Anatomy and physiology of genital organs – women. Neurology of Sexual and Bladder Disorders. Elsevier; 2015. pp. 39-60. [DOI: 10.1016/b978-0-444-63247-0.00004-3]

Innervation pattern and fiber counts of the human dorsal nerve of clitoris

Even tough clitoris plays a critical role in female sexuality, we lack a precise understanding of qualitative and quantitative aspects of the innervation of the human clitoris. To address this issue, we dissected human clitorides from body donors and imaged them after staining with iodine with microCT for a macroscopic analysis. To resolve innervation patterns at the microscopic level we prepared thin sections of clitorides and stained them with trichrome azan to reveal the tissue structure combined with immunocytochemistry against Neurofilament H antibodies to reveal all axons and luxol blue labeling to reveal myelinated axons. We find the clitoral branch of pudendal nerve that innervates the clitoris not as single nerve, but as number of loose bundles. In the crus of the clitoris, about 12 such bundles can be recognized while about 32 bundles are present in the clitoral hemi-body. We counted on avarage 2917 axons in the crus of the clitoris (76% of which are myelinated) and 3137 axons in the hemibody of the clitoris (71% of which are myelinated). While the human clitoris receives only one third of the number of axons that innervate the human penis, an estimate of innervation density (per surface area) revealed that clitoris has approximately 6 times denser innervation compared to the penis. Thus, our study combines histology with microCT analysis provides detailed information on the number, myelination and innervation density of dorsal nerve of clitoris.

Association between bladder cancer treatment and female sexual function

INTRODUCTION

Bladder cancer ranks 17th in prevalence of cancer types among women, and the trend is rising. The increased risk of female sexual dysfunction (FSD) after radical cystectomy (RC) underscores the need for greater focus on preserving and mitigating FSD.

OBJECTIVES

To place greater emphasis on the importance of female sexual function (FSF) in the treatment of bladder cancer and stimulate additional research to discover more effective solutions for enhancing the overall quality of life.

METHODS

This review used a narrative approach. Previous reviews on FSF after RC have provided limited and 1-sided solutions due to the lack of research. What makes this review unique is its innovative approach: it includes all available measures curing FSD as well as comparative analyses based on experimental data, thus making the findings more comprehensive. A detailed perspective of treatments for female bladder cancer is provided, including nerve- and organ-sparing RC, robot-assisted RC, and radiotherapy. We also analyze the impact of treatments for female bladder cancer on postoperative FSD. Additionally, solutions for addressing or alleviating postoperative FSD are summarized, such as urinary diversion, vaginal reconstruction, and drug and nondrug treatment.

RESULTS

Research has suggested that robot-assisted nerve- and organ-sparing RC is promising. Moreover, orthotopic neobladder among urinary diversions without a stoma helps to maintain a positive female body image. If part of the anterior vaginal wall must be removed during RC, vaginal reconstruction can restore the dimensions with synthetic grafts and biologic scaffolds. Additionally, postoperative measures, such as vaginal laser and hormone therapy, and use of vaginal dilators and lubricants have a significant role in reducing distress caused by FSD to provide maximum relief.

CONCLUSIONS

To support FSF after RC, various interventions are needed, and urologists must focus on patient recovery while minimizing treatment impact on FSF as much as possible.

