Received: 17 February 2022 Revised: 3 April 2022 Accepted: 4 April 2022

DOI: 10.1002/ca.23879

REVIEW

Female ejaculation and squirting as similar but completely

different phenomena: A narrative review of current research

Zlatko Pastor | Roman Chmel

Obstetrics and Gynecology Department,

University Hospital Motol and 2nd Medical
Faculty of Charles University, Prague,
Czech Republic
Correspondence
Zlatko Pastor, Obstetrics and Gynecology
Department, University Hospital Motol, V
Úvalu 84, Prague 5 150 06, Czech Republic.
Email: pastor.zlatko@volny.cz
Abstract
Women expel fluids of various quantities and compositions from the urethra during sex-
ual arousal and orgasm. These are classified as either female ejaculation (FE) or squirting
(SQ). The aim of our analysis was to present evidence that FE and SQ are similar but eti-
ologically different phenomena. A review of studies was performed on fluids expelled
from the urogenital tract during female sexual activities using the Web of Knowledge™
(Web of Science Core Collection) and MEDLINE (Ovid) databases from 1946 to 2021.
Until 2011, all female orgasmic expulsions of fluids were referred to as FE. The fluid
was known to be either from the paraurethral glands or as a result of coital inconti-
nence. At present, SQ is considered as a transurethral expulsion of approximately 10 mil-
liliters or more of transparent fluid, while FE is considered as a secretion of a few
milliliters of thick fluid. The fluid in SQ is similar to urine and is expelled by the urinary
bladder. The secretion in FE originates from the paraurethral glands and contains a high
concentration of prostate-specific antigen. Both phenomena can occur simultaneously.
The mechanisms underlying SQ and FE are entirely different. SQ is a massive transure-
thral orgasmic expulsion from the urinary bladder, while FE is the secretion of a very
small amount of fluid from the paraurethral glands.

KEYWORDS
female ejaculation, female prostate, orgasm, paraurethral glands, sexual arousal, squirting,
urinary bladder

1 | I N T RO DU CT I O N is a symptom of a disorder, such as urinary incontinence

Female sexual arousal is manifested in the genital area primarily
through vaginal lubrication, which results from plasma ultrafiltration in
the perivaginal vascular plexuses into the lumen of the vagina
(Levin, 2003; Pastor, 2013). However, during the orgasm, some
women can squirt or expel up to hundreds of milliliters of fluid. Until
2011, due to the similarity to male ejaculation, all fluids expelled dur-
ing ejaculation orgasm (EO) were considered as female ejaculation
(FE) without proper distinction among into FE, squirting (SQ), or coital
incontinence (CI). This ambiguity caused diagnostic confusion and
controversial conclusions (Rubio-Casillas & Jannini, 2011). SQ and FE
are considered physiological but uncommon sexual responses and CI
(Pastor, 2013; Pastor & Chmel, 2018). The fluid outflow during sexual
activities usually manifests as wetness, secretion, or gushes (Pastor &
Chmel, 2018). The uncertainties regarding orgasmic fluid relate partic-
ularly to their origin, volume, composition, and expulsion mechanism.
Previous studies did not have a uniform, objective methodology and
were mostly based on the women's subjective sensations without
adequate diagnostic examination to verify the fluid source, such as
ultrasonography, urinary bladder catheterization, and video visualiza-
tion (Addiego et al., 1981; Belzer Jr, 1981; Belzer Jr, 1982; Bullough
et al., 1984; Darling et al., 1990; Davidson et al., 1989; Heath, 1987;
Ladas et al., 2005; Perry & Whipple, 1981; Whipple &
Komisaruk, 1991; Zaviačič, 1999; Zaviačič et al., 2000; Zaviačič,

© 2022 American Association for Clinical Anatomists and the British Association for Clinical Anatomists.

