Annals of Anatomy 233 (2021) 151588

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Annals of Anatomy
journal homepage: www.elsevier.com/locate/aanat

RESEARCH ARTICLE

Anatomy of the bulbus vestibuli: A cadaveric study

Adam Ostrzenski
Institute of Gynecology, Inc., 7001 Central Ave, St. Petersburg, FL 33710, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: To describe the BV anatomy in detail, to compare previous BV descriptions and illustrations
Received 1 May 2020 to the current study’s findings and photograms, to show the BV topographic relation of the BV to the
Received in revised form 31 July 2020 urethral meatus, to document the BV anatomy using photograms.
Accepted 7 August 2020
Methods: Ten fresh human female adult cadavers were used. Stratum-by-stratum anatomical dissections
in sagittal, transverse, and coronal planes were performed. The BV was dissected-off from the original
Keywords:
location of the posterior-distal vaginal wall and the anterior anal wall.
Bulb of clitoris
Results: The BV was located within the posterior-distal vagina and composed of two vertical legs, which
Bulb of vestibule
Clitoris
fused to one another. The inferior pars intermedia fused both descending legs to the anterior-proximal
Corpus cavernous perineal urethral wall, and BV embraced the anterior-proximal urethra. The superior pars intermedia
Corpus spongiosum connects the BV to the posterior-distal clitoral body. The BV legs traversed parallel to and aside from the
Female genital anatomy vaginal introitus and the lateral urethra and not crossing the anterior-distal urethra. The tile-end was a
Pars intermedia tapered end which terminates in the vicinity of Bartholin glands. Laterally, the BV legs outspread to the
medial labia minora and attach to the ischiopubic ramus. The anatomical site-specific defect (s) occurs
within the BV.
Conclusions: The present study resolves the BV anatomical controversy and shows that the BV runs parallel
to and aside from the anterior-distal urethra and the BV. The site-specific defect(s) can occur within the
BV. This study provides important information for anatomy educators and surgeons.
© 2020 Published by Elsevier GmbH.

1. Introduction vascular structure (the spongiosum tissues) that coordinates vas-

The bulb of the vestibule plays an essential role in the new
surgical therapy of female stress urinary incontinence (urethral
stabilization procedure) or clitoral infrafrenulum bundle restora-
tion, or anterior vaginal introidoplasty. It is essential to resolve the
BV anatomical controversy and to provide adequate educational
materials as well as to present pertinent clinical information. To
reconstruct a site-specific defect(s) within the urethral stabiliz-
ing mechanism for female stress urinary incontinence, it requires
access to the ventral perineal membrane in the vicinity of the
BV and its bifurcation (Ostrzenski, 2020). To perform these sur-
gical treatments safely, understanding the gross and topographic
anatomy is pivotal for surgeons and anatomy educators.
In classic anatomy Kobelt (1844), describes and illustrates the
bulb of the vestibule (bulbus vestibuli) and the pars intermedia
in women. He presents this structure as two elongated masses
traversing on either side of the vaginal orifice and fuses to one
another by the distal pars intermedia. The pars intermedia is the
E-mail address: ao@baymedical.com
cular response during the female sexual response cycle, particularly
in the cycle’s arousal phase. Additionally, the pars intermedia is
networking with the erectile tissues (the cavernous tissue) of the
clitoris and the other vascular compartments of the vulva.
O’Connell et al. (2008) changed this anatomical description,
quote: “The urethral orifice and distal urethra are surrounded by
the erectile tissue of the clitoral bulb”). Hoag et al. (2017) add
an illustration of BV in which depicts BV overlapping the urethral
meatus, as O’Connell et al. (2008) describe. This BV anatomical dis-
crepancy (O’Connell et al., 2008; Hoag et al., 2017) is the base for
the BV anatomical controversy O’Connell et al. (2008). BV anatom-
ical description has never been verified despite repetitive reports
by those authors on this topic and multiple citations by others (the
number of times cited according to CrossRef).
A scarcity of the scientific-clinical published articles on BV and
the absence of the photographic documentation concerning BV
makes it a difficult task to understand which description is accurate.
The present study will authenticate one of these anatomic descrip-
tions and will document the VB appearance by photograms. There is
no histological controversy in the description of microscopic char-
acteristic features of the BV, and researchers agree that it is erectile