Maintaining vulvar, vaginal and perineal health: Clinical considerations

Knowledge of female genital anatomy and physiology is often inadequate or incorrect among women. Precise patient-physician conversations can be inhibited by a reluctance or inability to speak accurately about the vulva and vagina, with the terms often being used interchangeably. There is a paucity of scientific evidence and clinical guidelines to support women and physicians in ensuring best practices in feminine hygiene. In this review, the unmet needs in the field are highlighted. Evidence is provided for the complex array of physiological and pathological systems, mechanisms and behaviours that either protect or, if inappropriate, predispose the vulva and vagina to infections, irritation or other conditions. The need for attention to perineal health is recommended, given the interdependence of perineal and vulvar microbiota and the risk of colonic pathogens reaching the vulva and the vagina. Differences in feminine hygiene practices can vary widely across the world and among varying age groups, and suboptimal habits (such as vaginal douching or the use of certain cleansers) can be associated with increased risks of vulvar and vaginal conditions. Critical areas for discussion when advising women on their intimate health include: advice surrounding aesthetic vulvar cosmetic trends (such as depilation and genital cosmetic surgery), bowel health and habits, and protection against sexually transmitted infections. Routine, once-daily (maximum twice-daily) washing of the vulva with a pH-balanced, mild cleanser is optimal, ideally soon after bowel voiding, when feasible. Due to the finely balanced ecosystems of the vulva, the vagina and the perineal area, a scientific and clinical perspective is essential when determining the most appropriate vulvar cleansers based on their components. Correct intimate care may contribute to improved genital and sexual health and overall well-being. An increased awareness of correct practices will empower women to be the advocates of their own intimate health.

Sexually Induced Orgasm to Improve Postpartum Pelvic Floor Muscle Strength and Sexual Function in Primiparous Women After Vaginal Delivery: A Prospective Randomized Two-Arm Study

BACKGROUND

Postpartum pelvic floor dysfunction is known to affect the quality of life of women and the methods to treat it are more complex with majority requiring training under supervision.

AIM

To compare the efficacy of sexually induced orgasm along with Kegels exercises versus Kegels exercises alone as a treatment method to enhance postpartum pelvic floor muscle strength and sexual function in primiparous women undergoing uncomplicated vaginal deliveries.

METHODS

The prospective randomized two-arm study was conducted on sexually active primiparous women who had undergone uncomplicated vaginal deliveries. Those with risk factors for female sexual dysfunction and pelvic floor muscle dysfunction were excluded. Participants in Group 1 were advised daily Kegel's exercises, whereas, those in Group 2 were advised to initiate self-initiated/partnered sexual activity-induced orgasms along with daily Kegel's exercises. Their pelvic floor muscle strength on voluntary contraction, ability to relax pelvic floor voluntarily, and sexual function (using FSFI-6) were assessed monthly for 6 months and the analysis was done using G* Power software (© 2021 Heinrich-Heine-Universität Düsseldorf, Germany).

MAIN OUTCOME MEASURE

Postpartum pelvic floor strength and sexual function in 2 groups of women under study.

RESULTS

The study period was from January 2020 to December 2020. The Group 1 had 26 participants (mean age 29.69 ± 2.2 years) and Group 2 had 29 participants (mean age 30.07 ± 2.57 years). The sexual function as well as ability to relax pelvic floor were significantly better in Group 2 compared to Group 1 at each monthly intervals whereas strength of pelvic floor muscles during voluntary contraction was significantly higher in Group 2 compared to Group 1 at the end of 6 months and it was statistically significant at a P value of .05.

CLINICAL IMPLICATIONS

Novel method of using naturally occurring sexually induced orgasms for postpartum pelvic floor rehabilitation can revolutionize postpartum pelvic floor training in women, as it can be practiced at home with ease, along with easily performable Kegel's exercises.

STRENGTHS AND LIMITATIONS

Use of prospective randomization and minimization of confounding factors is the strength of the study. The small sample size is the limitation of the study.

CONCLUSIONS

Postpartum pelvic floor muscle strength and sexual function in primiparous women who have undergone uncomplicated vaginal deliveries can be significantly improved with the addition of sexually induced orgasm as a therapeutic tool along with physical exercises such as Kegels exercises in these women.

Application of Sol–Gels for Treatment of Gynaecological Conditions—Physiological Perspectives and Emerging Concepts in Intravaginal Drug Delivery