Clinical Anatomy. 2022;1–10. wileyonlinelibrary.com/journal/ca 1

2 PASTOR AND CHMEL
Doležalová, et al., 1988; Zaviačič, Zaviačičová, et al., 1988). The pres-
ence of prostate-specific antigen (PSA) has been considered as con-
clusive evidence that EO fluid originates from the paraurethral glands
(often referred to as the female prostate in sexological literature),
(Bullough et al., 1984; Dietrich et al., 2011; Wimpissinger et al., 2013;
Zaviačič, 1999; Zaviačič et al., 2000; Zaviačič, Doležalová, et al., 1988;
Zaviačič, Zaviačičová, et al., 1988). Although the secretion from
female prostate can contaminate other fluids secreted during sexual
activities (Pastor, 2013; Rubio-Casillas & Jannini, 2011; Salama
et al., 2015). While the classification and differential diagnosis for EO
have been proposed previously, (Levin et al., 2016; Pastor, 2013;
Pastor & Chmel, 2018; Rogers et al., 2018; Rubio-Casillas &
Jannini, 2011; Salama et al., 2015) it is rarely used both in practice
and in studies. The differences among sexual fluids are known at pre-
sent (Pastor, 2013; Pastor & Chmel, 2018; Rodriguez et al., 2021;
Rubio-Casillas & Jannini, 2011; Salama et al., 2015; Schubach, 2001)
However, orgasmic fluid excretion is often universally considered FE,
and the fluid itself is considered an ejaculate from female prostate
because it contains PSA (Rodriguez et al., 2021). This review aimed to
clarify the inaccuracies regarding “sexual” fluids and highlight the dif-
ferences between FE and SQ.
2 | MATERIALS AND METHODS
The systematic literature search of Web of Knowledge™ (Web of Sci-
ence of Core Collection) and MEDLINE (Ovid) articles published
between 1946 and 2021 was performed. The day of the last search
F I G U R E 1 Preferred reporting items for
systematic reviews and meta-analyses
(PRISMA) diagram showing methodology of
the systematic literature search
was December 13, 2021. The keyword “female ejaculation” was com-
bined with “female prostate,” “squirting,” “paraurethral (Skene's)
glands,” and “orgasm.” The search was limited to English language and
human studies (available only in Ovid). In total, 338 articles were
obtained (Web of Science: n = 292; Ovid: n = 46).
The duplicates were discarded (n = 18). The full-text articles and
abstracts were studied, and the articles exclusively referring to CI and
its therapy or those having inaccurate terminology or speculative con-
tent were excluded (n = 294). The list of 294 eligible articles was man-
ually rechecked, and 20 additional suitable studies and books were
added to the final list of literature sources relevant to this study.
Finally, a total of 46 studies were included (Figure 1).
3 | RE SU LT S
The articles on female expulsion of fluid during orgasm contain incon-
sistent results and controversial conclusions. Most studies were based
on these traditional premises:
(a) the expelled fluid is a single identical phenomenon usually
referred to as FE (Addiego et al., 1981; Bullough et al., 1984; Darling
et al., 1990; Ladas et al., 2005; Whipple & Komisaruk, 1991;
Wimpissinger et al., 2007; Wimpissinger et al., 2009; Wimpissinger
et al., 2013; Zaviačič, 1999; Zaviačič et al., 2000; Zaviačič, Doležalová,
et al., 1988; Zaviačič, Zaviačičová, et al., 1988).; (b) the source of the
fluid is the female prostate (paraurethral glands) (Rogers et al., 2018;
Zaviačič, 1999; Zaviačič et al., 2000; Zaviačič, Doležalová, et al., 1988;
Zaviačič, Zaviačičová, et al., 1988); (c) FE is highly prevalent (Bullough
PASTOR AND CHMEL 3

et al., 1984; Darling et al., 1990; Heath, 1987; Zaviačič, 1999; Zaviačič
et al., 2000; Zaviačič, Doležalová, et al., 1988; Zaviačič, Zaviačičová,
et al., 1988); (d) a relatively large volume of fluid is expelled (Bullough
et al., 1984; Goldberg et al., 1983; Heath, 1987; Zaviačič, 1999;
Zaviačič et al., 2000; Zaviačič, Doležalová, et al., 1988; Zaviačič,
Zaviačičová, et al., 1988); (e) the “sexual” fluid has a high-PSA concen-
tration (Rogers et al., 2018; Wimpissinger et al., 2007; Zaviačič, 1999;
Zaviačič et al., 2000; Zaviačič, Doležalová, et al., 1988; Zaviačič,
Zaviačičová, et al., 1988); (f) the expulsion of fluid is provoked by the
stimulation of the clitorourethrovaginal complex (Addiego et al., 1981;
Rubio-Casillas & Jannini, 2011; Zaviačič, 1999; Zaviačič et al., 2000;
Zaviačič, Doležalová, et al., 1988; Zaviačič, Zaviačičová, et al., 1988).
(Bullough et al., 1984; Darling et al., 1990; Davidson et al., 1989;
Ladas et al., 2005; Whipple & Komisaruk, 1991; Wimpissinger
et al., 2013). Only three previous studies distinguish between FE and
SQ (Rubio-Casillas & Jannini, 2011; Salama et al., 2015;
Schubach, 2001). Other papers describe EO without an exact distinc-
tion about which phenomenon is involved (Belzer Jr, 1981; Bullough
et al., 1984; Darling et al., 1990; Dwyer, 2012; Goldberg et al., 1983;
Masters & Johnson, 1966; Perry & Whipple, 1981; Wimpissinger
et al., 2007; Wimpissinger et al., 2009; Wimpissinger et al., 2013;
Zaviačič, 1999; Zaviačič et al., 2000; Zaviačič, Doležalová, et al., 1988;
Zaviačič, Zaviačičová, et al., 1988). In an online study, Wimpissinger
et al. studied 320 women with EO aged 18–73 years. In total, 19% of
women ejaculated in 91%–100% of their coitus, and 14% of

3.1 | Sources, types, and nature of ejaculation

TABLE 1 Comparison of the characteristics of FE and SQ
orgasm
Female ejaculation Squirting

The fluids expelled during sexual arousal or orgasm can be divided Source Paraurethral glands Urinary bladder
into four categories: vaginal lubrication, which is a physiological and Volume Approximately up to Tens to hundreds of ml
desirable manifestation of arousal; FE and SQ, which are physiological 1 ml

but sporadic phenomena; and symptoms of orgasmic urinary inconti- Color Whitish, milky Clear, transparent,
nence (Figure 2) (Pastor, 2013). yellowish

