245

A Comprehensive Review of the Clitoris and Its Role in Female

Sexual Function

Donna Mazloomdoost, MD and Rachel N. Pauls, MD

Division of Female Pelvic Floor Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology,
TriHealth/Good Samaritan Hospital, Cincinnati, OH, USA

DOI: 10.1002/smrj.61

ABSTRACT

Introduction. The clitoris is often considered the female version of the penis and less studied compared to its male
counterpart. Nonetheless, it carries the same importance in sexual functioning. While it has more recently been
allocated the appreciation it deserves, the clitoris should be examined as a separate and unique entity.
Aim. To review clitoral anatomy, its role in sexual functioning, the controversies of vaginal eroticism and the female
prostate, as well as address potential impacts of pelvic surgery on its function.
Methods. We examined available evidence (from 1950 until 2015) relating to clitoral anatomy, the clitoral role in
sexual functioning, vaginal eroticism, female prostate, female genital mutilation/cutting, and surgical implications for
the clitoris.
Main Outcome Measures. Main outcomes included an historical review of the clitoral anatomy and its role in sexual
functioning, the controversies regarding vaginal sources of sexual function, and the impact of both reconstructive and
nonmedical procedures on the clitoris.
Results. The intricate neurovasculature and multiplanar design of the clitoris contribute to its role in female sexual
pleasure. Debate still remains over the exclusive role of the clitoris in orgasmic functioning. Normal sexual function
may remain intact, however, after surgical procedures involving the clitoris and surrounding structures.
Conclusions. The clitoris is possibly the most critical organ for female sexual health. Its importance is highlighted by
the fact that the practice of female genital cutting is often used to attenuate the female sexual response. While its
significance may have been overshadowed in reports supporting vaginal eroticism, it remains pivotal to orgasmic
functioning of most women. Donna Mazloomdoost and Rachel N. Pauls. A comprehensive review of the
clitoris and its role in female sexual function. Sex Med Rev 2015;3:245–263.
Key Words. Clitoris; Orgasm; Sexual Function; G-spot; Female Ejaculation; Female Genital Mutilation

Introduction significant progress has been made, the clitoris is

poorly characterized compared to its male coun-

T he clitoris is universally recognized as the

focus for female sexual pleasure [1]. It bears
an intricate and magnificent anatomy composed
of internal and external structures. However, the
clitoris has been plagued with poor representation
and controversy throughout the ages. Despite
interest in female sexual function dating to the
time of Hippocrates, much of our current knowl-
edge of clitoral anatomy and function has
developed from recent studies [2,3]. Whereas
terparts. Indeed, the clitoris has been less studied
than the penis and is often represented simply as a
smaller version of that structure [4]. Confusion
even exists as to the origin of its name; the word
“clitoris” may have roots in Greek, Semitic, South
Arabian, or Eastern African descent [5].
While the first documentation of the clitoris
likely occurred centuries prior by Greek, Persian,
and Arabic medical writers, both Realdo Colombo
and Gabriele Falloppio claimed to have discovered

© 2015 International Society for Sexual Medicine Sex Med Rev 2015;3:245–263
246 Mazloomdoost and Pauls

this anatomical structure in the sixteenth century

[3]. Though they were not the first to describe the
clitoris, these two anatomists may have given cre-
dence to its role in sexual function compared to
prior descriptions [3]. Nonetheless, clitoral repre-
sentation did not resemble modern depictions
until the 19th century [4]. Labeling of the clitoris
in medical texts then disappeared from the 1950s
until the feminist movement in the 1970s. Its
departure coincided with the time period in which
Freud insisted the vaginally achieved orgasm was
superior to clitoral orgasm (CO), perhaps influ-
encing its removal from anatomical education.
Freud claimed that the ability to achieve vaginally
activated orgasms (VAOs) was central to a
woman’s psychological development; however, Figure 1 MRI image demonstrating the multiplanar struc-
ture of the clitoris.
this idea was later refuted by the works of both
Kinsey and Masters and Johnson [4].
When the clitoris returned to anatomical texts,
the labels were often very simple. Depictions of superior apex of the vestibule. The prepuce covers
the female genitalia largely focused on their role in the glans, which is otherwise in direct contact with
male sexual enjoyment [4]. In the current century, skin, as no tunica albuginea (discussed later) exists
however, the clitoris has become a symbol of the there [15]. The prepuce is a skin covering formed
advocacy for women’s rights in campaigns against by the labia minora and has been likened to penile
female genital cutting (to be discussed later in this foreskin [9,15]. The frenulum is a skin fold found
review) [6]. Emphasis on the clitoris has evolved, posterior to the glans and marks the delineation of
and more research has been dedicated to properly the prepuce and skin of the labia minora, which are
understanding this important organ. Furthermore, otherwise continuous [13]. External measurements
ability to view the clitoris in multiple dimensions of the clitoral glans were recorded in 200 pre-
using ultrasound, magnetic resonance imaging menopausal women to develop standard normative
(MRI), and cadaveric dissections has enhanced our dimensions. The mean transverse diameter of the
ability to characterize its anatomy. glans was found to be 3.4 +/− 1.0 mm. The longi-
tudinal diameter was 5.1 +/− 1.4 mm, and the total
length described as 16 +/− 4.3 mm. Age, height,
Clitoral Anatomy
weight, and current use of oral contraceptives were
The clitoris is often misrepresented as a small found to have no impact on clitoral size; however,
structure, when it is in fact a multiplanar erectile
organ located medial and inferior to the pubic arch
and symphysis [7]. The clitoris has a “boomerang”
appearance on MRI imaging, as it descends down-
ward during its movement from the pubic bone
into the adiposity of the mons (Figure 1) [8].
Given its multifaceted nature, it has been
referred to as the “clitoral complex” [9,10]. The
clitoris is best understood when divided into its
individual components consisting of a glans,
prepuce, body (or corpora), crura, bulbs, suspen-
sory ligaments, and root (Figure 2) [11–13]. These
elements and its neurovascular supply are pivotal
to its role in sexual functioning [14].

The Glans and Prepuce

The glans and prepuce are the visible portions of
the clitoral complex. It lies externally and at the Figure 2 The components of the clitoral complex.