https://doi.org/10.1016/j.aanat.2020.151588
0940-9602/© 2020 Published by Elsevier GmbH.
2 A. Ostrzenski / Annals of Anatomy 233 (2021) 151588
(cavernous) tissue. (O’Connell et al., 2004; Shih et al., 2013; Jackson
et al., 2019).
The present study’s question is raised, does the BV overlap the
urethral meatus? This
question leads to a hypothesis here; the bulb of the vestibule
runs parallel to and aside from the lateral urethral wall. The case
series study is designed, and ten fresh human adult female consec-
utive cadavers use to resolve this uncertainty. The objectives of this
study are to compare previous BV descriptions and illustrations to
the current study’s findings, to show the BV topographic relation to
the urethral meatus, to document the BV anatomy by photograms.
Stratum-by-stratum anatomical dissections in sagittal, transverse,
and coronal (frontal) planes are performed to examine the BV and
the pars intermedia.
2. Material & methods
2.1. Study population and ethics committee acceptance
The case series study was performed on BV fresh human adult
female cadavers. This investigation was approved by the University
Ethics Committee (AKBE 146/12). Medical records and demo-
graphic data were not available due to the type of services provided
by the Department of Forensic Medicine.
2.2. Inclusion/exclusion criteria
Those cadavers who expired within 24 h and were not sub-
jected to the preservation process were included for the study.
Those corpses who shown a disseminated illness, evidence of prior
operation on the external genitalia, demonstrate signs of conta-
gious diseases, anatomical disfiguration of the external genitalia,
increased in size of female external genitals, the presence of a
tumor, enlarged inguinal lymphatic nodes, and those who were
raped, or incest victims were excluded.
2.3. Anatomical dissection
The author performed all macro- and micro-dissections and uti-
lizing surgical loupe of 3.5–4.0 magnification. The skin incision
was made on the clitoral prepuce close to the inner edge of the
ischiocavernosus muscle and curried-down through the fat tissue
layer until the clitoral suspensory ligaments were exposed. A trac-
tion suture placed on the skin for better exposure of the clitoral
body, the clitoral glance, the bulb of the vestibule (BV), and the
pars intermedia. The bulbocavernosus muscles and fat pad were
resected to expose the ischiopubic ramus and the BV attachment.
When the defect was present within the bulb of vestibule, it was
entirely dissected-off to visualize the edges. The anatomy of the cli-
toris, BV and the pars intermedia, as well as any abnormality were
documented by digital photograms.
2.4. Literature search
The electronic searches of the medical literature carried out
for articles about the BV gross and topographic anatomy. The
Medical Subject Headings (MeSH) used in gathering relevant
scientific-clinical materials on BV. Conference Proceedings and
specializing website were included in searches. The following key-
words were used: Bulb of the vestibule; Bulb of clitoris; Bulb
of vestibule history; Bulb of vestibule magnetic resonance imag-
ing; Bulb of vestibule ultrasound; Clitoris; Clitoral root; Clitoral
frenulum; Clitoral urethrovaginal complex; Corpus cavernous;
Corpus spongiosum; Female; Female bulb of vestibule anatomy;
Female erectile tissue; Female erogenous organs; Female exter-
nal genitalia; Female genital anatomy; Female histology of bulb
of the vestibule; Female histology of external genitalia; Female
sexual function; Pars intermedia; Periurethral anatomy; Sexual
anatomy; Urethra; Vestibular bulbs; Vagina; Vaginal anatomy;
Vulva.
3. Results
In the present investigation, ten consecutive, fresh human
female cadavers were used. Searching the medical literature failed
to identify any scientific-clinical article about the occurrence of
site-specific defects within the bulb of the vestibule (the bulbus
vestibuli).
3.1. The bulb of vestibule (bulbus vestibuli) anatomy
The present study showed that the bulbus vestibuli did not over-
lap the urethral meatus (meatus ad ostium urethrae) or the distal
female perineal urethra (Figs. 1C, D, and 3 B). The current inves-
tigation verified the BV location in women. Topographically, BV is
located at the proximal urethra and on an average of 2 cm distant
from the urethral meatus.
The BV rested on the perineal membrane (membrana perinea
superficislis or the ligamentum triangulare), also in the past called
the urogenital diaphragm (diaphragma urogenitale). The vestibular
bulbs appeared as two vertical, small, cylinder-like structures and
bluish color (Figs. 2 and 4).
The BV consists of two legs traversed from the bifurcation par-
allel downwards and alongside the lateral female urethra. The pars
intermedia and BV borders were well-delineated (Figs. 1C and 3
B). Horizontally, the two-legs of BV were connected to the pars
intermedia. The pars intermedia fused with the posterior-distal
clitoral body (corpus clitoridis) in the vicinity of clitoral corona
(Figs. 1C, D, and 3 B). The BV structure resembled a reversed-U-
shape that rested on the superior surface of the ventral perineal
membrane (Figs. 1B and 3 B), covered by the fat tissue pad, and
the bulbocavernosus muscle (musculus bulbospongiosus), (Fig. 3A).
The anterior-distal urethral wall did not have any anatomical con-
tact with the BV (Figs. 1C, D, and 3 B). Posteriorly, the tail of BV
ended blindly and created the appearance of a “finger-like” struc-
ture. Laterally, the BV legs outspread to the medial labia minora
(labium minus) and attached to the ischiopubic ramus (ischiopu-
bis ramus), (Figs. 1C and 3 B). The posterior-distal BV ended at the
greater vestibular bulb (bulbus vestibuli vaginea). Both BV legs and
the pars intermedia were supported by the ventral perineal mem-
brane and covered by the thin, whitish tissues (Fig. 3B). The fat
tissue pad wrapped both proximal BV legs (Fig. 3A). The median
width of the vertical length of the bulb of the vestibule was 6.8 ± 3
cm and was 1.3 ± 0.2 cm, respectively. The median superior hori-
zontal segment of the BV was 1.3 ± 0.4 cm. The horizontal part was
attached to the inferior part of the pars intermedia (Figs. 1C and 3
B).
One subject demonstrated the site-specific defect within the
right BV. It looked-like an amputated limb with a hypertrophied
upper part, and the atrophied lower amputated part. The proximal
right amputated BV width measured 2.5 cm. The intact left BV leg
width was 1.1 cm. The defective right distal atrophic bulb width
measured 0.7 cm (Fig. 4A).
3.2. Pars intermedia
Grossly, the pars intermedia appearance was indistinguishable
from the BV. Its location was between the posterior-distal clitoral
body, near the clitoral corona, and the anterior-superior bulbs of
the vestibule. It filled the gap between the posterior-distal clitoral
body and the horizontal part of BV (Figs. 1C and 3 B). It looked like
an isosceles trapezoid with well-defined borders. The upper part of
 A. Ostrzenski / Annals of Anatomy 233 (2021) 151588 3