FE and SQ vary according to the source, volume, color, fluid con- Consistence Thick Thin

sistency, expulsion type, PSA concentration, manifestation, expulsion Expulsion Secretion, discharge Squirt
type
mechanism, subjective sensations, and biochemical composition
(Table 1) (Pastor, 2013). PSA +++ 0/+
Manifestation Wetness/secretion/ Massive expulsions of
discharge/ transparent fluid
asymptomatic
3.2 | Prevalence of fluids expelled during sexual
Expulsion Gland secretion (leakage Transurethral expulsion
arousal and orgasm mechanism of secretion) (detrusor muscle
contraction)
Studies on EO describe either sporadic incidence or prevalence rang- Subjective Orgasm/sexual arousal/ Orgasm/high-sexual
ing between 4.6% and 54% (Table 2) (Bullough et al., 1984; Darling feeling asymptomatic arousal
et al., 1990; Masters & Johnson, 1966; Perry & Whipple, 1981). Mas- Uric acid, ++
ters et al. described EO in only 14 women (4.6%) of their study group urea,
of 300 patients aged 18–40 years. In a cohort of a thousand women creatinine

undergoing sex therapy programs, only a “handful” of women Glucose +++ +

reported fluid “ejaculated” during orgasm (Masters et al., 1988). The Fructose +++ +
studies describing the high prevalence of FE in hundreds of cases are Abbreviations: PSA, prostate specific antigen; +++, large quantity; ++,
based only on questionnaire studies and women's subjective feelings moderate quantity; +, small quantity; , not present.

FIGURE 2 Overview of possible fluids expelled during orgasm according to the source
4 PASTOR AND CHMEL

respondents reported EO in 1%–10% of their coitus. On average, 57%
of women had experienced EO. Nevertheless, the study did not report
the real prevalence of EO as the group size from which the respon-
dents were recruited was not mentioned (Wimpissinger et al., 2013).
Some studies claim that the fluid produced during EO comes from the
female prostate, (Bullough et al., 1984; Zaviačič, 1999; Perry &
Whipple, 1981; Darling et al., 1990; Wimpissinger et al., 2007. but
other studies describe EO as urine expelled during CI (Bohlen, 1982;
Goldberg et al., 1983; Jha et al., 2012; Korda et al., 2010; Nilsson
et al., 2011; Serati et al., 2011; Vierhout & Gianotten, 1993).
3.3 | Paraurethral glands
The paraurethral glands (female prostate) are considered the source of
fluid in “real” FE (Pastor, 2013; Rubio-Casillas & Jannini, 2011). Female
prostate is found in every 2–3 women (Dietrich et al., 2011;
Dwyer, 2012; Wimpissinger et al., 2009). Its weight ranges from 2.6 to
5.2 g, which is approximately five times smaller than the male prostate
(Huffman, 1948; Zaviačič et al., 2000). The female prostate contains
glands, ducts, and musculofibrotic tissue. The ratio of the volume of the
ducts and fibrous structures to the glandular component in female
prostate is different from that of the male prostate since female pros-
tate has a smaller glandular component (Huffman, 1948). Moreover, its
secretion volume reaches a maximum of 2–4 ml (Wimpissinger
et al., 2009). The separate glands are localized periurethral, with
approximately 20 ducts opening to the lumen of the urethra (Figure 3)
(Huffman, 1948; Zaviačič et al., 2000). Occasionally, the ducts pass
along the urethra with outlets in the vaginal vestibulum (Dwyer, 2012).
Female prostate secretion contains PSA, prostate-specific alkaline
phosphatase, fructose, and glucose (Zaviačič, Doležalová, et al., 1988).
Rubio-Casillas and Jannini demonstrated a decreasing concentration
gradient of PSA in the fluids as follows: FE > urine>SQ > vaginal secre-
tion (Rubio-Casillas & Jannini, 2011). Notably, the function of female
prostate remains unclear. A protective antimicrobial effect of its fluid
has been speculated previously (Moalem & Reidenberg, 2009).

TABLE 2 Prevalence of EO relative to the sample size of the respondents and the corresponding

Prevalence Sample size of respondents Research methodology Authors, year of study

Handful 1000 Sex therapy program interview Masters & Johnson, 1966
4.6% 300 Sex therapy program interview Masters et al., 1988
10%–40% 47 Self-reporting questionnaire Perry & Whipple, 1981
Individual interview
14%–54% 227 Conversation after an oral practical presentation Bullough et al., 1984
40% 1289 Self-reporting questionnaire Darling et al., 1990

Abbreviation: EO, ejaculation orgasm.

F I G U R E 3 Localization of
paraurethral glands, which open to the
lumen of the distal urethra
PASTOR AND CHMEL 5

F I G U R E 4 Most common localizations of the paraurethral glands and ducts: (A) distal (meatal) urethra, (B) proximal urethra, and (C) along the
whole urethra