Sex Med Rev 2015;3:245–263

Clitoris and Its Role in Sexual Function
Figure 3 Cadaveric dissection of the bulb. Courtesy of Dr.
Rachel Pauls.
parity was associated with larger glans length and
width when compared to nulliparous women [16].
The Bulb, Body, Crura, and Suspensory Ligaments
The bulbs, body, and crura comprise most of the
clitoral erectile tissue [13]. The bulbs measure
3–4 cm in length when flaccid [15], up to 7 cm in
length when erect, and are located on the superfi-
cial aspect of the vaginal wall (Figure 3) [17]. Con-
trary to many anatomical texts, the bulbs do not
comprise the core of the labia minora, and it has
been suggested to refer to them as clitoral bulbs
versus vestibular. Similar to the corpus
spongiosum of the penis, the bulbs engorge during
sexual activity, perhaps increasing vaginal rigidity
and producing lubrication [17].
The clitoral body is composed of paired
corpora, which diverge to form the crura [11–
Figure 4 Anatomical association of
the suspensory ligaments and inner-
vation of the clitoris.
247
13,15,18]. The bilateral crura are the internal
extensions of the corpora, which attach to the
ischiopubic rami, and surround the urethra
[12,15,17]. The ischiocavernosus muscles lie over
the crura [15]. The body measures 1–2 cm in
width [17] and 0.5–3.5 cm in length [12,19], while
the crura measure 5–9 cm long [17]. The length of
the erectile tissue in the body is greater than that
of the glans and the segments of this tissue
decrease in length as they move caudally toward
the urethra [18]. The venous circulation of the
corpora cavernosa communicate with that of the
bulbs through the venous plexus of Kobelt [15].
The clitoris is secured to the labia and fascia of
the mons pubis and pubic symphysis by the sus-
pensory ligaments (Figure 4) [12,20]. Unlike the
flexibility of the penis, these ligaments prevent the
straightening of the clitoris, helping maintain its
bent shape [8]. A superficial portion composed of
fibro-fatty tissue attaches the body and glans of the
clitoris to the deep fascia of the mons and extends
into the labia majora [20]. The deep component of
the suspensory ligaments attaches the body to the
pubic symphysis and continues deeply and poste-
riorly to attach onto the bulbs. Thus, the body,
glans, and bulbs are secured to the pubic
symphysis via these fibrous deep ligaments [20].
The tunica albuginea, a dense connective tissue
sheath, covers the body of the clitoris [12,15]. The
ventral clitoral neurovascular bundles lie superfi-
cial to this tunica albuginea [12].
The Root
Essential to female sexual function is the root of
the clitoris, as this is the unification of all the
erectile bodies. This area is highly responsive to
Sex Med Rev 2015;3:245–263
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Figure 5 Cadaveric dissection of the dorsal nerve of the
clitoris. Courtesy of Dr. Rachel Pauls.
direct stimulation, which may be secondary to its
close location to the skin surface as well as the
extent of localized erectile tissue [13,18]. The pos-
terior portion of the root is in proximity to the
urethral opening [13].
Innervation
The clitoral complex is innervated by the dorsal
nerve of the clitoris (DNC), branches of the
pudendal nerve, and the cavernous nerves
(Figures 5 and 6) [13]. The DNC and its branches
provide somatic innervation [9,13] and originate
by running medial and close to the ischiopubic
Sex Med Rev 2015;3:245–263
Mazloomdoost and Pauls
rami on both sides of the clitoris [7]. They pierce
the perineal membrane and travel superior and
posterior to the crura [21,22]. Then the DNCs
continue posterior to the clitoral body and
medially cross the cavernous nerves to pass over
the clitoral body [2,18]. At the clitoral body, they
then course along the 11 and 1 o’clock positions
[23]. At the junction of the glans, the nerves split
into two cords to wrap around the glans, lying in
close proximity to the tunica [22,23]. These cords
terminate close to the tip of the glans [24].
Whereas the DNCs are large, measuring up to
2 mm at its largest diameter, the cavernous nerves
can only be viewed microscopically, making them
more difficult to study [8].
The cavernous nerves are fibers from the infe-
rior hypogastric plexus. They ultimately extend
from the lateral vaginal wall to the base of the
bladder and course laterally at the 2 and 10 o’clock
positions around the urethra to branch into the
clitoris [7]. The cavernous nerves supply the erec-
tile tissue arteries through visceral fibers [13].
Communicating branches between the cavernous
nerves and the DNC have been identified [24].
Signaling between the cavernous nerves and the
DNC through these branches leads to the
engorgement and tumescence (swelling) of the cli-
toris [7]. This signaling pathway supports the
theory that tactile stimulation of the clitoris may
lead to sexual arousal, marking the importance of
preservation of these nerves during surgical inter-
ventions (to be discussed later in this review) [24].
Figure 6 Dermatonal distribution of
the external female genitalia.
Clitoris and Its Role in Sexual Function
Histologically, the clitoral body is similar to the
penis [8]. The dorsal nerves and vessels lie on
the outer surface of the body, and the corpora in
the clitoris are also surrounded by branches of the
dorsal nerve [8]. The highest concentration of
small nerves are within the clitoral glans; these
dramatically decrease with caudal movement
toward the urethra [18]. A smaller quantity of
nerves is reported in the proximal clitoris. A simi-
larly rich distribution of large nerves in the glans
has been noted, suggesting the glans to be the area
of highest sensation [18]. The abundant innerva-
tion of the glans includes Pacini and Meissner
corpuscles, which are in higher concentrations
relative to the male glans, secondary to the smaller
size of the clitoris [15]. Pacinian corpuscles detect
both deep sensation and vibration [8]. Notably,
there is a paucity of nerves at the 12 o’clock posi-
tion of the glans, and the lowest nerve density in
general is on its ventral aspect [23,25]. It is impor-
tant to note that indirect stimulation of the glans is
central to female sexual response, but the dense
innervation of the glans may lead to extreme sen-
sitivity upon direct stimulation [13].
Vascularity
The dorsal clitoral arteries, perineal arteries, and
deep arteries provide blood supply to the erectile
tissues of the glans and body, while the prepuce
obtains its supply from the external pudendal
artery [13]. The perineal arteries are subdivided
into bulbar and urethral branches. Venous drain-
age of the erectile tissue is by the deep dorsal vein,
which drains into the vesical venous plexus [13].
Conclusion
The clitoris is a complex and fascinating organ
with an intricate neuronal and vascular supply.
This composition is fundamental to its important
role in sexual functioning.
Sexual Function
While clitoral anatomy did not appear in medical
literature until recent centuries, interest in female
sexual function has existed for hundreds of years.
The Kamasutra, written by the Indian scholar,
Mallanaga Vatsyayana, was likely one of the first
texts to discuss female sexuality. It emphasized the
importance of an erotic zone in the vagina for
sexual activity, possibly as early as the third century
[2]. Later, the Chinese first wrote regarding female
sexual symptoms in the fourth century. They felt
that sexual pleasure was essential to one’s health
249
and well-being, often stressing the importance of
female orgasm and commenting that a man who
could entice a female orgasm while controlling
himself would acquire her Yin essence. A classic
text reported that if a man could “copulate twelve
women without once emitting semen, he could
remain young and handsome forever” [2]
(p. 1966).
Understanding sexual function is key, as sexual
complaints may occur in up to 43% of the female
population with associations to age, lower educa-
tion levels, sexual trauma history, and poor health
[26]. The Diagnostic and Statistical Manual of
Mental Disorders 5 (DSM-5) divides female sexual
dysfunction into disorders of interest/arousal and
orgasm [27]. Female sexual interest/arousal disor-
der is characterized by absence or reduction of at
least three of the following: interest in sexual activ-
ity, sexual thoughts, initiation of sexual activity,
sexual excitement/pleasure during activity, interest
in response to internal/external erotic cues, or
genital/nongenital sensations [27]. Poor orgasmic
function is defined as reduced intensity, difficulty,
or absence of orgasm which may be primary or
secondary [27,28].
Contrary to male orgasms, many women do not
routinely experience orgasm with sexual penetra-
tion [29]. While women may experience orgasm
through direct clitoral stimulation, indirect clitoral
stimulation, vaginal stimulation, or stimulation
of other areas in the vagina, up to 10% of women
are reported to be completely anorgasmic [29].
To better understand sexual function, it is impera-
tive to understand the normal female sexual
response originally described as a linear progres-
sion through excitement, plateau, orgasm, and
resolution [30]. More recently, this has been modi-
fied to the following four phases: desire, arousal,
orgasm, and resolution [27]. Women do not nec-
essarily progress in that exact sequence, as the
phases may overlap, repeat, or be absent. Addi-
tionally, not all women may follow a linear
sequence at all, with other descriptions including
circular models fueled by intimacy [31].
A majority of males are able to achieve orgasm
after puberty, whereas women have a more gradual
developmental curve, with most, but not all,
achieving orgasm by their twenties [29]. The
importance of female sexual well-being is sug-
gested by studies demonstrating that women who
experience orgasms with intercourse have better
mental health than those who do not [32]. None-
theless, some argue that too much emphasis
is placed on vaginal penetration, and that the
Sex Med Rev 2015;3:245–263
250
majority of orgasms may essentially be a result of
some form of clitoral stimulation [29]. Wallen and
Lloyd used data collected originally by Marie
Bonaparte in 1924 and Carney Landis in 1940 to
demonstrate that women with a shorter distance
between the clitoral glans and urethral meatus
were more likely to experience orgasm with sexual
intercourse, suggesting that the source of the
orgasm was actually clitoral stimulation. This ana-
tomical relationship of the clitoris with the
urethra, however, was only correlated with
orgasms achieved through sexual intercourse and
not other forms of sexual stimulation [29].
Female sexual function is a complicated process
that is in its infancy of understanding. Orgasms are
likely regulated by both somatic and autonomic
nerves [33]. Five critical components to this reflex
have been described by O’Connell et al. [13]:
• Receptors within the clitoral complex and vulva.
• Somatic afferents in the dorsal clitoral and
perineal branches of the pudendal nerve.
• S2-4 segments of the spinal cord.
• Visceral efferents from pelvic splanchnic nerves
running in pelvic ganglia.
• Clitoral erectile tissue and secretory responses
from the glands of the bulbs and urethra.