Approaches for effective and sustained drug delivery to the female reproductive tract (FRT) for treating a range of gynaecological conditions remain limited. The development of versatile delivery platforms, such as soluble gels (sol–gels) coupled with applicators/devices, holds considerable therapeutic potential for gynaecological conditions. Sol–gel systems, which undergo solution-to-gel transition, triggered by physiological conditions such as changes in temperature, pH, or ion composition, offer advantages of both solution- and gel-based drug formulations. Furthermore, they have potential to be used as a suitable drug delivery vehicle for other novel drug formulations, including micro- and nano-particulate systems, enabling the delivery of drug molecules of diverse physicochemical character. We provide an anatomical and physiological perspective of the significant challenges and opportunities in attaining optimal drug delivery to the upper and lower FRT. Discussion then focuses on attributes of sol–gels that can vastly improve the treatment of gynaecological conditions. The review concludes by showcasing recent advances in vaginal formulation design, and proposes novel formulation strategies enabling the infusion of a wide range of therapeutics into sol–gels, paving the way for patient-friendly treatment regimens for acute and chronic FRT-related conditions such as bacterial/viral infection control (e.g., STDs), contraception, hormone replacement therapy (HRT), infertility, and cancer.

Can the Vaginal Photoplethysmograph and Its Associated Methodology Be Used to Assess Anal Vasocongestion in Women and Men?

Forty years ago, researchers documented changes in vascular and muscular activity within the anal canal of women and men who engaged in sexual self-stimulation. Vascular changes were assessed using a photoplethysmograph that aimed to detect changes in pelvic vasocongestion. An important advantage of detecting sexual response within the anal canal is that the device, its anatomical placement, and the data output are identical for women and men, therefore facilitating gender comparisons of response patterns. In this study, the vaginal photoplethysmograph (VPP), the most common measure of genital response in women, was administered intra-anally as an anal photoplethysmograph (APG) to examine its validity and sensitivity as an indicator of sexual response. The final sample comprised 20 women and 20 men who were exposed to 12, 90-s sexual and nonsexual film clips while their APG responses were recorded. Participants also rated their sexual arousal and affective responses to the stimuli. There was evidence that APG responses were specific to sexual stimuli and were sensitive to erotic intensity in women. The degree of discrimination between sexual and nonsexual stimuli was lower in men. Unlike most sexual psychophysiological studies, the positive correlation between physiological and self-reported sexual arousal was stronger in women than in men. There was a relatively high number of data artifacts and the waveform morphology was uncharacteristic of that typically observed with VPP. The potential role of anal musculature interference on the APG signal is discussed, as well as avenues for future research.

Recent Advances in Polymer-Based Vaginal Drug Delivery Systems

The vagina has been considered a potential drug administration route for centuries. Most of the currently marketed and investigated vaginal formulations are composed with the use of natural or synthetic polymers having different functions in the product. The vaginal route is usually investigated as an administration site for topically acting active ingredients; however, the anatomical and physiological features of the vagina make it suitable also for drug systemic absorption. In this review, the most important natural and synthetic polymers used in vaginal products are summarized and described, with special attention paid to the properties important in terms of vaginal application. Moreover, the current knowledge on the commonly applied and innovative dosage forms designed for vaginal administration was presented. The aim of this work was to highlight the most recent research directions and indicate challenges related to vaginal drug administrations. As revealed in the literature overview, intravaginal products still gain enormous scientific attention, and novel polymers and formulations are still explored. However, there are research areas that require more extensive studies in order to provide the safety of novel vaginal products.

FbD directed fabrication and investigation of luliconazole based SLN gel for the amelioration of candidal vulvovaginitis: a 2 T (thermosensitive & transvaginal) approach

