An approach to discussing personal and social identity terminology with patients.

As the United States of America becomes more socially diverse, it is more important now than ever for health care providers to become more aware of their patients' social identities. It is imperative that providers engage with their patients and see how each of them identifies personally in relation to social construction terminology. As with the terminology of human anatomy, there is a vast and diverse vocabulary concerning the anatomy of society, which is also clinically relevant to health care providers. If health care providers take the initiative to discuss how their patients identify, they can understand better how those patients experience the world, and this can significantly affect many facets of their health and health care experience. Giving respect fosters the creation of a strong relationship within which patients can share very personal and intimate information, which in turn allows health care providers the possibility of providing the best healthcare. This discussion will build upon and integrate current academic research and opinion for tangible clinical use while discussing various social and personal identities, including but not limited to race, gender, gender expression, sex, sexual orientation, religion, ethnicity, socioeconomic class, and physical and mental abilities. Clin. Anat. 31:136-139, 2018. © 2017 Wiley Periodicals, Inc.

Anatomy of genital reaffirmation surgery (male-to-female): Vaginoplasty using penile skin graft with scrotal flaps.

Gender reaffirmation surgery is the final step in an individual's transition to their preferred gender. A clear understanding of the anatomy pertinent to this procedure is essential by the surgeon and patient. In male-to-female transgenders, female genitalia is constructed using the individual's penile skin to form the neovaginal canal and their scrotal skin folds post orchiectomy to create the labia majora. The surgical precursors of the remaining anatomical structures of the female genitalia are as follows: the clitoris is crafted from the glans penis and hence retains its innervation, the labia minora is formed using excess penile skin tissue, and the long male urethra is shortened to that of its feminine counterpart. The main goal of these reconstructive methods is to create a functionally and aesthetically acceptable vagina and vulva, as well as normal voiding function and satisfactory sexual function. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Review of the relevant literature regarding the anatomy, procedure development, and outcomes is presented. Vaginoplasty utilizing penile skin grafts with scrotal flaps provides an aesthetically acceptable and psychologically satisfying results with normal voiding and sexual function. An advantage includes preserved erogenous sensation. Complications can arise, including chronic inflammation and fistula formation. The anatomy of vaginoplasty using penile skin grafts with scrotal flaps supports patients seeking male-to-female gender reaffirmation surgery. Clin. Anat. 31:140-144, 2018. © 2017 Wiley Periodicals, Inc.

The evolution of transgender surgery.

An estimated 1.4% of the population worldwide has been diagnosed with Gender Dysphoria, as defined by the Diagnostic and Statistical Manual of Mental Disorders. Gender reassignment, which holistically encompasses psychotherapy, hormonal therapy and genital and nongenital surgeries, is considered the most effective treatment for transgender nonconforming patients afflicted with gender dysphoria. Little research is currently available identifying the psychosocial needs of the transgender population and their access to preventative and primary care during this transitioning process. This article presents an overview of the evolution and current approaches to genital surgical procedures available for both male-to-female, as well as female-to-male gender-affirmation surgeries. Clin. Anat. 31:878-886, 2018. © 2018 Wiley Periodicals, Inc.

Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males.

Incidence of transexualism and request for neophalloplasty is increasing yielding a current prevalence of trans-male in the USA of 1:2500. Surgeons have explored various techniques to improve desirable outcomes of neophallic construction, decrease the length of surgery, and minimize stigmatizing scars. The anterolateral thigh (ALT) flap is an alternative to the traditional radial forearm flap for patients who do not want a forearm scar. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The ALT flap is a skin, fat and fascia flap that is usually supplied by the descending branch of the lateral circumflex femoral vessels and the lateral femoral cutaneous nerve. However, variability in neurovascular supply does exist with important clinical implications. In the pedicled surgical procedure, neurovascular supply is left partly attached to the donor site ("pedicle") and simply transposed to the perineum, keeping the pedicle intact as a conduit to supply the tissue with blood and innervation. ALT flap offers clinical advantages of less obvious donor site concealable with clothing, decreased surgical time, preservation of erogenous sensation and vascular supply of the flap without microsurgical anastomosis of nerves and vessels, and good potential for urethroplasty. This surgery may be difficult in patients with thicker skin and more subcutaneous thigh fat. Clin. Anat, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

The anatomy of abdominal flap phalloplasty for transgender surgery.