The route of orgasm likely initiates with the
pudendal nerve transmitting information from
the external genitalia (the clitoris and urethra) to
the brain [33]. Pelvic nerve stimulation in animal
models leads to increased vaginal and clitoral
blood flow [33]. Similarly in humans, stimulation
of the parasympathetics in the clitoris leads to dila-
tion of the dorsal and deep arteries [13]. The erec-
tile tissue subsequently becomes engorged due to
both increased inflow and decreased outflow of
blood. During this arousal, important vulvar struc-
tures also become exposed. If a sufficient threshold
is reached, orgasm may result. Activation of sym-
pathetic fibers via hypogastric nerves and the infe-
rior hypogastric plexus to the uterovaginal plexus
occurs. A reflex wave of skeletal muscle contrac-
tions of the vagina, urethra, and anus, all mediated
by the pudendal nerve, ensues. Uterine smooth
muscle contractions also occur, regulated in part
by autonomic nerves. Resolution follows sexual
arousal, secondary to arterial constriction and
pelvic venous decongestion [13].
Functional MRI studies of women with spinal
cord injuries suggest that the vagus nerve may also
be involved in arousal and orgasm, as the region of
the medulla oblongata to which the vagus nerve
projects is activated during self-stimulation [34].
Sex Med Rev 2015;3:245–263
Mazloomdoost and Pauls
In rat studies where the vagal nerve is cut, sexual
function is not abolished, suggesting this pathway
is either supplemental to other systems or is acti-
vated after the spinal cord injury [34]. Also impor-
tant to arousal are vascular changes. MRI studies
demonstrated no change in the width or shape of
the clitoral body or surrounding structures during
arousal, but increased enhancement correlating to
increased vasculature and engorgement during
this state was seen [35].
The pelvic muscles are also involved in sexual
activity. Contraction of the bulbocavernosus and
ishiocavernosus muscles aid clitoral erection
during intercourse [24]. Furthermore, Arnold
Kegel and others have postulated that pubo-
coccygeal strength may be related to the ability to
achieve orgasm vaginally, suggesting that in some
women, greater muscular tone might improve
contact of the vaginal erotic areas with the penis
[36]. While the importance and regulation of
vaginal muscular tone on arousal has been exam-
ined, this area is still under debate [33].
Mediators of Sexual Function
Understanding the physiology of the clitoris as
it pertains to sexual function is just as complex as
its anatomy. The vascular erectile component of
the clitoral–urethral complex is important for
engorgement during sexual arousal [21]. The
crura have similar erectile tissue to the body but
lack the large neurovasculature found in other
components [12]. The cavernous tissue of the
bulbs have large spaces and few nerves compared
to the body [8].
Mediators of clitoral and vaginal smooth muscle
are similar to those in the penis [8]. Although
similar to males in that testosterone plays a role,
estrogen is the primary hormone guiding the
female sexual response [8]. However, beyond this,
our understanding of clitoral regulators is still in
the early stages. As discussed, arousal is a result of
spinal cord reflex mechanisms, of which the affer-
ent reflex arm consists mostly of the pudendal
nerve, and the efferent arm is coordinated by
somatic and autonomic activity [37]. Some of the
more common markers used to characterize this
nerve activity include the antibody against human
vesicular acetylcholine transporter (VAChT),
neuronal nitric oxide synthase (nNOS), calcitonin
gene peptide (CGRP), and substance P (SP).
VAChT is a marker for cholinergic nerves, and
nNOS identifies autonomic nervous system
involvement [25]. CGRP and SP are reported to
be involved in sensation, often studied in pain
Clitoris and Its Role in Sexual Function
perception. Other important markers include
vasoactive intestinal polypeptide (VIP), peptide
histidine methionine, neuropeptide Y [25].
Fresh human specimen and fetal cadaver studies
have contributed to our knowledge of the signal-
ing pathways of the clitoris and vagina [25,38].
The clitoris is innervated by nerves demonstrating
VAChT, nNOS, CGRP, SP, VIP, peptide histidine
methionine, neuropeptide Y [25,33,39,40].
VAChT and nNOS have been identified on the
dorsal side of the clitoral shaft distal to the pubic
arch in the DNC [25]. The presence of VAChT in
the DNC is suggestive of its somatomotor and
parasympathetic activity. nNOS in the DNC
gradually declines as the nerves are followed proxi-
mally, with a complete lack of nNOS at the clitoral
dorsal nerves proximal to the clitoral body hilum
[25]. The cavernous supplies are nNOS reactive
throughout their course, in contrast to the DNC
[25,40]. nNOS detected in the cavernous nerves of
the penis helps promote smooth muscle relaxation
[41]. Similarly, nNOS in the cavernous nerves
likely mediates clitoral smooth muscle relaxation
[37,42,43]. Furthermore, nNOS existence in the
clitoris supports the theory that nitric oxide is
involved in clitoral erectile function, similar to the
penis [39].
While nitric oxide plays a critical role in clitoral
smooth muscle relaxation, VIP is involved in
mediating vaginal smooth muscle relaxation [37].
VIP has been shown to mediate vaginal blood flow
and lubrication, and its activity decreases after
menopause, likely contributing to changes in
sexual function after this stage [44]. CGRP and SP
have been detected and are concentrated in the
glans, again suggesting a sensory role to the glans
pertaining to sexual function [26]. In addition to
the previously described mediators, functional
MRI studies have demonstrated the role of
dopamine and oxytocin receptors in reward-
related brain systems as related to pair-bonding,
suggesting the importance of dopamine in attrac-
tion and arousal [45].
Hormones are also key to sexual function.
Estrogen is critical to willingness of animals to
have sex, exemplified by a muscular positioning
called lordosis [33]. Estrogens and androgens also
play a role in genital blood flow, lubrication, neu-
rotransmitter function, and smooth muscle con-
tractility [33,46]. The sensitivity of pudendal
innervation to the perineum has also been corre-
lated to increasing levels of estrogen [44]. In
animal models, androgens were noted to facilitate
vaginal smooth muscle relaxation [37].
251
Understanding of the regulators of sexual func-
tion has improved significantly in recent decades.
However, further research is still needed to help
identify causes and develop treatments of female
sexual dysfunction.
The Clitoris and Vaginal Eroticism
While the significance of the clitoris to sexual func-
tion is widely recognized, the source of orgasm
remains controversial. A distinction between
orgasm obtained exclusively from clitoral stimula-
tion (CO) versus one arising from vaginal penetra-
tion, without direct clitoral stimulation (VAO) has
been suggested [31,47]. The source of this VAO has
been debated since its hypothetical discovery [48–
50]. In the 1950s, the concept of the Grafenberg
spot, or “G-spot,” was introduced [48,51].
Although the term “G-spot” was not coined until
the 1980s by others, German gynecologist Ernest
Grafenberg is credited with depicting an erotic
zone in the anterior vaginal wall along the distance
of the urethra [51]. While Grafenberg’s work
focused on female ejaculation from the urethra, his
descriptions of the anterior vaginal wall fueled
research on the existence of an erogenous area
homologous to the male prostate [2].
Addiego et al. reported a case of one woman
who described orgasm upon manipulation of this
G-spot [52]. Upon this orgasm, she described
expulsion of fluid from the urethra that was found
to contain prostatic acid phosphatase (PAP), an
enzyme found in prostatic secretion. They coined
the term “Grafenberg spot” in honor of his earlier
description, and concluded that this one case study
supported the theory of both a G-spot and female
ejaculation. Building upon this, Goldberg et al.
evaluated 11 women also reporting ejaculation at
the time of orgasm [49]. These women were exam-
ined by two different gynecologists to identify
areas of the vaginal walls that swelled upon stimu-
lation. Of the 11, 4 women had swelling in a loca-
tion that correlated with the previously described
G-spot. Despite this report’s limited results, the
authors deemed that such a location existed. Shafik
et al. evaluated the vagina during varying vaginal
pressures induced by carbon dioxide distention of
a condom. By placing two electrodes in the vagina,
they demonstrated the possibility of a “pace-
maker” in the anterior vaginal wall that evoked
electric waves. While this location was deeper in
the vagina than descriptions by Goldberg and
Addiego, they concluded this pacemaker was the
source for vaginal eroticism [53].
Sex Med Rev 2015;3:245–263
252
More recently, Ostrzenski et al. asserted ana-
tomical proof of the G-spot through dissections
of eight Caucasian cadavers [54]. The tissues
were stained with hematoxylin and eosin, and two
additional specimens underwent immunohis-
tochemical staining. As a nerve ganglion and no
erectile tissue were demonstrated in this area, it
was believed to represent the G-spot. This could
not be correlated with clinical experiences of these
women. Moreover, functional MRI studies have
demonstrated that stimulation of the clitoris,
vagina, and cervix activated separate sensory
regions in the medial cortex, suggesting innerva-
tion by different afferent nerves [55]. Such findings
expound claims that stimulation of the anterior
vaginal wall may elicit a response that is separate
from clitoral stimulation.
While support for the theory of a G-spot may
exist, imaging studies show that clitoral stimula-
tion may actually be the source of the perceived
VAO [55–57]. Clitoral blood flow was demon-
strated by ultrasound to increase with stimulation
along the lower third of the vagina [58]. Ultra-
sound studies have also found increased thickness
of the urethrovaginal space in women reporting
VAO, possibly secondary to extensive clitoral
bulbar tissue, glands, and nerves, which might ulti-
mately be the source of the orgasms [47].
Sonography has also shown that the clitoral roots
undergo movement and pressure when the vagina
is penetrated and perineal contractions ensue [10].
Furthermore, MRI studies have demonstrated
larger clitoral glans size and shorter distance from
the clitoris to the vaginal lumen in women endors-
ing normal orgasmic function [59]. Likewise, as
previously mentioned, women with shorter
clitoral–urethral distances were better able to
achieve VAO [29]. Thus, orgasm thought to be
achieved via the G-spot may actually be stimula-
tion of the clitoris resulting in this effect. Due to
the possibility that orgasm may not be attributable
to one single structure, some authors have sug-
gested replacing the term “G-spot” with the
clitorurethrovaginal complex (CUV), to better
represent the contribution of all three areas to
sexual function [14].
Additionally, the G-spot has been refuted ana-
tomically. Pauls et al. were unable to demonstrate