Candidal vulvovaginitis (CVV), is the second most leading vaginal infection (global prevalence > 75%), caused due to excessive growth of Candida spp., predominantly Candida albicans (>95% cases). The current treatment regimens for CVV are marred with the challenges of fungal resistance & infection recurrence, subsequently leading to the compromised therapeutic efficacy of anti-fungal drugs, prolonged treatment and low patient compliance. The core of the present research was the fabrication & investigation of 2 T-SLN (solid lipid nanoparticles) gel carrying luliconazole for the amelioration of CVV. '2T' symbolizes transvaginal & thermosensitive attributes of the present formulation. SLNs were prepared by a modified melt emulsification-ultra sonication method using a combination of solid lipids (Gelucire 50/13 & Precirol ATO 5), surfactant (Tween 80) and co-surfactant (Kolliphor). Formulation by design (FbD) approach was adopted to obtain appropriately screened and tailored SLNs. The optimized SLNs yielded a particle size, polydispersity index & entrapment efficiency of 62.18 nm, 0.263 & 81.5% respectively. To formulate the 2 T-gel, the final SLNs were loaded into Carbopol 971P-NF and Triethanolamine based gel. The 2 T-SLN gel was found to be easily spreadable and homogenous with mean extrudability (15 ± 0.4 g/cm²), viscosity (696.42 ± 2.34 Pa·s) and %drug content (93.24 ± 0.73%) values.. The pH of the prepared 2 T-SLN gel (4.5 ± 0.5) was in concordance with the vaginal pH (normal conditions). For in-vitro characterization of an optimized 2 T-SLN gel the release kinetics & anticandidal activity were assessed which offers a %cumulative drug release of 62 ± 0.5% in 72 h and 37.3 ± 1.5 mm zone of inhibition in 48 h. The visual appearance & dimensions were determined using fluorescent microscopy (spherical shape) & transmission electron microscopy (90-120 nm) respectively. The optimized 2 T-SLN gel showcases a skin-friendly profile with no significant signs of erythema and oedema and was found to be stable at room temperature for 2 months without any visual non-uniformity/cracking/breaking. In conclusion, the current research serves a new therapeutic perspective in assessing the activity of luliconazole for vaginal drug delivery using a 2 T-SLN gel system.

Female ejaculation: An update on anatomy, history, and controversies

Female ejaculation is a contentious topic. From a review of the literature, history indicates that it is not a modern concept; some females were aware of it in times past without understanding the role of the fluid or composition of the ejaculate. Over time, scholars experimented, mainly with anatomical studies, in an attempt to identify the source of the ejaculate and explore its physiological and anatomical benefits for the female sexual experience. Despite these studies, views about female ejaculation remain controversial and inconsistent, with no clear conclusion as to its function. This review discusses the history of studies of female ejaculation and presents various hypotheses from an anatomical and physiological perspective. After reviewing 44 publications from 1889 to 2019, it became apparent that clinical and anatomical studies conducted during recent decades provide substantial evidence in support of the female ejaculatory phenomenon. Anatomical studies have shown that the ejaculate originates in the paraurethral (Skene's) glands, but its composition has been debated. Female ejaculate differs from urine in its creatinine and urea concentrations. The fluid also contains prostate specific antigen (PSA) and could have antibacterial properties that serve to protect the urethra. While the specific function of female ejaculation remains a topic of debate, there is sufficient evidence to support the existence of the phenomenon.

Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births

INTRODUCTION

Although postpartum sexual concerns are common, limited data exist on postpartum sexual response. Furthermore, the physiological process of vaginal birth may negatively impact genital response compared with unlabored cesarean section (C-section), but this hypothesis has yet to be tested.

AIM

To (i) compare genital and subjective sexual response and sexual concordance by mode of delivery with inclusion of a control group, (ii) compare groups on self-reported sexual function over the past month, (iii) examine the relationship between laboratory measurement of sexual response and self-reported sexual function, and (iv) investigate association between obstetrical factors and breastfeeding and between sexual response and self-reported sexual function.

METHODS

3 groups of cisgender women were recruited from the community: primiparous women who delivered via vaginal birth within the past 2 years (VB group; n = 16), primiparous women who delivered via unlabored C-section within the past 2 years (CS group, n = 15), and age-matched nulliparous women (NP group, n = 18). Laser Doppler imaging was used to assess genital response while participants watched a neutral and erotic film.

MAIN OUTCOME MEASURES

The main outcome measures were change in flux units from neural to erotic video as a measure of genital response, subjective sexual arousal rated continuously throughout films, perceived genital response rated after films, and Female Sexual Function Index (FSFI).

RESULTS

Women in the VB group had significantly lower change in flux units than women in the CS (P = .005, d = 1.39) and NP (P < .001, d = 1.80) groups. Groups did not differ on their subjective indices of sexual response or in sexual concordance. Women in both postpartum groups reported lower FSFI scores than women in the NP group. No relationship was determined between FSFI scores and sexual response in the laboratory. Results suggested that genital trauma and breastfeeding may negatively impact FSFI scores, but they were not related to genital response or subjective sexual arousal as measured in the laboratory.

