REVIEW Anatomy and Physiology of the Clitoris Vestibular Bulbs and Labia Minora With a - PDF document

AnatomyandPhysiologyoftheClitoris,VestibularBulbs,andLabiaMinoraWithaReviewoftheFemaleOrgasmandthePreventionofFemaleSexualDysfunctionVINCENZOPUPPOCentroItalianodiSessuologia(CIS),ViaRegnoli74,Bologna,ItalyThisreview,with21Þguresand1video,aimstoclarifysomeimportantaspectsof (i.e.,clitoris-urethra-distalvagina)complex,theclit-oralbulbs,theinternalclitoris,theclitoriscomposedoftwoarcs,theclitorisrootmadeoftwoclitoralbodiesandtwoclitoralbulbs,vaginalpenetrationcausesclosecontactbetweentheinnerclitorisandthedistalanteriorvaginalwall,theGrafenbergspot(i.e.G-spot),theG-spotrepresentsthatpartoftheurethrathatcontainstheperiglandularorparaurethraltissue,thegenitosensorycomponentofthevagusnerve,Hal-banÕsfasciaerogenouszone,theperiurethralglans,thevaginalanteriorfornixerogenouszone,femaleejaculation,theanteriorvaginalwallasanorganforthetransmissionofactiveforcestotheurethraandtheclitoris(Addiegoetal.,1981;PerryandWhipple,1981;Hoangetal.,1991;Levin,1991,2002,2011;Ingelman-Sundberg,1997;OÕConnelletal.,1998,2004,2005,2008;Chalker,2000;Goldstein,2000;Komisaruketal.,2004,2006;Mestonetal.,2004;OÕConnellandDeLancey,2005;Goldsteinetal.,2006;Yangetal.,2006;LevinandRiley,2007;Buissonetal.,2008,2010;Thabet,2009;FoldesandBuisson,2009;Buisson,2010;Janninietal.,2010,2012;Salo-niaetal.,2010;Dwyer,2012;Ostrzenski,2012;SanDiegoSexualMedicine,2012),theclitorisformedbycrown-corpus-cruraandthewomanÕsglanssurround-ingtheurethralopening(Sevely,1987,1988;Levin,1991),thecompleteclitorisconsistsof18parts(Chalker,2000),theurethrovaginalspace,thepres-enceofpseudocavernoustissue(clitoralbulb)intheanteriorvaginalmucosa,thevaginalorgasm,thewomanÕshistoryofvaginalorgasmisdiscerniblefromherwalk,thevaginalorgasmismoreprevalentamongwomenwithaprominenttubercleoftheupperlip(Goldsteinetal.,2006;Gravinaetal.,2008;Nicholasetal.,2008;BrodyandCosta,2011;Janninietal.,2012),thevariationinthedistancebetweenawom-anÕsglansclitorisandherurethrapredictsthelikeli-hoodthatshewillexperienceorgasminintercourse(WallenandLloyd,2011),theprematurefemaleorgasm(Carvalhoetal.,2011),persistentgenitalarousaldisorder(Kordaetal.,2009;Rosenbaum,2010),orgasmandresolutionarenotessentialinBas-sonÕsmodelofthesexualresponsecycle(Bassonetal.,2005;RosenandBarsky,2006),whicharewithoutscientiÞc(i.e.,embryological,anatomicalandphysio-logical)basis(Dickinson,1949;Grafenberg,1950;MastersandJohnson,1966;Hite,1981;Mastersetal.,1988;Laqueur,1992;Hines,2001;Puppo,2006a,2006b,2011a,2011b,2011c,2012b;Vicentini,2008;Puppoetal.,2008a;ShaÞketal.,2009;Youtube/newsexology,2009,2010;Magnin,2010;Kilchevskyetal.,2012;PuppoandGruenwald,inpress)andtheyarenotacceptedorsharedbyanatomists(TestutandLatarjet,1972;ChiarugiandBucciante,1975;Standring,2008;Netter,2010).Theanatomyofthefemaleerectileorgansisdescribedinhumananatomytextbooks(TestutandLatarjet,1972;ChiarugiandBucciante,1975;Standring,2008;Netter,2010;Puppo,2011a),butinsexologytextbooks(Komisaruketal.,2006),theanatomyandphysiologyoftheclitoris,otherfemaleerectileorgans,andofthefemaleorgasmareoftenneglected(Puppo,2011c).ÔÔInanatomytextbooksthereisaseparationbetweentheembryologicaldevelopmentoftheinternalandexternalgenitalorgansinmalesandfemales.Itisimportanttoknowthisbecauseitisrelatedtothefunctionoftheseorgans,thatis,theinternalgenitalshavearepro-ductivefunctionwhiletheexternaloneshavethefunctionofgivingpleasureÕÕ(Puppo,2011a).Thevulva(i.e.,femaleexternalgenitalia)isformedbythelabiamajoraandvestibule,withitserectileapparatus:clitoris(glans;body;cruraorroots),ves-tibularbulbswiththeparsintermedia(i.e.,femalecorpusspongiosum),andlabiaminora.Thesestruc-turesareexternaltotheperinealmembrane(i.e.,urogenitaldiaphragm),infrontofthepubicsymphy-sisandintheanteriorperinealregion(Figs.1and2)(TestutandLatarjet,1972;ChiarugiandBucciante,1975;Standring,2008;SteinandDeLancey,2008;Netter,2010;Puppo,2011a,2011d).Thelabiamajoraaretwoprominentcutaneousfoldsandfromthemonspubis,reachuptotheperi-neum,andcorrespondtothemalescrotum;nor-mallytheyareincontactandseparatedonlybythevulvarcleft(rimapudendi).Whenthelabiamajoraareseparated,twosmallerfoldsareseen,thelabiaminora,whichanteriorlyembracetheclitoris,andinthespacebetweenthem(i.e.,vaginalvestibule)isfoundthevaginaloriÞcecontainingthehymenoritsremainsandtheurethraloriÞce(Hartmann,1913;TestutandLatarjet,1972;ChiarugiandBucciante,1975;Friedmanetal.,2004;Standring,2008).Themucosaofthevaginalvestibule,whichoriginatesfromtheembryonicendoderm,isnonkeratinized(FarageandMaibach,2006).ThetermÔÔperiurethralglansÕÕ(Levin,1991,2002)forthisarea(i.e.,vaginalvestibule)isanincorrectanatomicalterm(Puppoetal.,2008a;Puppo,2011a,2011c).FemalesexualphysiologywasÞrstdescribedinDickinsonÕstextbooksin1949andsubsequentlybyMastersandJohnsonin1966(Puppo,2011c).Thehumansexualresponsecanbephysiologicallydescribedasacyclewithfourphases:excitement,plateau,orgasm,andresolution(i.e.,theperiodofreturntotheunarousedstate).Duringsexual Fig.1.Thefemaleperineum(fromPuppo,FemaleErectileOrgansandtheFemaleOrgasm arousal,thereisincreaseinbloodßowtotheerectiletissuesofthefemale:anengorgementwitherectionasseeninthepenis(MastersandJohnson,1966;Mastersetal.,1988;ArgiolasandMelis,2003;Puppo,2011a).Thisreviewaimstoclarifysomeimportantaspectsoftheanatomyandphysiologyofthefemaleerectileorgansandofthefemaleorgasm,whichareneces-saryforcorrect(i.e.,scientiÞc)sexeducationandforfemalesexualdysfunctionprevention(Puppo,2012a,2012c,2012d).THECLITORISTheclitorisisthehomologueofthemaleÕsglansandcorporacavernosa(Fig.3)(Puppoetal.,2008b;Standring,2008;Puppo,2011a).Theclitorisisanexternalorganandhasthreeerectiletissueparts,mostofwhichliebeneaththeskin:theglans,thebody,andthecrura.Theclitoris,inthefreepartoftheorgan,iscomposedofthebodyandtheglanslocatedinsideoftheprepuce,whichisformedbythelabiaminora(TestutandLatarjet,1972;ChiarugiandBucciante,1975;Standring,2008;Netter,2010;Puppo,2011a).Thesizeoftheclitorisvariesconsiderably(Dickinson,1949).Theclitoralbodyintheßaccidstateis1Ð3cmlong(Lloydetal.,2005;Puppo,2011a).Thediameteroftheglansrangesfromthe3to8mm,andthemostcommondiameteris4Ð5mm(Fig.4)(Dickinson,1949).Parityinßuencesclitoralsizebutage,height,weight,andoralcontraceptiveusedonot(Verkaufetal.,1992).StudiesbyDickinson(1949)foundthatclitoralsizeÔÔisnotnecessarilyacriterionofrespon-siveness.Averytinyclitoris,sothinandlowitcanhardlybepickedupbytheÞngers,maybeassoci-atedwithpowerfulorgasmfromfrictionorpressureontheorganaloneÕÕÔÔtheotherrelevantÞndingistheextentofexcursion,ortherangeofmobilityoftheglansÕÕ(Fig.5).Theclitorisisattachedbythesus-pensoryligamenttothefrontofthesymphysispubis(Dickinson,1949;TestutandLatarjet,1972);thesuspensoryligamentisastructurewithsuperÞcialanddeepcomponents(ChiarugiandBucciante,1975;Reesetal.,2000).Ifthegenitaltuberclesarehypoplasticorfailtofuse,theclitorismaybeextremelysmallorabsent(NeillandLewis,2009).