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.

The overlooked reproductive function of the human clitoris-News media responses to the published review.

A brief survey of how the news media reported and misreported on the publication of the review that revealed the overlooked empirical evidence for the reproductive function of the human clitoris.

The Clitoris-An Appraisal of its Reproductive Function During the Fertile Years: Why Was It, and Still Is, Overlooked in Accounts of Female Sexual Arousal.

Stimulating the clitoris activates the brain to instigate changes in the female genital tract, namely, the enhancement of vaginal blood flow that increases vaginal luminal pO2 , vaginal transudate (lubrication) facilitating painless penile penetration and partial neutralization of the basal luminal acidic pH, vaginal tenting, and ballooning delaying sperm transport and allowing semen de-coagulation and capacitation (sperm activation) factors to act until arousal ends (often by orgasm induction). All these genital changes taken together are of major importance in facilitating the possibility of reproductive success (and thus gene propagation) no matter how or when the clitoris is stimulated-they reveal its overlooked reproductive function. Of course, also commensurate with these changes, is its activation of sexual pleasure. The clitoris thus has both procreative (reproductive) and recreative (pleasure) functions of equal importance. Clitoridectomy creates not only sexual disability but also a reproductive disability. Clin. Anat. 32:136-145, 2019. © 2019 Wiley Periodicals, Inc.

The clitoral activation paradox - Claimed outcomes from different methods of its stimulation.

This article reviews clitoral structures, their functions and how they are activated during the stages of female life. The paradox that occurs is that different procedures of activation are claimed by some to favor 'noxious outcomes' to the physical and psychic health of women who use it to achieve sexual arousal/orgasm with or without penile vaginal intercourse. A number of the difficulties and inconsistencies in relation to these claims are explored. The proposed justification for the 'noxious outcomes' is that 'evolution' punishes sexual arousals other than by coitus because it is the only one that leads to gene propagation. In this context, however, the new, evolutionary interpretation of clitoral function in the fertile years as a fundamental proximate mechanism for facilitating female reproductive fitness makes such a justification improbable. The role of coital alignment technique (CAT) in the treatment of female orgasmic disorder is discussed in relation to its features of introital, clitoral and periurethral glans stimulation. Attempts to control female sexuality through various 'clitoridectomies' are examined, and unanswered questions about clitoral stimulation are listed. Clin. Anat. 31:650-660, 2018. © 2018 Wiley Periodicals, Inc.

Exceptionalism is not exceptional in relation to sexual and reproduction mechanisms: Contrasts of human and animal sexuality.

Speculation that the release of oxytocin by orgasm in the human female during coitus facilitates fertility by enhancing uterine sperm transport has been criticized as having no unequivocal empirical human evidence. However, a counter claim that this supports human "exceptionalism" as some form of uterine sperm transport occurs in other species. This is a misconception as it ignores that human uterine peristalsis, powered by contractions of the smooth muscle of the archimyometrium, facilitates sperm transport even without any systemic oxytocin involvement. Moreover, examination of various unique reproductive mechanisms in numerous animals also indicates that the claim is misjudged and rests on a biased interpretation of what "exceptionalism" means in this biological context. Ten chosen aspects of our sexuality are presented as being exceptional to humans. Clin. Anat. 30:940-945, 2017. © 2017 Wiley Periodicals, Inc.

Toward a More Evidence-Based Nosology and Nomenclature for Female Sexual Dysfunctions-Part II.