Fig. 1. The illustrations and representative photo of the bulb of the vestibule.
Reproduced with permission from the Editorial Office of the Journal of Sex Medicine (Hoag N, Keast JR, O’Connell H.E. (2017). J Sex Med 14:1524–1532).
A. Authors changed the term of the bulb of the vestibule “bulb of clitoris.”
B. The bulb of the vestibule overlaps the superior urethral meatus.
C. The surrounding tissue of the bulb of the vestibule was removed. The proximal perineal urethral wall is in direct contact with the bulbs of the vestibule and does not
overlap the urethral meatus or the anterior-distal urethra.
D. The graphic illustration of the bulb of the vestibule relation to the anterior-proximal and distal urethra.

the pars intermedia was shorter than the lower base. (Figs. 1C, D, 3
A, and B). The clitoral glance was not in direct anatomical contact
with BV.
4. Discussion
4.1. Principal findings
The Department of Forensic Medicine did not furnish the author
with the medical records to determine how the age or site-specific
defect would impact, and because of these deficiencies, a woman’s
well-being could not be determined by the present study. In
general, there are limited articles on the female urogenital tract
atrophies related to the advancing age (Perucchini et al., 2002; Jundt
et al., 2005; Trowbridge et al., 2007; Alperin et al., 2016).
The current study’s findings showed that the bulb of the
vestibule did not surround the distal perineal urethra as other
authors postulated urethra or urethral meatus. Additionally, the
present study expended our knowledge about the occurrences of
site-specific defects within the bulb of the vestibule. This finding
itself helps physicians to consider site-specific defects within the
BV as one of the causes of female sexual response cycle dysfunc-
tion. One subject out of ten showed a site-specific defect within
BV, and this abnormality coexisted with the ventral perineal mem-
brane defect (membrana perinea superficislis or the ligamentum
triangulare) (Fig. 4). The perineal membrane was also known as
the Diaphragma urogenitale. However, in 1983, Oelrich discovered
the perineal membrane and eliminate the existence of Diaphragma
urogenitale. In 2008, Stein and Delancey confirmed this finding
anatomically and histologically. When compared the right defec-
4 A. Ostrzenski / Annals of Anatomy 233 (2021) 151588

