.
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Women diagnosed with complete spinal cord injury (SCI) at T10 or above report vaginal-cervical perceptual awareness. To test whether the Vagus nerves, which bypass the spinal cord, provide the afferent pathway for this response, we hypothesized that the Nucleus Tractus Solitarii (NTS) region of the medulla oblongata, to which the Vagus nerves project, is activated by vaginal-cervical self-stimulation (CSS) in such women, as visualized by functional magnetic resonance imaging (fMRI). Regional blood oxygen level-dependent (BOLD) signal intensity was imaged during CSS and other motor and sensory procedures, using statistical parametric mapping (SPM) analysis with head motion artifact correction. Physiatric examination and MRI established the location and extent of spinal cord injury. In order to demarcate the NTS, a gustatory stimulus and hand movement were used to activate the superior region of the NTS and the Nucleus Cuneatus adjacent to the inferior region of the NTS, respectively. Each offour women with interruption, orbcompleteQinjury, ofthe spinal cord (ASIA criteria), and one womanwithsignificant,butbincompleteQSCI,allatoraboveT10,showedactivationoftheinferiorregionoftheNTSduringCSS.Eachwoman showed analgesia, measured at the fingers, during CSS, confirming previous findings. Three women experienced orgasm during the CSS. The brain regions that showed activation during the orgasms included hypothalamic paraventricular nucleus, medial amygdala, anterior cingulate, frontal, parietal, and insular cortices, and cerebellum. We conclude that the Vagus nerves provide a spinal cord-bypass pathway for vaginal- cervical sensibility in women with complete spinal cord injury above the level of entry into spinal cord of the known genitospinal nerves. D 2004 Elsevier B.V. All rights reserved. Theme: Motor systems and sensorimotor integration Topic: Spinal cord and brainstem
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The aim of this study was to compare female sexual function after surgical treatment of anterior vaginal prolapse with either small intestine submucosa grafting or traditional colporrhaphy. Subjects were randomly assigned, preoperatively, to the small intestine submucosa graft (n = 29) or traditional colporrhaphy (n = 27) treatment group. Postoperative outcomes were analyzed at 12 months. The Female Sexual Function Index questionnaire was used to assess sexual function. Data were compared with independent samples or a paired Student's t-test. In the small intestine submucosa group, the total mean Female Sexual Function Index score increased from 15.5±7.2 to 24.4±7.5 (p<0.001). In the traditional colporrhaphy group, the total mean Female Sexual Function Index score increased from 15.3±6.8 to 24.2±7.0 (p<0.001). Improvements were noted in the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. There were no differences between the two groups at the 12-month follow-up. Small intestine submucosa repair and traditional colporrhaphy both improved sexual function postoperatively. However, no differences were observed between the two techniques.
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There is general agreement that it is possible to have an orgasm thru the direct simulation of the external clitoris. In contrast, the possibility of achieving climax during penetration has been controversial. Six scientists with different experimental evidence debate the existence of the vaginally activated orgasm (VAO). To give reader of The Journal of Sexual Medicine sufficient data to form her/his own opinion on an important topic of female sexuality. Expert #1, the Controversy's section Editor, together with Expert #2, reviewed data from the literature demonstrating the anatomical possibility for the VAO. Expert #3 presents validating women's reports of pleasurable sexual responses and adaptive significance of the VAO. Echographic dynamic evidence induced Expert # 4 to describe one single orgasm, obtained from stimulation of either the external or internal clitoris, during penetration. Expert #5 reviewed his elegant experiments showing the uniquely different sensory responses to clitoral, vaginal, and cervical stimulation. Finally, the last Expert presented findings on the psychological scenario behind VAO. The assumption that women may experience only the clitoral, external orgasm is not based on the best available scientific evidence.
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In attempt to identify and validate different types of orgasms which females have during sex with a partner, data collected by Mah and Binik (2002) on the dimensional phenomenology of female orgasm were subjected to a typological analysis. A total of 503 women provided adjectival descriptions of orgasms experienced either with a partner (n = 276) or while alone (n = 227). Latent-class analysis revealed four orgasm types which varied systematically in terms of pleasure and sensations engendered. Two types, collectively labelled "good-sex orgasms," received higher pleasure and sensation ratings than solitary-masturbatory ones, whereas two other types, collectively labelled "not-as-good-sex orgasms," received lower ratings. These two higher-order groupings differed on a number of psychological, physical and relationship factors examined for purposes of validating the typology. Evolutionary thinking regarding the function of female orgasm informed discussion of the findings. Future research directions were outlined, especially the need to examine whether the same individual experiences different types of orgasms with partners with different characteristics, as evolutionary theorizing predicts should be the case.