differences in nerve distribution along differing
areas of the vaginal walls, lending no support to
innervation variances of the G-spot, as claimed by
others [60]. No difference was also found between
biopsies of women with and without sexual dys-
function. While supporters of the G-spot theory
Sex Med Rev 2015;3:245–263
Mazloomdoost and Pauls
warn that disruption during pelvic floor recon-
struction may lead to sexual dysfunction, studies
evaluating sexual function after such surgery have
actually shown improvements [61]. Though other
explanations exist for these findings, they do
suggest that the anterior vaginal wall may not be a
sole contributor to sexual pleasure of women.
The work of Alzate, which sought to describe
areas of the vagina that stimulated sexual pleasure,
additionally denounced the G-spot [62]. Rhythmic
pressure was applied digitally to all the walls of the
vagina in 27 women. In these subjects various
regions of the vagina produced similar effects to
this named G-spot, and the posterior vaginal wall
was shown to have erotic sensitivity in 85% of the
subjects examined [62]. Studies of twins have failed
to demonstrate a genetic correlation in self-reports
of the G-spot, further refuting physiologic verifi-
cation [63]. Finally, several reviews of the literature
have also concluded insufficient evidence to defini-
tively prove the existence of a G-spot, and addi-
tional data are still necessary [48,51,64].
Despite a paucity of scientific support for the
G-spot, it remains a powerful social phenomenon
[48,64]. Early studies supporting the G-spot,
however, bore small numbers or were anecdotal
[49,50,52], and subsequent cadaver dissections
have lacked sufficient biologic evidence [54].
Though the data remain controversial [48–
50,54,63], potential existence of such an area has
important implications for surgeons performing
pelvic floor reconstruction. Surgical manipulation
could potentially disrupt its erogenous function,
thus stimulating continued interest in its possible
existence. At present, however, inadequate scien-
tific evidence exists to fully prove this concept.
Until more definitive studies are available, it is
unclear if any surgical precautions are necessary;
however, surgeons should still be cautious around
this potential structure.
Female Ejaculation and the Female Prostate
Similar to the argument of the G-spot is the con-
troversial understanding of female ejaculation and
the possibility of a “female prostate,” despite a
long history. The concept of female ejaculation
dates back as early as 500 b.c., by Greek philoso-
phers, as it was thought to have reproductive sig-
nificance [2]. Hippocrates described a female
semen, which he believed determined the gender
of the child produced at that time. Claudius
Galenus noted the equivalent of female ejaculation
in the second century a.d., asserting that women,
Clitoris and Its Role in Sexual Function
like men, would need to release their “semen” at
regular intervals so as to avoid pain secondary to
accumulation. Taoists wrote about female ejacula-
tion as well as the role of the clitoris/vagina in
female sexual pleasure in the fifth century. In
Persia, the 11th century physician Ibn Sina, con-
sidered the most influential Middle Eastern phy-
sician, described a female ejaculation that was
emitted during the pleasure of an orgasm [2].
Similar to his descriptions of the purported
G-spot, the work of Ernest Grafenberg is a more
recent description of fluid emitted with orgasm
that is not urine or lubricant [65]. The Bartholin’s
glands were the theorized source of this fluid [66],
though others claim Skene’s paraurethral glands
produce it, deeming them homologous to the male
prostate and capable of producing this female
ejaculate to add to sexual pleasure [67]. Contro-
versy still surrounds this concept, with many
arguing for the true existence of female ejaculation
while others assert it is merely urinary inconti-
nence. Small studies have suggested no resem-
blance of this fluid to urine; however, generalizable
conclusions should be made with caution [49].
Belzer’s review of the literature as well as anec-
dotal evidence concluded that these orgasmic
expulsions may come from four potential sources:
bladder, Bartholin’s glands, vaginal excretions, or
the Skene’s glands. While he deduced that female
ejaculation does indeed exist, his review failed to
provide enough data to definitively prove the
source of this fluid [68].
Though the true prevalence of this condition is
unknown, a survey of 1,245 professional women
revealed 39.5% reported experiencing ejaculation
at the time of orgasm. However, of these women,
nearly 40% believed that they had ever urinated
during orgasm, perhaps perceiving urine as ejacu-
lation or vice versa [69,70]. Proponents of female
ejaculation argue that such a fluid cannot be urine,
as women reporting urinary incontinence are less
likely to report orgasms during sexual intercourse
[71]. Noteworthy is that a similar relationship
has not been found with other forms of orgasm
[71]. Additionally, one study suggested stronger
pubococcygeal muscle and uterine contractions in
“ejaculators” than “non-ejaculators” when exam-
ined during Kegel exercises [72]. The authors of
this report proposed that the lower portion of the
hypogastric plexus or strong pelvic muscle con-
tractions propelled this fluid out of the urethra
[72].
Much of the published literature supporting
female ejaculation is hampered by very few sub-
253
jects. In his practice, Desmond Heath, a psychia-
trist, encountered women describing a vaginal
discharge emitted during sexual activity that was
sufficient to “wet the bed.” [73] He further evalu-
ated one particular case through consultation with
the literature and experts and determined this fluid
could anatomically and physiologically be a
product of Skene’s glands, which he likened to the
male prostate. The author concluded that women
have an ejaculatory function similar to men,
without the sperm component. Addiego et al. pub-
lished a case study of only one woman who emitted
an ejaculate with orgasm. Four samples of this
fluid as well as her urine were collected and
analyzed. Glucose and PAP were detected in this
fluid along with low levels of urea and creatinine,
two substances typically found in urine. The
authors felt their findings should relieve women of
embarrassment, that the release of such fluid may
actually be ejaculation rather than urinary incon-
tinence [52].
In another small study, Goldberg et al. evaluated
11 women who felt they ejaculated, and fluid was
able to be collected from 6 [49]. While the fluids
mostly resembled urine, three were found to
contain PAP at levels higher than that found in
urine, and thus could arise from a different source
than bladder [49]. Prostate-specific antigen (PSA),
another marker advocated to prove the existence of
a female prostate, has been detected in female urine
and at increased concentrations after orgasm, theo-
retically resulting from increased production and
emission by the female prostate [74].
Further support for a female prostate lies in
histopathological examinations. Microscopic
evaluation has revealed ducts and prostatic tissue in
the anterior urethra of female autopsy specimens
[75]. Secretory and basal cells were identified in the
glands as well as ducts lined by pseudostratified
columnar epithelium [75]. Expression of PSA was
found in the secretory cells of the glands and the
membranes of the pseudostratified columnar epi-
thelium of the ducts [74].
Such findings have led some investigators to
conclude that there is convincing evidence of a
female prostate, and this term is preferred over
“Skene’s glands” [74]. These individuals argue that
the female prostate has received little support
because it rarely causes clinical disease, but that
disregarding its existence may lead to overlooking
pathology [74]. Others have argued that there
is no advantage to describing this fluid as “female
ejaculation” or the Skene’s glands as the “female
prostate” as the terminology is confusing [66].
Sex Med Rev 2015;3:245–263
254
Moreover, it appears to diminish the importance
of the female anatomy as distinct from male
anatomy and deserving of its own nomenclature.
Opponents of female ejaculation further argue
that a majority of females do not appear to have
this fluid emission solely from the Skene’s glands
[66]. Most of the cases described are self-reports,
not necessarily corroborated by an unbiased
observer, and researchers who studied large popu-
lations of women did not describe this phenom-
enon. Additionally, a vaginal acid phosphatase
(VAP) has been described that is obtained from the
vagina. Thus, collected specimens from studies
may have been contaminated with VAP, or an
alternative acid phosphatase that could be mis-
taken by the assays for PAP, such as were utilized in
the research by Goldberg [66].
A more recent evaluation of women reporting
large fluid emission, or “squirting,” with sexual
activity examined bladder and fluid emissions
using ultrasonography as well as biochemical
analysis. These particular fluid emissions were
identified to be consistent with involuntary urinary
incontinence rather than an ejaculatory emission,
which the authors deemed should be in a smaller
quantity [76]. Thus, to discount the potential for
this fluid to be urine may result in the failure to
diagnose urinary incontinence [77]. Given the
small nature of the paraurethral glands it seems
unlikely that enough fluid could be secreted from
these structures to “wet the bed,” as has been
described [73,76]. Furthermore, its composition
is not similar enough to male ejaculate, which
is composed of prostatic, seminal vesicle, and
bulbourethral gland emission and on average gen-
erates 3.5–5 mL per episode [78].
Nonetheless, it is important not to classify
women who emit urethral fluids during sexual
activity as abnormal, as it may lead to sexual frus-
tration and anxiety [66]. Female fluid emission
during sexual activity may be incontinence, emis-
sion from the Skene’s glands in response to sexual
arousal or orgasm, or a mix of urine with Skene’s
secretions [66]. Although the research is still
inconclusive, women’s reports of such fluids
should be medically evaluated when appropriate.
Female Genital Mutilation/Cutting
Regardless of the sources and properties of sexual
function, an area of great concern for female
sexuality is the act of female genital mutilation/
cutting. According to the World Health Organi-
zation, female genital mutilation/cutting
Sex Med Rev 2015;3:245–263
Mazloomdoost and Pauls
(FGM/C) refers to “all procedures involving
partial or total removal of the female external geni-
talia or other injury to the female genital organs
for non-medical reasons” [79]. While such proce-
dures are often referred to as “female genital muti-
lation,” “female genital cutting” has been suggested
as a more appropriate term to protect those sup-
porting or subjected to FGM/C from humiliation
or emotional offense [80,81]. Over 125 million
females have undergone FGM/C in the 29 African
and Middle Eastern countries where FGM/C is
performed [82]. However, the practice is not solely
found in those nations; reports of FGM/C have