ÔÔIsolatedabsenceoftheclito-risisarareentitywithmedicalandsexualimplicationsforpatientsÕÕ(Martino«n-Torresetal.,2000;BellemareandDibden,2005).Thedimensionsoftheclitorisvary;ÔÔclitoromegalyisdeÞnedasaclitoralareagreaterthan35Ð45mmÕÕ(Oyamaetal.,2004).Acquiredclitoralenlargementisrelativelyrareinadultfemalesandoccursunderavarietyofcircumstances,ÔÔthecausesofclitoromegalycanbeclassiÞedintofourgroups:hormonalconditions,nonhormonalcondi- Fig.2.Thevulva(withoutlabiamajora.FromPuppo,2011d).1,Pubis;2,ischiopubicramus;3,sus-pensoryligament;4,rootoftheclitoris;5,angleoftheclitoris;6,bodyoftheclitoris;7,glans;8,vestibularbulb;9,urethra;10,vagina;11,labiaminora;12,BartholinÕsgland. Fig.3.Theclitorisandthepenis(fromPuppoetal.,:Clitoris,corporacavernosaandglans;penis,corporacavernosaandcorpusspongiosum(glans,parsintermedia,andbulb). Fig.4.Sizesofclitoris(fromDickinson,1949).136Puppo tions,pseudoclitoromegalyandidiopathicclitorome-galyÕÕ(Copcuetal.,2004).Pseudohypertrophyoftheclitorishasbeenreportedinsmallgirlsduetomastur-bationwiththechronicmanipulationoftheskinoftheprepuceleadingtomechanicaltrauma,whichexpandstheprepuceandlabiaminoraresultinginclitoralenlargement(Copcuetal.,2004).Clitoralreductionisaprocedureinwhichthecor-poracavernosaarepartiallyremovedandtheglansclitorisisleftintact(Oyamaetal.,2004);ÔÔthegoalsofclitoroplastyaretoachieveanormalgenitalappearanceandtopreservesensationwithasatis-factorysexualresponseÕÕ(Sayeretal.,2007).Clito-ralreconstructionisfeasibleinpatientswithgenitalmutilationandcanreduceclitoralpainandimprovepleasure(Abdulcadiretal.,2012).Theglansoftheclitoris,asinthemale,containscavernoustissueandisindirectcontactwiththeskinduetotheabsenceofatunicaalbuginea.Theprepucecoversallorpartoftheglans,itssizevariesconsider-ably,andiscomparabletotheforeskinofthepenis;theprepuceisaspecializederogenoustissueinbothmalesandfemales.Thefetaldevelopmentofthepre-puceandtheglansinmaleandfemalesissimilar;theyarefusedtogetherandthecavityoftheprepuceisformedduringtheÞrstyearafterbirthandiftheydonotseparate,itispossible,asinthemale,foradhesionsandresultantphimosisoftheclitoristoresult(Dickinson,1949;ColdandTaylor,1999;Puppo,2011a);ÔÔabsenceoftheprepucehasbeennotedfourtimes,withouthistoryofcircumcisionÕÕ(Dickinson,1949).Clitoralphimosismaybeassoci-atedwithclitoralpainsyndromes(Munarrizetal.,2000).Smegmaininfantsandpreadolescentgirlsmaydevelopundertheprepuce,andtheirritationcausedbyitsaccumulationmayresultinadhesionsformingbetweentheglansandprepuce,insmeg-maticpseudocyst,andinphimosisoftheclitoris(Dickinson,1949;ColdandTaylor,1999;GoldsteinandBurrows,2007;Puppo,2011a).Therefore,itisimportanttomaintainproperhygieneofthevulva.TheclitorisisaspecializedstructurecoveredwithastratiÞedsquamousepitheliumthatisthinlycorniÞed.Therearenosebaceous,apocrine,orsweatglandspresent(NeillandLewis,2009).Thebodyoftheclitorisconsistsoftwocorporacavernosa,whichbecometur-gidwithsexualarousal.Thecorporacavernosabeginwiththerootsorcrura(i.e.,thehiddenpartoftheclito-ris),whicharelocatedalongsidetheischiopubicramus.Therootsarejoinedunderandinfrontofthepubicsymphysisandconstitutethebodyoftheclitoris,whichterminatesintheglans.Therootsarecoveredbytheischiocavernosusmuscles(TestutandLatarjet,1972;ChiarugiandBucciante,1975;Yangetal.,2006;Standring,2008;Netter,2010;Puppo,2011a).TheperinealmusclesareinnervatedbybranchesofthepudendalnervederivedfromOnufÕsnucleus;ÔÔpudendalnerveintegritymayplayaroleinfemalesexualdysfunctionÕÕ(Connelletal.,2005).OnufÕsnucleusislocatedinthesacrallevelsofthespinalcordandisformedbymotoneuronsinnervatingtheperinealmuscles;thenumberandthesizeoftheseneuronsaresexuallydimorphic:thisdimorphismismediatedbyandrogens(intheabsenceofthesehormonesthemotoneuronsdiebyapoptosis)withciliaryneurotrophicfactorandothertrophicfactors(Catala,2002).Becauseofthis,infemales,theischiocavernosusmusclesaremuchthinnerthantheirmalecounterparts.Theircontractionduringfemalearousalresultsinasurgeofbloodinthecruratowardthecorporacavernosaoftheclitorisandcompressionofthedeepdorsalveins,contribut-ingtoerectionoftheclitoris(Dickinson,1949;TestutandLatarjet,1972;Puppo,2011a).Theischiocavernosusmuscles,likethebulboca-vernosusmuscle,aremixedmuscles(evenifhisto-logicallytheyarebothstriated).Duringerection,theyproduceacontinuousinvoluntaryreßexhyper-toniccontraction,whichisimportantformaintainingerection(ShaÞk,1995;Puppo,2011a).Theerectiletissueofthecorporacavernosaismadeupofasys-temofcaverns(i.e.,trabeculaeandsinusoidalspaces)coveredbythetunicaalbuginea.ThetwocorporacavernosaareseparatedbyaÞbrousseptum(Yangetal.,2006;Puppo,2011a).Thedorsalnervesoftheclitoristravelalongthedorsalaspectofclitorisinthe11and1oÕclockpositions,andatthejunctionoftheglanswiththeclitoralbody,theyentertheglansbeneaththeco-ronaandfurtherbranch(Gingeretal.,2011a).Largesensorycorpuscleshavebeenrecognizedmorphologicallyinthehumanexternalgenitaliaformorethanacentury(Martin-Alguaciletal.,2006). Fig.5.Clitoralexcursion(fromDickinson,1949).FemaleErectileOrgansandtheFemaleOrgasm Theglansisrichinnerveendingsandingenitalcor-puscles(characteristicreceptorsoftheexternalgen-itals),andamongthese,asinmales,Krause-Fingercorpusclespredominant.Thesecorpusclesaremoreconcentratedinthefemalethaninthepenis(Dick-inson,1949;TestutandLatarjet,1972;ChiarugiandBucciante,1975;Yangetal.,2006;Puppo,2011a).StudiesbyJohnsonandKitchell(1987)revealedthatpenilemechanoreceptorsaremoreresponsivewhenthepenisiserectornearbodytemperature.Clitoralreceptorsoftenhavemultipleinnervationsandmayreceive8Ð10nerveÞberseach.Thismayfacilitatetransmissionoferogenoussignalstocranialcenters(ChiarugiandBucciante,1975;HalataandMunger,1986;ColdandTaylor,1999;Puppo,2011a).TheclitorishasauniquefunctionÑsexualpleas-ure.StudiesbyDickinson(1949)andMastersandJohnson(1966)haveshownerectionandanincreaseinsize(especiallythediameter)oftheclitorisduringsexualarousal.Duringtheplateauphase,theyalsoobservedthatattheheightofarousalandorgasmthereisÔÔretractionÕÕoftheglansintotheprepuce(MastersandJohnson,1966;Mastersetal.,1988).