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Past findings on the diagnostic sensitivity of vaginal photoplethysmography are limited by testing among women with heterogeneous sexual dysfunctions and by the use of statistical techniques that are unable to assess how changes in subjective arousal are associated with changes in physiological arousal. The aims of this study were to: (i) test the sensitivity of vaginal photoplethysmography and continuous measures of subjective sexual arousal in differentiating between women with and without sexual arousal or orgasm dysfunction; and (ii) examine the diagnostic utility of measuring the synchrony between genital and subjective sexual responses. Sexual arousal was assessed in sexually healthy women (n = 12), women with orgasm disorder (OD; n = 12), and 38 women who met the criteria for the three subcategories of sexual arousal dysfunction described by Basson et al. (i.e., genital sexual arousal disorder [GAD; n = 9], subjective sexual arousal disorder [SAD; n = 13], and combined genital and subjective arousal disorder [CAD; n = 16]). Physiological sexual arousal was assessed using vaginal photoplethysmography, and subjective sexual arousal was measured continuously and using a Likert-scale in response to sexual videos. Women with GAD showed the lowest and women with CAD showed the highest levels of vaginal pulse amplitude response to erotic stimuli. Women with sexual arousal disorder showed significantly lower levels of subjective sexual arousal to erotic stimuli than did sexually healthy women. Relations between subjective and physiological measures of sexual arousal were significantly weaker among women with sexual arousal disorder than sexually healthy women or women with OD. Preliminary support was provided for the diagnostic utility of measuring the synchrony between subjective and genital arousal in women with sexual arousal disorder. Findings do not support the sensitivity of using vaginal photoplethysmography, or continuous or Likert-scale measures of subjective arousal for differentiating between subtypes of women with sexual arousal disorder.
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No controversy can be more controversial than that regarding the existence of the G-spot, an anatomical and physiological entity for women and many scientists, yet a gynecological UFO for others. The pros and cons data have been carefully reviewed by six scientists with different opinions on the G-spot. This controversy roughly follows the Journal of Sexual Medicine Debate held during the International Society for the Study of Women's Sexual Health Congress in Florence in the February of 2009. To give to The Journal of Sexual Medicine's reader enough data to form her/his own opinion on an important topic of female sexuality. Expert #1, who is JSM's Controversy section editor, reviewed histological data from the literature demonstrating the existence of discrete anatomical structures within the vaginal wall composing the G-spot. He also found that this region is not a constant, but can be highly variable from woman to woman. These data are supported by the findings discussed by Expert #2, dealing with the history of the G-spot and by the fascinating experimental evidences presented by Experts #4 and #5, showing the dynamic changes in the G-spot during digital and penile stimulation. Experts #3 and #6 argue critically against the G-spot discussing the contrasting findings so far produced on the topic. Although a huge amount of data (not always of good quality) have been accumulated in the last 60 years, we still need more research on one of the most challenging aspects of female sexuality.
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The aim of this study is to elucidate the innervation of human vagina by performing a microdissection and PGP immunohistochemistry study. Seven fresh Korean cadavers were used. In five cadavers, the site at which the nerve entered the vaginal wall was observed by microdissection. Two vaginas were stained with trichrome and protein gene product 9.5 (PGP) immunostain. Terminal nerve branches in the vaginal wall were most dense at the second 1/5 partition from the inferior anterior wall (1.49 +/- 0.51/cm(2)). Its density started decreasing (0.57 +/- 0.09/cm(2) -0.89 +/- 0.46/cm(2)) and became scarce at the fourth and fifth 1/5 partitions from the bottom (0.37 +/- 0.14/cm(2)/3-0/cm(2)). The mucosa of the anterior vaginal wall at the distal 1/3 point (designated 1) was 3.50 +/- 2.06 mm in thickness and was 1.18 +/- 0.20 mm at the proximal point (designated 2). It was 1.57 +/- 0.78 mm at the distal 1/3 point (designated 3) of the lateral wall and 1.43 +/- 0.39 mm at the proximal 1/3 point (designated 4) of the posterior wall. Point 1 was thicker than 2, 3, and 4. The vaginal muscle of 1 (5.59 +/- 2.74 mm) was thicker than 2 (3.19 +/- 0.62 mm), 3 (3.31 +/- 1.31 mm), and 4 (2.98 +/- 0.33 mm). Small nerve fibers were most dense at 1 (6.5 +/- 1.1/mm(2)) and scarce at 4 (3.8 +/- 1.5/mm(2)). Large nerve fibers were most dense at 1 (1.9 +/- 0.9/mm(2)) and scarce at 2 (0.7 +/- 0.7/mm(2)) and 4 (0.7 +/- 1.0/mm(2)). The density of small nerve fibers is 2 approximately 2.9/mm(2) in the muscle and 0.7 approximately 1.5/mm(2) in large nerve fibers. The second 1/5 partition of the distal anterior wall had significantly richer innervation than the surrounding areas. Therefore, we think this 1/5 partition of the distal anterior wall could be so called "G-spot."