been documented in Malaysia, Indonesia, Russia,
Peru, Brazil, Eastern Mexico, and aboriginal tribes
in Australia [83]. At the current rate, 30 million
female children are at risk of undergoing FGM/C
by their 15th birthday [82].
History and Rationale
Over 90% of women are thought to have under-
gone FGM/C in Somalia, Guinea, Sierra Leone,
Egypt, and Djibouti, with Sudan coming close at
88% [82]. While those endorsing the practice
often cite a religious indication, in fact, no religion
condones these procedures. Some believe there to
be support from Islam, but no mention is made of
FGM/C in the Koran, and most Muslims do not
perform it on their daughters [83–87]. Further-
more, the practice predates Islam; in Africa proce-
dures have been performed as far back as 4,000 b.c.
[88].
Historically, clitorectomy was performed all
around the world for indications other than those
currently dictating the practice. One proposed
rationale in ancient Egypt was the Pharaonic belief
in the bisexuality of the gods and that all individu-
als were thought to be composed of both male and
female parts [84]. Female clitoral excision was,
therefore, performed to remove the male side of a
female so that she may become a full female and
assume the natural and sexual roles of a woman
[83,84]. In the West, particularly in the 19th
century, clitorectomy served as treatments for
medical conditions such as excessive masturbation,
nymphomania, hysteria, gynecologic problems,
and even epilepsy [83,84,88]. The importance of
the clitoris continued to be poorly appreciated into
the 20th century when Freud, as previously men-
tioned, hypothesized that women needed to
achieve vaginal orgasm to achieve emotional
adequacy, claiming COs were linked to emotional
immaturity [83]. This potentially hindered
Clitoris and Its Role in Sexual Function
advances in appropriate therapy to many women
and may have even contributed to sexual exploita-
tion of women [83].
Most cultures that perform FGM/C currently
cite social integrity as the motivation. Sexual
purity of a woman is highly valued [84,89] and seen
as a prerequisite for marriage, with a virgin bride
often being used to unite quarreling groups [83].
In the poorer societies of these nations, women
have few options but to marry well, and FGM/C is
viewed as a means to secure a successful marriage
[88,90] that will provide economic and social secu-
rity [83,84]. FGM/C is also thought to decrease
both a woman’s sexual desires and pleasure, there-
fore, reducing the chances of promiscuity and pro-
tecting female chastity [81,84]. Uncut women are
believed to have a strong appetite for sexual activ-
ity, and FGM/C is thought to separate the pure
women from those who may be prostitutes [84,91].
Additionally, FGM/C may be considered proof
that a female has never engaged in sexual activity,
as the tiny opening would prevent such an act;
although others argue that reinfibulations (recon-
struction of the cutting) can always be performed
after sexual activity [87]. Other explanations
for FGM/C include cultural consistency, fertility
preservation, health or hygiene preservation,
and enhancing the sexual enjoyment of men
[84,85,87]. Some fear that uncut genitalia may be
harmful to the husband and newborns [91]. Addi-
tionally, expectations regarding appearance have
led to the perception that uncut genitalia seem
abnormal [87].
The above factors influence parental decision
making. Parents are afraid that if their daughters
are not cut, they will be labeled as filthy, undesir-
able, not marriable, and subsequently be shunned
by the community [85,92]. The ritual is highly
celebrated in certain areas, as a “coming of age”
rite to passage. In some societies, there is a cel-
ebration surrounding the procedure, and the day
of circumcision may be regarded as the most
important day in a woman’s life [83,91].
Procedure
The variations of this practice may involve any
component of the female genitalia. The term
“infibulation” is used to refer to the reapproxi-
mation of cut labial edges, creating a small new
opening, often hiding the urethra [85]. The World
Health Organization has designated four forms of
FGM/C [79].
• Type I—Partial or total removal of the clitoris
and/or the prepuce (clitoridectomy).
255
• Type II—Partial or total removal of the clitoris
and the labia minora, with or without excision of
the labia majora.
• Type III—Narrowing of the vaginal orifice with
creation of a covering seal by cutting and
appositioning the labia minora and/or the labia
majora (infibulation), with or without excision
of the clitoris.
• Type IV—All other harmful procedures to the
female genitalia for non-medical purposes
(pricking, piercing, incising, scraping, and
cauterization).
FGM/C procedures are typically performed by a
layperson with no formal medical or surgical
training, with instruments such as razor blades,
kitchen knives, sharp stones, hot rocks, scissors,
and glass [83,90,91]. Often, these tools are not
washed, just simply wiped on rags [83]. Both
anesthesia and sutures to control bleeding are
rarely used [83]. There is great variation in the
performance of these procedures due to the lack
of formal anatomical and surgical training of the
operators [90]. FGM/C is frequently performed
on young girls, but may be postponed until
before marriage or even after the birth of the first
child [90].
Complications
Complications present either immediately or later
in a woman’s life. Immediate complications occur
in up to 25% of women, while delayed complica-
tions afflict over 31% among all forms of FGM/C.
Some of the immediate complications include
urinary retention, hemorrhage, infection, or shock
[83,93]. Other immediate complications include
physical injury from pressure placed on the child’s
body to keep her from struggling, such as fractures
of the clavicle, femur, and humerus [85]. Delayed
complications include chronic pelvic inflammatory
disease, chronic urinary tract infections, inclusion
dermoid cysts, neuromas, sexual difficulties, labor
difficulties, and fistulas [83]. The most common
long-term complication appears to be dermoid
cysts in the scar, occurring in over half of women
seeking treatment for complications [90,94].
Obstruction of the vaginal environment can also
lead to recurrent yeast infections, which has been
found in up to 26% of women with infibulation
[95]. Infertility is estimated to be found in 25–30%
of those with Type III FGM/C, and may be a result
of physical barriers due to the small introitus
[85,96,97]. Additionally, women with FGM/C are
more likely to report low abdominal pain, vaginal
Sex Med Rev 2015;3:245–263
256
discharge, and genital ulcers [81]. Higher risks of
acquiring HIV have also been documented [80].
Overall, Type III appears to have the greatest
risk of morbidity, with up to 50% of women with
this experiencing some form of complication [83].
Further problematic is that only an estimated
15–20% of those with complications seek medical
attention [83]. Despite so few women seeking care,
these complications comprise a significant propor-
tion of healthcare resources, and were shown in
one country to comprise 1,967 hospital days in a
calendar year [98]. Valuable resources are used in
countries that otherwise have little to spare to
manage such preventable issues [83].
Obstetrical complications comprise another
worrisome category. Due to the tight opening,
women often cannot dilate safely to allow the
delivery of a neonate’s head without either tearing
or requiring an episiotomy [91]. Women who have
undergone FGM/C have been shown to have
higher rates of stillborn and fistulas [80,83]. In
fact, in a Khartoum teaching hospital in Sudan, all
women with prior FGM/C who were hospitalized
with fistulas also had a stillborn in labor [83]. Addi-
tional fetal complications include increased fetal
distress in labor and lower 5 minute APGAR
scores [99]. Women often requiring episiotomies
in labor may have higher risks of third and fourth
degree perineal extensions [83,99]. Women with
FGM/C have also been shown to have increased
incidences of perineal lacerations, wound infec-
tions, episiotomy complications, postpartum hem-
orrhage, and sepsis [100].
In a collaborative study by the World Health
Organization, women with FGM/C were evalu-
ated for obstetrical outcomes [101]. Over 28,000
women delivering at 28 different obstetrical
centers in Africa were included. Women with
FGM/C were significantly more likely to have
cesarean delivery, postpartum hemorrhage,
extended hospital stays, and stillbirth or neonatal
deaths, depending on their procedure type.
Women with Type III were almost twice as likely
to have a postpartum hemorrhage or stillborn. In
general, the overall perinatal death rates were sig-
nificantly greater in women with Type II and III
procedures. The authors concluded that 22% of
perinatal deaths in this report could be attributed
to FGM/C. One limitation of the study is that
women who were higher risk may have been over-
represented due to the nature of the design and
that such women may have been more likely to
present to hospitals in these areas. Also, in general,
the background rates of maternal and infant com-
Sex Med Rev 2015;3:245–263
Mazloomdoost and Pauls
plications in these areas are high, as high as 88 per
1,000 births in Nigeria [100].
Male partner complications have also been
reported, including difficulty with penetration
during sex and even penile wounds and infection
[87]. Complications are not limited to physical
damage, however. Psychological disorders attrib-
utable to FGM/C have been documented, and
women with FGM/C who live in societies where
these procedures are not performed may have dif-
ficulties with the development of their sexual iden-
tity [90].
Sexual Function
Healthy sexual function is possible following
FGM/C; however, research findings are greatly
conflicted. It appears that women with FGM/C
are capable of normal libido and possibly even
have increased urges when surveyed [81]. Contrary
to beliefs that men prefer sexual activity with
women who have had FGM/C, men are increas-
ingly reporting preference for women who have
not been cut, the trauma of hurting their wives
possibly contributing [85,87,101]. No significant
differences have been noted in studies of women
who were cut compared with uncut women when
it came to arousability and frequency of sexual
intercourse [81]. In fact, women who had FGM/C
were 31% more likely to report initiating sexual
intercourse with their partners than those who had
not experienced FGM/C [81]. Large proportions
of women with FGM/C surveyed reported an
ability to achieve orgasm, although it may take
longer to achieve [87,89,102]. In some studies cut
women often reported their breasts being their
most sexually sensitive body part compared with
the clitoris in uncut women [81].
Conversely, some researchers have reported a
significant difference in arousal, lubrication,
orgasm, and satisfaction of sexual activity in
women with FGM/C compared to those without
[103]. While it may be the case that women with
FGM/C can enjoy normal sexual activity, these
procedures still have the potential to cause sexual
harm and damage the ability to enjoy sex [87].