Fig. 2. The bulbospongiosus muscles over the bulb of vestibule. The bulbospongiosus muscles cover the bulb of the vestibule (black arrows). The fragment of the left bulb of
the vestibule is visible through a small artificially created window on the medial part of the descending leg of the bulbospongiosus muscle (the white arrow).

Fig. 3. The bulb of the vestibule, pars intermedia, the distal urethra, and urethral meatus.
A. The fat tissue covers the bulb of the vestibule. The urethral meatus is free of any connection with vestibular bulbs.
B. The prifascial fat tissue, the fat tissue, and the bulbocavernous muscles were removed to get access to the vestibular bulbs and the pars intermedia. The bulb of the vestibule
does not surround the urethral meatus.

Fig. 4. The site-specific defect within the bulb of the vestibule and the ventral perineal membrane.
A. The thick edges of the site-specific defects within the right bulb of the vestibule and the perineal membrane indicate the long-lasting defects.
B. Graphic illustration of the site-specific defect within the right bulb of the vestibule.

tive BV to the left intact bulb of the vestibule in this subject, the for any subject; consequently, to determine whether the subject
proximal width of the right defective BV was as twice as large as had suffered from sexual dysfunction was impossible to establish in
the width of the left intact BV (Fig. 4). The distal part of the BV this study. The female sexual dysfunction prevalence is estimated
defect was atrophic (Fig. 4). The medical history was not available to be 43% (Laumann et al., 1999). How often the BV site-specific
 A. Ostrzenski / Annals of Anatomy 233 (2021) 151588
defects affects female sexual function, will need to be established
by a clinical investigation.
Kobelt (1844) provided the BV accurate anatomical description
and illustrations. Other European authors of classical books and
atlases also presented accurately BV description (Kopsch, 1941;
Corning, 1946) until O’Connell et al. (2008) changed the topo-
graphic description of BV to, quote: “The urethral orifice and distal
urethra are surrounded by the erectile tissue of the clitoral bulb.”
These authors changed not only BV location but also the change the
terminology from the bulb of the vestibule to “the clitoral bulb.” The
BV new color illustration (Fig. 1B) was presented in the Hoag et al.
(2017) publication. These authors’ descriptions and illustrations
differ from Kobelt (1844) and the current investigation findings
(Figs. 1C and 3 B). The present study established that the bulb of
the vestibule did not surround the urethral meatus or the distal
perineal urethra (Figs. 1C and 3 B). The BV anatomical description
presented by O’Connell et al. (2008), and the illustration (Fig. 1B)
published by Hoag et al. (2017) did not correspond to the BV original
Kobelt’s (1844) description or present study’s findings of (Figs. 1C
and 3 B).
O’Connell et al. (2004), presented, quote: “The bulbs lie ven-
tral to the urethra and descend on either site lateral to the vaginal
introitus on the lateral wall of the distal vagina.” In 2005, O’Connell
and DeLancey (2005) published an MRI study and described the
BV anatomical location as, quote: “. . .the bulbs is just visible lat-
eral to the urethra.” These two descriptions differ from the later
description of BV by O’Connell et al. (2008) and Hoag et al. (2017).
From 2008, other authors cited the O’Connell et al. (2008) and this
new description was disseminated in medical literature. Indeed, BV
teaching was affected by this new information. Clarifying this exist-
ing anatomical controversy (Fig. 1B) helps educators, surgeons, and
other clinicians to properly understand the BV anatomy (Figs. 1C
and 3 B). Such clarification is particularly important in the view
that BV rests on the ventral perineal membrane, which is an inte-
gral part of the urethral stabilization procedure for female stress
urinary incontinence in women (Ostrzenski, 2020). Female stress
urinary incontinence can result from the site-specific defect within
the ventral perineal membrane (Fig. 4), and to reconstruct the ven-
tral perineal defect(s), surgery is performed in the vicinity of BV and
the proximal urethra (Ostrzenski, 2019a, b, 2020). According to the
Ostrzenski (2014) publication, the BV covered the anterior-distal