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The vascular responses of clitoral arteries to vaginal pressure stimulation in 10 volunteer women were evaluated by Doppler ultrasonography. Pressure stimulations (20-160 mm Hg) along the lower third of the vagina increased blood velocity and flow into clitoral arteries in 9 of the 10 women. The latency and duration of the Doppler responses ranged from 0.1 to 1.6 sec and from 3.2 to 9.5 sec, respectively, and the response was associated with a blood flow increase of 4 to 11 times the baseline prestimulation level. This response parallels that recorded in the cavernous arteries in men when a similar range of pressure stimulations are applied to the glans penis. Similar responses evoked in the male and female suggest a sexual synergy that may occur during intercourse in that such physiological responses and reflexes may be reciprocally reinforced.
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A priori hypothesis: vaginal and/or cervical self-stimulation will not produce perceptual responses in women with "complete" spinal cord injury (SCI) at or above the highest level of entry of the hypogastric nerves (T10-12) but will produce perceptual responses if SCI is below T-10. Women with complete SCI were assigned to a group with "upper" (T-10 and/or above) (n = 6) or "lower" (below T-10) (n = 10) SCI; uninjured women (n = 5) constituted a control group. Perceptual response to vaginal and/or cervical self-stimulation was quantified as magnitude of analgesia to calibrated finger compressive force. Rutgers, The State University of New Jersey, Human Physiology Laboratory, College of Nursing, Newark. Consecutive samples of first 16 of 34 women with SCI who responded to nationwide advertisements, met inclusion criteria, and volunteered; control group was the first 5 respondents. Vaginal or cervical (cervix uteri) self-stimulation applied for 12 minutes, interspersed with non-stimulation periods, while measuring analgesia. Quantify analgesia magnitude to vaginal or cervical self-stimulation. Significant analgesia was produced in the uninjured group and the group with lower SCI, supporting the hypothesis. Unexpectedly, significant analgesia was also produced in the group with upper SCI. Women in the group with upper SCI also experienced menstrual discomfort, awareness of vaginal and/or cervical stimulation per se, and orgasms. (1) Genitospinal visceral afferent pathways function in the women in the group with upper SCI, although unrecognized by the American Spinal Injury Association criteria, and/or (2) there exists a functional genital afferent pathway that bypasses the spinal cord and projects directly to the brain, which we propose to be via the vagus nerves.
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We investigated the anatomical relationship between the urethra and the surrounding erectile tissue, and reviewed the appropriateness of the current nomenclature used to describe this anatomy. A detailed dissection was performed on 2 fresh and 8 fixed human female adult cadavers (age range 22 to 88 years). The relationship of the urethra to the surrounding erectile tissue was ascertained in each specimen, and the erectile tissue arrangement was determined and compared to standard anatomical descriptions. Nerves supplying the erectile tissue were carefully preserved and their relationship to the soft tissues and bony pelvis was noted. The female urethra, distal vaginal wall and erectile tissue are packed into the perineum caudal (superficial) to the pubic arch, which is bounded laterally by the ischiopubic rami, and superficially by the labia minora and majora. This complex is not flat against the rami as is commonly depicted but projects from the bony landmarks for 3 to 6 cm. The perineal urethra is embedded in the anterior vaginal wall and is surrounded by erectile tissue in all directions except posteriorly where it relates to the vaginal wall. The bulbs of the vestibule are inappropriately named as they directly relate to the other clitoral components and the urethra. Their association with the vestibule is inconsistent and, thus, we recommend that these structures be renamed the bulbs of the clitoris. A series of detailed dissections suggest that current anatomical descriptions of female human urethral and genital anatomy are inaccurate.
