Is the Female G‐Spot Truly a Distinct Anatomic Entity?

The prostate in women: an updated histological and immunohistochemical profile of the female periurethral glands and their relationship to an implanted midurethral sling

BACKGROUND

There is evidence of glandular tissue in the region of the anterior vaginal wall-female periurethral tissue (AVW-FPT) that has similar morphology and immunohistochemistry to the prostate in men. Surgical injury to this tissue has been suggested as a potential cause of sexual dysfunction following midurethral sling (MUS) procedures. However, the anatomy and embryology of these glands have not been fully resolved. This has led to difficulties in classifying this tissue as a prostate and defining its clinical significance related to MUS procedures.

AIM

To describe the histological and immunohistochemical characteristics of the female periurethral glands using markers of prostate tissue and innervation and to examine their anatomical relationships to an implanted MUS.

METHODS

Using gross and fine dissection, the AVW-FPT was dissected from 9 cadavers. Prior to dissection, 2 cadavers underwent simulation of the MUS procedure by a urogynecologist. Samples were paraffin embedded and serially sectioned. Immunohistochemistry was performed using markers of prostate tissue and innervation.

OUTCOMES

Redundant immunohistochemical localization of markers for prostatic tissue and innervation of the glandular tissue of the AVW-FPT, including the region of MUS implantation.

RESULTS

Female periurethral glands were immunoreactive for markers of male prostatic tissue, including prostate-specific antigen, androgen receptor, HOXB13, and NKX3.1. Markers of innervation (protein gene product 9.5, choline acetyl transferase, and vasoactive intestinal polypeptide) also localized to certain regions of the glandular tissue and associated blood supply. Surgical simulation of the MUS procedure demonstrated that some periurethral glands are located in close proximity to an implanted sling.

CLINICAL TRANSLATION

The AVW-FPT contains glandular tissue in the surgical field of MUS implantation. Iatrogenic damage to the female periurethral glands and the associated innervation during surgery could explain the negative impacts on sexual dysfunction reported following MUS procedures.

STRENGTHS AND LIMITATIONS

This is the first study to characterize the female periurethral glands using markers of prostatic tissue in concert with markers of general and autonomic innervation and characterize their anatomical relationships within the surgical field of MUS implantation. The small sample size is a limitation of this study.

CONCLUSION

We provide further evidence that the AVW-FPT contains innervated glands that are phenotypically similar to the male prostate and may share a common embryonic origin. The microscopic and immunohistochemical features of the periurethral glands may be indicative of their functional capacity in sexual responses. The location of these glands in the surgical field of MUS procedures underscores the clinical significance of this tissue.

A Review of Aesthetic Gynecologic Procedures for Women

Aesthetic gynecologic surgery is gaining popularity among women and physicians. Aesthetic genital surgery for women encompasses both minimally invasive and open surgical procedures. Cosmetic genital procedures for women described in this article include perineoplasty, vaginoplasty, vaginal rejuvenation, labiaplasty, G-spot enlargement, Bartholin gland surgery, clitoral hoodoplasty, clitroplasty, hymenoplasty, and mons pubis plastic surgery. Based on a review of the literature for each procedure, the article discusses procedural methods and techniques, indications for implementation, potential consequences and side effects of the procedure, nursing implications, patients' motives for undergoing the procedure, and positions of scientific institutions relative to the procedure.

Should We Call It a Prostate? A Review of the Female Periurethral Glandular Tissue Morphology, Histochemistry, Nomenclature, and Role in Iatrogenic Sexual Dysfunction

INTRODUCTION

There is evidence of glandular tissue within the region of the anterior vaginal wall-female periurethral tissue (AVW-FPT) having similar morphology and immunohistochemistry to the prostate in men and having physiological roles in the female sexual response (FSR). Whether this tissue should be called a prostate in women has been debated. Iatrogenic injury to structures of the AVW-FPT, including these glands and the associated neurovasculature, could be a cause of female sexual dysfunction (FSD).

OBJECTIVES

To consolidate the current knowledge concerning the glandular tissue surrounding the urethra in women, evidence was reviewed to address whether: (i) these glands comprise the prostate in women, (ii) they have specific functions in the FSR, and (iii) injury to the AVW-FPT and prostate has sexual dysfunction as a likely outcome.

METHODS

A literature review was conducted using keywords including female prostate, Skene's/paraurethral glands, periurethral tissue, Gräfenberg (G)-spot, female ejaculation, mid-urethral sling (MUS), and sexual dysfunction.

RESULTS

Histological and immunohistochemical studies of the glandular tissue surrounding the urethra support the existence of prostate in women. Evidence suggests this tissue may have physiologically and clinically relevant autonomic and sensory innervation, and during sexual arousal may contribute to secretions involved in ejaculation and orgasm. Gaps in knowledge relating to the functional anatomy, physiological roles, and embryological origins of this tissue have impeded the acceptance of a prostate in women. Injury to the innervation, vasculature, and/or glandular tissue within the surgical field of MUS implantation suggests iatrogenic sexual dysfunction is plausible.