Abdominal flap phalloplasty is surgical construction of a neophallus using a pedicled abdominal flap for patients transitioning female to male, for males whose penis is congenitally absent, or lost from trauma. It is an option for trans men whose goals do not require urethroplasty or vaginectomy but would like a phallus suitable for male gender appearance. A prosthesis can be placed for penetrative sexual capability. Surgical text descriptions were enhanced by creation of new anatomic illustrations. Anatomy of donor site and surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. Significant structures of the donor site of the abdominal flap include the superficial external pudendal artery and ilioinguinal nerve that provide the blood supply and sensory innervation to the base of the flap, respectively. As a pedicled phalloplasty procedure, microsurgical anastomosis is not needed. Patients can expect to have tactile sensation but not innate rigidity. The dorsal nerve of clitoris (and sometimes the clitoris itself) is preserved to provide erogenous sensation. Abdominal flap phalloplasty makes it possible to maintain the natural blood supply and innervation to the neophallus. The neophallus created by abdominal flap phalloplasty has the advantage of homogeneous skin color and texture from contiguous skin. Grafting leaves a less stigmatizing horizontal scar running from one side of the pelvis to the other along the lower abdomen. The anatomy of the abdominal flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:181-186, 2018. © 2017 Wiley Periodicals, Inc.

Neovaginal Construction with Pelvic Peritoneum: Reviewing an Old Approach for a New Application.

Transgender reassignment surgeries have become a major topic of interest within the last decade. Although there are numerous surgical techniques for male-to-female reassignment, a physician must assess each patient's anatomy and past medical history to determine the most suitable technique. Additionally, patient preference is important. The neovaginal constructive technique most commonly used in male-to-female reassignment surgery is penile skin inversion, but various other techniques and tissues can also be used including pelvic peritoneum, buccal mucosa, and bowel. Surgical text descriptions were enhanced by creating new anatomical illustrations. Donor and recipient site anatomies, and the surgical technique leading to creation of the neovagina, are demonstrated in detail with relevant illustrations. A review of the literature concerning the anatomy, procedure development, and outcomes is presented. The pelvic peritoneum was originally used in neovaginal construction for females with vaginal agenesis as a result of MRKH syndrome. The use of this technique to create a neovagina in male-to-female transgender reassignment surgery has become appealing owing to the relative ease of the procedure, low complication rates, and overall high patient satisfaction. This technique offers a potential new choice for transgender male-to-female neovaginal construction, but further studies are needed to confirm its successful use in transgender surgery. Clin. Anat. 31:175-180, 2018. © 2017 Wiley Periodicals, Inc.

The anatomy of free fibula osteoseptocutaneous flap in neophalloplasty in transgender surgery.

The Free Fibula Osteoseptocutaneous flap is a reliable option when used in neophalloplastic procedures. It possesses intrinsic rigidity that is sufficient for penetrative intercourse, and satisfactory sensation. We review the pros and cons of this procedure, as well the anatomy and surgical steps involved. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites, as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The free fibula osteoseptocutaneous flap provides the neophallus with many desirable characteristics. Its thick subcutaneous and fascial layer, along with the thicker fibula (compared to the radius), allows for a neophallus of greater diameter. Skin marking, flap lifting, and transfer to the perineum with all relevant neurovascular anastomosis; fibular artery is anastomosed with the femoral artery, while the fibular veins are anastomosed to branches of the saphenous vein, as well as neurorrhaphy of the dorsal nerves of the clitoris and the LSCN are demonstrated. The osteomatized fibula is fixed to the periosteum of the pubic symphysis as shown. Anatomical traits of the Free Fibula Osteoseptocutaneous flap allow intercourse without prosthesis. The donor-site scar in this procedure can be covered by a long sock, and donor site morbidity is acceptable. Clin. Anat. 31:169-174, 2018. © 2018 Wiley Periodicals, Inc.

Perceptions of the living dead: An assessment of knowledge and opinions about whole body donation, its process, and willingness to become cadaveric donors in Pennsylvania.

