3D quantitative analysis of normal clitoral anatomy in nulliparous women by MRI.

INTRODUCTION AND HYPOTHESIS: We present a 3D computational approach for automated clitoral measurements. We hypothesized that computationally derived measurements would be comparable and less variable than reported manual measures. METHODS: In this retrospective study, MRIs of 22 nulliparous women age 20-49 years with normal vaginal and clitoral anatomy were collected. Manual segmentations were performed to reconstruct 3D models of the whole clitoris (glans, body, crura, and bulbs) and vagina. The length, width, and volume of the clitoral structures and the distance between the vagina and clitoral structures were calculated. Computed clitoral morphometrics (length, width) were compared to median [range] values from a previously published cadaver study (N = 22) using the median test and Moses extreme reaction test. Calculated distances were compared to mean (± SD) reported by a 2D MRI study (N = 20) using independent t-test and Levene's test. RESULTS: Overall, computed clitoral morphometrics were similar to manual cadaver measurements, where the majority of length and width measures had ~1-2 mm difference and had less variability (smaller range). All calculated distances were significantly smaller and had smaller SDs than manual 2D MRI values, with two-fold differences in the means and SDs. Large variation was observed in clitoral volumetric measures in our cohort. CONCLUSIONS: The proposed 3D computational method improves the standardization and consistency of clitoral measurements compared to traditional manual approaches. The use of this approach in radiographic studies will give better insight into how clitoral anatomy relates to sexual function and how both are impacted by gynecologic surgery, where outcomes can assist treatment planning.

Increased clitoral artery pulsatility index and decreased sexual desire level in women with polycystic ovary syndrome.

OBJECTIVES: Polycystic ovary syndrome (PCOS) is claimed to effect the sexual desire, and recently, blood flow in the clitoral artery (CA) was measured by Doppler ultrasound (USG) examination and the level of sexual desire was objectively demonstrated by determining the pulsatility index (PI). In the present study, it was aimed to quantitatively determine the sexual desire levels in women with PCOS using Doppler USG and to compare the data with healthy women. MATERIAL AND METHODS: The study included 71 patients diagnosed with PCOS and 78 healthy women who applied to our tertiary hospital gynecology clinics and for control purposes. Pulsatility indices were determined by measuring blood flows in the clitoral artery, uterine artery, ovarian artery and labial artery using Doppler USG in all participants. The clitoral artery pulsatility index was found to be increased significantly in women with PCOS. RESULTS: The mean age was 28.5 ± 3.7 in the polycystic ovary syndrome group and 30.0 ± 5.2 in the control group. The mean clitoral artery pulsatility index (1.4 ± 0.5 cm/sec) in the PCOS group was significantly higher than the control group (1.2 ± 0.4 cm/sec) (p = 0.033 cm/sec).The mean ovarian artery pulsatility index (0.8 ± 0.2 cm/sec) in the PCOS group was also significantly higher than the control group (0.7 ± 0.2 cm/sec) (p = 0.015 cm/sec). PCOS is showed to influence sexual desire with an objective measurement. Since trying to obtain objective data about the level of sexual desire, questionnaires were not applied to the participants and no questions were asked. CONCLUSIONS: In our study, it was found that the clitoral artery pulsatility index, that is, the rate of resistance in the blood flow to the clitoral region, increased significantly in women with PCOS. This finding shows that the level of sexual desire in women with PCOS has decreased compared to healthy women.

Clitoral blood flow using color Doppler ultrasonography in women with and without provoked vestibulodynia.