CONCLUSIONS

Continuing to advance our understanding of the morphology, histochemistry, and physiologic capacity of this glandular tissue will clarify the characterization of this tissue as the "prostate" involved in the FSR, and its role in FSD following surgical injury. Tomalty D, Giovannetti O, Hannan J, et al. Should We Call It a Prostate? A Review of the Female Periurethral Glandular Tissue Morphology, Histochemistry, Nomenclature, and Role in Iatrogenic Sexual Dysfunction. Sex Med Rev 2021;XX:XXX-XXX.

A Review of Aesthetic Gynecologic Procedures for Women

Aesthetic gynecologic surgery is gaining popularity among women and physicians. Aesthetic genital surgery for women encompasses both minimally invasive and open surgical procedures. Cosmetic genital procedures for women described in this article include perineoplasty, vaginoplasty, vaginal rejuvenation, labiaplasty, G-spot enlargement, Bartholin gland surgery, clitoral hoodoplasty, clitroplasty, hymenoplasty, and mons pubis plastic surgery. Based on a review of the literature for each procedure, the article discusses procedural methods and techniques, indications for implementation, potential consequences and side effects of the procedure, nursing implications, patients' motives for undergoing the procedure, and positions of scientific institutions relative to the procedure.

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.

International Society for the Study of Vulvovaginal Disease Recommendations Regarding Female Cosmetic Genital Surgery

Female genital cosmetic surgeries (FGCSs) and procedures are increasingly being advertised as common, simple, and complication-free, capable of not only improving aesthetic appearance but also increasing self-esteem and sexual pleasure.Guidelines for physicians and clear, scientifically correct information for patients must be made available, to minimize the number of ineffective or deleterious procedures.The International Society for the Study of Vulvovaginal Disease positions/recommendations regarding FGCS are as follows:1. There is a wide variation regarding genital normalcy; providers must be able to explain this to women.2. There are no data supporting FGCS including, G-spot augmentation, hymenoplasty, vulvar and perianal bleaching/whitening, vaginal tightening procedures, and other procedures aimed at increasing sexual function.3. Women should not be offered FGCS before the age of 18 years.4. Women undergoing FGCS should be evaluated by a provider with expertise in vulvovaginal diseases, including attention to their psychological, social, and sexual context. Evaluation by an experienced mental health provider should be considered when the motivation for seeking surgery and/or expectations are not clear or realistic.5. Female genital cosmetic surgery is not exempt from complications.6. Informed consent must always be obtained.7. Surgeons performing FGCS should refrain from solicitous advertising or promoting procedures without scientific basis, including on Web sites.8. Surgeons should not perform surgery that they do not agree with and explain their rationale/position when pressured by patients.9. The genital surgeon must be adequately trained in performing FGCS including knowledge of the anatomy, physiology and pathophysiology of the vulva, vagina and adjacent organs.

Survey on Aesthetic Vulvovaginal Procedures: What do Portuguese Doctors and Medical Students Think?

Objective To assess the medical doctors and medical students' opinion regarding the evidence and ethical background of the performance of vulvovaginal aesthetic procedures (VVAPs). Methods Cross-sectional online survey among 664 Portuguese medical doctors and students. Results Most participants considered that there is never or there rarely is a medical reason to perform: vulvar whitening (85.9% [502/584]); hymenoplasty (72.0% [437/607]); mons pubis liposuction (71.6% [426/595]); "G-spot" augmentation (71.0% [409/576]); labia majora augmentation (66.3% [390/588]); labia minora augmentation (58.3% [326/559]); or laser vaginal tightening (52.3% [313/599]). Gynecologists and specialists were more likely to consider that there are no medical reasons to perform VVAPs; the opposite was true for plastic surgeons and students/residents.Hymenoplasty raised ethical doubts in 51.1% (283/554) of the participants. Plastic surgeons and students/residents were less likely to raise ethical objections, while the opposite was true for gynecologists and specialists.Most considered that VVAPs could contribute to an improvement in self-esteem (92.3% [613/664]); sexual function (78.5% [521/664]); vaginal atrophy (69.9% [464/664]); quality of life (66.3% [440/664]); and sexual pain (61.4% [408/664]). Conclusions While medical doctors and students acknowledge the lack of evidence and scientific support for the performance of VVAPs, most do not raise ethical objections about them, especially if they are students or plastic surgeons, or if they have had or have considered having plastic surgery.

The whole versus the sum of some of the parts: toward resolving the apparent controversy of clitoral versus vaginal orgasms

BACKGROUND

The nature of a woman's orgasm has been a source of scientific, political, and cultural debate for over a century. Since the Victorian era, the pendulum has swung from the vagina to the clitoris, and to some extent back again, with the current debate stuck over whether internal sensory structures exist in the vagina that could account for orgasms based largely on their stimulation, or whether stimulation of the external glans clitoris is always necessary for orgasm.