Despite the many important uses for human cadavers, there is a relative shortage of bodies donated to the scientific community in the United States of America. The purpose of this study was to determine the community's perceptions regarding whole body donation and their willingness to become donors. Moreover, we aimed to investigate people's understanding of the process of whole body donation, and examine their opinions regarding its importance. Individuals in Erie, Pennsylvania were surveyed. Data were collected via a questionnaire, which was offered to friends and family members of patients in the waiting area of the UPMC Hamot Surgery Center. All participants were residents of Erie County. The questionnaire was designed to evaluate knowledge and opinions about whole body donation. A total of 123 people completed the survey. We found people were willing to become whole body donors and understood the importance of this giving act, but lacked understanding about the registration process and the use of donated bodies. Participants revealed the belief that they have the right to decide what is to be done with their bodies after death, but did not indicate specific negative repercussions of becoming whole body donors. In conclusion, our findings indicate that the shortage of cadaveric donors could be due to lack of understanding about whole body donation and the registration process.

Terminal innervation of female genitalia, cutaneous sensory receptors of the epithelium of the labia minora.

INTRODUCTION: Little information is available regarding the sensory nerve endings within the glabrous skin of the external female genitalia. The diversity of possible sensations suggests a variety of receptor types. Comprehensive knowledge of the sensory stimuli, including stimulus position, changes in temperature, pressure and pain, is critical for addressing pain and sexual function disorders clinically. The aim of this neuro-histological study is document the presence and characteristics of cutaneous sensory receptors in female genital tissue. MATERIALS AND METHODS: Labial skin samples were obtained from ten normal girls (aged 1-9 years). The specimens were waste tissue obtained during surgical intervention. They were all obtained by the senior investigator, a pediatric urologist, after the parent or legal guardian had given informed consent. The specimens were stained by Cajal-type silver impregnation and by immunocytochemistry against protein gene product (PGP) 9.5 and neuron-specific enolase (NSE). RESULTS: PGP 9.5 was the most sensitive neural marker for identifying cutaneous sensory receptors. Free nerve endings (FNEs) in the papillary dermis appeared as thin fibers, varicose, branched or single processed, straight or bent. In the labia minora, FNEs were identified in the strata basale, spinosum and granulosum of the epidermis. Non-capsulated (Meissner-like) corpuscles in the dermal papillae interdigitated with epidermal ridges of the skin. Capsulated corpuscles protruded from the deep dermis into the epidermis. Encapsulated corpuscles and cells located in the inner and outer cores were strongly positive for PGP 9.5. CONCLUSIONS: FNEs, Meissner's corpuscles and Pacinian corpuscles are present in the female labia minora and exhibit characteristic staining patterns.

Self-assessment of anatomy, sexual sensitivity, and function of the labia and vagina.

Patient perceptions of genital esthetics are motivating requests for plastic surgeries that could change sexual sensitivity. There is little information about the sensitivities of labial and introital sites. The aim of this study is to assess the relationship between sexual sensitivity and self-reported sizes of labial and introital sites. Sixty-two healthy, sexually active, adult women (mean age 37.9, range 21-60) with no history of genital or vaginal surgery gave written consent to participate in this study. A modified version of Self-Assessment of Genital Anatomy and Sexual Function (L-SAGASF-F) was used to assess labial and introital size. Site-specific sensation was rated on Likert scales of 1-5. Anatomical locations were compared for ratings. Of 62 responders, 84% (52) described their labia as "average-sized," 11% (7) described their labia minora and 13% (8) their labia majora as "large", and 3% (2) and 5% (3) as "small". Sexual pleasure ratings were "moderate" (median value: 3.0 for external genitalia and vaginal lumen) or "strong" (median value: 4.0 for the interior vagina). Significantly higher rankings related to the vaginal opening (P=0.007). Orgasm intensity for stimulation of the external genitalia progressively increased toward the vaginal opening, from 1.0 to 3.0 (P=0.001); vaginal ratings showed a similar progression, from 2.0 at the external luminal margin to 3.0 in the deep interior (P<0.0001). Orgasm effort scores were intermediate (median: 3.0), uniform throughout the external and internal areas (P=0.626). Ratings for labial and introital sensitivity, regardless of self-reported size, were very similar to those at other genital sites for sexual pleasure. Surgical excision of labial and introital structures could modify sexual sensation.

Terminal innervation of the male genitalia, cutaneous sensory receptors of the male foreskin.