INTRODUCTION AND HYPOTHESIS: To compare blood flow of the dorsal clitoral artery in women diagnosed with provoked vestibulodynia (PVD) and in healthy controls using color Doppler ultrasonography. We hypothesized that women with PVD would have a restricted blood flow compared to controls. METHODS: This cross-sectional study evaluated the function of the dorsal clitoral artery through the spectral wave analysis of color Doppler ultrasonography (US) in 20 women diagnosed with PVD according to Friedrich's criteria and 21 healthy controls. Participants were evaluated during their follicular phase and were asked to abstain from sexual activities 24 ho prior the examination. Assessment was performed by an assessor blinded to participant diagnosis, in the morning after a 10-min rest period in a supine lying position in a room with temperature set at 22 °C. Measurements of the peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility (PI) and resistance index (RI) were performed at rest considering the mean value of three consecutive waveforms. RESULTS: Women with PVD and healthy controls did not present any statistically different baseline characteristics. Participants with PVD presented higher values of Doppler-US PSV, TAMX, EDV and RI compared to controls (p ≤ 0.05), which are suggestive of a decrease in blood flow. However, non-significant difference was found regarding PI values between the two groups (p > 0.05). CONCLUSION: Our findings revealed decreased peripheral tissue perfusion in women with PVD compared to healthy controls using color Doppler US, based on the alteration of four of the five assessed data of US parameters.

The role of clitoral topography in sexual arousal and orgasm: transperineal ultrasound study.

INTRODUCTION AND HYPOTHESIS: The clitoris has a critical pivotal role in female orgasm and arousal. The aim of this cross-sectional study was to evaluate topographic measurements of the clitoris, as well as to explore potential relationships between the clitoral complex and the orgasm domain of female sexual function, combining transperineal ultrasound with morphometric measurements. METHODS: In sexually active, heterosexual, premenopausal women, three-dimensional transperineal ultrasound imaging was used to measure the subpubic angle, the anterior triangle area (ATA) of the genital hiatus, the levator urethra gap, and the anteroposterior and transverse diameters of the genital hiatus. Mons pubis thickness, clitoris-urethra distance (CUD), clitoris-fourchette distance, and fourchette-perineal body distance were measured using a caliper. Comparison of measurements and correlation with orgasm score were performed. RESULTS: Among the 108 sexually active women, 30 (27.7 %) reported a low orgasm domain score. There were statistically significant differences between the low orgasm group and the control group in the ATA (4.05 vs 3.64 cm2 respectively; p = 0.03), CUD (21 mm; p = 0.04 vs 16.1 mm; p = 0.04), and volume of the glans clitoris (947.7 mm3 vs 1081 mm3; p = 0.02). There was a moderate and inverse correlation between clitoris-urethra distance and orgasm (r = -0.53, p < 0.001), and arousal (r = -0.42 p < 0.001). Broader ATA (OR = 0.47; 95 % CI = 0.23-0.99; p = 0.04) and longer CUD (OR = 0.57; 95 % CI = 0.44-0.73; p < 0.001) were identified as the only independent predictors of orgasm problems. CONCLUSIONS: Longer glans clitoris-urethra distance and broad space for the deep structures of the clitoris is related to difficulty in reaching orgasm and arousal problems.

Cardiometabolic risk is unraveled by color Doppler ultrasound of the clitoral and uterine arteries in women consulting for sexual symptoms.

Female sexual dysfunction (FSD) may be a mirror of a poor cardiometabolic state. In a small pilot study enrolling 71 women with FSD, we previously demonstrated that clitoral Pulsatility Index (PI) evaluated by using color Doppler ultrasound (CDU), reflecting vascular resistance, was associated with cardiometabolic risk factors. Data on uterine CDU in this context are lacking. First, to confirm previously reported data on the direct association between clitoral PI and cardiometabolic risk factors on a larger study population of women consulting for sexual symptoms; second, to investigate eventual similar correlations between cardiometabolic risk factors and CDU parameters of the uterine artery. We also ascertained whether uterine artery PI, similarly to what had previously been observed for clitoral artery PI, was directly related to body image uneasiness and psychopathological symptoms, assessed by validated questionnaires. N = 230 women consulting our clinic for sexual symptoms were examined with clitoral CDU and blood sampling and were asked to fill out the Female Sexual Function Index, the Middlesex Hospital Questionnaire (MHQ) and the Body Uneasiness Test (BUT). In a subgroup of women (n = 164), we also performed transvaginal CDU with measurement of uterine artery parameters. At multivariate analysis, we found a direct association between clitoral PI and body mass index (BMI) (p = 0.004), waist circumference (WC) (p = 0.004), triglycerides (p = 0.006), insulin (p = 0.029) and HOMA-IR (p = 0.009). Furthermore, a correlation between obesity and Metabolic Syndrome (MetS) and a higher clitoral PI was observed (p = 0.003 and p = 0.012, respectively). Clitoral PI was also correlated with MHQ-S (p = 0.010), a scale exploring somatized anxiety symptoms, and BUT-B Positive Symptom Distress Index (p = 0.010), a measure of body image concerns. Similarly, when investigating the uterine artery, we were able to demonstrate an association between its PI and BMI (p < 0.0001), WC (p = 0.001), insulin (p = 0.006), glycated haemoglobin (p = < 0.0001), and HOMA-IR (p = 0.009). Women diagnosed with obesity and MetS showed significantly higher uterine PI values vs. those without obesity or MetS (p = 0.001 and p = 0.004, respectively). Finally, uterine PI was associated with BUT-A Global Severity Index (p < 0.0001) and with several other BUT-A subdomains. Vascular resistance of clitoral and uterine arteries is associated with cardiometabolic risk factors and body image concerns in women consulting for sexual symptoms. If further confirmed in different populations, our data could suggest CDU, a common examination method, as a useful tool for an identification-and possible correction-of cardiometabolic risk factors.