METHOD

We review the history of the clitoral versus vaginal orgasm debate as it has evolved with conflicting ideas and data from psychiatry and psychoanalysis, epidemiology, evolutionary theory, feminist political theory, physiology, and finally neuroscience.

RESULTS

A new synthesis is presented that acknowledges the enormous potential women have to experience orgasms from one or more sources of sensory input, including the external clitoral glans, internal region around the "G-spot" that corresponds to the internal clitoral bulbs, the cervix, as well as sensory stimulation of non-genital areas such as the nipples.

CONCLUSIONS

With experience, stimulation of one or all of these triggering zones are integrated into a "whole" set of sensory inputs, movements, body positions, autonomic arousal, and partner- and contextual-related cues, that reliably induces pleasure and orgasm during masturbation and copulation. The process of integration is iterative and can change across the lifespan with new experiences of orgasm.

Anatomic distribution of nerves and microvascular density in the human anterior vaginal wall: prospective study

Background

The presence of the G-spot (an assumed erotic sensitive area in the anterior wall of the vagina) remains controversial. We explored the histomorphological basis of the G-spot.

Methods

Biopsies were drawn from a 12 o’clock direction in the distal- and proximal-third areas of the anterior vagina of 32 Chinese subjects. The total number of protein gene product 9.5–immunoreactive nerves and smooth muscle actin–immunoreactive blood vessels in each specimen was quantified using the avidin-biotin-peroxidase assay.

Results

Vaginal innervation was observed in the lamina propria and muscle layer of the anterior vaginal wall. The distal-third of the anterior vaginal wall had significantly richer small-nerve-fiber innervation in the lamina propria than the proximal-third (p = 0.000) and in the vaginal muscle layer (p = 0.006). There were abundant microvessels in the lamina propria and muscle layer, but no small vessels in the lamina propria and few in the muscle layer. Significant differences were noted in the number of microvessels when comparing the distal- with proximal-third parts in the lamina propria (p = 0.046) and muscle layer (p = 0.002).

Conclusions

Significantly increased density of nerves and microvessels in the distal-third of the anterior vaginal wall could be the histomorphological basis of the G-spot. Distal anterior vaginal repair could disrupt the normal anatomy, neurovascular supply and function of the G-spot, and cause sexual dysfunction.

The pharmacology of the human female orgasm - its biological and physiological backgrounds

The female orgasm has been examined over the years by numerous scientific disciplines yet it still has many secrets to be disclosed. Because its physiology, especially its neurophysiology, is sparingly understood its pharmacology is necessarily limited based mainly on the side effects of drugs. Few published studies have used a placebo group as controls. The paucity of focussed studies is well illustrated by the fact that there still is no approved medication to treat female orgasmic dysfunction. The present brief overview examines the most important aspects of its biology and especially its physiology highlighting the many questions that need answering if we are to have a comprehensive pharmacology of the female orgasm.

Female genital cosmetic surgery: a review of techniques and outcomes

The aesthetic and functional procedures that comprise female genital cosmetic surgery (FGCS) include traditional vaginal prolapse procedures as well as cosmetic vulvar and labial procedures. The line between cosmetic and medically indicated surgical procedures is blurred, and today many operations are performed for both purposes. The contributions of gynecologists and reconstructive pelvic surgeons are crucial in this debate. Aesthetic vaginal surgeons may unintentionally blur legitimate female pelvic floor disorders with other aesthetic conditions. In the absence of quality outcome data, the value of FGCS in improving sexual function remains uncertain. Women seeking FGCS need to be educated about the range and variation of labia widths and genital appearance, and should be evaluated for true pelvic support disorders such as pelvic organ prolapse and stress urinary incontinence. Women seeking FGCS should also be screened for psychological conditions and should act autonomously without coercion from partners or surgeons with proprietary conflicts of interest.

Does the G-spot exist? A review of the current literature

In 1950, Gräfenberg described a distinct erotogenic zone on the anterior wall of the vagina, which was referred to as the Gräfenberg spot (G-spot) by Addiego, Whipple (a nurse) et al. in 1981. As a result, the G-spot has become a central topic of popular speculation and a basis of a huge business surrounding it. In our opinion, these sexologists have made a hotchpotch of Gräfenberg's thoughts and ideas that were set forth and expounded in his 1950 article: the intraurethral glands are not the corpus spongiosum of the female urethra, and Gräfenberg did not report an orgasm of the intraurethral glands. G-spot amplification is a cosmetic surgery procedure for temporarily increasing the size and sensitivity of the G-spot in which a dermal filler or a collagen-like material is injected into the bladder-vaginal septum. All published scientific data point to the fact that the G-spot does not exist, and the supposed G-spot should not be identified with Gräfenberg's name. Moreover, G-spot amplification is not medically indicated and is an unnecessary and inefficacious medical procedure.