Zaviačič et al. described five types of female prostate according T A B L E 3 Volume of fluid excreted during sexual arousal and
to its localization: meatal (66%), posterior (10%), rudimentary (8%), orgasm in studies of FE, studies of SQ, and studies without distinction
whole length (6%), and others (10%) (Zaviačič et al., 2000). Meanwhile, between these phenomena
Romashchenko et al. reported only four types of female prostate: dis- Author and year of study
tal (65%), proximal (23%), whole length (7%), and others (5%) publication Volume of fluid described only as FE
(Figure 4) (Romashchenko et al., 2018). Addiego et al., 1981 1 to few ml
Zaviačič, 1988 1–5 ml
Belzer Jr, 1982 10 ml
3.4 | Volume, source, and mechanism of fluid Bullough et al., 1984 3–12 ml
secretion during EO
Goldberg et al., 1983 3–15 ml
Heath, 1987 30–50 ml
The volume of fluid released during EO ranges from a few to hun-
Wimpissinger et al., 2013 0.3–150 ml and more
dreds of ml and is usually described as FE (Table 3) (Belzer Jr, 1981;
Belzer Jr, 1982; Bullough et al., 1984; Goldberg et al., 1983; Author and year of study Volume of fluid with distinction
publication between FE and SQ
Heath, 1987; Rubio-Casillas & Jannini, 2011; Salama et al., 2015;
Schubach, 2001 2 ml (FE) 50–500 ml (SQ)
Wimpissinger et al., 2009; Wimpissinger et al., 2013; Zaviačič,
Doležalová, et al., 1988). Some authors speculate that FE fluid is simi- Rubio-Casillas & 1 ml (FE) 120 ml (SQ)
Jannini, 2011
lar to urine in CI (Goldberg et al., 1983).
Salama et al., 2015 15–110 ml
The fluid in FE is considered to be produced by the female pros-
(median 60 ml) (SQ)
tate (Addiego et al., 1981; Belzer Jr, 1982; Cabello Santamaria, 1991;
Pastor & Chmel, 2018 60 ml (SQ)
Wimpissinger et al., 2007; Zaviačič, Doležalová, et al., 1988; Zaviačič,
Zaviačičová, et al., 1988) or the urinary bladder, in which the fluid can Abbreviations: FE, female ejaculation; SQ, squirting.
be contaminated with PSA from female prostate, similar to urine
(Rubio-Casillas & Jannini, 2011; Salama et al., 2015; Schubach, 2001)
Schubach first demonstrated the mechanism underlying SQ as the ultrasound was examined: (a) after voluntary micturition, (b) during
expulsion of fluid from the urinary bladder using an inserted Foley sexual stimulation immediately before SQ, and (c) immediately after
catheter. Additionally, “milky-white, mucous-like excretion from the SQ. Involuntary expulsion of urine during orgasm was confirmed
urethra outside the catheter” was observed in four women and was (Salama et al., 2015).
considered female prostate secretion (Schubach, 2001). Rubio-Casillas The normal maximum capacity of the urinary bladder reaches up
and Janinni collected 120 ml of fluid coming from the urethra during to 400–500 ml. The urinary bladder is a reservoir of fluid expulsed
SQ. Meanwhile, 1 ml of FE, described as “very scanty, thick, and whit- transurethrally during SQ, expulsed by the strong contraction of the
ish fluid,” was collected using a sterile tong depressor from the outer detrusor muscle (Pastor, 2013; Rubio-Casillas & Jannini, 2011; Salama
urethral orifice (Rubio-Casillas & Jannini, 2011). Using ultrasound et al., 2015; Schubach, 2001). Due to the limited glandular capacity of
examination, Salama et al. confirmed the origin of SQ to be the urinary the female prostate, as demonstrated by magnetic resonance imaging,
bladder. In seven women, filling of the urinary bladder using female prostate cannot produce a volume of more than a few ml of
6 PASTOR AND CHMEL
thick secretion (Figure 5) (Lawrentschuk & Perera, 2000; Pastor &
Chmel, 2018; Wimpissinger et al., 2009). The glandular structures of
the female prostate are distributed along the urethral wall, while in
the male prostate, glandular structures are localized around the proxi-
mal urethra (Figure 6). Aside from the myofibrils, the female prostate
does not have effective smooth muscle contractile fibers for massive
fluid expulsion (Zaviačič et al., 2000).
3.5 | Biochemical parameters of the fluid expulsed
during SQ and FE
The volume of the fluid produced by the female prostate is small,
approximately less than 1 ml. The fluid is thick in consistency, whitish
in color, and contains PSA, glucose, and fructose. On the other hand, a
large volume of clear fluid, up to hundreds of ml, is ejected trans-
urethrally by the detrusor muscle contraction in SQ (Rubio-Casillas &
Jannini, 2011; Salama et al., 2015; Schubach, 2001). Urea, creatinine,
and uric acid in the SQ fluid confirm that it comes from the kidneys
and is collected in the urinary bladder. There is no agreement on
whether the biochemical composition of SQ fluid is identical to urine
or is actually its diluted form (Pastor & Chmel, 2018; Rodriguez
et al., 2021; Rubio-Casillas & Jannini, 2011; Salama et al., 2015;
Schubach, 2001). Two studies reported that SQ fluid is the diluted
urine, (Rubio-Casillas & Jannini, 2011; Schubach, 2001) while others
assumed that it is biochemically identical with urine (Table 4)
(Goldberg et al., 1983; Pastor & Chmel, 2018; Salama et al., 2015).
Goldberg et al. describe SQ as the expulsion of colorless, odorless,