Because women with FGM/C can still achieve
normal sexual health, they should be offered
therapy if they complain of sexual dysfunction
[102]. Importantly, the clitoris, particularly the
deeper components, may have been spared in
FGM/C; careful surgical technique, as will be dis-
cussed later, may help preserve normal function in
these women undergoing repair [104].
Clitoris and Its Role in Sexual Function
Implications for Care in the West
Many women who have undergone FGM/C worry
that practitioners outside of their home country
will not be able to provide quality care because of
inexperience with these procedures [105]. In par-
ticular, women are emotionally impacted when
providers respond negatively to their physical
appearance and when they are displayed for train-
ees to view the scars [85,105]. Such reactions from
providers can prevent women from seeking further
medical care [85]. From an obstetrical viewpoint,
many women fear they will undergo unnecessary
cesarean deliveries because of the provider’s lack
of familiarity with defibulation (the undoing of the
infibulation) and general care of these prior scars
[85].
When possible, women with FGM/C should be
cared for by a female provider, as examinations by
a male provider may be viewed as abusive by
women from cultures demanding only female
practitioners care for women [91]. It is similarly
important to establish a rapport with the male
family member and include him in the decision
making. Furthermore, women from these cultures
are often taught to mask their pain and not express
any discomfort, and providers should be sensitive
to this. Women from African societies have great
respect for nurses, as these individuals are often
the sole practitioners of women in their societies,
and involving nurses in their care may ease anxiety
[91].
It may be possible that a woman with tight
infibulation may need defibulation just to have an
examination performed [90]. If treating complica-
tions such as abscesses or cysts in the genital area,
physicians should be careful to proceed with
caution and perform minimal dissection of these
already damaged and scarred areas [90].
Providers in the United States are left with a
dilemma of how to care for women after birth who
have lacerations of their prior FGM/C scars.
While the American College of Obstetricians
and Gynecologists (ACOG) recommends defibu-
lation during the second trimester of pregnancy,
there are no clear recommendations for how to
proceed postpartum [106]. Refusal to recreate the
infibulation may cause women to cease seeking
care in trained facilities and opt for potentially
more hazardous home-births [91,106]. ACOG
opposes medically unnecessary modifications of
the female genitalia, and while FGM/C is illegal in
the United States, this legal protection is limited
to women under the age of 18 [106,107]. There-
fore, practitioners in the United States are left
257
with little guidance on how to care for these
women in relation to reinfibulation, particularly
those over 18 years of age. The Royal College of
Obstetrics and Gynaecology, however, emphasized
in a press release that reinfibulation is illegal in the
United Kingdom and should never be performed
[90].
Practitioners can reassure patients who do not
have reinfibulation after defibulation that women
and their husbands are satisfied with defibulation.
In a study by Nour et al., women were followed
after defibulation, and 100% of the patients inter-
viewed reported satisfaction with the results, their
new appearance, and sexual activity [101]. Twelve
percent had ongoing problems, such as occasional
dyspareunia, but all said intercourse had improved
significantly. Of the husbands who were inter-
viewed, all reported satisfaction with the surgical
outcome, their wife’s appearance, and sexual activ-
ity [101].
Regulation
There has been a growing movement to outlaw
FGM/C around the world. The efforts began in
1906, when the Church of Scotland started efforts
to ban circumcision in Kenya [83], and the proce-
dures were outlawed for girls under the age of 17
in 2001 [80]. In 2011, it became illegal for all ages
and also banned taking a woman abroad to have
FGM/C performed [80]. In 1946, the British
Colonial Office mandated that Pharaonic circum-
cision (now categorized as Type III) be outlawed in
Sudan [83]. While it became illegal in 1956, the
law has not been implemented [91]. Limitations
are likely secondary to the fact that Sudan is the
second least developed country in the world, and
tradition still appears to rule the customs [91].
Some support for FGM/C has decreased in Sudan
as campaigns are educating men about the details
of these procedures, often causing great alarm
among these men at the extent of damage caused
[87]. Progress has also been made in Egypt, where,
in 1958, FGM/C was declared illegal [84]. In 1979,
the World Health Organization convened a
seminar to discuss FGM/C, and a steering com-
mittee was formed in 1981 to follow up on recom-
mendations regarding cessation of these practices
[83].
Despite these regulations, FGM/C is still per-
formed. Likely until religious arguments and
influential people support its cessation, and indi-
viduals can be convinced of the lack of sexual
benefit, these procedures will continue [87].
Nonetheless, there is promise. Many women in
Sex Med Rev 2015;3:245–263
258
these regions feel the practice should be discontin-
ued and smaller proportions plan to have their
daughters cut compared to historical percentages
[80,87].
Clitoris and Pelvic Surgery
Reports from FGM/C trials are reassuring that
sexual function may remain intact even in invasive
procedures. Nonetheless, clitoral relevance to
sexual activity is highlighted by studies of women
post clitorectomy showing increased sexual inhibi-
tions and ambivalence toward sexual activity [1].
Preserving sexual function is imperative to the
planning of pelvic floor reconstructive surgeries
[7,24]. There is no definitive consensus on the
effect of gynecologic surgeries on sexual function,
likely attributed to the complexity of studying
sexual function, the potential impact of the disease
state requiring surgical intervention, and differ-
ences in the preferred mode of genital stimulation
[14]. While the debate over the G-spot and poten-
tial vaginal versus COs continues, avoiding ana-
tomical injury to important sexual structures is
essential for surgeons [14,108]. Thus, knowledge
of the impact of pelvic surgeries on clitoral inner-
vation and vascularity is crucial [7].
As reported earlier in this manuscript, the cli-
toris is a multicomponent structure containing
erectile tissue and is attached to the mons, labia
majora, and pubic symphysis by suspensory liga-
ments [11]. Preserving the bulbs’ erectile tissue is
Sex Med Rev 2015;3:245–263
Mazloomdoost and Pauls
paramount for sexual function, and sparing the
ligaments is important for anatomical positioning
[11]. In cases of revision following female genital
cutting where the clitoris was left intact, the
surgeon must assure that the clitoral shaft remains
attached to the suspensory ligaments to best
restore clitoral function [104]. Additionally, the
dorsal and deep arteries of the clitoris follow the
course of the pudendal nerve, making them sus-
ceptible to injury during invasive procedures along
this path.
Notwithstanding the above, it is likely that dis-
ruption of the intricate neuronal network of the
clitoris via gynecologic surgery may be most dev-
astating to its function. Disruption of innervation
may result in decreased sensitivity and possible
decreased arousal from tactile stimulation [7].
Injury to the DNC could also lead to decreased
orgasmic function or pain [109,110]. With the role
of the cavernous nerves in clitoral tumescence,
injury could lead to altered vascular and possibly
sexual function [111]. The DNC, cavernous
nerves, as well as clitoral erectile tissue all lie in
close proximity to the urethra, thus making them
particularly vulnerable in surgical techniques
involving the paraurethral space (Figure 7) [17]. As
noted previously, preservation of these nerves and
structures during surgical interventions is critical
to sexual arousal [24].
The urethra is not the only location of concern
for clitoral neuronal injury. Neurovascular bundles
supplying the clitoris have been located at the
Figure 7 Innervation to the clitoris
and vulva.
Clitoris and Its Role in Sexual Function
anterior rectum and rectovaginal septum [112].
These neurovascular bundles contain erectile
fibers intended for the clitoris and are important to
avoid during surgical procedures near this area
[112]. Understanding such anatomical relation-
ships can help avoid potential complications in
pelvic floor reconstruction [11,18,24].
While any pelvic floor surgery has the potential
for neuronal morbidity, perhaps the most hazard-
ous are treatments for incontinence. Specifically,
mid-urethral slings for the treatment of stress
urinary incontinence come in close proximity to
these important genital structures [113]. The
threat of injury to the DNC by transobturator
slings has been suggested and recognized [7,109].
Bekker et al. found that the mean distance of the
Tension-Free Vaginal Tape Obturator (Gynecare
TVT-O; Ethicon Inc., Cincinnati, OH, USA) to
the DNC was 9 mm, placing it at risk of iatrogenic
damage, especially during the dissection toward
the foramen [7].
Achtari et al. compared placement of Tension-
free Vaginal Tape (Gynecare TVT; Ethicon Inc.),
TVT-O, and Monarc transobturator slings (Ameri-
can Medical Systems Inc., Minnetonka, MN, USA)
to the anatomical relationship of the DNC. The
mean distances were approximately 11–12 mm
from the DNC. While there was no significant
mean difference in distance between the three tech-
niques, the outside-in approach of the Monarc was
found to have the farthest mean distance from the
DNC and was suggested by the authors to poten-
tially be the safest device for avoiding injury to the
DNC [110]. Clinical significance of these distances,
however, remains to be elucidated.
Direct neuronal damage is not the only
concern. Neurological sequelae from hematoma
pressure, while rare, may also occur during
midurethral sling placement [110]. The presence
of a foreign body, such as with synthetic
midurethral slings, can result in tissue reaction
that may impact the neurovasculature of the
vaginal wall and clitoris [114]. Furthermore, scar-
ring and fibrosis, such as may occur with
paraurethral dissection, may impact both vascular
and nerve function, leading to decreased blood
flow to the clitoris [114–116]. Nonetheless, these
theoretical concerns are not necessarily supported
by research. In fact, clitoral blood flow has been
shown to be increased after transobturator
suburethral tape (TOT), suggesting preservation
of clitoral sensitivity [114].
Retropubic procedures, however, may have dif-
ferent, but related outcomes. In cadaveric studies,
259
the TVT needle was demonstrated to pierce the
cavernous nerves [7]. Perhaps this plays a role in
the decreased clitoral blood flow reported rarely
after TVT procedures [115]. Of concern is
whether such findings impact sexual function
[117], as normal sexual function is not guaranteed
after any procedure [118].