Effects of testosterone treatment on clitoral haemodynamics in women with sexual dysfunction.

PURPOSE: To explore the effects of 6-month systemic testosterone (T) administration on clitoral color Doppler ultrasound (CDU) parameters in women with female sexual dysfunction (FSD). METHODS: 81 women with FSD were retrospectively recruited. Data on CDU parameters at baseline and after 6 months with four different treatments were available and thus further longitudinally analyzed: local non-hormonal moisturizers (NH group), n = 37; transdermal 2% T gel 300 mcg/day (T group), n = 23; local estrogens (E group), n = 12; combined therapy (T + E group), n = 9. Patients underwent physical, laboratory, and genital CDU examinations at both visits and completed different validated questionnaires, including the Female Sexual Function Index (FSFI). RESULTS: At 6-month visit, T therapy significantly increased clitoral artery peak systolic velocity (PSV) when compared to both NH (p < 0.0001) and E (p < 0.0001) groups. A similar increase was found in the T + E group (p = 0.039 vs. E). In addition, T treatment was associated with significantly higher FSFI desire, pain, arousal, lubrication, orgasm, and total scores at 6-month visit vs. baseline. Similar findings were observed in the T + E group. No significant differences in the variations of total and high-density lipoprotein-cholesterol, triglycerides, fasting glycemia, insulin and glycated hemoglobin levels were found among the four groups. No adverse events were observed. CONCLUSION: In women complaining for FSD, systemic T administration, either alone or combined with local estrogens, was associated with a positive effect on clitoral blood flow and a clinical improvement in sexual function, showing a good safety profile. TRIAL REGISTRATION NUMBER: NCT04336891; date of registration: April 7, 2020.

Clitoromegaly, Vulvovaginal Hemangioma Mimicking Pelvic Organ Prolapse, and Heavy Menstrual Bleeding: Gynecologic Manifestations of Klippel-Trénaunay Syndrome.

Klippel-Trénaunay Syndrome (KTS) is a genetic vascular malformation involving the capillary, lymphatic, and venous channels. Prenatal sonographic diagnosis of KTS with an enlarged fetal limb is well-known; however, postnatal gynecologic manifestations are rarely reported. KTS can cause clitoromegaly, vulvovaginal hemangioma, and heavy menstrual bleeding. Somatic mosaicism of the PIK3CA gene is considered as responsible for KTS but reports based on whole-genome sequencing are limited. A 31-year-old woman with KTS presented with bulging of the clitoris and vagina. Analysis of whole-genome sequencing variant data revealed that gene ontology terms related to development and differentiation such as 'skeletal system morphogenesis', 'embryonic morphogenesis', and 'sensory organ development' were nominally significant in non-coding regions. Variants in non-coding genes may be responsible for this phenotype.

Are anogenital distance and external female genitalia development changed in neural tube defects? Study in human fetuses.