and tasteless fluid (Goldberg et al., 1983).
There is a consensus on FE regarding its source (paraurethral
glands), volume (up to 1 ml), appearance (thick consistency and whit-
ish color), mechanism of expulsion (secretion), and composition (high
levels of PSA, glucose, and fructose) (Rubio-Casillas & Jannini, 2011;
Salama et al., 2015; Schubach, 2001).
4 | DI SCU SSION
The massive orgasmic transurethral expulsion during sexual activity is
called SQ, and the SQ fluid originates from the urinary bladder. The
term FE should be reserved for the expulsion of a small volume of
thick secretion from the female prostate, which can also be asymp-
tomatic. Both phenomena have different etiologies, mechanisms, and
manifestations (Pastor, 2013; Pastor & Chmel, 2018; Rubio-Casillas &
Jannini, 2011; Salama et al., 2015; Schubach, 2001). Their inter-
changing causes much confusion and derails from the correct identifi-
cation of the two different phenomena, as we observe in research. In
this review, we reported the high prevalence of EO (up to 54%)
referred to as FE (Bullough et al., 1984; Darling et al., 1990;
Heath, 1987; Wimpissinger et al., 2013) by merging similar but
F I G U R E 5 The contrast between
large-capacity fluid collection in the
urinary bladder, expulsed by contraction
of the detrusor muscle during SQ (yellow),
and the small volume of fluid excretion
from paraurethral glands, due to the
contraction of the fine periurethral
myofibrils (red) during FE. FE, female
ejaculation; SQ, squirting
F I G U R E 6 The localization, volume,
and ratio of glands, ducts, and fibro-
muscular connective tissue of the
paraurethral glands compared to those in
the male prostate
PASTOR AND CHMEL
TABLE 4 The results from the biochemical analysis of the fluid expelled during SQ
Sample
Author size Volume (ml) Urea (mmol/L)
SQ producing fluid with a composition identical to urine
Salama 7 15–110 307 (62–376)
et al., 2015 (median: 60)
Pastor & 1 60 299
Chmel, 2018
SQ producing fluid with a composition identical to diluted urine
Schubach, 2001 7 50–500 87–398
Rubio-Casillas & 1 120.67 ± 56.36 417.0 ± 42.88
Jannini, 2011
Abbreviations: N/A, not available; PSA, prostate specific antigen; SQ, squirting.
etiologically distinct phenomena (SQ, FE, vaginal lubrication, and CI)
that are incorrectly labeled with one umbrella term (FE). We consider
SQ a sporadic manifestation of sexual arousal and orgasm that can
occur in highly aroused and multi-orgasmic women. A realistic estima-
tion of the prevalence of SQ could be approximately 5% (Masters
et al., 1988; Masters & Johnson, 1966).
4.1 | Presence of PSA in expelled fluids
The presence of PSA in the fluid excreted during sexual activity is not
conclusive evidence of the exclusive origin of the female prostate
fluid. The admixture of PSA is also found in other fluids (Rubio-
Casillas & Jannini, 2011). Female prostate secretion into the urethra
may contaminate urine, vaginal lubrication, or SQ fluid.
4.2 | Terminological inaccuracies about the female
ejaculate
To date, the term female ejaculate is mainly used to describe all fluids
emitted during orgasm. More accurately, this fluid is mainly from FE
or SQ. The difference between these two terms, in terms of their simi-
larity to urine, has been discussed (Rodriguez et al., 2021). In our opin-
ion, the ambiguity between these two terms may unnecessarily
complicate previous and future clinical and anatomical research. It has
been well established that the fluid in FE is expelled from the female
prostate, and the fluid in SQ is expelled from the urinary bladder. In
CI, the leakage of urine is related to stress urinary incontinence or an
overactive urinary bladder (Pastor & Chmel, 2018; Rubio-Casillas &
Jannini, 2011; Salama et al., 2015; Schubach, 2001).
4.3 | Origin, volume, and mechanism of fluid
expulsion during female sexual arousal and orgasm
There are three potential sources of female sexual fluids: the urinary
bladder, the vagina, and the paraurethral glands. Notably, it could also
7
Creatinine Uric acid Glucose
(mmol/L) (mmol/L) PSA (ng/ml) Density fructose
9.3 (1.9–17.9) 2.6 (0.1–3.5) 0.72 (0–3.74) N/A N/A
7.9 3,0 0.55 1005 Negative
9–46 N/A N/A N/A Negative
21.37 ± 4.16 10.37 ± 1.48 0.23 ± 0.25 1001.67 ± 2.89 N/A
be a combination of these (Pastor, 2013). The urinary bladder is the
only organ that can collect up to hundreds of ml of fluid, which is
expulsed through the urethra as a squirt using the strong contractions
of the detrusor muscle. Female prostate is not present in all women
(Dietrich et al., 2011; Dwyer, 2012; Wimpissinger et al., 2009); more-
over, it cannot be the source of massive SQ. The female prostate has a
small secretion capacity and does not have the adequate muscle for a
strong contraction. Fine myofibrils surround the separated female pros-
tate glands with minimal contractile activity. Simultaneous SQ of a large
volume of fluid is not possible from approximately 20 ducts in the para-
urethral glands. Female prostate is localized around the external meatus
of the urethra. This minimizes the kinetic energy required to expulse a