ÔÔClitoralerectioncausestheshafttoretractintotheswollenprepuceorclitoralhoodandoccursineverywoman,regardlessofthetypeofstimulation,coitalposition,degreeofclitoraltumescenceortheinitialclitoralsizeÕÕ(Sherfey,1973).Thisoccursbecauseinadultwomen,thesizeoftheglansismuchsmallerthanthatinmalesanddoesnotgrowduringpu-berty.Infact,itdoesnotenlargeduringsexualarousal.Inaddition,duringsexualarousal,thefemaleprepucedoesnotretractasitdoesinmales,becauseitiscontinuouswiththelabiaminora.Sowitherectionofthebodyoftheclitoris,thereistheapparentdisappearanceoftheglanswithinthepre-puce(MastersandJohnson,1966;Mastersetal.,1988;Puppo,2011a).Itissaidthattherootoftheclitorisismadeoftwoclitoralbodiesandtwobulbs(Buissonetal.,2008;FoldesandBuisson2009;Buisson,2010).Buissonstatedthattheclitorisiscomposedoftwoarcs,theÞrstconsistingoftwocorporacavernosaalongtherightandleftischiopubicramus,withalengthof12Ð15cm;theyjoinonthesummitofthevulvatobend90forward;therapheendsintheglansclitoris,thevisiblepartoftheclitoris.Thesecondarcconsistsoftwobulbsthatsurroundthelateralwallsofthevagina.However,BuissonÕsstate-mentisnotcorroboratedbyanyembryological,ana-tomical,orphysiologicalevidence:theclitorisisnotcomposedofÔÔtwoarcs.ÕÕTheclitoralrootsarenotÔÔmadeoftwoclitoralbodiesandtwobulbsÕÕ(TestutandLatarjet,1972;ChiarugiandBucciante,1975;Standring,2008;Netter,2010;Puppo,2011a,2011b,2011c).THEVESTIBULARBULBSThevestibularbulbscorrespondtobulbofthepenis(Figs.2and3).Theyaretwoerectileorganssituatedintheanteriorregionoftheperineum(i.e.,bulbo-clitoralregion).Anteriorly,thetwobulbsarejoinedtogether,underthevestibuleofthevagina,withthecommissureofthebulbs,andthroughtheparsintermediaorfemalecorpusspongiosum,theyextendtothebaseoftheglans(Fig.6)(Dickinson,1949;TestutandLatarjet,1972;ChiarugiandBuc-ciante,1975;VanTurnhoutetal.,1995;Yangetal.,2006;Standring,2008;Puppo,2011a).Duringsex-ualarousal,thecommissurebecomesverydistended(Sherfey,1973).Undertheangleoftheclitoris,thereisthevenousplexusofKobeltthatcommunicatesthevenouscir-culationofthebulbstothatofthecorporacaver-nosa.Thisvenousplexuscorrespondstotheinferiorveinsofthemalecorporacavernosa,whichopenintotheinferiormediansulcusbetweentheseandthemaleurethraandthatreceivetheveinsthatbeginintheupperpartofthemalecorpusspongio-sum.Thebulbsarecoveredbythebulbocavernosusmuscles(Dickinson,1949;TestutandLatarjet,1972;ChiarugiandBucciante,1975;Standring,2008;Puppo,2011a).Oneithersideofthevagina,therearethebulbsthatwithstimulationincreaseinsizeastheydoinmales.StudiesbyDickinson(1949)foundthatÔÔtheareaofmostmarkederectionisoneachsideoftheentrancetothevagina.Herethedistensionwithbloodoftheerectiletissuesofthebulbsofthevesti-buleproducesabulginginward.ÕÕTherefore,theswollenvestibularbulbsalsoleadtoengorgementoftheouterthirdofthevaginaanddeterminethefor-mationoftheorgasmicplatformofMastersandJohnson(Fig.7)(Dickinson,1949;MastersandJohnson,1966;Mastersetal.,1988;Puppo,2011a).ThevestibularbulbscausetheÔÔvaginalÕÕorgasmiccontractionsobservedevery0.8secthroughtherhythmiccontractionofbulbocavernosusmuscles(TestutandLatarjet,1972;Puppo,2011a).StudiesbyHartmann(1913)foundthatÔÔvaginismusischar-acterizedbyapainfulreßexcontractionofthesphincterofthevulvo-vaginaloriÞce.Itinvolvesthesphincterofthevulva(constrictorofthevulva)and Fig.6.Thefemalecorpusspongiosum(fromDick-inson,1949).138Puppo thesphincterofthevagina(anteriorÞbersofthele-vatorani),whichleadstoadistinctionbetweenaninferiorandsuperiorvaginismusÕÕ:thebulbocaverno-susmusclesareimplicatedininferiorvaginismus,whilethepubovaginalismuscleisresponsibleforsuperiorvaginismus(Dickinson,1949;TestutandLatarjet,1972;Kearneyetal.,2004;Larsonetal.,2010;Puppo,2011a;SelbmannandPuppo,2012).WithKegelexercisesitispossibletotraintheperi-nealmuscles,theischiocavernosusmuscle(muscleoferection),thebulbocavernosusmuscles(muscleofmaleejaculation,musclesoffemaleorgasm),theexternalsphinctermuscleoftheanus(whosecontractionsincreasetheorgasmicsensations),thestriatedurethralsphinctermuscle,thetransverseperinealmuscles,andthelevatoranimuscles.Kegelexercises,whichstrengthenthesemuscles,maybeimportantforpreventingvaginismus(Puppo,2006b,2006d;SelbmannandPuppo,2012).StudiesbySteinandDeLancey(2008)foundthattheperinealmembraneisacomplexstructurecom-posedoftworegions,onedorsalandoneventral.ThedorsalportionconsistsofbilateraltransverseÞ-broussheetsthatattachthelateralwalloftheva-ginaandperinealbodytotheischiopubicramus.Thisportionisdevoidofstriatedmuscle.Theventralportionispartofasolidthree-dimensionaltissuemassinwhichseveralstructuresareembedded.Itisintimatelyassociatedwiththecompressorurethraemuscleandtheurethrovaginalsphinctermuscleofthedistalurethrawiththeurethraanditssurround-ingconnective.OÕConnelletal.(2008),intheJournalofSexual,statedÔÔTheurethraloriÞceanddistalure-thraaresurroundedbytheerectiletissueoftheclit-oralbulbs.ÕÕYavagaletal.(2011)statedÔÔTheclitorisconsistsofthepairedcorpora,vestibularbulbs,andtheglansThedeepsuspensoryligamentorig-inatesfromthesymphysispubisandattachestothebody,bulbs,andglansoftheclitoris.ÕÕHowever,ÔÔclitoralbulbsÕÕisanincorrecttermfromanembryo-logicalandanatomicalviewpoint,infactthebulbsdonotdevelopfromthephallus,andtheydonotbelongtotheclitoris:Thecorrecttermforthesestructuresisvestibularbulbs(TestutandLatarjet,1972;Chiar-ugiandBucciante,1975;Puppo,2006a,2006b,2011a,2011c;Puppoetal.,2008a;Standring,2008;SteinandDeLancey,2008;Larsonetal.,Gravinaetal.(2008)statedÔÔTheclosephysicalproximityoftheurethraandtheclitoristotheante-riorvaginalwallsuggestsanassociationbetweentheseanatomicalstructuresandsexualfunctionThepresenceofpseudocavernoustissue(clitoralbulb)intheanteriorvaginalmucosaisafrequentbutnotuniversalÞnding(86%).