CLINICAL IMPLICATIONS

Results underscore the importance of balancing objective and subjective indices of sexual response and function, especially considering the biopsychosocial nature of postpartum sexuality.

STRENGTHS & LIMITATIONS

The present study is the first to apply modern sexual psychophysiological methodology to the study of postpartum sexuality. Cross-sectional methodology limits the ability to make causal inferences, and the strict inclusion criteria limits generalizability.

CONCLUSION

Physiological changes as a result of labor and delivery may have a detrimental impact on genital response; however, these physiological differences may not impact women's subjective experience of postpartum sexuality. Cappell J, Bouchard KN, Chamberlain SM, et al. Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births. J Sex Med 2020; 17:257-272.

Neuromodulation for Pelvic and Urogenital Pain

Chronic pain affecting the pelvic and urogenital area is a major clinical problem with heterogeneous etiology, affecting both male and female patients and severely compromising quality of life. In cases where pharmacotherapy is ineffective, neuromodulation is proving to be a potential avenue to enhance analgesic outcomes. However, clinicians who frequently see patients with pelvic pain are not traditionally trained in a range of neuromodulation techniques. The aim of this overview is to describe major types of pelvic and urogenital pain syndromes and the neuromodulation approaches that have been trialed, including peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and brain stimulation techniques. Our conclusion is that neuromodulation, particularly of the peripheral nerves, may provide benefits for patients with pelvic pain. However, larger prospective randomized studies with carefully selected patient groups are required to establish efficacy and determine which patients are likely to achieve the best outcomes.

Climacteric women at work: What lurks behind poor occupational quality of life?

Physical and psychological changes during menopausal transition may affect various aspects of everyday functioning including women's work ability and work productivity. Presence of menopausal symptoms has been well-acknowledged to negatively affect quality of life (QOL). However, data on factors associated with occupational QOL among women at this period of life are lacking. The authors' purpose in this study was to evaluate factors affecting occupational QOL in a sample of employed mid-life women who are experiencing menopause. The authors performed a cross-sectional study among 335 employed women aged 40 to 65 years from Serbia. Socio-demographic questionnaire, Utian's Quality of Life Scale, and Beck's Depression Inventory were used in data collection. Women's average monthly household income and educational level were positively correlated, while having uterine prolapse was negatively associated with occupational QOL. Significant regression models assessing impact of gynecological illnesses and menopause-specific symptoms on occupational QOL (direct value and categories-below vs. above mean) showed that having insomnia, uterine prolapse, and genital inflammations may differentiate "good" from "poor" occupational QOL. Uterine prolapse, genital inflammation, and insomnia were associated with worse occupational QOL among working women in menopausal transition.

Six Out of Ten Women with Recurrent Urinary Tract Infections Complain of Distressful Sexual Dysfunction - A Case-Control Study

Uncomplicated recurrent urinary tract infections (rUTIs) are common among reproductive-aged women. We aimed to assess the prevalence and predictors of sexual dysfunction (FSD) in a cohort of women with rUTIs and compare their psychometric scores to those of matched controls. Data from 147 rUTIs women and 150 healthy controls were analysed. Participants completed the International Prostatic Symptoms Score (IPSS), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (SDS). Descriptive statistics and logistic regression models tested prevalence and predictors of distressful FSD. Women with rUTIs had lower FSFI scores (p < 0.001) and a greater proportion of pathological FSFI (78.9% vs. 21.4%; p < 0.001) and SDS scores (77.8% vs. 21.4%; p < 0.001) than controls. Of rUTIs patients, 88 (60%), 77 (52.2%), and 75 (51.1%) reported pathological scores for FSFI-pain, lubrication and arousal, respectively; moreover, 64% had concomitant pathological FSFI and SDS scores. Age, IPSS severity, rUTIs, a history of ≥6 UTIs/year and a history of constipation were independent predictors of pathologic FSFI and SDS (all p ≤ 0.05). In conclusion, up to 80% of women with rUTIs showed pathologic FSFI and SDS scores, with 60% reporting scores suggestive of distressful FSD. Having ≥6 UTIs/year and a history of constipation independently predicted distressful FSD.