small volume of fluid from the dilated urethral orifice overlapped by the
labia minora. The delicate fibers of the sphincter muscle around the
proximal urethra contract during sexual arousal and orgasm, and, there-
fore, urine should not be expelled during orgasm (Korda et al., 2010;
Lawrentschuk & Perera, 2000). However, this paradigm is true for men
but unequivocally not for women (Rubio-Casillas & Jannini, 2011). In
women, orgasm may trigger involuntary urinary bladder contractions,
which suppress the urethral and urinary bladder sphincter and may lead
to the leakage of urine from the urinary bladder (Khan et al., 1988).
Thus, pulse contractions of the detrusor muscle may cause spraying.
Sensory adjustment of receptors in the urinary bladder varies per indi-
vidual. In some women, urinary bladder filling during orgasm may
prompt emptying. In contrast to patients with CI, SQ provides women
with maximal sexual catharsis. Notably, unwanted leakage of actual
urine can be psychotraumatic for some women (Pastor, 2013;
Wimpissinger et al., 2013). Women with SQ do not suffer from overac-
tive urinary bladder (Cartwright et al., 2007; Pastor, 2013) or stress uri-
nary incontinence due to increased urethrovaginal junctional mobility
(Pastor, 2013; Perry & Whipple, 1981).
4.4 | Biochemical composition and densities of
fluids expelled during FE and SQ
Most women do not consider fluid during SQ to be urine and believe
that the expulsed fluid is different in smell, taste, and appearance
8 PASTOR AND CHMEL
(Goldberg et al., 1983). The excreted fluid can be biochemically identi-
cal to urine but can also be considered diluted urine with different
osmolarities and concentrations of urea, creatinine, and uric acid.
Because the biochemical composition of urine can change in different
situations (e.g., dehydration or increased glomerular filtration in the
kidneys), it can be diluted, clear, and odorless during increased sexual
arousal. The concentration of urinary metabolites depends on the
actual volume and osmolarity of urine at the onset of sexual stimula-
tion until the moment of SQ. When a large volume of concentrated
urine is in the urinary bladder just before sex, the expelled fluid may
be identical to urine. Conversely, initiation of stimulation shortly after
voiding may produce diluted urine with low osmolality. The urinary
bladder could be filled relatively quickly by the residual urine from the
ureters and renal pelvis and by frequent pulses of ureters. The
changes in the osmolality of urine could be caused by the psycho-
sexual condition of increased blood pressure and glomerular filtration
rate and the secretion of the antidiuretic hormone vasopressin.
Together with corticoliberin, these changes mobilize defense mecha-
nisms against emotional stressors. During sexual relaxation and emo-
tional intimacy, vasopressin serum concentration and urine osmolality
decrease (Carter, 2017). The effect of aldosterone on reabsorptive
mechanisms in the kidneys could also be considered a contributory
factor (Schubach, 2001). These pathophysiological consequences and
precoital habits (e.g., micturition) could be some causes of the differ-
ences in urine concentration during SQ in different situations.
4.5 | Initiation of SQ and FE according to the
anatomic location of sexual stimulation
SQ is achieved mainly through the stimulation of the
clitorourethrovaginal complex (Rubio-Casillas & Jannini, 2011)
through the glans clitoridis and through vaginal stimulation of the dor-
sal part of the clitoris (corpus clitoridis and bulbus vestibuli) during
masturbation or coitus. FE is induced by a similar mechanism but
occurs most frequently during transvaginal stimulation of the distal
part of the anterior vaginal wall during urethral stimulation (Zaviačič,
Zaviačičová, et al., 1988). However, FE seems to be a direct mechani-
cal extrusion of fluid from the female prostate. FE and SQ could also
be induced during stimulation of other extragenital erogenous zones.
4.6 | Opinions on FE and SQ and their impact on
the general population
The diverse conclusions of studies to date reflect how sexual aspects
have been incompletely explored. This ambiguity can inadequately
affect the opinions of experts and the general population on different
“sexual standards.” Inaccurate or incomplete information about FE
and SQ as a frequent symptom of sexual arousal (e.g., one in two
women) (Wimpissinger et al., 2013) can cause frustration and mislead
women experiencing these symptoms. Moreover, many erotic videos
with abundant squirts of sexual fluid are showing this sexual
phenomenon as a natural part of orgasm. Unfortunately, it can result
in a feeling of sexual imperfection in women without SQ and may set
unrealistic expectations for men. On the other hand, although not
considered scientifically relevant, erotic videos and other similar mate-
rials demonstrate transurethral SQ of a large volume of watery fluid
with an extraordinary pressure gradient and thus, at least, dispel
doubts about its origin.
4.7 | Limitations and weaknesses of the review
This review has some limitations. First, it includes studies with con-