Despite these purported anatomical impacts, cli-
toral innervation appears resilient. Outcomes fol-
lowing clitoroplasty and metoidioplasty (female-
to-male gender assignment surgery) have shown no
postoperative difficulty in sexual arousal, masturba-
tion, or orgasms [119]. Though such procedures
involve release of the clitoral ligaments and great
risk to innervation, sexual function appears to be
preserved [119]. Additionally, no difference in sen-
sations has been noted in patients undergoing cli-
toral reduction compared to controls [1]. Women
have also reported preservation of sexual function
following female genital cutting [108], although
this may be secondary to the diminished number of
terminal small nerve fibers in the skin overlying the
vestibular bulbs as opposed to nerve regeneration
[18]. While a thorough understanding of the clito-
ral neurovascular anatomy is imperative, current
literature suggests that clitoral dysfunction from
pelvic surgeries is not a common phenomenon.
Just as reassuring are studies demonstrating
that sexual function either remains unaltered
or improved after anti-incontinence surgery
[120,121]. Elzevier et al. found that most women
reported no difference with sexual function fol-
lowing placement of TOT or TVT-O [121]. They
also discovered no significant difference in lubri-
cation, clitoral sensitivity, tumescence, or sexual
desire between the two procedures, with the
majority of women reporting no negative impact
overall. In fact, both procedures positively
impacted sexual activity because of their success in
treating incontinence. Murphy et al. compared
sexual function following TVT vs. TVT-O and
found similar results [122]. The majority of
women in this study reported no change in sexual
function following either procedure, with no sig-
nificant difference between the two procedures.
Additionally, over a third of women in both groups
reported a positive effect from their procedure on
sexual function [122].
Conclusion
Sexual function is complex, and patient emotional
well-being and motivation are important to ensur-
ing satisfactory activity. Healthy sexual function-
Sex Med Rev 2015;3:245–263
260
ing is critical to a woman’s health [32]. The role of
the clitoris is significant in the achievement of this.
Recognition of its importance along with advocacy
for the abolishment of FGM/C together have
peaked interest in the study of the clitoris over the
last several decades. Furthermore, as increasing
numbers of women undergo pelvic floor recon-
struction [123], surgeons have been alerted to the
challenge of avoiding complications that may
disrupt normal sexual function. Though the con-
troversy over the G-spot and female ejaculation
remains, clitoral influence on orgasm is undis-
puted. A thorough understanding of the clitoral
anatomy is imperative to preserving its function
and maintaining this important aspect of women’s
health.
Corresponding Author: Donna Mazloomdoost, MD,
3219 Clifton Ave., MOB Suite #100, Cincinnati, OH
45206. Tel: 513-862-4171; Fax: 513-862-4498; E-mail:
Donna_Mazloomdoost@trihealth.com
Conflict of Interest: The authors report no conflicts of
interest.
References
1 Mininberg DT. Phalloplasty in congenital adrenal
hyperplasia. J Urol 1982;128:355–6.
2 Korda JB, Goldstein SW, Sommer F. The history of female
ejaculation. J Sex Med 2010;7:1965–75.
3 Stringer MD, Becker I. Colombo and the clitoris. Eur J
Obstet Gynecol Reprod Biol 2010;151:130–3.
4 Moore LJ, Clarke AE. Clitoral conventions and transgres-
sions: Graphic representations in anatomy texts, c1900–1991.
Fem Stud 1995;21:255–301.
5 Cohen M. The mysterious origins of the word “clitoris.” In:
Lowry TP, ed. The classic clitoris: Historic contributions to
scientific sexuality. Chicago: Nelson Hall; 1978:5–9.
6 Saylor DS. Clitoris. In: Malti-Douglas F, ed. Encyclopedia
of sex and gender. Vol. 1. Detroit: Macmillan; 2007:299–
301.
7 Bekker MD, Hogewoning CR, Wallner C, Elzevier HW,
DeRuiter MC. The somatic and autonomic innervation of
the clitoris; preliminary evidence of sexual dysfunction after
minimally invasive slings. J Sex Med 2012;9:1566–78.
8 O’Connell HE, Sanjeevan KV, Hutson JM. Anatomy of the
clitoris. J Urol 2005;174(4 Pt 1):1189–95.
9 Puppo V. Anatomy and physiology of the clitoris, vestibular
bulbs, and labia minora with a review of the female orgasm
and the prevention of female sexual dysfunction. Clin Anat
2013;26:134–52.
10 Foldes P, Buisson O. The clitoral complex: A dynamic
sonographic study. J Sex Med 2009;6:1223–31.
11 Yavagal S, de Farias TF, Medina CA, Takacs P. Normal
vulvovaginal, perineal, and pelvic anatomy with reconstruc-
tive considerations. Semin Plast Surg 2011;25:121–9.
12 O’Connell HE, Anderson CR, Plenter RJ, Hutson JM. The
clitoris: A unified structure. Histology of the clitoral glans,
body, crura and bulbs. Urodynamica 2004;14:127–32.
13 O’Connell H, Eizenberg N, Rahman M, Cleeve J. The
anatomy of the distal vagina: Towards unity. J Sex Med
2008;5:1883–91.
Sex Med Rev 2015;3:245–263
Mazloomdoost and Pauls
14 Jannini EA, Buisson O, Rubio-Casillas A. Beyond the G-spot:
Clitourethrovaginal complex anatomy in female orgasm. Nat
Rev Urol 2014;11:531–8.
15 Puppo V. Embryology and anatomy of the vulva: The female
orgasm and women’s sexual health. Eur J Obstet Gynecol
Reprod Biol 2011;154:3–8.
16 Verkauf BS, Von Thron J, O’Brien WF. Clitoral size in
normal women. Obstet Gynecol 1992;80:41–4.
17 O’Connell HE, Hutson JM, Anderson CR, Plenter RJ. Ana-
tomical relationship between urethra and clitoris. J Urol
1998;159:1892–7.
18 Oakley SH, Mutema GK, Crisp CC, Estanol MV, Kleeman
SD, Fellner AN, Pauls RN. Innervation and histology of the
clitoral-urethal complex: A cross-sectional cadaver study. J
Sex Med 2013;10:2211–8.
19 Lloyd J, Crouch NS, Minto CL, Liao LM, Creighton SM.
Female genital appearance: “Normality” unfolds. BJOG
2005;112:643–6.
20 Rees MA, O’Connell HE, Plenter RJ, Hutson JM. The sus-
pensory ligament of the clitoris: Connective tissue supports of
the erectile tissues of the female urogenital region. Clin Anat
2000;13:397–403.
21 Ginger VA, Cold CJ, Yang CC. Surgical anatomy of the
dorsal nerve of the clitoris. Neurourol Urodyn 2011;30:
412–6.
22 Vaze A, Goldman H, Jones JS, Rackley R, Vasavada S,
Gustafson KJ. Determining the course of the dorsal nerve of
the clitoris. Urology 2008;72:1040–3.
23 Baskin LS, Erol A, Li YW, Liu WH, Kurzrock E, Cunha GR.
Anatomical studies of the human clitoris. J Urol 1999;162(3
Pt 2):1015–20.
24 Martin-Alguacil N, Pfaff DW, Shelley DN, Schober JM.
Clitoral sexual arousal: An immunocytochemical and inner-
vation study of the clitoris. BJU Int 2008;101:1407–13.
25 Yucel S, De Souza A Jr, Baskin LS. Neuroanatomy of the
human female lower urogenital tract. J Urol 2004;172:191–5.
26 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the
United States: Prevalence and predictors. JAMA 1999;281:
537–44.
27 American Psychiatric Association. Diagnostic and statistical
manual of mental disorders, 5th edition. Washington, DC:
American Psychiatric Association; 2013.
28 Graham CA. The DSM diagnostic criteria for female orgas-
mic disorder. Arch Sex Behav 2010;39:256–70.
29 Wallen K, Lloyd EA. Female sexual arousal: genital anatomy
and orgasm in intercourse. Horm Behav 2011;59:780–92.
30 Masters WH, Johnson VE. The sexual response cycle. In:
Masters WH, Johnson VE, eds. Human sexual response.
New York: Ishi Press; 2010:5.
31 Jannini E, Rubio-Casillas A, Whipple B, Buisson O,
Komisaruk B, Brody S. Female orgasm(s): One, two, several.
J Sex Med 2012;9:956–65.
32 Brody S, Costa RM. Vaginal orgasm is associated with less use
of immature psychological defense mechanisms. J Sex Med
2008;5:1167–76.
33 Giraldi A, Marson L, Nappi R, Pfaus J, Traish AM, Vardi Y,
Goldstein I. Physiology of female sexual function: Animal
models. J Sex Med 2004;1:237–53.
34 Komisaruk BR, Whipple B. Functional MRI of the brain
during orgasm in women. Annu Rev Sex Res 2005;16:62–86.
35 Suh DD, Yang CC, Cao Y, Heiman JR, Garland PA,
Maravilla KR. MRI of female genital and pelvic organs during
sexual arousal. J Psychosom Obstet Gynaecol 2004;25:153–
62.
36 Chambless DL, Stern T, Sultan FE, Williams AJ, Goldstein
AJ, Lineberger MH, Lifshitz JL, Kelly L. The
pubococcygens and female orgasm: A correlational study with
normal subjects. Arch Sex Behav 1982;11:479–90.
Clitoris and Its Role in Sexual Function
37 Munarriz R, Kim SW, Kim NN, Traish A, Goldstein I. A
review of the physiology and pharmacology of peripheral
(vaginal and clitoral) female genital arousal in the animal
model. J Urol 2003;170(2 Pt 2):S40–4. discussion S44–5.
38 Burnett AL, Calvin DC, Silver RI, Peppas DS, Docimo SG.
Immunohistochemical description of nitric oxide synthase
isoforms in human clitoris. J Urol 1997;158:75–8.
39 Hoyle CH, Stones RW, Robson T, Whitley K, Burnstock G.
Innervation of vasculature and microvasculature of the
human vagina by NOS and neuropeptide-containing nerves.
J Anat 1996;188(Pt 3):633–44.
40 O’Connell HE, DeLancey JO. Clitoral anatomy in
nulliparous, healthy, premenopausal volunteers using
unenhanced magnetic resonance imaging. J Urol 2005;173:
2060–3.
41 Yucel S, Baskin LS. Identification of communicating branches
among the dorsal, perineal and cavernous nerves of the penis.
J Urol 2003;170:153–8.
42 Yoon HN, Chung WS, Park YY, Shim BS, Han WS, Kwon
SW. Effects of estrogen on nitric oxide synthase and histo-
logical composition in the rabbit clitoris and vagina. Int J
Impot Res 2001;13:205–11.
43 Park K, Moreland RB, Goldstein I, Atala A, Traish A.
Sildenafil inhibits phosphodiesterase type 5 in human clitoral
corpus cavernosum smooth muscle. Biochem Biophys Res
Commun 1998;249:612–7.
44 McKenna KE. The neurophysiology of female sexual func-
tion. World J Urol 2002;20:93–100.
45 Ortigue S, Bianchi-Demicheli F, Patel N, Frum C, Lewis
JW. Neuroimaging of love: fMRI meta-analysis evidence
toward new perspectives in sexual medicine. J Sex Med
2010;7:3541–52.
46 Min K, Munarriz R, Kim NN, Goldstein I, Traish AM.
Effects of ovariectomy and estrogen and androgen treatment
on sildenafil-mediated changes in female genital blood flow
and vaginal lubrication in the animal model. Am J Obstet
Gynecol 2002;187:1370–6.
47 Gravina GL, Brandetti F, Martini P, Carosa E, Di Stasi SM,
Morano S, Lenzi A, Jannini EA. Measurement of the thick-
ness of the urethrovaginal space in women with or without
vaginal orgasm. J Sex Med 2008;5:610–8.
48 Hines TM. The G-spot: A modern gynecologic myth. Am J
Obstet Gynecol 2001;185:359–62.
49 Goldberg DC, Whipple B, Fishkin RE, Waxman H, Fink PJ,
Weisberg M. The Grafenberg spot and female ejaculation:
A review of initial hypotheses. J Sex Marital Ther 1983;9:27–
37.
50 Ostrzenski A. G-spot anatomy: A new discovery. J Sex Med
2012;9:1355–9.
51 Puppo V, Gruenwald I. Does the G-spot exist? A review of
the current literature. Int Urogynecol J 2012;23:1665–93.
52 Addiego F, Belzer EG, Comolli J, Moger W, Perry JD,
Whipple B. Female ejaculation: A case study. J Sex Res
1981;17:13–21.
53 Shafik A, El Sibai O, Shafik AA, Ahmed I, Mostafa RM. The
electrovaginogram: Study of the vaginal electric activity and
its role in the sexual act and disorders. Arch Gynecol Obstet
2004;269:282–6.