PURPOSE: Understanding the types of sensory nerve termini within the glabrous skin of the human male foreskin could throw light on surgical outcomes and therapeutic possibilities for the future. Various receptor types sense changes in temperature, position, pressure, pain, light touch, itch, burning and pleasurable sexual sensations. Similarities and differences in innervation characteristics and density might become apparent when the glans penis is compared with homologous structures in the female genitalia. The aim of this study is to document the presence and characteristics of cutaneous sensory receptors in the human penile foreskin using a histopathological study of the nerve termini to achieve a more complete understanding of sensory experiences. METHODS: Foreskin samples were obtained from ten boys (aged 1-9 years) who had undergone circumcision. Informed consent was obtained from the parent/legal guardian. The samples were examined after modified Bielschowsky silver impregnation of neural tissue, and immunocytochemistry against gene protein product (PGP) 9.5 and neuron-specific enolase (NSE). RESULTS: PGP 9.5 appeared to be the most sensitive neural marker. Free nerve endings were identified in the papillary dermis visualized as thin fibers, mostly varicose, with either branched or single processes, either straight or bent. Two types of sensory corpuscle were identified: capsulated and non-capsulated. Meissner-like corpuscles were located in the papillary dermis. Capsulated corpuscles resembled typical Pacinian corpuscles, comprising a single central axon surrounded by non-neural periaxonic cells and lamellae. The capsulated corpuscles were strongly positive for PGP 9.5 and NSE. CONCLUSIONS: Free nerve endings, Meissner's corpuscles and Pacinian corpuscles are present in the human male foreskin and exhibit characteristic staining patterns.

Male circumcision decreases penile sensitivity as measured in a large cohort.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The sensitivity of the foreskin and its importance in erogenous sensitivity is widely debated and controversial. This is part of the actual public debate on circumcision for non-medical reason. Today some studies on the effect of circumcision on sexual function are available. However they vary widely in outcome. The present study shows in a large cohort of men, based on self-assessment, that the foreskin has erogenous sensitivity. It is shown that the foreskin is more sensitive than the uncircumcised glans mucosa, which means that after circumcision genital sensitivity is lost. In the debate on clitoral surgery the proven loss of sensitivity has been the strongest argument to change medical practice. In the present study there is strong evidence on the erogenous sensitivity of the foreskin. This knowledge hopefully can help doctors and patients in their decision on circumcision for non-medical reason. OBJECTIVES: To test the hypothesis that sensitivity of the foreskin is a substantial part of male penile sensitivity. To determine the effects of male circumcision on penile sensitivity in a large sample. SUBJECTS AND METHODS: The study aimed at a sample size of ≈1000 men. Given the intimate nature of the questions and the intended large sample size, the authors decided to create an online survey. Respondents were recruited by means of leaflets and advertising. RESULTS: The analysis sample consisted of 1059 uncircumcised and 310 circumcised men. For the glans penis, circumcised men reported decreased sexual pleasure and lower orgasm intensity. They also stated more effort was required to achieve orgasm, and a higher percentage of them experienced unusual sensations (burning, prickling, itching, or tingling and numbness of the glans penis). For the penile shaft a higher percentage of circumcised men described discomfort and pain, numbness and unusual sensations. In comparison to men circumcised before puberty, men circumcised during adolescence or later indicated less sexual pleasure at the glans penis, and a higher percentage of them reported discomfort or pain and unusual sensations at the penile shaft. CONCLUSIONS: This study confirms the importance of the foreskin for penile sensitivity, overall sexual satisfaction, and penile functioning. Furthermore, this study shows that a higher percentage of circumcised men experience discomfort or pain and unusual sensations as compared with the uncircumcised population. Before circumcision without medical indication, adult men, and parents considering circumcision of their sons, should be informed of the importance of the foreskin in male sexuality.

Inhibitory effects of 405 nm irradiation on Chlamydia trachomatis growth and characterization of the ensuing inflammatory response in HeLa cells.