ÕÕHowever,theva-ginahasnotanatomicalrelationwiththeclitorisandintheanteriorvaginalmucosathereisnoÔÔclitoralbulbÕÕ(TestutandLatarjet,1972;ChiarugiandBuc-ciante,1975;Standring,2008;Netter,2010;Puppo,THELABIAMINORAThelabiaminora,ornymphs,areatrest,approxi-matedtogether,inmalescorrespondtotheventralwallofthecavernosaurethraandofthecorpusspongiosumoftheurethra(Fig.8)(Puppoetal.,2008b;Puppo,2011a,2011d).Thelabiaminoraaretwothinfoldsofskin,againdevoidofhairbutstillpossessingsebaceousandeccrineglands.Theylackalayerofsubcutaneousfatandsitmedialtothelabiamajoraandlateraltothevestibule.Thelabiaminoraareseparatedfromthelabiamajorabyinterlabialfurrowsinwhichthenor-malsecretionsfromtheadjacentskinsurfacesmayaccumulate(NeillandLewis,2009).Anteriorly,thelabiaminoradivideintolateralandmedialparts.Thelateralpartsformtheprepuceoftheclitoris.Themedialpartsuniteontheundersur-faceoftheclitoristoformitsfrenulum.Posteriorly,theyformthefrenulumofthelabiaminorabutthey Fig.7.Bulbswellingsduringexcitement(fromDickinson,1949).FemaleErectileOrgansandtheFemaleOrgasm canbealsoseparated(NeillandLewis,2009;Puppo,Thereisgreatvariationinthesizeandmorphol-ogyofthelabiaminora.Theymaybealmostunrecognizableormayprotrudefromthelabiamajora(ÔÔhypertrophicÕÕlabiaminorashouldnotbeconsideredamalformation).Inaddition,theycanbeasymmetricalordoubledononeorbothsides(Fig.9)(Dickinson,1949;Puppo,2011a).Lloydetal.(2005)foundnostatisticallysigniÞcantassocia-tionbetweenanyofthedifferentgenitalmeasure-mentsandage,parity,ethnicity,hormonaluse,orhistoryofsexualactivity.Insomecultures,thelabiaminoracanbeverylargebecauseofthepracticeofstretchingthem.Forexample,insomeAfricanpopulationstheycanbeaslargeas20cmandareknownasaÔÔHottentotapronÕÕ(Dickinson,1949;TestutandLatarjet,1972;ChiarugiandBucciante,1975).Today,elongationofthelabiaminoraisclassiÞedinthetypeIVfemalegenitalmutilation(KosterandPrice,2008;Abdulca-diretal.,2011).Theskinofthelabiaminoraissmoothormildlyrugoseandpigmented,particularlyattheedges.ThedermisofthelabiaminoraiscomposedofathickofconnectivetissuecomposedmainlyofelasticÞbersandsmallbloodvessels.ÔÔThearrangementofbloodvesselswithinthelabiaminoraformserectiletissuesimilartothatinthepenilecorpusspongiosus,whichistheirembryologicalcounterpartinthemaleÕÕ(NeillandLewis,2009).Thelabiaminorahaveanotablesensibility,infact,likethevaginalvestibuleandtheglansclitoris,theyhaveaconsiderablenumberoffreenervousendingsandsensoryreceptors.Thegenitalcor-pusclesaremostimportantfortheperceptionoferogenoussensibility,butPacinianandMeissnercor-pusclesarealsopresent(Martin-Alguaciletal.,2011;Puppo,2011a).Thelabiaminoraarehighlyinnervatedalongtheirentireedge,andthisisimportantforsexualresponse(Schoberetal.,2010).Astheyengorge, Fig.8.Labiaminoraandthepenis(fromPuppoetal.,2008b;Puppo,2011d).:1,Penis;2,correspond-ingparttothelabiaminora;3,scrotum;4,anus.:1,Clitoris;2,labiaminora;3,labiamajora;4,anus;5,frenulum;6,sulcusnympholabialis. Fig.9.Labiaminora:normaldimensions(fromDickinson,1949).140Puppo thelabiaminorabecometurgid,doublingortriplinginthickness(Figs.10and11,SupportingInforma-tionVideo1)(Dickinson,1949;MastersandJohn-son,1966;Puppo,2011a,2011d,2011e).Anotherconstantphenomenonhasbeenobservedinthelabiaminoraduringtheplateauphase.Whenthesestructureshavealreadydoubledortripledtheirsize,theyshowanintensechangeincolorfrompinktointenseredsignalingimpendingorgasm(Dick-inson,1949;MastersandJohnson,1966).StudiesbyBattagliaetal.(inpress)foundthatestrogenpro-ductionmayinßuencetheanatomicandvascularchangesofthelabiaminoraduringthemenstrualcycle,andthesechangescanbeeasilyidentiÞedwithultrasound.Fusionofthelabiaminoramayoccurinassocia-tionwithdefectivesexualdifferentiation.ThisshouldnotbeconfusedwithsuperÞciallabialadhesionsseenintheneonatalperiodorininfancyasaresultofaninßammatorycondition(NeillandLewis,2009).OÕConnelletal.(2008)statedÔÔThelabiae,liketheclitoris,arederivedembryologicallyfromtheundif-ferentiatedphallus.ÕÕAlthoughPuppo(2011c)believesthatonlythecorporacavernosaoftheclito-risandtheglansareformedfromthephallus.THECORPUSSPONGIOSUMOFTHEFEMALEURETHRATheexternalurethraloriÞceliesinthevestibule,itispositionedinthemidlinebutitsexactlocationisvariable.TheurethraisÞxedatitsoriginbythepubovesicalligamentsandthroughoutitslengthbytheanteriorwallofthevagina.Asitenterstheperi-neum,itisÞxedbytheperinealmembrane,alsoknownastheurogenitaldiaphragmortriangularlig-ament(NeillandLewis,2009).Theurethrallumenissurroundedbysmoothmus-cleÞbersandbyspongytissue(i.e.,corpusspongio-sumofthefemaleurethra).ÔÔThetissueisgrosslydistinctfromthevasculartissueoftheclitorisandbulbs,andonmacroscopicobservation,ispalerthanthedarktissueofthebulbsÕÕ(Yangetal.,2006).Thecorpusspongiosumofthefemaleurethraispresentinallwomen.Itisacavernoustissuerichinmultiplesmallvessels,situatedinthesubmucosalandamongthemuscularbundlesofthesmoothmusculartunicaoftheurethralwall.Itbecomeserectwithsexualarousal,asinmales(Puppo,2011a):studiesbyGra¬fenberg(1950)revealÔÔduringsexualstimulationtheurethraisenlarged.ÕÕInnervationofthefemaleurethrahasbeenscantlyinvestigatedalthoughDickinson(1949)observedthatÔÔthemeatusisverywellendowedwith Fig.10.Clitorisandlabiaminoraerection(fromDickinson,1949). Fig.11.ThumbnailVideo1(SupportingInforma-tionVideoisavailableonline).Woman28yearsold.Clitorisandlabiaminora::Flaccidstate;:Erectstate(fromPuppo,2011d).FemaleErectileOrgansandtheFemaleOrgasm aspecialsensitivity...Inadvancedcasesoftheure-thralmasturbation,themeatuswilladmitthetipofthelittleÞngerforashortdistanceandwithoutdis-comfort.ÕÕGra¬fenberg(1950)describedsomecasesofmaleandfemaleurethralmasturbation.COMPARISONBETWEENMALESANDÔÔErectilegenitaltissuesinbothmalesandfemalesarisefromthesameembryologicalstructuresandthusarehomologousÕÕ(Yangetal.,2006).Theexternalgenitaliaofmalesandfemalesdevelopfromtheuro-genitalsinus(whichisdividedintopelvicandphallicparts),fromthegenitaltubercleorphallus,fromtheurogenitalfolds,andfromthelabioscrotalswellings.Thecorporacavernosaoftheclitorisandtheglansareformedfromthephallus.Thevestibuleofthevagina,thelabiaminora,thevestibularbulbs,andthefemalecorpusspongiosumareformedbythepelvicandphal-licpartoftheurogenitalsinusandfromtheurogenitalfolds(TestutandLatarjet,1972;ChiarugiandBuc-ciante,1975;Standring,2008;Puppo,2011a).Thephallicportionoftheurogenitalsinusremainsopen,andthegenitalfoldsdonotfuse,anddetailsofclitoralanatomycanbevisualizedwithultrasoundandMRIprenatally(WunschandSchober,2007).OÕConnelletal.(2008)statedÔÔTheclitorisiscom-posedoftheglans,whichisitsonlyexternalmani-festation.ÕÕÔÔtheclitorisitself,inturn,beingcoveredbythevulvaThedistalvaginaisastructurethatissointerrelatedwiththeclitoristhatitisamatterofsomedebatewhetherthetwoaretrulyseparateTheclitoralcomplex,composedofthedistalvagina,urethra,andclitoris,isthelocationoffemalesexualactivity,analogoustothepenisinmen.ÕÕPuppo(2011c)respondedtoOÕConnelletal.ÕsstatementsbystatingthatÔÔTheclitorisisnotcov-eredbythevulvaÕÕ:itisapartofthevulva!Thewholeclitoris(glans,body,roots)isanexternalgen-italorgan.Therootsarehidden:theyarenotÔÔinter-nal.