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To find out whether taking images of the male and female genitals during coitus is feasible and to find out whether former and current ideas about the anatomy during sexual intercourse and during female sexual arousal are based on assumptions or on facts. Observational study. University hospital in the Netherlands. Magnetic resonance imaging was used to study the female sexual response and the male and female genitals during coitus. Thirteen experiments were performed with eight couples and three single women. The images obtained showed that during intercourse in the "missionary position" the penis has the shape of a boomerang and 1/3 of its length consists of the root of the penis. During female sexual arousal without intercourse the uterus was raised and the anterior vaginal wall lengthened. The size of the uterus did not increase during sexual arousal. Taking magnetic resonance images of the male and female genitals during coitus is feasible and contributes to understanding of anatomy.
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We aimed to define the gross anatomy of the supporting structures of the clitoris. We performed a dissection of the perineum of a series of 22 female and four male cadavers. Specific dissection of the clitoral and penile suspensory ligament complex was performed in four female and two male cadavers. Serial written observations and photography were used to document the findings. Our findings were then compared with the anatomical description of these structures in the historical and current anatomical literature. The suspensory ligament of clitoris consistently displayed two components: a superficial fibro-fatty structure extending from a broad base within the mons pubis to converge on the body of the clitoris and extending into the labia majora: in addition there is a deep component with a narrow origin on the symphysis pubis extending to the body and the bulbs of the clitoris. The supporting structures of the clitoris are more substantial and complex than previously described. Their shape, extent, and orientation are different from analogous structures of the penis, the suspensory ligament of which was found as described in the literature.
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The physiology of ejaculation includes emission of sperm with the accessory gland fluid into the urethra, simultaneous closure of the urethral sphincters, and forceful ejaculation of semen through the urethra. Emission and closure of the bladder neck are primarily alpha-adrenergically mediated thoracolumbar sympathetic reflex events with supraspinal modulation. Ejaculation is a sacralspinal reflex mediated by the pudendal nerve. The most common ejaculation disorder is premature ejaculation, but there is little agreement regarding the definition of this disorder or its etiology, diagnosis, and treatment options. Premature ejaculation is in fact classically considered psychogenic in nature. However, recent data have demonstrated that prostatic inflammation/infection has been found with high frequency in premature ejaculation, suggesting a role of prostatic pathologies in the pathogenesis of some cases of failure of ejaculatory control. Rarer disorders are emission and ejaculation failure and urine contamination of semen. The new use of diagnostic procedures and the availability of pharmacological aids place this topic in the mainframe of medical sexology.
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Anatomy studies normally precede physiology. While the anatomy of the penis and the biochemical and molecular regulation of erection are largely known, the exact anatomical description of the human clitoris was produced in 1998, the taxonomy of female sexual dysfunctions classified in 1999, and biochemistry of female excitation described only in 2002. There are various reasons for this. Female sexual physiology is much more complex than that of the male, and cultural and religious considerations have discouraged the scientific study of female sexuality. However, it is now apparent that modern sexology cannot be truly 'medical' if female sexual anatomy and the physiology of female sexual response are unknown.
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We investigated the hypothesis that the vagina generates electric waves which effect vaginal contraction during penile thrusting. In 24 healthy female volunteers, the electric waves of the vagina were recorded by two electrodes applied to its wall. The vaginal pressure was registered by a manometric tube. The electric waves and vaginal pressure were recorded at rest and on vaginal distension by condom in increments of 10 ml of carbon dioxide. The test was repeated after vaginal anesthetization proximally and distally to the electrodes. Slow waves (SWs) were recorded from the two electrodes with regular rhythm and similar frequency, amplitude and conduction velocity. They were randomly followed or superimposed by action potentials (APs). Vaginal pressure increase was coupled with APs. Large-volume condom distension significantly increased the electric waves' variables and pressure. Upon vaginal anesthetization, the electric waves were recorded proximal but not distal to the anesthetized area. Electric waves could be recorded from the vagina. They spread caudad. A pacemaker was postulated to exist at the upper vagina evoking these waves. The electric waves seem to be responsible for the vaginal contractile activity. Large-volume vaginal distension effected an increase in the vaginal electric waves and pressure which probably denotes increased vaginal muscle contraction. It appears that penile thrusting during coitus stimulates the vaginal pacemaker which effects an increase in vaginal electric activity and muscle contractility and thus leading to an increase in sexual arousal. The vaginal pacemaker seems to represent the G spot, which is claimed to be a small area of erotic sensitivity in the vagina. The electrovaginogram may act as a diagnostic tool in the investigation of sexual disorders.