BACKGROUND: Chlamydia trachomatis is an intracellular bacterium that resides in the conjunctival and reproductive tract mucosae and is responsible for an array of acute and chronic diseases. A percentage of these infections persist even after use of antibiotics, suggesting the need for alternative treatments. Previous studies have demonstrated anti-bacterial effects using different wavelengths of visible light at varying energy densities, though only against extracellular bacteria. We investigated the effects of visible light (405 and 670 nm) irradiation via light emitting diode (LEDs) on chlamydial growth in endocervical epithelial cells, HeLa, during active and penicillin-induced persistent infections. Furthermore, we analyzed the effect of this photo treatment on the ensuing secretion of IL-6 and CCL2, two pro-inflammatory cytokines that have previously been identified as immunopathologic components associated with trichiasis in vivo. RESULTS: C. trachomatis-infected HeLa cells were treated with 405 or 670 nm irradiation at varying energy densities (0 - 20 J/cm2). Bacterial growth was assessed by quantitative real-time PCR analyzing the 16S: GAPDH ratio, while cell-free supernatants were examined for IL-6 and monocyte chemoattractant protein-1 (CCL2) production. Our results demonstrated a significant dose-dependent inhibitory effect on chlamydial growth during both active and persistent infections following 405 nm irradiation. Diminished bacterial load corresponded to lower IL-6 concentrations, but was not related to CCL2 levels. In vitro modeling of a persistent C. trachomatis infection induced by penicillin demonstrated significantly elevated IL-6 levels compared to C. trachomatis infection alone, though 405 nm irradiation had a minimal effect on this production. CONCLUSION: Together these results identify novel inhibitory effects of 405 nm violet light on the bacterial growth of intracellular bacterium C. trachomatis in vitro, which also coincides with diminished levels of the pro-inflammatory cytokine IL-6.

How generalized CNS arousal strengthens sexual arousal (and vice versa).

Heightened states of generalized CNS arousal are proposed here to facilitate sexual arousal in both males and females. Genetic, pharmacologic and biophysical mechanisms by which this happens are reviewed. Moreover, stimulation of the genital epithelia, as triggers of sex behavior, is hypothesized to lead to a greater generalized arousal in a manner that intensifies sexual motivation. Finally, launched from histochemical studies intended to characterize cells in the genital epithelium, a surprising idea is proposed that links density of innervation with the efficiency of wound healing and with the capacity of that epithelium to stimulate generalized CNS arousal. Thus, bidirectional arousal-related mechanisms that foster sexual behaviors are envisioned as follows: from specific to generalized (as with genital stimulation) and from generalized to specific.

Self- and proxy-reported outcomes after surgery in people with disorders/differences of sex development (DSD) in Europe (dsd-LIFE).

BACKGROUND: Surgery is performed in many individuals with disorders/differences of sex development (DSD). Irreversibility of some surgical procedures, lack of information about the procedures, and lack of follow-up care for physical and psychological outcomes, lead to wish for more knowledge from both surgeons and patients. After the consensus conference in 2006, multidisciplinary care is provided to a higher degree with psychological support and more restricted surgical procedures. Outcome studies after genital surgery often lack of patient's perspective. OBJECTIVE: To describe surgical procedures in relation to diagnosis, to evaluate the outcomes of surgery through genital examination, and through patient's and observer's satisfaction with the anatomical and functional result after genital surgery. STUDY DESIGN: In a cross-sectional clinical study performed in six European countries in 2014/15, we have included 500 participants where surgery was performed, from a total of 1040 adolescents (≥16years) and adults with a DSD. Diagnoses included Turner syndrome (n = 301), mixed gonadal dysgenesis (45,XO/46,XY; n = 45), Klinefelter syndrome (n = 218), XYY (n = 1), 46, XY DSD (n = 222) and 46, XX DSD (n = 253). Study protocol included clinical report files, an optional gynecological or urological examination, patient reported outcomes including received surgical interventions, satisfaction with appearance and function after surgery, and impact of the surgical procedure on life. RESULTS: Five hundred participants had received genital or breast surgery, with the highest rate in 46, XY DSD and the lowest in Turner syndrome. Altogether; 240 participants had feminizing surgery, 112 had masculinizing surgery, and 217 underwent gonadectomy. Physicians evaluated anatomical appearance at genital examination as poor in less than 10%. Dissatisfaction with anatomical appearance was reported by 22% of the participants, dissatisfaction with function by 20%. Being (very) dissatisfied with anatomical appearance and function was reported by 13% of the study participants. Most participants reported no impact, or positive impact, of the surgical procedures on their lives, but 29% experienced a negative effect of gonadectomy on their life. DISCUSSION: There might be a selection bias and/or a recall bias for participating in our studies. Due to poor data quality about surgical procedures performed in the past, we also relied on participants memory about surgical procedures in their past. Ideally, patient reported outcomes should be evaluated both before and after surgical procedures. CONCLUSION: A vast majority are satisfied with appearance and function, but still genital or breast surgery have a long-lasting effect on patient's life. Self-reported satisfaction is usually lower than the observer's evaluation regarding both appearance and function.

Fatal anorectal trauma in the setting of sexual assault: case report and literature survey.