ÕÕOÕConnelletal.ÕsclitoralcomplexdeÞnitionÔÔhasnoembryological,anatomical,andphysiologicalsupportÕÕÔÔthevaginahasnoanatomicalrelationwiththeclitorisÕÕÔÔandinthemalepenisthereisnova-gina.ÕÕThefemalevaginacorrespondsinmalestotheprostaticutricle(i.e.,malevagina)situatedintheprostate(Fig.12)(Puppo,2011c,2011d).Thishasbeenknownformanydecades(TestutandLatarjet,1972;ChiarugiandBucciante,1975),butaccordingtocurrentopinioningynecology,urol-ogy,andsexologytextbooksthefemalevaginaisstillamixedstructure,formedbytheurogenitalsinusandfromtheMullerianducts,evenifweknowthatthevaginaalwayshasthesamestructureforallofitslength,furthermoretheglycogenispresentintheepitheliumoftheurogenitalsinus,inthevagina,andcervix,whileitismissingintheMu(TestutandLatarjet,1972).Inthefemale,thepelvicpartoftheurogenitalsinusmovesdown,itisincorporatedbythephallicpart,anditopensexternallywiththevaginalandurethraloriÞ- Fig.12.Themalevagina(fromPuppo,2011d).1,Maleprostate;2,prostaticurethra;3,seminalcol-licle;4,malevagina;5,bladder.:1,Prostaticure-thra;2,seminalcolliculus;3,malevagina;4,ejacula-toryduct;5,vaginaloriÞce;6,ejaculatoryductoriÞce. Fig.13.Developmentofthevestibuleandvagina(fromPuppoetal.,2008b).:1,Phallus;2,phallicpartofurogenitalsinus;3,pelvicpartofurogenitalsinus;4,bladder;5,urethra;6,sinovaginalbulb;7,perineum;8,anus;9,rectum.:1,Clitoris;2,vaginalvestibule;3,bladder;4,urethra;5,vaginaandcervix;6,peri-neum;7,anus.142Puppo ces(Fig.13),whileinthemalethepelvicpartoftheurogenitalsinuscorrespondstotheinternalportionoftheurethrasituatedundertheseminalcolliculus(verumontanum),aprominenceofthedorsalsurfaceoftheprostaticurethrainwhichthetwoejaculatoryductsopenandamongthemexiststheprostaticutricleormalevagina(sometimestheejaculatoryductsopenintothemalevaginaandnotintotheprostaticure-thra):onlythesmallsegmentoftheprostaticurethra,whichreachestheseminalcolliculusfromthebladder,correspondstothewholefemaleurethra(TestutandLatarjet,1972;ChiarugiandBucciante,1975;Shapiroetal.,2004;Standring,2008;Puppoetal.,2008b;Puppo,2011a,2011c,2011d).Themaleandfemalevagina(andcervix)developfromthesinovaginalbulbthatgrowsfromthedorsalwalloftheurogenitalsinustotheleveloftheMuiantubercle(whichwillbecometheseminalcolliculusinmalesandthehymeninfemales),withoutthecontributionoftheMullerianducts(Figs.14and15).Infemales,onlythebodyoftheuterusandtheuter-inetubesareformedbytheMuducts(TestutandLatarjet,1972;ChiarugiandBucciante,1975;«nandAcie«n,2011;Puppo,2011c).ThefusedMullerianductsformtheuterusuptotheexternalcervicalos,andtheinducingmesoneph-ricductsregresscranially,althoughtheyenlargecaudallyfromthelevelofthecervicalos,formthesinuvaginalbulbs,incorporatetheMutubercleÕscells,andgiverisetothevaginalplate.TheembryologicaldevelopmentofthehumanvaginadoesnotproceedfromtheurogenitalsinusandMulerianducts(asclassicallythought)butfromtheWolfÞanductsandMulleriantubercle(Acie«nand«n,2011).Themaindifferencebetweenthemaleandthefemaleistheabsenceofthedevelopmentoftheexternalurethrainthefemale(tobeprecise,onlytheurethraintheglansismissing)duetothenonfu-sionoftheurogenitalfolds;however,thestructures Fig.14.Developmentofthevagina(fromChiarugiandBucciante,1975;Puppoetal.,2008b).1,Urogenitalsinus.2,Muduct.3,WolfÞanduct.4,Mutubercle.5,Sinovaginalbulbfromwhichthefemalevaginaandcervixwillbeformed.6,Mullerianductinregression.7,Developmentvaginallumen. Fig.15.Developmentofthemalevagina(fromChiarugiandBucciante,1975).1,Urogenitalsinus.2,Seminalcollicle.3,VaginaloriÞce.4,Malevagina.5,llerianduct.FemaleErectileOrgansandtheFemaleOrgasm thatformtheexternalurethrainthemalearepres-entinthefemaleandcorrespondtothevestibuleofthevaginaandtheinternalsurfaceofthelabiaminora(TestutandLatarjet,1972;Standring,2008;Puppo,2011a).Thefemaleexternalgenitals,atrest,arejoinedto-gethereventhoughseparatedbythepresenceofthevaginalopening,andrepresentthepenisandthescro-tumofthemale(Dickinson,1949;VanTurnhoutetal.,1995).Theclitorishascorporacavernosathataresmallerbutanalogoustothoseofthepenis(Martin-Alguaciletal.,2006;Puppo,2011a).Yilmazetal.(2002)demonstratedthatevokedandspontaneousclitoralelectromyographyactivityseemstoindicateasympathetictonusofthecorpusclitoris,asseeninthecorpuscavernosumofthepenisinhumanmales.Lencketal.,(1992),intheirobservationsontheurethralsphincter,foundanincreaseinthedimen-sions,afteranteriorvaginalpalpation,ofthesphinc-ter,conÞrmingitserectilecharacter,andthus,theurethro-clitorido-vulvalcomplexseemstobetheana-tomicalsupportforfemalegenitalsexuality.ÔÔThelabiaminoraengorgewitharousalandhavearoleinthefemalesexualresponseÕÕ(Gingeretal.,2011b).AsdiscussedbyPuppo(2006c,2008a,2008b,2011a,2011c,2011d),thecorrectandsimpleana-tomicaltermtodescribetheclusteroferectiletissues(clitoris,vestibularbulbsandparsintermedia,labiaminora,corpusspongiosumofthefemaleurethra)re-sponsibleforfemaleorgasm,isfemalepenis(Fig.16).Theerectilecyclehasbeenextensivelystudiedinthepenisandtoalesserextentintheclitorisandinotherfemaleerectileorgans.However,erectionfromtheßaccidstate,isreachedinthreephases:latent,tumescence,andrigidormuscular(Fig.17)(Benoitetal.,1987;ShaÞk,1995;Weinetal.,2007;Ander-sson,2011;Puppo,2011d).Erectionisduetoaneurovascularmechanism:aninßowofarterialbloodandanobstructionofvenousreturn.Tumescenceisduetoareductioninthealpha-sympathetictonusofthecavernoustissuepermittinginßuxofarterialblood,andadecreasedvenousßowfromcompressionofthesubalbuginealvenousnetworkagainstthetunicaalbugineaofthecorpuscavernosum.Rigidityisduetoanincreaseinintracavernousarterialpressuretogetherwithcon-tractionoftheperinealmuscles(ischiocavernosus)underthesomaticcontrolofthepudendalnerve(Benoitetal.,1987).Contractionoftheischiocavernosusmusclespro-ducesthemalerigid-erectionphase.AsdiscussedbyToescaetal.