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The controversy about clitoral versus vaginal orgasms was discussed in Chapter 10. In this article, the Singers offer a new typology of orgasm, which tries to integrate recent physiological research with women’s subjective experience of orgasm. While the authors’ typology has not gained widespread acceptance, this article is valuable for its careful description of the various subjective and physiological components of orgasm. The authors also make the point that description of what orgasm is can cause distress in women who discover that their orgasm does not meet some criteria. Orgasms are indeed different for different women, and for the same women on different occasions.
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The phenomenal success of Viagra has prompted research into the differing factors that fuel female sexual function and dysfunction. The new theory suggests that the desire for intimacy and other aspects of the personal relationship - rather than the need for physical sexual release - may matter most.
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Introduction: The female sexual response is dynamic; anatomic mechanisms may ease or enhance the intensity of orgasm. Aim: The aim of this study is to evaluate the clitoral size and location with regard to female sexual function. Methods: This cross-sectional TriHealth Institutional Board Review approved study compared 10 sexually active women with anorgasmia to 20 orgasmic women matched by age and body mass index (BMI). Data included demographics, sexual history, serum hormone levels, Prolapse/Incontinence Sexual Questionnaire-12 (PISQ-12), Female Sexual Function Index (FSFI), Body Exposure during Sexual Activity Questionnaire (BESAQ), and Short Form Health Survey-12. All subjects underwent pelvic magnetic resonance imaging (MRI) without contrast; measurements of the clitoris were calculated. Main outcome measures: Our primary outcomes were clitoral size and location as measured by noncontrast MRI imaging in sagittal, coronal, and axial planes. Results: Thirty premenopausal women completed the study. The mean age was 32 years (standard deviation [SD] 7), mean BMI 25 (SD 4). The majority was white (90%) and married (61%). Total PISQ-12 (P < 0.001) and total FSFI (P < 0.001) were higher for orgasmic subjects, indicating better sexual function. On MRI, the area of the clitoral glans in coronal view was significantly smaller for the anorgasmic group (P = 0.005). A larger distance from the clitoral glans (51 vs. 45 mm, P = 0.049) and body (29 vs. 21 mm, P = 0.008) to the vaginal lumen was found in the anorgasmic subjects. For the entire sample, larger distance between the clitoris and the vagina correlated with poorer scores on the PISQ-12 (r = -0.44, P = 0.02), FSFI (r = -0.43, P = 0.02), and BESAQ (r = -0.37, P = 0.04). Conclusion: Women with anorgasmia possessed a smaller clitoral glans and clitoral components farther from the vaginal lumen than women with normal orgasmic function.
Article
It has been demonstrated that clitoral and vaginal tissues express nitric oxide synthase isoforms in a way that parallels that of the penile corpus cavernosum. Considering the role of the vagina in the female sexual response and the anatomic connection between the clitoris and the anterosuperior vaginal wall, our aim was to study the distribution of type 5 phosphodiesterase (PDE5) in the anterosuperior wall of the human vagina. Immunohistochemistry was performed on the vaginal tissue of 14 women obtained at autopsy and on exfoliated cells of the vaginal epithelium obtained from 5 healthy female donors. Specific antibodies against PDE5 were tested on both paraffin sections and cytologic smears. Immunoblotting experiments were performed in parallel with the same antibodies. The histologic analysis of human cadaveric vaginal tissue revealed that PDE5 immunoreactivity was mostly localized in the smooth muscle of vessels, forming a pseudocavernous tissue in the vaginal wall and endothelium. The Skene periurethral glands and vaginal epithelium were also positive for the antibody. The latter finding was confirmed using exfoliated cells of the vaginal epithelium harvested in vivo. The presence and tissue distribution of PDE5 in the human vagina suggest that the integrated system of nitric oxide synthase-PDE5 may play a physiologic role not only in the male sexual response but also in female sexual arousal.