Homicides exclusively due to genital trauma have not been widely reported, and anorectal trauma in sexual assaults is uncommon. We describe a case of a 45-year-old white woman who sustained devastating homicidal colorectal trauma that served as a primary cause of death in the setting of rape. Our patient sustained a 15-cm laceration of the anterior rectal wall and ultimately died of peritonitis and sepsis. Death from rectal perforation and sepsis in the setting of sexual assault is rare and has only been documented in 3 other cases, 2 pediatric patients and 1 elderly debilitated patient. Other representative and unique methods of perforation are reviewed along with a brief discussion of the development of peritonitis after perforating colorectal trauma.

Adequacy of sanitization and storage of catheters for intermittent use after washing and microwave sterilization.

PURPOSE: Clean intermittent catheterization is used to treat neurogenic bladders and it can be adequate to maintain sterile urine. Typically polyvinylchloride, individually packaged catheters are used but they are not intended for repeat use by the manufacturer. Antibacterial soap alone or combined with microwave heating was advocated to decrease pathogens and bacterial residue, which could inoculate the bladder from a colonized catheter. We assessed the efficacy of catheter sanitizing and storage for reuse. MATERIALS AND METHODS: Catheters were inoculated with a 24-hour broth culture of Escherichia coli and washed in antibacterial soap, washed and microwaved or immediately packaged (positive controls) and stored for 1, 3 and 7 days, respectively. Common packaging was used, including paper towels, sealable plastic bags or sealable rigid plastic containers. Each condition was assessed in triplicate via culture of the entire catheter contents, yielding a total of 27 catheters per sanitization method. RESULTS: Antibacterial wash alone failed to sanitize 67% of catheters (6 of 9 with 2 of 3 positive per container) on day 1, 22% (2 of 9 with all positive catheters in a paper towel) on day 3 and 44% (4 of 9 with 1 in a paper towel and 3 in a plastic container) on day 7. For combined antibacterial wash and microwave heating the positive rate was 0% (0 of 9 catheters) on day 1, 22% (2 of 9 in a plastic container) on day 3 and 56% (5 of 9 with 3 in a paper towel, 1 in a plastic bag and 1 in a plastic container) on day 7. Positive untreated controls showed viable organisms throughout the test period. CONCLUSIONS: Overall 44% of catheters (12 of 27) washed with antibacterial soap yielded E. coli vs 26% (7 of 27) with combined antibacterial soap-microwave treatment. The latter is a more effective but not an absolute way to sanitize catheters for intermittent use. Longer storage time increased the risk of E. coli growth on the catheters.

Self-ratings of genital anatomy, sexual sensitivity and function in men using the 'Self-Assessment of Genital Anatomy and Sexual Function, Male' questionnaire.

OBJECTIVE: To assess the perceptions of healthy men of their genital anatomy and sexual sensitivity, along with the re-test reliability of these ratings, in a new self-reported questionnaire, the Self-Assessment of Genital Anatomy and Sexual Function, Male (SAGASF-M). SUBJECTS AND METHODS: Eighty-one healthy, sexually active, men aged 22-57 years (median 33), with no history of genital surgery, completed the SAGASF-M. This questionnaire comprises written text and images enabling men to rate details of their genital appearance, overall genital erotic and pain sensitivity, orgasm intensity, and effort required for achieving orgasm through stimulation of specified areas around the glans and shaft of the penis, scrotum and anus, along with the contribution of other sexually sensitive areas of the body. Anatomical locations were compared for the functional ratings by mixed-model analysis of variance (anova). A second sample of 38 healthy men (median age 26 years, range 22-64) from the same source completed the SAGASF-M twice with an interval of 2 weeks. RESULTS: There was little variability in anatomy ratings. Ratings of overall penile sensitivity to sexual stimulation gave higher values of 'sexual pleasure' for penile stimulation by the partner than by self (P = 0.002) and marginally higher ratings of 'orgasm intensity' by partner stimulation (P = 0.077), but there were no corresponding differences on ratings of 'effort needed to reach orgasm' or of 'discomfort/pain'. Overall discrimination between genital areas was highly significant (mixed-model anova, P = 0.001) for ratings of 'sexual pleasure', 'orgasm intensity' and 'orgasm effort', but was not significant for 'discomfort/pain'. Ranked by degree of 'sexual pleasure', the area 'underside of the glans' was highest, followed by 'underside of the penile shaft', 'upper side of the glans', 'left and right sides of the glans', 'one or both sides of the penis', 'upper side of the penile shaft', 'foreskin' (11 subjects), 'skin between the scrotum and anus', 'back side of the scrotum', 'front side of the scrotum', and 'around anus', but not all pair differences were significant. The rank order was similar for 'orgasm intensity', but less similar and with fewer significant pair differences for 'orgasm effort'. Overall discrimination of other body parts that help orgasm when touched/stimulated was also highly significant (P = 0.001) and included (in order of degree) scrotum, ear, skin between scrotum and anus, neck, breast/nipples, buttocks, anus (exterior skin), anus (inside with penetration), wrist, and axilla, but many pair differences were not significant. In the reliability study, which was limited to the 45 function items with sufficient variability and sample size, the re-test reliability values (Pearson r) were distributed as follows: seven were >or=0.80, 16 >or=0.70, 15 >or=0.60, four >or=0.50, two >or=0.40, and one >or=0.30. CONCLUSION: The SAGASF-M discriminates reasonably well between various genital and nongenital areas in terms of erotic sensitivity, when administered to genitally unoperated men varying widely in age and socio-economic level.