(1996)ÔÔtheabsenceofthevenousplexusintheclitorissuggeststhatthisorganachievestumescencebutnotrigidityduringsexualHowever,studiesbyDickinson(1949)identiÞedasmallnumberofreportsshowingthatpronouncederectioncanoccur.Infact,asinmales,infemales,itispossibletohavepriapismoftheclitoris,ararecon-ditionassociatedwithprolongederectionofthecor-poracavernosalastingformorethan6hrandunas-sociatedwithsexualarousal.Itcausesengorgement,swelling,andpainoftheclitorisandofitsimmediateadjacentarea.Thecauseofpriapisminmalesandfemalesisimpairedoutßowofbloodfromthecorporacavernosabecauseofvenousobstructionorbecauseoffailureofthealpha-adrenergicrelaxationsystem(Medina,2002;ArntzenanddeBoer,2006;Kordaetal.,2009;Rosenbaum,2010;Puppo,2011a).VAGINALORGASMANDTHE‘‘G-SPOT’’DONOTEXISTEventoday,femalesexualityisstillmainlyconsid-eredintermsofreproduction(thevaginaisaninter-nalandreproductiveorgan),insteadofpleasure,andwomenhavetoreachorgasmduringvaginalintercoursetobeconsideredÔÔtruewomen,ÕÕhow-ever,thefemaleorgasmiscausedbyfemaleerectileorgans(i.e.,femalepenis)andnotbythevagina(MastersandJohnson,1966;Hite,1981;Mastersetal.,1988;Laqueur,1992;Puppo,2011a,2011c).VaginalorgasmdoesnothaveanyscientiÞcbasisandisatheorythatwasinventedbyFreudin1905.Laqueur(1992)statedÔÔThestorybeginsin1905whenFreudrediscoveredtheclitoris,orinanycaseclitoralorgasm,byinventingitsvaginalcounterpartÕÕthatis,thevaginalorgasm,ÔÔAfterfourhundred,perhapseventwothousandyearstherewasallofasuddenasecondplacefromwhichwomenderivedsexualpleasure,ÕÕÔÔIn1905,fortheÞrsttime,adoc-torclaimedthatthereweretwokindsoforgasmandthatthevaginalsortwastheexpectednormamongadultwomen,ÕÕÔÔbefore1905,noonethoughtthattherewasanyotherkindoffemaleorgasmthantheclitoralsort,ÕÕÔÔTheclitoris,likethepenis,wasfortwomillenniabothÔapreciousjewelÕandsexualorgan,ÕÕÔÔFreud,inshort,musthaveknownthathewasinventingvaginalorgasmandthathewasatthesametimegivingaradicalnewmeaningtotheclitoris,ÕÕÔÔFreudknewthatthenaturallocusofa Fig.16.Thefemalepenis(fromPuppoetal.,2008b;Puppo,2011d)(withoutlabiaminoraandcorpusspongiosumofurethra).1,Glans;2,body;3,root;4,angle;5,suspensoryligament;6,bulb;7,corpusspon-giosum;8,BartholinÕsgland;9,pubis;10,ischiopubic144Puppo womanÕseroticpleasurewastheclitorisandthatitcompetedwiththeculturallynecessarylocusofherpleasure,thevagina,ÕÕÔÔAndofcourseFreudhimselfpointsoutthatbiologyhasbeenobligedtorecognizethefemaleclitorisasatruesubstituteforthepenis,ÕÕÔÔFreud,inshort,musthaveknownthatwhathewroteinthelanguageofbiologyregardingtheshiftoferotogenicsensibilityfromtheclitoristotheva-ginahadnobasisinthefactsofanatomyorphysiol-ogy,ÕÕÔÔForawomantomaketheswitchfromclitoristovaginaistoacceptthefemininesocialrolethatonlyshecanÞll.ÕÕThevaginadoesnothaveananatomicalstructurethatcancauseanorgasmandupbynowinanatomytextbooksthepresenceofvagusnerveterminationsinthevaginaandcervixhasnotbeendemonstrated(TestutandLatarjet,1972;ChiarugiandBucciante,1975;Standring,2008;Netter,2010;Puppoetal.,2008a;Puppo,2011a,2011c).ThegenitosensorycomponentofthevagusnervewasonlyahypothesisbyKomisaruk,Whippleetal.(2004)studiedÞvewomenwithcompletespinalcordinjury(onewomanwithsigniÞcant,butincompletespinalcordinjury;onlythreewomenexperiencedvaginalorgasm)(Puppoetal.,2008a;Puppo,2011a,2011c).StudiesbyNicholasandBrodyetal.(2008)foundthatÔÔAwomanÕshistoryofvaginalorgasmisdis-cerniblefromherwalkÕÕÔÔExploratoryanalysessug-gestthatgreaterpelvicandvertebralrotationandstridelengthmightbecharacteristicofthegaitofwomenwhohaveexperiencedvaginalorgasm.ÕÕStudiesbyBrodyandCosta(2011)examinedthehypothesisthataprominenttubercleoftheupperlipisassociatedspeciÞcallywithagreaterlikelihoodofexperiencingvaginalorgasm.However,thevaginalorgasmdoesnotexist:Brodyetal.Õsstatementsarewithoutembryological,anatomical,andphysiologicalbasis.OtherstudiesbyWallenandLloyd(2011)pro-posedthatthevariationinthedistancebetweenawomanÕsglansclitorisandherurethrapredictsthelikelihoodthatshewillexperienceorgasmduringintercourseanditwasproposedthatifthisdistancewaslessthan2.5cm,awomanwasverylikelytohaveorgasmssolelyfromsexualintercourse.Stud-iesbyMastersandJohnson(1966)concludedthatclitoralretraction,whichalwaysdevelopsduringtheplateauphaseandelevatestheclitoralbodyfromitsnormalpudendal-overhangpositioning,furtherremovestheglansfromeventhetheoreticalpossibil-ityofdirectpenilecontact(Fig.18).ThevariationofthedistancebetweenawomanÕsglansclitorisandherurethraisahypotheseswithoutanatomicalandphysiologicalbasis;itcannotpredictthatwomenwillexperienceorgasmduringinter- Fig.17.Theerectilecycle(fromPuppo,2011d).FemaleErectileOrgansandtheFemaleOrgasm course,anditcannotsuggestthatwomenexposedtolowerlevelsofprenatalandrogensaremorelikelytoexperienceorgasmduringsexualintercourse(WallenandLloyd,2011).GravinaandJannini(anandrologist)etal.(2008),intheJournalofSexualMedicine,statedÔÔTheure-throvaginalspace(whereHalbanÕsfasciaruns)seemscritical,beingconstitutedofÞbroconnectivetissueandlargenumbersofbloodvessels,glands,muscularÞbers,andnerveendings.ÕÕButÔÔurethrovaginalspaceÕÕisanincorrecttermfromascientiÞcpointofview,theanteriorvaginalwallisseparatedfromtheposteriorurethralwallbytheurethrovaginalseptum(TestutandLatarjet,1972;ChiarugiandBucciante,1975).InadditionHalbanÕsfascia,alayerofdenseconnectivesituatedinthebladder-vaginalseptum(TestutandLatarjet,1972),doesnotcorrespondtothemalecorpusspongiosum,anditisnotthesiteoforiginofvaginalorgasm,assomeresearchersbelieve(Hoangetal.,1991);thisassumptionhasnoembryologicalandanatomicalsupport.HalbanÕsfas-ciaandtheanteriorfornixarenotfemaleerogenouszones(Puppoetal.,2008a;Puppo,2011c).Levin(2011)statedÔÔitisknownthatpenile-vagi-nalintercourseactuallystimulatestheclitoristhroughthrustingtractiononitsattachedligamentsviatheanteriorvaginalwallÕÕ;GravinaandJanninietal.(2008)statedÔÔInfact,theanteriorvaginalwallisanactiveorgan,transmitting,duringintercourse,theeffectofpenilethrustinginthevaginatotheclit-oris,bystretchingthetwoligamentsthatinsertarounditsbase.ÕÕButthesestatementsareonlyhypothesesderivedfromIngelman-Sundberg(1997)andarenotcorroboratedbyanyanatomicalorphys-iologicalevidence(Puppo,2011c)(Figs.18and19).StudiesbyPuppoandGruenwald(inpress)statedÔÔIn1950,Gra¬fenbergdescribedadistincterotogeniczoneontheanteriorwallofthevagina,whichwasreferredtoastheGra¬fenbergSpot(G-spot)byAddiegoetal.in1981.Asaresult,theG-spothasbecomeacentraltopicofpopularspeculation.ÕÕIn2008,GravinaandJanninietal.claimedthattheyhadultrasoundimagesoftheG-spot,butnosuchimageswereincludedinthepublishedarticlebytheJournalofSexualMedicineTheG-spotrepresentsthatpartoftheurethrathatcontainstheperiglandularorparaurethraltissue(SanDiegoSexualMedicine,2012),butstudiesbyPuppoandGruenwald(inpress)statedthatthesupposedG-spotoftheanteriorvaginalwallislocatedinPawlikÕstriangle,aregionthatcorrespondstoLieutaudÕstrian-gleinthebladder.Themucosaofthisregionofthean-teriorvaginalwallissmooth,withoutrugae(i.e.,transversefolds);PawlikÕstriangleisanareawithminorresistance;hence,itcaneasilybulgeintothevaginaofawomanwithacystocele(Figs.19and20).Ostrzenski(2012)extractedpartsoftheanteriorvaginalwallofthecadaverofan83-yearoldwomanandcalleditG-spotandhestatedthatÔÔTheana-tomicexistenceoftheG-spotwasdocumentedinthisstudywithpotentialimpactonthepracticeandclinicalresearchintheÞeldoffemalesexualfunc-tionÕÕÔÔTheG-spotwasidentiÞedasasacwithwallsthatgrosslyresembledtheÞbroconnectivetissues,waseasytoobserve,andwasawelldelineatedstructure.