flicting terminology, inconsistent methodology, and limited use of imag-
ing methods to objectively confirm their conclusions (Addiego
et al., 1981; Bullough et al., 1984; Zaviačič, 1999; Zaviačič et al., 2000;
Zaviačič, Doležalová, et al., 1988; Zaviačič, Zaviačičová, et al., 1988);
(Belzer Jr, 1981; Belzer Jr, 1982; Darling et al., 1990; Davidson
et al., 1989; Heath, 1987; Ladas et al., 2005; Whipple &
Komisaruk, 1991). The heterogeneity of the analyzed studies caused dif-
ficulties in their comparison. Second, all selected studies were assessed
to maximize objectivity. However, some of them were inaccurate and
had generally accepted conclusions (Ladas et al., 2005). Third, it was dif-
ficult to justify some opinions on FE and SQ when only a limited number
of studies were available to support the conclusions of this review
(Pastor, 2013; Pastor & Chmel, 2018; Rubio-Casillas & Jannini, 2011;
Salama et al., 2015; Schubach, 2001). Nevertheless, this review refuted
some traditional misconceptions concerning FE and SQ, which were not
confirmed by adequate research methods, by studying relevant scientific
studies and generally accepted anatomical and physiological facts.
5 | CONC LU SION
Relevant and robust studies confirmed that FE and SQ are entirely dif-
ferent physiological sexual phenomena with low prevalence in
women. FE and SQ are not a common part of female sexual arousal
and orgasm. Incorrect assessment of the manifestation of these phe-
nomena can significantly disrupt a couple's sexual life and cause sub-
stantial misconceptions in human sexuality. The use of precise
definitions and terminologies may refine the differential diagnosis of
FE and SQ and facilitate further research in this field.
ACKNOWLEDG MENTS
The authors would like to thank Dr. Jan Balko from the Department
of Pathology and Molecular Medicine, Motol University Hospital, for
assisting with the figures and the guidance on the anatomical struc-
tures of the female genitalia. We would also like to thank Prof.
Miroslava Horáčková from the Department of Internal Medicine,
Motol University Hospital, for valuable comments on the urinary tract
function during sexual stimulation.
OR CID
Zlatko Pastor https://orcid.org/0000-0002-1425-5982
PASTOR AND CHMEL
RE FE R ENC E S
Addiego, F., Belzer, E. G., Commoli, J., Moger, W. H., Perry, J., &
Whipple, B. (1981). Female ejaculation. A case study. Journal of Sex
Research, 17, 13–21.
Belzer, E. G., Jr. (1981). Orgasmic expulsions of women: A review and heu-
ristic inquiry. Journal of Sex Research, 17, 1–12.
Belzer, E. G., Jr. (1982). A review of female ejaculation and the Grafenberg
spot. Women's Health, 9, 5–16.
Bohlen, J. G. (1982). Female ejaculation and urinary stress incontinence.
Journal of Sex Research, 18, 360–363.
Bullough, B., David, M., Whipple, B., Dixon, J., Allgeier, E. R., & Drury, K. C.
(1984). Subjective reports of female orgasmic expulsion of fluid. The
Nurse Practitioner, 9, 55–59.
Cabello Santamaria, F. (1991). Female ejaculation, myth and reality. Valen-
cia, Spain: 13th World Congress of Sexology.
Carter, C. S. (2017). The oxytocin-vasopressin pathway in the context of
love and fear. Frontiers in Endocrinology, 6, 356.
Cartwright, R., Elvy, S., & Cardozo, L. (2007). Do women with female ejac-
ulation have detrusor overactivity? The Journal of Sexual Medicine, 4,
1655–1658.
Darling, C. A., Davidson, J. K., & Conway-Welch, C. (1990). Female ejacula-
tion: Perceived origins, the Grafenberg spot area, and sexual respon-
siveness. Archives of Sexual Behavior, 19, 29–47.
Davidson, J. K., Darling, C. A., & Conway-Welch, C. (1989). The role of
Gräfenberg spot and female ejaculation in the female orgasmic
response: An empirical analysis. Journal of Sex & Marital Therapy, 15,
102–119.
Dietrich, W., Susani, M., Stifter, L., & Haitel, A. (2011). The human
female prostate-immunohistochemical study with prostate-specific
antigen, prostate-specific alkaline phosphatase, and androgen recep-
tor and 3-D remodeling. The Journal of Sexual Medicine, 8, 2816–
2821.
Dwyer, P. L. (2012). Skene's gland revisited: Function, dysfunction and the
G spot. International Urogynecology Journal, 23, 135–137.
Goldberg, D. C., Whipple, B., Fishkin, R. E., Waxman, H., Fink, P. J., &
Weisberg, M. (1983). The Grafenberg spot and female ejaculation: A
review of initial hypotheses. Journal of Sex & Marital Therapy, 9,
27–37.
Heath, D. (1987). Female ejaculation: Its relationship to disturbances of
erotic function. Medical Hypotheses, 24, 103–106.
Huffman, J. W. (1948). The detailed anatomy of paraurethral ducts in the
adult human female. American Journal of Obstetrics and Gynecology, 55,
86–101.
Jha, S., Strelley, K., & Radley, S. (2012). Incontinence during intercourse:
Myths unravelled. International Urogynecology Journal, 23, 633–637.
Khan, Z., Bhola, A., & Starer, P. (1988). Urinary incontinence during
orgasm. Urology, 31, 279–282.
Korda, J. B., Goldstein, S. W., & Sommer, F. (2010). The history of female
ejaculation. The Journal of Sexual Medicine, 7, 1965–1975.
Ladas, A. K., Whipple, B., & Perry, J. D. (2005). The G spot and other recent