INTRODUCTION: Current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) definitions of sexual dysfunction do not identify all sexual problems experienced clinically by women and are not necessarily applicable for biologic or biopsychosocial management of female sexual dysfunction. A unified nomenclature system enables clinicians, researchers, and regulatory agencies to use the same language and criteria for determining clinical end points, assessing research results, and managing patients. AIM: To develop nomenclature with classification systems for female sexual desire, arousal, and orgasm disorders with definitions pertinent to clinicians and researchers from multiple specialties who contribute to the field of sexual medicine. METHODS: Key national and international opinion leaders diverse in gender, geography, and areas of expertise met for 2 days to discuss and agree to definitions of female sexual desire, arousal, and orgasm disorders and persistent genital arousal disorder. The attendees consisted of 10 psychiatrists and psychologists; 12 health care providers in specialties such as gynecology, internal medicine, and sexual medicine; three basic scientists; and one sexuality educator, representing an array of societies working within the various areas of sexual function and dysfunction. MAIN OUTCOME MEASURE: A unified set of definitions was developed and accepted for use by the International Society for the Study of Women's Sexual Health (ISSWSH) and members of other stakeholder societies participating in the consensus meeting. RESULTS: Current DSM-5 definitions, in particular elimination of desire and arousal disorders as separate diagnoses and lack of definitions of other specific disorders, were adapted to create ISSWSH consensus nomenclature for distressing sexual dysfunctions. The ISSWSH definitions include hypoactive sexual desire disorder, female genital arousal disorder, persistent genital arousal disorder, female orgasmic disorder, pleasure dissociative orgasm disorder, and female orgasmic illness syndrome. CONCLUSION: Definitions for female sexual dysfunctions that reflect current science provide useful nomenclature for current and future management of women with sexual disorders and development of new therapies.

The Physiology of Female Sexual Function and the Pathophysiology of Female Sexual Dysfunction (Committee 13A).

INTRODUCTION: The article consists of six sections written by separate authors that review female genital anatomy, the physiology of female sexual function, and the pathophysiology of female sexual dysfunction but excluding hormonal aspects. AIM: To review the physiology of female sexual function and the pathophysiology of female sexual dysfunction especially since 2010 and to make specific recommendations according to the Oxford Centre for evidence based medicine (2009) "levels of evidence" wherever relevant. CONCLUSION: Recommendations were made for particular studies to be undertaken especially in controversial aspects in all six sections of the reviewed topics. Despite numerous laboratory assessments of female sexual function, genital assessments alone appear insufficient to characterise fully the complete sexual response.

Recreation and procreation: A critical view of sex in the human female.

This review deals critically with many aspects of the functional genital anatomy of the human female in relation to inducing sexual arousal and its relevance to procreation and recreation. Various controversial problems are discussed including: the roles of clitorally versus coitally induced arousal and orgasm in relation to the health of women, the various sites of induction of orgasm and the difficulty women find in specifically identifying them because of "'ambiguity problems" and "genital site pareidolia," the cervix and sexual arousal, why there are so many sites for arousal, why multiple orgasms occur, genital reflexes and coitus, the sites of arousal and their representation in the brain, and identifying aspects and functions of the genitalia with appropriate new nomenclature.

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.

Can the controversy about the putative role of the human female orgasm in sperm transport be settled with our current physiological knowledge of coitus?

INTRODUCTION: Spermatozoal uptake, facilitated by uterine contractions induced by oxytocin at orgasm during coitus, has been a long term concept. Studies attempting its support, however, have been poorly examined especially in the context of the changes in the female genital tract activated by sexual arousal. AIM: To examine experimental support for the concept. METHODS: Using a variety of search engines, mainly peer reviewed articles and un-reviewed books were examined relating to sperm transport and function in the human female genital tract in the absence and presence of arousal to orgasm. MAIN OUTCOME MEASURES: Identifying evidence-based data to support authority-based opinion. RESULTS: All the experimental observations of sperm or model substitute's transport have been undertaken in women who were not sexually aroused. They fail to take into account that arousal creates vaginal tenting lifting the cervico-uterine complex into the false pelvis away from the ejaculated semen. This delays sperm uptake and transport making conclusions from these observations invalid in relation to transport during coitus. Studies injecting oxytocin have not used women in their sexually aroused state and used supraphysiological doses unlikely to be comparable with coitus and orgasm. The proposal that the transport of extra sperm by oxytocin-induced uterine contractions at orgasm is needed to facilitate fertility ignores possible harm from increased sperm numbers creating polyspermy and sperm enzyme release causing ovum degeneration, leading to decreased fertility. The role of sperm motility in their uptake from the vagina into the cervix as opposed to en bloc transfer through uterine archimyometrial-mediated transport in the absence of orgasm is at present unresolvable because of conflicting studies. CONCLUSION: The bulk of the reported evidence favors the conclusion that the female orgasm, with its concomitant central release of oxytocin, has little or no effective role in the transport of spermatozoa in natural human coitus.