ÕÕOstrzenski(2012)alsostatedthattheG-spotgenehadbeenlocatedbutthiswasamisunder-standingofoneofthereferences.Buisson(2010)commentedthattheG-spotwaspopularizedbysex-ologistBeverlyWhipplein1980inhonorofthegyne-cologistErnstGrafenberg,andthatvaginalpenetra-tioncausesaclosecontactbetweentheinnerclitorisandthedistalanteriorvaginalwall.However,studiesbyPuppo(2011c)concludedthatthefemaleperinealurethra,whichislocatedinfrontoftheanteriorvagi-nalwall,isabout1cminlength,andthepresumedG-spotislocatedinthepelvicwalloftheurethra,2Ð3cmintothevagina.Therefore,thepeniscannotcomeintocontactwiththevenousplexusofKobeltorwiththerootsoftheclitoris(whichdonothavesensoryreceptorsorerogenoussensitivity)duringvaginalintercourse(Figs.18and19).Pastor(2010)concludedthattheÔÔExistenceofaspeciÞcanatomicalstructureknownastheGspothasnotbeenprovenbyanyrelevantscientiÞcstud-iesÕÕandMagnin(2010)thoughtÔÔThereisnoanatomical,biologicalandphysiologicalbasisfortheexistenceofG-spot.ÕÕStudiesbyHines(2001)con-cludedwithsimilarthoughts.FEMALEGENITALCOSMETICSURGERYThereisawidevarietyintheappearanceofnor-malfemaleexternalgenitalia(Michalaetal.,2011).StudiesbyBraun(2010)statedthatÔÔFemalegenitalcosmeticsurgeryprocedureshavegainedpopularityintheWestinrecentyears.Marketingbysurgeonspromotesthesurgeries,butprofessionalorganiza-tionshavestartedtoquestionthepromotionandpracticeoftheseprocedures.Despitesomesurgeonclaimsofdrastictransformationsofpsychological,emotional,andsexuallifeassociatedwiththesur-gery,littlereliableevidenceofsucheffectsexists.ÕÕStudiesbyMcPencowandGuess(2012)suggestedthatfemalecosmeticgenitalsurgeryhasgainedinternationalpopularityoverthepasttwodecades,despitethelackofwell-designedclinicaltrialstocon- Fig.18.Thepeniscannotcomeintocontactwiththeclitoris(fromPuppo,2011c).146Puppo ÞrmbeneÞt.TheAmericanCollegeofObstetriciansandGynecologists(2007)foundthattheÔÔSo-calledvaginalrejuvenation,designervaginoplasty,revirgi-nation,andG-spotampliÞcationarevaginalsurgicalproceduresbeingofferedbysomepractitioners.WomenshouldbeinformedaboutthelackofdatasupportingtheefÞcacyoftheseproceduresandtheirpotentialcomplications,includinginfection,alteredsensation,dyspareunia,adhesions,andscarring.ÕÕAlthoughG-spothasbecomeamultimilliondollarbusiness(Kilchevskyetal.,2012)PuppoandGruen-wald(inpress)concludedthatG-spotampliÞcationisnotmedicallyindicatedandisunnecessary.GiulianoandCle«ment(2005)concludedthatÔÔorgasmisacerebralprocesswithaseriesofperiph-eralphysicaleventscomprisingcontractionofacces-sorysexualorgans.ÕÕFEMALEEMISSIONInthevaginalvestibule,theexternaloriÞceoftheurethrawiththeparaurethral(SkeneÕs)ductsopen-ingonbothsidesisseen.Theirlengthis0.5Ð3cmandtheyarefound,inwomen,withtheintraurethral(SkeneÕs)glandsconsideredbysomeasthefemaleprostate.Thisstructurecanbeaffectedbythesamediseasesasitsmalecounterpart,includingcarci-nomaandprostatitis(Zaviacicetal.,2000;Puppo,2011a).ThesecretionoftheseglandsisexpelledthroughtheurethralmeatusorthroughtheoriÞcesoftheparaurethralductsintothevaginalvestibule,whichcorrespondstothedorsalwallofthemalecavernosaurethra(whilethelabiaminoracorre-spondtotheventralwall);femaleÔÔprostateÕÕsecre-tionduringorgasmcorrespondstotheemissionphaseofmaleejaculation(Puppo,2011a).StudiesbyShaÞketal.(2009)revealedthatopin-ionsvaryoverwhetherfemaleejaculationexistsornot.Theseauthorsfoundthatfemaleorgasmwasnotassociatedwiththeappearanceofßuidcomingoutofthevaginaorurethra.Fromaphysiologicalpointofview,thetermÔÔfemaleemissionÕÕisamoreaccuratetermthanfemaleejaculation;inthemale,thiscorrespondstoemissionofseminalßuidintotheprostaticurethra(Fig.21)(Puppo,2011a,2011d).THEFEMALEORGASMOrgasmisanintensesensationofpleasureachievedbystimulationoferogenouszones(glansclitorisisthefemaleprimaryerogenouszone)thathaveaheightenedsensitivity.TheÔÔvaginalÕÕorgasmthatsomewomenreportiscausedbythesurround-ingerectileorgans(Hite,1981).Distinguishingbetweenclitoralandvaginalorgasmisnotcorrectfromaphysiologicalpointofview(MastersandJohnson,1966).StudiesbySher-fey(1973)concludedthatÔÔThevaginalorgasmasdistinctfromtheclitoralorgasmdoesnotexist.ÕÕThehighsensitivityofthefemaleexternalgenitalsisnot Fig.19.Theclitoris,thepelvicandperinealurethra,andthevagina.G-spotdoesnotexist(fromPuppo,2011c,2011d).FemaleErectileOrgansandtheFemaleOrgasm onlyduetotheclitorisbutalsotothethinepithelialliningcoveringthelabiaminoraandthevestibule.Thestimulationofthelabiaminoraandofthevesti-buleofthevagina(thereforealsotheurethralori-Þce)wouldfacilitatetheachievementoforgasminwomen,withfeelingsevenhigherthanclitoralstimu-lationalone,withamoreglobalstimulationoftheexternalgenitalia,whichincludesthewholefemaleerectileapparatus(Puppo,2011d).Kingetal.(2011)foundfourtypesoffemaleorgasm,whichvariedsystematicallyintermsofpleasureandsensations.StudiesbyMastersandJohnson(1966)foundthattheclitorisrespondswithequalfacilitytobothsomatogenicandpsychogenicformsofstimulationandHerbenickandFortenberry(2011)statedthatÔÔOrgasmistypicallyconsideredtobeasexualexperience.However,orgasmsoccur-ringduringphysicalexercisehavebeenoccasionallyStudiesbyMastersetal.(1988)revealedthatÔÔFemaleshavethephysicalcapabilityofbeing-thatis,theycanhaveoneormoreaddi-tionalorgasmswithinashorttimewithoutdroppingbelowtheplateaulevelofsexualarousal.Beingmul-tiorgasmicdependonbothcontinuedeffectivesexualstimulationandsexualinterestmultipleorgasminfemalesseemstooccurmorefrequentlyduringmas-turbationÕÕÔÔFromtheviewpointofphysicalcapability,femaleshaveanalmostunlimitedorgasmicpoten-tial,whilemen,becauseoftherefractoryperiod,areunabletohavearapidseriesofejaculations.Womendonothaveatruerefractoryperiod;orgasmicpotentialisundoubtedlyrestrictedbyfatigue.Stud-iesbyDarlingetal.(1991)foundthat42.7%ofwomenhadexperiencedmultipleorgasms.Shtark-shalletal.(2008)supportedthisandconcludedÔÔawomanÕscapabilitytohavemultipleorgasmsisde-pendentonacombinationofdevelopmental,psycho-logicalandpsychosocialconditions.