54 Ostrzenski A, Krajewski P, Ganjei-Azar P, Wasiutynski AJ,
Scheinberg MN, Tarka S, Fudalej M. Verification of the
anatomy and newly discovered histology of the G-spot
complex. BJOG 2014;121:1333–9.
55 Komisaruk BR, Wise N, Frangos E, Liu WC, Allen K, Brody
S. Women’s clitoris, vagina, and cervix mapped on the
sensory cortex: fMRI evidence. J Sex Med 2011;8:2822–30.
56 Buisson O, Foldes P, Jannini E, Mimoun S. Coitus as
revealed by ultrasound in one volunteer couple. J Sex Med
2010;7:2750–4.
261
57 Buisson O, Jannini EA. Pilot echographic study of the differ-
ences in clitoral involvement following clitoral or vaginal
sexual stimulation. J Sex Med 2013;10:2734–40.
58 Lavoisier P, Aloui R, Schmidt MH, Watrelot A. Clitoral
blood flow increases following vaginal pressure stimulation.
Arch Sex Behav 1995;24:37–45.
59 Oakley SH, Vaccaro CM, Crisp CC, Estanol MV, Fellner
AN, Kleeman SD, Pauls RN. Clitoral size and location in
relation to sexual function using pelvic MRI. J Sex Med
2014;11:1013–22.
60 Pauls R, Mutema G, Segal J, Silva WA, Kleeman S,
Dryfhout Ma V, Karram M. A prospective study examining
the anatomic distribution of nerve density in the human
vagina. J Sex Med 2006;3:979–87.
61 Azar M, Noohi S, Radfar S, Radfar MH. Sexual function in
women after surgery for pelvic organ prolapse. Int
Urogynecol J Pelvic Floor Dysfunct 2008;19:53–7.
62 Alzate H. Vaginal eroticism: A replication study. Arch Sex
Behav 1985;14:529–37.
63 Burri AV, Cherkas L, Spector TD. Genetic and environmen-
tal influences on self-reported G-spots in women: A twin
study. J Sex Med 2010;7:1842–52.
64 Kilchevsky A, Vardi Y, Lowenstein L, Gruenwald I. Is the
female G-spot truly a distinct anatomic entity? J Sex Med
2012;9:719–26.
65 Grafenberg R. The role of urethra in female orgasm. Int J
Sexol 1950;3:145–8.
66 Alzate H, Hoch Z. The “G spot” and “female ejaculation”: A
current appraisal. J Sex Marital Ther 1986;12:211–20.
67 Lowndes SJ, Bennett JW. Concerning female ejaculation and
the female prostate. J Sex Res 1978;14:1–20.
68 Belzer EG. Orgasmic expulsions of women: A review and
heuristic inquiry. J Sex Res 1981;17:1–12.
69 Darling CA, Davidson JK Sr, Conway-Welch C. Female
ejaculation: Perceived origins, the Grafenberg spot/area, and
sexual responsiveness. Arch Sex Behav 1990;19:29–47.
70 Davidson JK Sr, Darling CA, Conway-Welch C. The role of
the Grafenberg Spot and female ejaculation in the female
orgasmic response: An empirical analysis. J Sex Marital Ther
1989;15:102–20. Summer.
71 Freese MP, Levitt EE. Relationships among intravaginal
pressure, orgasmic function, parity factors, and urinary
leakage. Arch Sex Behav 1984;13:261–8.
72 Perry JD, Whipple B. Pelvic muscle strength of female ejacu-
lators: Evidence in support of a new theory of orgasm. J Sex
Res 1981;17:22–39.
73 Heath D. An investigation into the origins of a copious
vaginal discharge during intercourse: “Enough to wet the
bed”-that “is not urine.” J Sex Res 1984;20:194–215.
74 Zaviacic M, Ablin RJ. The female prostate and prostate-
specific antigen. Immunohistochemical localization, implica-
tions of this prostate marker in women and reasons for using
the term “prostate” in the human female. Histol Histopathol
2000;15:131–42.
75 Zaviacic M, Jakubovská V, Belosovic M, Breza J.
Ultrastructure of the normal adult human female prostate
gland (Skene’s gland). Anat Embryol (Berl) 2000;201:51–
61.
76 Salama S, Boitrelle F, Gauquelin A, Malagrida L, Thiounn
N, Desvaux P. Nature and origin of “squirting” in female
sexuality. J Sex Med 2015;12:661–6.
77 Pastor Z. Female ejaculation orgasm vs. coital incontinence: a
systematic review. J Sex Med 2013;10:1682–91.
78 Roof J. Ejaculation. In: Malti-Douglas F, ed. Encyclopedia of
sex and gender. Vol. 2. Detroit: Macmillan; 2007:451–3. Gale
Virtual Reference Library. Web. 23 Feb. 2015.
79 World Health Organization. Eliminating female genital
mutilation: An interagency statement, WHO, UNFPA,
Sex Med Rev 2015;3:245–263
262
UNICEF, UNIFEM, OHCHR, UNHCR, UNECA,
UNESCO, UNDP, UNAIDS. Geneva: WHO; 2008.
80 Patra S, Singh RK. Attitudes of circumcised women towards
discontinuation of genital cutting of their daughters in
Kenya. J Biosoc Sci 2015;47:45–60.
81 Okonofua FE, Larsen U, Oronsaye F, Snow RC, Slanger TE.
The association between female genital cutting and correlates
of sexual and gynaecological morbidity in Edo State, Nigeria.
BJOG 2002;109:1089–96.
82 UNICEF. UNICEF Data: Monitoring the Situation of Chil-
dren and Women. Available at: http://data.unicef.org/child-
protection/fgmc#_ftn1 (accessed March 18, 2015).
83 Cutner LP. Female genital mutilation. Obstet Gynecol Surv
1985;40:437–43.
84 Assaad MB. Female circumcision in Egypt: Social implica-
tions, current research, and prospects for change. Stud Fam
Plann 1980;11:3–16.
85 Nour NM. Female genital cutting: Clinical and cultural
guidelines. Obstet Gynecol Surv 2004;59:272–9.
86 Arberry AJ. The Koran interpreted: A translation. New York:
Touchstone; 1996.
87 Gruenbaum E. Sexuality issues in the movement to abolish
female genital cutting in Sudan. Med Anthropol Q 2006;
20:121–38.
88 Hellsten SK. Rationalising circumcision: From tradition to
fashion, from public health to individual freedom—critical
notes on cultural persistence of the practice of genital muti-
lation. J Med Ethics 2004;30:248–53.
89 Lightfoot-Klein H. The sexual experience and marital adjust-
ment of genitally circumcised and infibulated females in the
Sudan. J Sex Res 1989;26:376–92.
90 Toubia N. Female circumcision as a public health issue. N
Engl J Med 1994;331:712–6.
91 Lightfoot-Klein H, Shaw E. Special needs of ritually circum-
cised women patients. J Obstet Gynecol Neonatal Nurs
1991;20:102–7.
92 Briggs L. Male and female viewpoints on female circumcision
in Ekpeye, Rivers State, Nigeria. Afr J Reprod Health
2002;6:44–52.
93 Egwuatu VE, Agugua EN. Complications of female circum-
cision in Nigerian Igbos. Br J Obstet Gynaecol 1981;88:
1090–3.
94 Dirie MA, Lindmark G. A hospital study of the complications
of female circumcision. Trop Doct 1991;21:146–8.
95 DeSilva S. Obstetric sequelae of female circumcision. Eur J
Obstet Gynecol Reprod Biol 1989;32:233–40.
96 MacLeod T. Female genital mutilation. J Soc Gynaecol Can
1995;17:333–42.
97 Meniru G. Female genital mutilation. BMJ 1994;101:832.
98 Taba AF. Female circumcision. Trop Doct 1980;10:21–3.
99 Johnson EB, Reed SD, Hitti J, Batra M. Increased risk of
adverse pregnancy outcome among Somali immigrants in
Washington state. Am J Obstet Gynecol 2005;193:475–82.
100 Nour NM, Michels KB, Bryant AE. Defibulation to treat
female genital cutting: Effect on symptoms and sexual func-
tion. Obstet Gynecol 2006;108:55–60.
101 Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M.
Female genital mutilation and obstetric outcome: WHO col-
laborative prospective study in six African countries. Lancet
2006;367:1835–41.
102 Catania L, Abdulcadir O, Puppo V, Verde JB, Abdulcadir J,
Abdulcadir D. Pleasure and orgasm in women with Female
Genital Mutilation/Cutting (FGM/C). J Sex Med 2007;
4:1666–78.
103 Alsibiani SA, Rouzi AA. Sexual function in women with
female genital mutilation. Fertil Steril 2010;93:722–4.
104 Foldes P. Surgical techniques: Reconstructive surgery of the
clitoris after ritual excision. J Sex Med 2006;3:1091–4.
Sex Med Rev 2015;3:245–263
Mazloomdoost and Pauls
105 Chalmers B, Hashi KO. 432 Somali women’s birth experi-
ences in Canada after earlier female genital mutilation. Birth
2000;27:227–34.
106 Rosenberg LB, Gibson K, Shulman JF. When cultures
collide: Female genital cutting and U.S. obstetric practice.
Obstet Gynecol 2009;113:931–4.
107 ACOG committee opinion. Female genital mutilation.
Number 151-January 1995. Committee on Gynecologic
Practice. Committee on International Affairs. American
College of Obstetricians and Gynecologists. Int J Gynaecol
Obstet 1995;49:209.
108 Thabet SM. Reality of the G-spot and its relation to female
circumcision and vaginal surgery. J Obstet Gynaecol Res
2009;35:967–73.
109 Delorme E, Droupy S, de Tayrac R, Delmas V.
Transobturator tape (Uratape): A new minimally-invasive
procedure to treat female urinary incontinence. Eur Urol
2004;45:203–7.
110 Achtari C, McKenzie BJ, Hiscock R, Rosamilia A, Schierlitz
L, Briggs CA, Dwyer PL. Anatomical study of the obturator
foramen and dorsal nerve of the clitoris and their relationship
to minimally invasive slings. Int Urogynecol J Pelvic Floor
Dysfunct 2006;17:330–4.
111 Moszkowicz D, Alsaid B, Bessede T, Zaitouna M, Penna C,
Benoit G, Peschaud F. Neural supply to the clitoris:
Immunohistochemical study with three-dimensional
reconstruction of cavernous nerve, spongious nerve, and
dorsal clitoris nerve in human fetus. J Sex Med 2011;8:1112–
22.
112 Peschaud F, Moszkowicz D, Alsaid B, Bessede T, Penna C,
Benoit G. Preservation of genital innervation in women
during total mesorectal excision: Which anterior plane?
World J Surg 2012;36:201–7.
113 Lowenstein L. Topographic relation of mid-urethral sling for
stress incontinence to critical female genital structures. J Sex
Med 2009;6:2954–7.
114 Matarazzo MG, Cianci S, Rampello L, Presti LL, Caruso S.
Urethral sphincter innervation and clitoral blood flow after
the transobturator (TOT) approach. Int Urogynecol J
2013;24:621–5.
115 Caruso S, Rugolo S, Bandiera S, Mirabella D, Cavallaro A,
Cianci A. Clitoral blood flow changes after surgery for stress
urinary incontinence: Pilot study on TVT versus TOT pro-
cedures. Urol 2007;70:554–7.
116 Goldstein I, Berman JR. Vasculogenic female sexual dysfunc-
tion: Vaginal engorgement and clitoral erectile insufficiency
syndromes. Int J Impot Res 1998;10(suppl 2):S84–90; discus-
sion S98–101.
117 Yeni E, Unal D, Verit A, Kafali H, Ciftci H, Gulum M. The
effect of tension-free vaginal tape (TVT) procedure on sexual
function in women with stress urinary incontinence. Int
Urogynecol J Pelvic Floor Dysfunct 2003;14:390–4.
118 Pauls RN, Karram MN. Sexual function following
anti-incontinence surgery. Minerva Urol Nefrol 2008;60:
113–22.
119 Vukadinovic V, Stojanovic B, Majstorovic M, Milosevic A.
The role of clitoral anatomy in female to male sex reassign-
ment surgery. ScientificWorld Journal 2014;2014:437378.
120 Rogers RG, Kammerer-Doak D, Darrow A, Murray K,
Qualls C, Olsen A, Barber M. Does sexual function change
after surgery for stress urinary incontinence and/or pelvic
organ prolapse? A multicenter prospective study. Am J Obstet
Gynecol 2006;195:e1–4.
121 Elzevier HW, Putter H, Delaere KP, Venema PL,
Lycklama à Nijeholt AA, Pelger RC. Female sexual function
after surgery for stress urinary incontinence: Transobturator
suburethral tape vs. tension-free vaginal tape obturator. J Sex
Med 2008;5:400–6.
Clitoris and Its Role in Sexual Function
122 Murphy M, van Raalte H, Mercurio E, Haff R, Wiseman B,
Lucente VR. Incontinence related quality of life and sexual
function following the tension-free vaginal tape versus the
“inside-out” tension-free vaginal tape obturator. Int
Urogynecol J Pelvic Floor Dysfunct 2008;19:481–7.
263
123 Wu JM, Kawasaki A, Hundley AF, Dieter AA, Myers ER,
Sung VW. Predicting the number of women who will
undergo incontinence and prolapse surgery, 2010 to 2050.
Am J Obstet Gynecol 2011;205:230e1–5.
Sex Med Rev 2015;3:245–263