BACKGROUND: Anogenital distance (AGD), the distance from the anus to the genitals, is a marker of normal genital development. AGD and other biometric parameters of external female genitalia are important as ultrasonographic markers that can determine fetal gender in the first trimester. Neural tube defects are one of the commonest congenital malformations of the central nervous system, with anencephaly being the most severe defect. Female genitalia development and their association with anencephaly have not been previously described. AIM: The aim of this study was to compare the biometric parameters of external female genitalia in fetuses with anencephaly and compare it to the parameters of normocephalic fetuses at different gestational ages. STUDY DESIGN: We studied 34 female fetuses, 22 normocephalic and 12 anencephalic, aged between 12 and 22 weeks post-conception. The fetuses were placed in the classic lithotomy position and before the fetal dissection, the external female genitalia were photographed with a digital camera. Biometric parameters were recorded and measurements were performed using the Image J software, version 1.46r. Clitoral length and width, clitoris to anus distance, vaginal opening length and width, vaginal opening to labia majora distance, and AGD were measured (Figure). For statistical analysis, the Wilcoxon-Mann-Whitney test was used (p < 0.05). RESULTS: We observed a significant difference between some measurements of the groups: the vaginal opening width was significantly greater in anencephalic fetuses and the vaginal opening length, clitoris to anus distance and vaginal opening to labia majora distance were significantly greater in normocephalic fetuses. For the clitoris length and width, we did not find statistical differences. We also did not find statistical significance in AGD between groups (normocephalic 2.32 mm [2.46-6.42/SD = 2.17] vs. anencephalic 3.93 mm [1.15-6.65/SD = 1.93]; p = 0.499). The linear regression analysis indicated that AGD increased more with age in anencephalic than in the normocephalic group, but without significant differences (r2 = 0.01677; p < 0.318). DISCUSSION: This article is the first to report the female external genitalia parameters in fetuses with anencephaly. In our study we observed some alterations in biometry of the external genitalia in anencephalic fetuses, with a pattern of morphological reduction in this group. The vaginal opening length, clitoris to anus distance and vaginal opening to labia majora distance were significantly lower in anencephalic fetuses but we did not find statistical significance in clitoris measurements and AGD. CONCLUSIONS: Anencephalic fetuses had some alterations in external genitalia development, but the anogenital distances did vary significantly between the groups.

Validation of a Sagittal Section Technique for Measuring Clitoral Blood Flow. Volume Flow: A New Parameter in Clitoral Artery Doppler.

BACKGROUND: Clitoral artery Doppler has been used as an objective technique to measure changes in genital women response. However, the technique has not been fully validated, and arterial volume flow has never been used as an outcome measure. AIMS: To validate the technique clitoral artery Doppler measured in a sagittal section and explore arterial volume flow as a new parameter in clitoral Doppler. METHODS: We examined 90 healthy volunteers by clitoral artery Doppler using the sagittal section approach described by Battaglia et al in 2008. We calculated intraobserver, interobserver, and intraobserver intersession variability and reliability for all Doppler parameters and described and validated arterial volume flow as a new parameter in clitoral artery Doppler. OUTCOMES: We calculated peak systolic velocity (PSV), time-averaged maximum velocity, time-averaged mean velocity, end-diastolic velocity, pulsatility index, resistance index, and volume flow (v-flow) in all groups. We conducted reliability analyses using the intraclass correlation coefficient for agreement. We explored differences between and within observers and calculated agreement limits using the Bland-Altman test. RESULTS: The intraclass correlation coefficient analysis showed correlation values higher than 0.75 (good reliability) for most of the variables and higher than 0.60 (moderate reliability) for the remaining ones. There were statistically significant differences between PSV and time-averaged maximum velocity in the intraobserver intersession measurements. For the remaining groups and variables, no statistically significant differences were observed. Bland-Altman analyses showed that the limits of agreement were acceptable and the regressions were not significant. The v-flow parameter also showed good reliability and low variability between groups. CLINICAL IMPLICATIONS: We found that PSV was not a good outcome measure because of its high intraobserver and intersession variability. Moreover, it is possible to measure v-flow in the clitoral artery using the sagittal technique described by Battaglia et al, and it seems that this measure is reliable and reproducible. This could be the best parameter to assess clinical changes. STRENGTHS & LIMITATIONS: This study provided full validation of the sagittal section approach and of a new parameter, v-flow, which could beuseful for assessing clitoral blood flow. The main limitation of the study is its retrospective nature for validating v-flow. CONCLUSION: We found that clitoral artery Doppler measured using a sagittal approach is a valid and reliable technique for studying clitoral blood flow in women. The v-flow variable is a promising and reliable parameter for measuring changes in clitoral blood flow. Pérez MF, Agís IF, La Calle Marcos P, et al. Validation of a Sagittal Section Technique for Measuring Clitoral Blood Flow: Volume Flow - A New Parameter in Clitoral Artery Doppler. J Sex Med 2020;17:1109-1117.