Clitoral sexual arousal: neuronal tracing study from the clitoris through the spinal tracts.

PURPOSE: Although genital tactile stimulation is regarded as a precursor to sexual arousal and a recognized initiator of central nervous system arousal, specific afferent neural pathways transmit sensory stimuli of arousal, beginning at the epithelial level on the clitoris and following the course of arousal stimuli through the central nervous system. Limited knowledge exists of the pathway from the cutaneous receptors of nerves originating in the epithelial tissue of the clitoris and continuing to spinal cord afferents. Such information may contribute to an understanding of sexual arousal, particularly in female vertebrates. We further defined the neural pathways and mechanisms responsible for arousal originating in the epithelium of the clitoris as well as related neural pathways to the spinal cord in a murine model. MATERIALS AND METHODS: We performed a comprehensive review of the published relevant clinical and histological material from human and nonhuman vertebrate studies. In 29 adult female C57B1/6 mice the distribution of pelvic nerves and vessels was mapped. Gross dissection of 4 female mice was facilitated by resin injection of the vascular system in 2. Neuronal tracing was performed in 25 mice that received clitoral injection of wheat germ agglutinin-horseradish peroxidase into the clitoris and were sacrificed after 72 to 96 hours. The spinal cord and periclitoral tissue were removed and fixed. Immunohistochemistry was performed. RESULTS: Gross anatomy of the mouse clitoris showed that pudendal and hypogastric nerves have a major role in the innervation of the external genitalia. Neuronal tracing revealed that the greatest nerve density was noted in the L5/6 spinal cord. The distribution extended from S1 to L2 with no labeling seen in the L3 spinal cord. Wheat germ agglutinin-horseradish peroxidase labeling was seen caudal in levels S1 through L4 and rostral in L2. CONCLUSIONS: Understanding the neuroanatomy of the clitoris using a murine model may provide a valuable tool for the study of sexual arousal disorders and the further understanding of sexual function related to neural pathologies and trauma.

Oestrogen receptor expression and neuronal nitric oxide synthase in the clitoris and preputial gland structures of mice.

OBJECTIVE: To study the presence of oestrogen receptors (ER) and neuronal nitric oxide synthase (nNOS) in the mouse clitoris. MATERIALS AND METHODS: A series of sections of the pelvic area, including the preputial glands and clitoris, of 10 mice were assessed by immunocytochemical studies specific for ER-alpha and -beta, and nNOS; selected sections were also stained with Masson's trichrome. RESULTS: ER alpha was detected in the epithelium of the gland of the clitoris, and in the glandular tissue, preputial and apocrine gland. ER alpha was detected in the nuclei of stromal cells around the cavernous tissue and near the epithelium of the clitoris. Cytoplasm ER alpha was detected in a few cells in an area ventral to the clitoral gland. There was also nuclear staining in the connective tissue cells surrounding the clitoris. Very light ER beta immunostaining was detected in the clitoris and in the tissue related to it. There were some cells with nuclear staining in the vessels of the cavernous tissue of the clitoris. nNOS immunostaining was detected in the clitoris, the preputial gland and the connective tissue. CONCLUSION: ER alpha and beta isoforms, and nNOS, are present in the clitoris and preputial glands of female mice in different cellular locations and with differing levels of receptivity. Functional studies would further elucidate the role of receptor functions and their relationship to the neuronal expression of NO.