Article
Introduction: Women describe at least two types of orgasms: clitoral and vaginal. However, the differences, if any, are a matter of controversy. In order to clarify the functional anatomy of this sexual pleasure, most frequently achieved through clitoral stimulation, we used sonography with the aim of visualizing the movements of the clitorourethrovaginal (CUV) complex both during external, direct stimulation of the clitoris and during vaginal stimulation. Method: The ultrasounds were performed in three healthy volunteers with the General Electric® Voluson® sonography system (General Electric Healthcare, Vélizy, France), using a 12-MHz flat probe and a vaginal probe. We used functional sonography of the stimulated clitoris either during manual self-stimulation of the external clitoris or during vaginal penetration with a wet tampon. Main outcome measures: Functional and anatomic description, based on bidimensional ultrasounds, of the clitoris and CUV complex, as well as color Doppler signal indicating speed of venous blood flow, during arousal obtained by external or internal stimulation. Results: The sagittal scans obtained during external stimulation and vaginal penetration demonstrated that the root of the clitoris is not involved with external clitoral stimulation. In contrast, during vaginal stimulation, because of the movements and displacements, the whole CUV complex and the clitoral roots in particular are involved, showing functional differences depending on the type of stimulation. The color signal indicating flow speed in the veins mirrored the anatomical changes. Conclusions: Despite a common assumption that there is only one type of female orgasm, we may infer, on the basis of our findings, that the different reported perceptions from these two types of stimulation can be explained by the different parts of the clitoris (external and internal) and CUV complex that are involved.
Article
Female genital mutilation/cutting (FGM/C) refers to a cultural practice which involves partial removal of or injury to the female external genitalia for cultural or other non-therapeutic reasons. Estimates suggest that there are 100–130 million girls and women currently living with various health consequences from FGM/C. We aimed to conduct a systematic review and meta-analysis of the sexual consequences of FGM/C. A total of 15 studies, of variable methodological quality, with 12,671 participants from seven different countries were included. The majority of the 65 outcomes were statistically associated with FGM/C status at study level. Meta-analysis results showed that compared to women without FGM/C, women who had been subjected to FGM/C were more likely to report dyspareunia (relative risk (RR) = 1.52, 95% confidence interval (CI) = 1.15, 2.0), no sexual desire (RR = 2.15, 95% CI = 1.37, 3.36) and less sexual satisfaction (standardized mean difference = −0.34, 95% CI = −0.56, −0.13). Heterogeneity precluded additional consideration of other outcomes. The systematic review substantiates the proposition that a woman whose genital tissues have been partly removed is more likely to experience increased pain and reduction in sexual satisfaction and desire. Increased research efforts to investigate the sexual harms from FGM/C are indicated. Sexual education and therapy could be offered to women with FGM/C who want that.
Article
In the scant reports that are available about sexual response and orgasm in women with complete spinal cord injury (SCI), some researchers state that these women cannot achieve orgasm; others label the orgasms of women with SCI as “phantom orgasms.” However, subjective reports of women do not support these contentions. The purpose of this study was to obtain objective correlates of the subjective reports of women with complete SCI during self‐stimulation. The volunteer study participants consisted of 5 women without SCI (control group) and 16 women diagnosed with complete SCI. Systolic blood pressure, heart rate, and self‐report of level of sexual arousal were determined during self‐stimulation of the vagina, the cervix, and a “hypersensitive” area. Blood pressure and heart rate increased significantly in response to vaginal or cervical self‐stimulation in the control group. Blood pressure increased significantly in response to vaginal and cervical self‐stimulation only in the group with complete SCI below T‐10, whereas heart rate showed no significant change in the SCI groups. Three women with SCI, one as high as T‐7, and one without SCI self‐reported orgasms during the laboratory study. The current findings support anecdotal reports from women with complete SCI of sexual arousal and orgasm from genital and non‐genital self‐stimulation.