Test-retest reliability of clitoral blood flow measurements using color Doppler ultrasonography at rest and after a pelvic floor contraction task in healthy adult women.

AIMS: Test-retest reliability assessment of the dorsal clitoral artery's blood flow at rest and after muscle activation has never been documented. If this outcome measure is to be used in conditions impeding vascularity, it requires a psychometric evaluation. The aim of this study was to assess the inter-session test-retest reliability of clitoral blood flow in healthy women using color Doppler ultrasonography at rest and after a pelvic floor muscle (PFM) contraction task. METHODS: Two assessment sessions were conducted using a clinical ultrasound system. Clitoral blood flow measurements were repeated at rest and after a PFM contraction task. Measurements of the peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were taken. The test-retest reliability was assessed using paired t-test, intraclass correlation coefficient (ICC), and Bland-Altman plots. RESULTS: For reliability at rest, ICC values were 0.95 for PSV, 0.87 for TAMX, and 0.67 for both PI and RI. The variability between measurements, as per Bland-Altman plots, was small for PSV, TAMX, and RI and acceptable for PI. For reliability after the PFM contractions task, ICC values were 0.85 for PSV, 0.77 for TAMX, 0.79 for PI, and 0.81 for RI. The variability between measurements was small for PSV and RI and acceptable for TAMX and PI. EDV parameter did not perform as well in both conditions. CONCLUSIONS: Assessment of the clitoral blood flow with color Doppler ultrasound is reliable at rest and after a PFM contraction task.

Os clitoris in dogs: 17 cases (2009-2017).

Medical records of 17 client-owned dogs diagnosed with os clitoris on physical examination or diagnostic imaging were reviewed to describe the clinical signs and surgical management of this condition. All dogs were phenotypically female. The most common presenting complaints included an enlarged clitoris (n = 10), urinary tract infection (n = 5), and licking of the vulva (n = 3). Other frequently reported clinical signs included vaginal discharge and/or lower urinary tract signs such as pollakiuria. Ten dogs were surgically managed with os clitorectomy. Concurrent related procedures included gonadohysterectomy (n = 7), and episioplasty (n = 3). Clitorectomy in the surgically managed dogs created a more normal female anatomy and resolved clinical signs associated with the exposed clitoris.

Os clitoridien chez les chiennes : 17 cas (2009­2017). Les dossiers médicaux de 17 chiennes appartenant à des clients qui avaient été diagnostiquées avec l'os clitoridien lors de l'examen physique ont été étudiés afin de décrire les signes cliniques et la gestion chirurgicale de cette affection. Tous les chiens étaient phénotypiquement femelles. Les plaintes les plus communes à la présentation incluaient un clitoris élargi (n = 10), une infection des voies urinaires (n = 5) et le léchage de la vulve (n = 3). Les autres signes cliniques fréquemment signalés incluaient l'écoulement vaginal et/ou des symptômes des voies urinaires inférieures comme la pollakiurie. Dix chiennes ont été gérées chirurgicalement par une clitoridectomie. Les interventions concomitantes incluent la gonado-hystérectomie (n = 7) et l'épisioplastie (n = 3). La clitoridectomie chez les chiennes gérées par chirurgie a créé une anatomie femelle plus normale et a donné lieu à une résolution des signes cliniques associés au clitoris exposé.(Traduit par Isabelle Vallières).