ÕÕSomewomenmayexperienceÔÔstatusorgasmus,ÕÕwhichisasin-gle,long-continuedorgasmicepisodeoraseriesofrapidlyrecurrentorgasmicexperiencesbetweenwhichnorecordableplateau-phaseintervalscanbedemonstrated,whichcanlastupto1min(MastersandJohnson,1966).Thelackoftheejaculationphaseinwomencouldexplainwhywomendonothavearefractoryperiodandwhytheyareabletohavemultipleorgasms(Puppo,2011a).Menopauseresultsinadeclineincirculatingestro-genlevels,whichresultsinatrophyofurogenitaltis-sues,vaginalshorteningandthinning,decreaseinvaginalelasticityandlubricationreduction.Forthesereasons,sexualintercoursemaybecomeuncomfort-able.However,thesephysiologicalalterationsareonlyrelatedtothereproductive(i.e.,internal)organsofwomenbecauseestrogendoesnotaffecttheclito- Fig.20.Anteriorvaginalwall(fromChiarugiandBuc-ciante,1975).A,Anteriorvaginalwall;c,cervix;cl,clito-ris;pl,labiaminora;ou,urethraloriÞce;cu,carinaure-thralis;cr,anteriorcolumnofrugae;tP,PawlikÕstriangle. Fig.21.Perinealmusclecontractionstotheorgasmandthefemaleemission(fromPuppo,2011d).1,StereotypedrhythmiccontractionsoftheÔÔorgasmicplatform,ÕÕthatis,ofthebulbocavernosusandpubovaginalismuscles;2,rhythmiccontractionsoftheischiocavernosusandtransversesperinealmuscles;3,rhythmiccontractionsofthelevatoranimuscle;4,rhythmiccontractionsoftheexternalanalsphincter;5,femaleemission;6,rhythmiccontractionsoftheuterus.148Puppo ris(MastersandJohnson,1966;Mastersetal.,1988;Martin-Alguaciletal.,2006).MastersandJohnson(1966)believethattherewasnoreasonwhymeno-pauseshouldbeexpectedtobluntthehumanfemaleÕssexualcapacity,performance,ordrive.Femaleorgasmandclitoralsexualresponsearenotaffectedbyagingandforthisreasonwomenhavethephysicalcapabilityofbeingorgasmicinallages.Forwomen,clitoralstimulationisimportantforachievingtheorgasm,andtheclitorisexistsinallwomen:whynotsimplystimulate,duringinter-coursewithpenetrationofthepenis,theclitoriswithaÞnger?TheclaimsthatweremadeinthenumerousarticlesthathavebeenwrittenbyAddiego,Whipple,Jannini,Buisson,OÕConnell,Brody,Ostrzenski,andothers,havenoscientiÞcbasis.Clitoral/vaginal/uter-ineorgasm,G-/A-/C-/U-/K-/O-/DVZ-spotorgasm,femaleejaculation,persistentgenitalarousaldisorder,clitoralbulbs,clitoralorclitoris-ure-thra-vaginalcomplex,internalclitoris,periurethralglans,genitosensorycomponentofthevagusnerve,aretermsthatmustnotbeusedbygynecologists,sexologists,sexualmedicineexperts,womenandmass-media.Asamatteroffactfemalesexualdys-functionsarepopularbecausetheyarebasedonsomethingthatdoesnÕtexist,i.e.thevaginalorgasm(Puppo,2012a,2012c).Gynecologists,sexologists,andsexualmedicineexpertsmustconveythatorgasmmayoccurinbothpartnerswithorwithoutavaginalintercourse(Puppo,2012d).ÔÔSexualityisanimportantpartofhealth,qualityoflifeandgeneralwellbeingÕÕ(Elnasharetal.,2007).AccordingtotheWorldHealthOrganizationÔÔSexualhealthisastateofphysical,emotional,mentalandsocialwellbeingrelatedtosexuality;itisnotmerelytheabsenceofdisease,dysfunctionorinÞrmity...SexualhealthisaglobalissuethatisvitaltooverallwellbeingÕÕ(Abdooletal.,2009).WomenÕssexualrightsarefundamentalanduniversalhumanrightsandthesexualpleasure,includingautoeroticism,isasourceofphysicalandpsychologicalwellbeingthatcontrib-utestohumanhappiness(WorldAssociationforSex-ualHealth,2008).TheknowledgeoftheanatomyandphysiologyoffemaleerectileorgansandoffemaleorgasmisessentialintheÞeldofwomenÕssexualhealth.AbdulcadirJ,MargairazC,BoulvainM,IrionO.2011.Careofwomenwithfemalegenitalmutilation/cutting.SwissMedWkly140:w13137.AbdulcadirJ,BoulvainM,PetignatP.2012.Reconstructivesurgeryforfemalegenitalmutilation.Lancet380:90Ð92.AbdoolZ,ThakarR,SultanAH.2009.Postpartumfemalesexualfunction.EurJObstetGynecolReprodBiol145:133Ð137.«nP,Acie«nMI.2011.Thehistoryoffemalegenitaltractmalfor-mationclassiÞcationsandproposalofanupdatedsystem.HumReprodUpdate17:693Ð705.AddiegoF,BelzerEG,ComolliJ,MogerW,PerryJD,WhippleB.1981.Femaleejaculation:Acasestudy.JSexRes17:13Ð21.AmericanCollegeofObstetriciansandGynecologists.2007.ACOGCommitteeOpinionNo.378:VaginalÔÔrejuvenationÕÕandcos-meticvaginalprocedures.ObstetGynecol110:737Ð738.AnderssonKE.2011.Mechanismsofpenileerectionandbasisforpharmacologicaltreatmentoferectiledysfunction.PharmacolRev63:811Ð859.ArgiolasA,MelisMR.2003.Theneurophysiologyofthesexualcycle.JEndocrinolInvest26(3Suppl):20Ð22.ArntzenBW,deBoerCN.2006.Priapismoftheclitoris.BJOG113:742Ð743.BassonR,BrottoLA,LaanE,RedmondG,UtianWH.2005.Assess-mentandmanagementofwomenÕssexualdysfunctions:Prob-lematicdesireandarousal.JSexMed2:291Ð300.BattagliaC,BattagliaB,BusacchiP,ParadisiR,MeriggiolaMC,Ven-turoliS.inpress.2Dand3Dultrasoundexaminationoflabiaminora.ArchSexBehav;DOI10.1007/s10508-012-9899-5BellemareS,DibdenL.2005.Absenceoftheclitorisina13-year-oldadolescent:Medicalimplicationsforchildandadolescenthealth.JPediatrAdolescGynecol18:415Ð418.BenoitG,DelmasV,GillotC,JardinA.1987.Theanatomyoferec-tion.SurgRadiolAnat9:263Ð272.BraunV.2010.Femalegenitalcosmeticsurgery:Acriticalreviewofcurrentknowledgeandcontemporarydebates.JWomensHealth19:1393Ð1407.BrodyS,CostaRM.2011.Vaginalorgasmismoreprevalentamongwomenwithaprominenttubercleoftheupperlip.JSexMed8:2793Ð2799.BuissonO.2010.TheG-spotandlackoffemalesexualmedicine.GynecolObstetFertil38:781Ð784.BuissonO,FoldesP,PanielBJ.2008.Sonographyoftheclitoris.JSexMed5:413Ð417.BuissonO,FoldesP,JanniniE,MimounS.2010.Coitusasrevealedbyultrasoundinonevolunteercouple.JSexMed7:2750Ð2754.CarvalhoS,MoreiraA,RosadoM,CorreiaD,MaiaD,PimentelP.2011.Femaleprematureorgasm:Doesthisexist?Sexologies20:215Ð220.CatalaM.2002.ControlofthedevelopmentofOnufÕsspinalnucleus.ProgUrol12:340Ð343.ChalkerR.2000.TheClitoralTruth:TheSecretWorldatYourFingertips.NewYork:SevenStoriesPress.p1Ð257.ChiarugiG,BuccianteL.1975.IstituzionidiAnatomiadellÕuomo.Testo-Atlante.Vol3.11thEd.Milano:CasaEditriceDr.Fran-cescoVallardi-Societa`EditriceLibraria.p1Ð950.ColdCJ,TaylorJR.1999.Theprepuce.BJUInt83(Suppl1):34ÐConnellK,GuessMK,LaCombeJ,WangA,PowersK,LazarouG,MikhailM.2005.Evaluationoftheroleofpudendalnerveinteg-rityinfemalesexualfunctionusingnoninvasivetechniques.AmJObstetGynecol192:1712Ð1717.CopcuE,AktasA,SivriogluN,CopcuO,OztanY.2004.Idiopathicisolatedclitoromegaly:Areportoftwocases.ReprodHealth1:4.DarlingCA,DavidsonJKSr.,JenningsDA.1991.Thefemalesexualresponserevisited:Understandingthemultiorgasmicexperienceinwomen.ArchSexBehav20:527Ð540.DickinsonRL.1949.AtlasofHumanSexAnatomy.2ndEd.Balti-more:Williams&Wilkins.p1Ð145.DwyerP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