Article
Introduction: As the field of sexual medicine evolves, it is important to continually improve patient care by developing contemporary "standard operating procedures" (SOPs), reflecting the consensus view of experts in sexual medicine. Few, if any, consensus SOPs have been developed for the diagnosis and treatment of Female Orgasmic Disorder (FOD). Aim: The objective is to provide standard operating procedures for FOD. Methods: The SOP Committee was composed of a chair, selected by the International Society for the Study of Sexual Medicine, and two additional experts. To inform its key recommendations, the Committee used systematic reviews of available evidence and discussions during a group meeting, conference calls and e-mail communications. The Committee received no corporate funding or remuneration. Results: A total of 12 recommendations for the assessment and treatment of FOD were generated, including suggestions for further research. Conclusions: Evidence-based, practice recommendations for the treatment of FOD are provided that will hopefully inform clinical decision making for those treating this common condition.
Article
Sexual dysfunction is common in women with pelvic organ prolapse (POP). Treatment of symptomatic prolapse often requires surgery. The outcome of prolapse symptoms following surgery is well studied and reported, but evidence on outcomes of sexual function following pelvic reconstructive surgeries is limited. The objective of this study was to assess the impact of different forms of surgery for POP on sexual function using prospectively collected data. In this ethically approved project, data were collected prospectively for women undergoing prolapse repair between 2008 and 2010 and were stratified into four groups: "posterior repair,"anterior repair,"anterior repair with vaginal hysterectomy," and "combined anterior and posterior repair." The electronic personal assessment questionnaire-pelvic floor (ePAQ-PF) was used to assess symptoms. The sexual dimension of ePAQ-PF computes domain scores for sexual dysfunction secondary to vaginal symptoms and dyspareunia on a scale of 0-100 (0 = best possible and 100 = worst possible health status). ePAQ-PF was completed in 123 sexually active women both pre- and 3-6 month postoperatively. Results were analyzed using SPSS (SPSS Inc., Chicago, IL, USA). Pre- and postoperative scores for each domain were compared in all groups (Student's t-test). Individual symptoms in these domains were compared using Wilcoxon signed-rank test. Change in sexual symptoms and dyspareunia following prolapse surgery in each group. Women undergoing anterior repair or anterior repair and vaginal hysterectomy reported significant improvement in sexual symptoms and dyspareunia. Women undergoing a posterior repair in isolation had improved sexual function following surgery though improvement in dyspareunia was not significant. Women undergoing combined anterior and posterior repair had the least improvement in sexual function. Sexual function improves in women following pelvic reconstructive surgery, but the improvement is more substantial following anterior repair either alone or in combination with a vaginal hysterectomy when compared with posterior repair.
Article
The prevailing view in the literature is that hysterectomy improves the quality of life. This is based on claims that hysterectomy alleviates pain (dyspareunia and abnormal bleeding) and improves sexual response. Because hysterectomy requires cutting the sensory nerves that supply the cervix and uterus, it is surprising that the reports of deleterious effects on sexual response are so limited. However, almost all articles that we encountered report that some of the women in the studies claim that hysterectomy is detrimental to their sexual response. It is likely that the degree to which a woman's sexual response and pleasure are affected by hysterectomy depends not only on which nerves were severed by the surgery, but also the genital regions whose stimulation the woman enjoys for eliciting sexual response. Because clitoral sensation (via pudendal and genitofemoral nerves) should not be affected by hysterectomy, this surgery would not diminish sexual response in women who prefer clitoral stimulation. However, women whose preferred source of stimulation is vaginal or cervical would be more likely to experience a decrement in sensation and consequently sexual response after hysterectomy because the nerves that innervate those organs, that is, the pelvic, hypogastric, and vagus nerves, are more likely to be damaged or severed in the course of hysterectomy. However, all published reports of the effects of hysterectomy on sexual response that we encountered fail to specify the women's preferred sources of genital stimulation. As discussed in the present review, we believe that the critical lack of information as to women's preferred sources of genital stimulation is key to accounting for the discrepancies in the literature as to whether hysterectomy improves or attenuates sexual pleasure.