MR Imaging of the Female Perineum: Clitoris, Labia, and Introitus.

The female perineum has a complex anatomy and can be involved by a wide range of pathologies. In this article, we specifically focus on the clitoris, labia, and introitus. We discuss the normal anatomy of these structures, the MR imaging techniques to optimize their evaluation, and several common and uncommon entities that may affect them, including benign and malignant tumors, as well as infectious and inflammatory, vascular, iatrogenic, and developmental entities.

Aggressive Angiomyxoma of the Vulva Mimicking Clitoromegaly in a Young Child.

Aggressive angiomyxoma (AAM) is a rare soft tissue tumor of mesenchymal origin that chiefly involves the vulvar and perineal region. In 90% of cases, AAM presents in women of reproductive age with a peak incidence in the fourth decade of life. To date, AAM of the vulva in young children and infancy has never been reported. We present a case of AAM of the vulva that was initially interpreted as clitoromegaly in a 3-year-old girl.

The sexuological impact of hormonal contraceptives based on their route of administration.

Evidence on the effects of hormonal contraceptives on female sexuality is conflicting. We enrolled 556 women, divided into six groups: two composed of subjects using a combined hormonal contraceptive (COC) containing 0.020 ("COC20") and 0.030 ("COC30") mg of ethynyl estradiol (EE), "natural", using COC containing 1.5 mg of estradiol (E2), "ring", using a vaginal ring releasing each day 0.015 mg of EE + 0.120 of etonogestrel, "subcutaneous", using a progestin only subcutaneous contraceptive implant releasing etonogestrel and "controls", using no hormonal contraceptive methods. The subjects were required to answer to the McCoy female sexuality questionnaire and were subjected to a blood test for hormonal evaluation. An ultrasound evaluation of the dorsal clitoral artery was also performed. The higher McCoy sexological value were recorded in the subdermal group; significant differences were recorded among the groups in terms of hormone distribution, with the higher levels of androstenedione in subdermal and control groups. The ultrasound evaluation of dorsal clitoral artery shows a significative correlation between pulsatility and resistance indices and orgasm parameters of McCoy questionnaire. The recorded difference in the sexual and hormonal parameters among the studied hormonal contraceptives may guide toward the personalization of contraceptive choice.

Clitoral Metastasis From Advanced Cervical Carcinoma on 18F-FDG-PET/CT.

Metastatic tumors of the clitoris from cervical carcinoma are extremely rare. Here, we described a 54-year-old woman with clitoral metastasis from cervical carcinoma demonstrated on F-FDG PET/CT images.

Biocompatible porcine dermis graft to treat severe cystocele: impact on quality of life and sexuality.

PURPOSE: To study the quality of life (QoL) and sexual function changes of women affected by severe cystocele treated using biocompatible porcine dermis graft. METHODS: 20 women (ranging in age from 47 to 71 years, mean age 58.7) with third- and fourth-degree cystocele (according to Baden and Walker classification) were enrolled. The Short Form-36 questionnaire to assess QoL was administrated at baseline and 12 months after surgical treatment. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to measure the changes of sexual behavior was used at baseline and 12 months after surgical treatment. Each woman underwent translabial color Doppler ultrasonography to measure the clitoral blood flow before and 12 months after surgical treatment. RESULTS: Women reported QoL improvement (P < 0.001). By PISQ-12, improvement of the behavioral emotive factor score, the physical factor score, the partner-related factor score and of the total score during the 12-month follow-up with respect to baseline experience was observed (P < 0.001). Color Doppler measurement showed that the mean pulsatility index, peak systolic velocity, resistance index and end-diastolic velocity of clitoral arteries did not significantly change (P = NS). CONCLUSIONS: Biocompatible porcine dermis graft to treat severe cystocele considerably improves QoL and sexual function, and does not influence clitoral blood flow. Our data could add new information about sexual behavior after prolapse treatment using this kind of graft, particularly about the impact on clitoral blood flow changes.