urethra and the urethral meatus; therefore, the surgical reconstruc-
tion of the ventral perineal membrane would be challenging for
surgeons.
Photographic documentation helps to correct imprecisions
within diagrams and assists educators and surgeons in identify-
ing appropriately the gross and topographic anatomy of the BV.
Moreover, the present study’s findings assist a clinician to appreci-
ate that site-specific defects can occur within the bulb of vestibule
(Figs. 1C–4). The site-specific defect occurrence within the BV
(Fig. 4) presents opportunities to explore how the BV site-specific
defect(s) influences the arousal phase of the sexual response cycle
in women.
In many instances, vaginal deliveries caused anatomical site-
specific defects within female genitalia (Schwertner-Tiepelmann
et al., 2012; Leijonhufvud et al., 2011; DeLancey et al., 2003). Con-
sequently, it is safe to assume that site-specific defects within BV
can also be related to vaginal childbirth or trauma. Furthermore,
anatomical variations of BV structures and their innervation can
influence women’s frequency and intensity of sexual experiences
(Emhardt et al., 2016).
4.2. Strengths and limitations
Resolving the BV anatomical controversy between traditional
and new descriptions support by photographic documentation is
5
the most significant strength of this study. Furthermore, the present
study shows that the site-specific defect can occur within the bulbs
of vestibule. Using fresh human adult female cadavers is also a
strength of this study, since this provides an opportunity to work on
the tissue with minimal shrinkage, minimal anatomical distortion,
and with well-preserved bounders. Such a condition of the corpse
assists in an anatomical interpretation and allows taking photos for
reliable documentation.
The limitation of the current study is lack of access to subjects’
medical records; cadaveric anatomical structure measurements do
not correspond to the actual size of BV; research on fresh cadav-
ers cannot establish the functional anatomy of BV. Additionally, a
single researcher interpretation of the anatomical findings is also a
limitation.
4.3. Future research implications
The current study presents an opportunity to research the role
of the bulb of the vestibule and pars intermedia in the female
sexual response cycle dysfunction. Moreover, a future study can
establish symptoms and signs of defective bulb of the vestibule
in women as well as treatment(s) modality for BV dysfunction.
Furthermore, an investigation will be needed to establish the preva-
lence or incidence of the bulb of the vestibule in women who suffer
from sexual dysfunction. How the potential anatomical variations
or site-specific defects within the BV affect women’s sexual func-
tion, the new, well-designed, and well-executed study will resolve
this medical dilemma.
5. Conclusion
The bulb of the vestibule does not overlap the perineal anterior-
distal urethra or the urethral meatus. The bulb of the vestibule
traverses parallel to and aside from the urethral wall. Anatomy
education should be within this line of anatomical description.
The anatomical site-specific defect(s) occurs within the bulb of the
vestibule. A future investigation is needed to determine the role of
site-specific defects within the bulbs of vestibule.
Ethical statement
The University Bioethics Committee approved the study’s pro-
tocol before the study was commenced.
Funding
This work did not receive any funding
Conflict of interest
The author declares no conflict of interest.
Author contributions
The author establishes concept, designs the study’s protocol, col-
lects data, analyses and interprets data, and drafts the manuscript.
Acknowledgements
The author is grateful to Prof. Dr. Pawel Krajewski for providing
fresh human female cadavers and assisting in obtaining the study’s
protocol approval from the Bioethics Committee. Also, the author
likes to thank Prof. Dr. Hellen O’Connell for furnishing me with a
reprint of her article. The author also wishes to sincerely thank
those who donated their bodies to science to perform anatomical
6 A. Ostrzenski / Annals of Anatomy 233 (2021) 151588
research. Results from such a study can potentially improve patient
care and increase mankind’s overall knowledge. Therefore, these
donors and their families deserve our highest gratitude.
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