Article
Pelvic organ prolapse is a common condition among women with a prevalence of 11% and may affect the anterior, posterior, or apical compartment with a negative impact on sexual function. Aim of the current study was to evaluate sexual function before and after surgical rectocele fascial repair in sexually active patients who suffer from symptomatic rectoceles.   Female Sexual Function Index (FSFI) and anatomical outcome after rectocele repair. Between December 2000 and December 2009, we asked sexually active female patients who were to undergo rectocele fascial repair for symptomatic rectoceles to participate in this study. The patients were gynecologically examined before and after surgery and prolapse staging was performed using the ICS-Pelvic Organ Prolapse Staging. Patients were asked to fill in the FSFI before surgery and at 6 months follow-up. For statistical analysis, Graph Pad Prism version 5.0 for Windows was used (Graph Pad, La Jolla, CA, USA). Student's t-test was used after normality tests to compare groups and α was set 0.05. Sixty-eight patients were included in this study. Median age was 72 years (range 47-91), median parity of 2 (range 0-3) and median body mass index was 29 kg/m2 (range 23-31). Main complaints preoperatively were painful prolapse feeling (n=52), dyspareunia (n=59), and a feeling of vaginal heaviness (n=39). One patient who had suffered from postoperative infection that resulted in excessive scar tissue of the posterior wall suffered from de novo dyspareunia. Statistical analyses (paired t-test) showed significant improvement for desire (P<0.001), satisfaction (P<0.0001), and pain (P<0.0001) and no significant changes for arousal (P=0.0897), lubrication (P=1), and orgasm (P=0.0893). Posterior fascial repair improves some domains of sexual function but not all in sexually active patients with symptomatic rectoceles, and local oestrogene treatment may contribute to this finding.
Article
The anatomy and function of the G-spot remain highly controversial. Ultrasound studies of the clitoral complex during intercourse have been conducted to gain insight into the role of the clitoris and its relation to vagina and urethra during arousal and penetration. Our task was to visualize the anterior vaginal wall and its relationship to the clitoris during intercourse. The ultrasound was performed during coitus of a volunteer couple with the Voluson® General Electric® Sonography system (Zipf, Austria) and a 12-MHz flat probe. The woman was in a gynecologic position, and her companion penetrated her with his erected penis from a standing position. We performed a coronal section on the top of the vulva during the penetration. We focused on the size of the clitoral bodies before and after coitus. The coronal section demonstrated that the penis inflated the vagina and stretched the root of the clitoris that has consequently a very close relationship with the anterior vaginal wall. This could explain the pleasurable sensitivity of this anterior vaginal area called the G-spot. The clitoris and vagina must be seen as an anatomical and functional unit being activated by vaginal penetration during intercourse.
Article
The tension-free vaginal tape obturator (TVT-O) procedure is one of the most commonly used anti-incontinence surgeries, but little is known about its impact on sexual function. To evaluate sexual function after the TVT-O procedure at 6 months postoperatively. Fifty-six sexually active women who underwent the TVT-O procedure for severe stress urinary incontinence (SUI) were evaluated using the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) before and 6 months after surgery. The perception of incontinence-related quality-of-life were also evaluated by the short form of the Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) to assess the effect of surgery on incontinence. Total score and score for each PISQ-12 item. The mean total PISQ-12 score did not differ significantly before (24.0 + or - 12.2) and after (23.0 + or - 13.2) (P = 0.194) the TVT-O procedure. Scores for individual items on the PISQ-12 varied, with incontinence-related items improving but others, such as the frequency of achieving orgasm deteriorating for some women. The scores of UDI-6 and IIQ-7 were significantly improved by 6-month follow-up, indicating that the operation successfully resolved the incontinence. Despite successful amelioration of SUI by the TVT-O procedure, sexual function does not necessarily improve in the first 6 months after surgery.
Article
Sexual function is complex and involves interaction of many factors, including emotional connection, body image, intact physical response and partner sexual function. Disease processes such as abnormal uterine bleeding, endometriosis, urinary incontinence and pelvic organ prolapse may have a negative impact on various parameters of sexual health. Gynecological surgery to address these common complaints may correct the pathological process. However, despite improvements in symptoms related to the disease, improvements in sexuality are not guaranteed and occasionally there may be deteriorations. This review will summarize the current literature assessing sexual symptoms following benign gynecological surgery, including hysterectomy, and bilateral salpingo-oophorectomy, tubal ligation, anti-incontinence surgery and pelvic organ prolapse reconstruction with and without mesh. In the majority of cases, sexual function and quality of life benefit from these surgical interventions. However, it is critical that physicians remain aware of the potential for negative outcomes. Subjects who experience worsening should undergo thorough evaluation early in the postoperative period in order to mitigate symptoms. Treatment modalities for sexual dysfunction following surgery should be the focus of future research.