Physiology of women's sexual function: basic knowledge and new findings.

INTRODUCTION: Data concerning the physiology of female sexual functioning are still obtained from animal studies, but an increasing amount of novel evidence comes from human studies. AIM: To gain knowledge of psychological and biologic physiology of women's sexual functioning, mainly addressing sexual arousal and orgasm. METHODS: A broad-based literature review of current knowledge of the psychological and biologic physiology aspects of women's sexual functioning. RESULTS: A comprehensive understanding of the anatomical, neurobiological, and psychological mechanisms behind sexual function and responses is of paramount importance. A biopsychological paradigm was considered when reviewing currently available data, thus considering aspects of: (i) sexual differentiation of the brain, which is critical for sex differentiation in behavior; (ii) central neurobiology of sexual function, highlighting specific and innovative findings from neuroimaging methods that enable visualization of active brain areas during arousal and orgasm; and (iii) peripheral functional anatomy, mainly addressing genital arousal and orgasm. Translational science was also covered, providing data about the actual role of sexual arousal in women in both procreation/reproduction and recreation/pleasure. The interaction between physiological and psychological states of women's sexual response, nonspecific sexual response, interoceptive awareness, and flexibility of sexual interests have also been addressed. CONCLUSION: Further research on normal physiology of women's sexual function is needed in order to expand and "translate" current knowledge into the pathophysiological clinical setting. This manuscript encompasses data presented at the 3rd International Consultation on Sexual Medicine in Paris, France, July 10-13, 2009.

Revisiting post-ejaculation refractory time-what we know and what we do not know in males and in females.

INTRODUCTION: The post-ejaculation refractory time (PERT), the period after a single ejaculation when further erections and ejaculations are inhibited, has been studied and well-documented in male rats. Since its first attribution in men by Masters and Johnson and its inaccurate delineation in their graphic sexual response model in 1966 it has been infrequently studied whereas scant attention has been paid to any such possible activity in women after female ejaculation. AIM: To critically review our current knowledge about PERT in rats and humans and describe and correct shortcomings and errors in previous publications and propose corrections. METHODS: Review of published literature. MAIN OUTCOME MEASURES: Identifying evidence-based data to support authority-based facts. RESULTS: The review exposes the extremely limited evidence-based data that our knowledge of PERT is based on. The paucity of data for most aspects of human PERT is remarkable; even the generally accepted statement that the duration of PERT increases with age has no published support data. CONCLUSIONS: Despite numerous studies in rats the mechanisms and site(s) of the activity are poorly understood. Dopaminergic and adrenergic pathways are thought to shorten PERT whereas serotonergic pathways lengthen its duration. Raising the brain serotonin levels in men using SSRIs helps reduce early or premature ejaculation. Rats have an absolute PERT (aPERT) during which erection and ejaculation is inhibited and a relative PERT (rPERT) when a stronger or novel stimulus can, whether such phases exist in men is unexamined. Apart from possible depressed activity in the amygdala and penile dorsal nerve and rejection of prolactin as a major factor in PERT little or no significant advance in understanding human male PERT has occurred. No evidence-based data on women's PERT after female ejaculation exists. New investigations in young and older men utilizing brain imaging and electromagnetic tomography are priority studies to accomplish.

The clitoral photoplethysmograph: a new way of assessing genital arousal in women.