discoveries about human sexuality. Henry Holt & Co.
Lawrentschuk, N., & Perera, M. (2000). Benign prostate disorders. In K. R.
Feingold, B. Anawalt, A. Boyce, et al. (Eds.), South Dartmouth. MDText.
com, Inc https://www.ncbi.nlm.nih.gov/books/NBK279008/
Levin, R. J. (2003). The ins and outs of vaginal lubrication. Sex Relation
Therapy, 18, 509–513.
Levin, R.J., Both, S., Georgiadis, J., Kukkonen, T., Kwangsung, P., &
Yang, C.C. (2016). The physiology of female sexual function and the
pathophysiology of female sexual dysfunction (committee 13A) 13,
733–759.
Masters, W., Johnson, V., & Kolodny, R. (1988). Human sexuality. Scott,
Foresman.
Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Little,
Brown.
9
Moalem, S., & Reidenberg, J. S. (2009). Does female ejaculation serve an
antimicrobial purpose? Medical Hypotheses, 73, 1069–1071.
Nilsson, M., Lalos, O., Lindkvist, H., & Lalos, A. (2011). How do urinary
incontinence and urgency affect women's sexual life? Acta Obstetricia
et Gynecologica Scandinavica, 90, 621–628.
Pastor, Z. (2013). Female ejaculation orgasm vs. coital incontinence: A sys-
tematic review. The Journal of Sexual Medicine, 10, 1682–1691.
Pastor, Z., & Chmel, R. (2018). Differential diagnostics of female “sexual”
fluids: A narrative review. International Urogynecology Journal, 29,
621–629.
Perry, J. D., & Whipple, B. (1981). Pelvic muscle strength of female ejacula-
tors: Evidence in support of a new theory of orgasm. Journal of Sex
Research, 17, 22–39.
Rodriguez, F. D., Camacho, A., Bordes, S. J., Gardner, B., Levin, R. J., &
Tubbs, R. S. (2021). Female ejaculation: An update on anatomy, his-
tory, and controversies. Clinical Anatomy, 34, 103–107.
Rogers, R. G., Pauls, R. N., Thakar, R., Morin, M., Kuhn, A., Petri, E.,
Fatton, B., Whitmore, K., Kinsberg, S., & Lee, J. (2018). An international
Urogynecological association (IUGA)/international continence society
(ICS) joint report on the terminology for the assessment of sexual
health of women with pelvic floor dysfunction. Neurol Urodyn, 37,
1220–1240.
Romashchenko, O., Grygorenko, V., Biloholovska, V., Kosiukhno, M., &
Melnykov, S. (2018). Types of female prostate gland. The Journal of
Sexual Medicine, 15, S317.
Rubio-Casillas, A., & Jannini, E. A. (2011). New insights from one case of
female ejaculation. The Journal of Sexual Medicine, 8, 3500–3504.
Salama, S., Boitrelle, F., Gauquelin, A., Malagrida, L., Thiounn, N., &
Desvaux, P. (2015). Nature and origin of “squirting” in female sexual-
ity. The Journal of Sexual Medicine, 12, 661–666.
Schubach, G. (2001). Urethral expulsions during sensual arousal and blad-
der catheterization in seven human females. EJ Human Sex, 4 http://
www.ejhs.org/volume4/Schubach/abstract.html
Serati, M., Salvatore, S., Cattoni, E., Siesto, G., Soligo, M., Braga, A.,
Sorice, P., Cromi, A., Ghezzi, F., Cardozo, L., & Bolis, P. (2011). Female
urinary incontinence at orgasm: A possible marker of a more severe
form of detrusor overactivity. Can ultrasound measurement of bladder
wall thickness explain it? The Journal of Sexual Medicine, 8, 1710–
1716.
Vierhout, M. E., & Gianotten, W. L. (1993). Mechanisms of urine loss dur-
ing sexual activity. European Journal of Obstetrics, Gynecology, and
Reproductive Biology, 52, 45–47.
Whipple, B., & Komisaruk, B. R. (1991). In P. Kothari (Ed.), The Proceedings
of the First International Conference on Orgasm The G spot, vaginal
orgasm and female ejaculation: are they related? (pp. 227–230). VRP
Publishers.
Wimpissinger, F., Springer, C., & Stackl, W. (2013). International online sur-
vey: Female ejaculation has a positive impact on women's and their
partners' sexual lives. BJU International, 112, E177–E185.
Wimpissinger, F., Stifter, K., Grin, W., & Stackl, W. (2007). The
female prostate revisited: Perineal ultrasound and biochemical
studies of female ejaculate. The Journal of Sexual Medicine, 4,
1388–1393.
Wimpissinger, F., Tscherney, R., & Stackl, W. (2009). Magnetic resonance
imaging of female prostate pathology. The Journal of Sexual Medicine,
6, 1704–1711.
Zaviačič, M. (1999). The human female prostate. Slovak Academic Press.
Zaviačič, M., Doležalová, S., Holomáň, I. K., Zaviačičová, A.,
Mikulecký, M., & Brázdil, V. (1988). Concentrations of fructose in
female ejaculate and urine: A comparative biochemical study. Journal
of Sex Research, 24, 319–325.
Zaviačič, M., Zajíčková, M., Blažeková, J., Donárová, L., Stvrtina, S.,
Mikulecký, M., Zaviačič, T., Holomáň, I. K., & Breza, J. (2000).
Weight, size, macroanatomy, and histology of the normal prostate
10 PASTOR AND CHMEL

in the adult human female: A minireview. Journal of Histotechnology,

23, 61–69. How to cite this article: Pastor, Z., & Chmel, R. (2022). Female
Zaviačič, M., Zaviačičová, A., Holomáň, I. K., & Molčan, J. (1988). Female
ejaculation and squirting as similar but completely different
urethral expulsions evoked by local digital stimulation of the G-spot:
Differences in the response pattern. Journal of Sex Research, 24,
phenomena: A narrative review of current research. Clinical
311–318. Anatomy, 1–10. https://doi.org/10.1002/ca.23879