INTRODUCTION: In the present study, we introduce clitoral photoplethysmography as an instrument to assess clitoral blood volume (CBV). In research on female sexual functioning, vaginal pulse amplitude (VPA), as measured using vaginal photoplethysmography, has been used extensively as a measure of vaginal vasocongestion. Measurement of clitoral blood flow has thus far been problematic, mainly because of methodological constraints. AIM: To demonstrate that CBV is a valuable, easy to use complementary measure for the female sexual response, offering additional information to the VPA. METHODS: Thirty women with and without female sexual dysfunction (FSD) watched neutral and erotic film clips. At the end of the erotic clip, the session was interrupted to induce inhibition of the sexual response. Another neutral clip followed the interruption. VPA and CBV were measured simultaneously, as well as skin conductance levels (SCLs), to assess the amount of sympathetic activity. MAIN OUTCOME MEASURES: VPA, CBV, SCL. RESULTS: For both FSD and non-FSD women, VPA and CBV increased when sexually explicit material was presented. Changes in skin conductance significantly predicted changes in CBV (b = -0.61, t[27] = -3.88, P < 0.001), but not in VPA. A large increase in sympathetic activity was accompanied by a large decrease in CBV. Furthermore, a large increase in CBV at the end of the erotic film clip presentation, as compared with the neutral clip, was accompanied by a relatively small increase in VPA (b = -0.39, t[29] = -2.25, P < 0.033). CONCLUSION: CBV is a valid and sensitive tool to measure the female genital response. In the present study, it was particularly useful in investigating sexual inhibition, when used in combination with SCL. Furthermore, high CBV appeared to inhibit VPA, suggesting that VPA reflects an automatic preparatory response rather than genital arousal per se.

Vaginal vasomotion--its appearance, measurement, and usefulness in assessing the mechanisms of vasodilatation.

INTRODUCTION: In a number of tissue microcirculations, the phenomenon of vasomotion occurs where only a proportion of the total number of capillaries present are open at the same time; they normally open and close in a random or chaotic order, partly determined by the metabolic state of their surrounding cells. AIM: A pilot to examine by photoplethysmography whether the vaginal microcirculation shows evidence of vasomotion and the effect when sexual arousal is induced. METHODS: The vaginal microcirculation in 14 healthy, premenopausal women was monitored by intravaginal infrared photoplethysmography using the vaginal pulse amplitude (VPA) as the index of blood content in the basal condition and during sexual arousal induced by video and/or clitoral stimulation. MAIN OUTCOME MEASURE: Analysis and interpretation of vaginal photoplethysmographic traces. RESULTS: The basal traces in all the sexually unaroused subjects (N = 14) showed at least two populations of their VPAs: a high amplitude VPA (h-VPA) with rapid ascending phase (short duration of systolic infill) and descending phase (short duration of diastolic outflow) among which were pseudorandomly scattered, low amplitude VPAs (l-VPA) with less acute ascending and descending phases; the l-VPAs were usually half the amplitude of the h-VPAs. On sexual arousal, the l-VPAs were converted into h-VPAs so that the l-VPAs decreased and in some cases practically disappeared, and the h-VPAs usually showed an increase; with cessation of the vasodilatory stimulus (N = 6), there was a slow recovery of the l-VPAs. The induction of orgasm did not appear to facilitate their recovery. Even during a short duration of sexual arousal (1 minute), the decrease in the l-VPAs (N = 6) was a more sensitive index of the occurrence of genital arousal than relying solely on changes in the maximum amplitude of the VPA. CONCLUSION: Because of vasomotion, the vaginal microcirculation can react to a vasodilatory stimulus with one of four theoretical photoplethysmographic responses, viz., Type 1 (full response), where there is a significant increase in the amplitude of the h-VPA signal and the number of l-VPAs are greatly reduced with a near corresponding increase in the h-VPAs; Type 2 (partial response), where the amplitude (and in some cases the number) of the h-VPAs increases but there is no decrease in the number of l-VPAs; Type 3 (partial response), where the amplitude of the h-VPAs changes little but the number of l-VPAs is reduced and the number of h-VPAs are correspondingly increased; and Type 4, where neither the amplitude of the h-VPAs (or their number) nor the number of the l-VPAs change significantly (a noneffective stimulus). This new analysis allows a more comprehensive and better discriminatory assessment of vaginal vasodilatation (genital arousal) and its return to the basal state in response to sexual arousal and now includes a new measure that is independent of an increase in the h-VPA maximum amplitude (Type 3 response).

Nipple/Breast stimulation and sexual arousal in young men and women.

INTRODUCTION: The role of nipple/breast stimulation in influencing sexual arousal in men and women during lovemaking has only been the subject of opinion-based comment rather than evidence-based study. No attempt to question people about such sexual behavior has ever been undertaken. AIM: The study was designed to ascertain the effects of nipple/breast manipulation in young men and women on their sexual arousal. METHODS: A short questionnaire about nipple/breast stimulation during sexual activity was administered to 301 (148 men; 153 women) sexually experienced undergraduates (age range 17-29 years, 95% between 18 and 22). MAIN OUTCOME MEASURES: Replies to questions in questionnaire. RESULTS: The major findings in regard to the women were that 81.5% reported that stimulation of their nipples/breasts caused or enhanced their sexual arousal, 78.2% agreed that when sexually aroused such manipulation increased their arousal, 59.1% had asked to have their nipples stimulated during lovemaking, and only 7.2% found that the manipulation decreased their arousal. In regard to the men, 51.7% reported that nipple stimulation caused or enhanced their sexual arousal, 39% agreed that when sexually aroused such manipulation increased their arousal, only 17.1% had asked to have their nipples stimulated, and only 7.5% found that such stimulation decreased their arousal. CONCLUSION: Manipulation of the nipples/breasts causes or enhances sexual arousal in approximately 82% of young women and 52% of young men with only 7-8% reporting that it decreased their arousal.

Sleep exacerbation of persistent sexual arousal syndrome in a postmenopausal woman.

AIM: To investigate possible causes and treatment of persistent sexual arousal syndrome, which was exacerbated by sleep onset, in a postmenopausal subject. METHODS: A clinical examination and interviews with the patient to obtain her case history and follow-up of the effects of drug treatments. Pretreatment laboratory investigations monitored vaginal blood flow by photoplethysmography and heated electrode. Routine blood chemistry and endocrine assessments were undertaken. Magnetic resonance imaging (MRI) scans of brain, pelvis, and spinal cord and genito-sensory neural analysis of clitoral and vaginal areas were performed. A selective internal iliac artery arteriogram was utilized to check the normality of the pelvic blood supply. RESULTS: Genitalia appeared normal and uncongested. No structural abnormalities were observed in the MRI scans. Hormonal levels and blood chemistry were commensurate with the subject's postmenopausal status. Basal vaginal blood flow (heat electrode) was within the range of normal premenopausal women and showed (photoplethysmography) normal vasomotion. On becoming drowsy and falling lightly asleep in the laboratory the vaginal pulse amplitude (VPA) increased by 95% of the basal value and the low-amplitude VPAs were replaced by high-amplitude VPAs--all evidence of increased vaginal blood flow and congestion and confirming the subject's complaint of persistent sexual arousal during sleep. A simple cognitive task of repeatedly subtracting 7 from 500 out aloud did not hasten the reversion to the basal level. There was no evidence of malfunction of the brain, spinal cord, or pelvic area by MRI but genito-sensory analysis of the clitoral and vaginal area showed evidence of reduced sensory function. CONCLUSIONS: Of the treatments tried only risperidone has been effective allowing the subject to sleep throughout the night without disturbance and according to the subject has significantly reduced the aggravation of the arousal during the day.