Recommended standardized anatomic terminology of the posterior female pelvis and vulva based on a structured medical literature review

Assessing comfort levels with female sexual dysfunction among medical residents: a nationwide cross-sectional survey study and its implications for medical education

BACKGROUND

Female sexual dysfunction (FSD) affects 30%-50% of women but is substantially underdiagnosed and undertreated due in large part to the fact that just half of US medical schools offer formal sexual health teaching with an overwhelming skew toward male sexual health.

AIM

The aim of this study is to assess the knowledge and confidence of residents in conducting a comprehensive pelvic examination and their comfortability diagnosing and managing conditions of FSD.

METHODS

In June 2023, the authors used Qualtrics to administer this cross-sectional survey. The target audience included resident physicians in Urology, Obstetrics and Gynecology, Dermatology, Internal Medicine, Family Medicine, and Emergency Medicine. The authors emailed a survey link and brief description of the project to all residency program directors in these specialties with valid email addresses in the FREIDA American Medical Association Residency Database. Program directors shared the link to the anonymous online survey with their current resident cohorts.

RESULTS

In total, n = 128 residents completed the survey. Less than half of all respondents indicated they had received prior formal training in physical exam of the clitoris (23%), vulvar vestibule (45%), and pelvic floor (35%). Regarding FSD, the following percentage of respondents indicated they had received training in these conditions: 78% genito-pelvic pain/penetration disorder, 38% hypoactive sexual desire disorder, 23% female orgasmic disorder, and 30% female sexual arousal disorder. The majority of respondents reported feeling uncomfortable with diagnosis and management of these conditions.

CLINICAL IMPLICATIONS

Improving residents' ability to diagnose and treat FSD is essential for preparing the next generation of physicians to appropriately attend to the needs of female patients.

STRENGTHS AND LIMITATIONS

One limitation of this study is the low survey response rate despite outreach to all relevant US residency programs. Additionally, our study did not account for the potential impact of different educational backgrounds on respondents' comfort levels with FSD, which could be addressed in subsequent research. A major strength of this study is being the first study to survey residents across specialties about their knowledge of FSD.

CONCLUSION

Residents across several specialties are uncomfortable with diagnosing and managing common FSDs owing to a lack of training in both pelvic examination and conditions of FSD.

The coronation of the clitoris: formally introducing the corona of the glans clitoris

The glans clitoris has a corona; however, unlike the corona of the glans penis, the corona of the glans clitoris is practically "nonexistent" as evidenced by the noteworthy absence of its mention and depiction in anatomical and clinical sciences. Accordingly, the corona of the glans clitoris has been neglected in anatomical education and clinical practice. This report details the history regarding the anatomical terminology of the glans and identifies that descriptions of the glans penis, corona of the glans penis, and other penile structures have preceded descriptions of the homologous anatomy of the clitoris by at least a century. Today, recognition of the corona of the glans clitoris, as well as the coronal sulcus and neck of the clitoris should be commonplace. Henceforth, the corona of the glans clitoris and its related anatomy including the sulcus of the glans clitoris and neck of the clitoris should be incorporated into anatomical and clinical language, illustrations, textbooks, education, and practice. Likewise, efforts should be made to propagate knowledge regarding the corona of the glans clitoris, coronal sulcus, and neck of the clitoris to the general public. Giving names to the anatomical structures of the clitoris will undoubtedly increase the awareness of their existence which, in turn, will encourage their clinical assessment and result in decreased morbidity and mortality. Likewise, improved self-awareness of clitoral anatomy will promote self-care which is important in the prevention of disease and the promotion of optimal sexual health.

Key Anatomical Concepts, Landmarks, and Proposed Terminology for Nerve-Sparing Gynecologic Surgery: A Narrative Review

OBJECTIVE

To synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary.

DESIGN

We performed a literature search on PubMed using the search terms "pelvis" and "nerve-sparing." Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures.

RESULTS

224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms.

CONCLUSION

Surgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal.

Anatomy of the clitoris: the corona of the glans clitoris, clitoral coronal papillae, and the coronopreputial frenulum

The corona of the glans clitoris is a clinically important yet poorly understood anatomical structure. There has been longstanding confusion regarding the prevalence of the corona of the glans clitoris and, moreover, its very existence. Therefore, this anatomical study assesses the prevalence of the corona of the glans clitoris and the gross anatomy of the proximal glans clitoris. Anatomy was assessed in 104 female donor bodies ranging in age from 50 to 102 years with an average age-at-death of 78.1±10.9 years (mean±SD). All clitorises (100%; 104:104 dorsums and 100%; 208:208 sides) were found to have a well-defined clitoral corona. Three of 104 (2.9%) coronas possessed grossly visible, outward-projecting, bluntly rounded papillae. Some donors possessed a coronopreputial frenulum. Clitoropreputial adhesions were common and associated with clitoral pearls. Clitoral pearls were identified in 37.8% (14:37) of unembalmed donors and observed to create clitoral craters, structural deformations in the surface of the corona and glans. The results of this study suggest that the corona of the glans clitoris is a ubiquitous anatomical structure. The clitoral coronal papillae and coronopreputial frenulum are novel, previously undescribed, anatomical structures. This study identifies that the corona of the glans clitoris is prone to pathological processes such as clitoral pearl formation and clitoral deformation. In addition to novel anatomical findings, the results of this study call attention to the need for life-long clitoral examinations. Furthermore, the corona of the glans clitoris should be regularly included in anatomical texts and accurately depicted in anatomical illustrations.

Postpartum care: Clinical considerations for improving genital and sexual health

The postpartum period encompasses the biological and psychoaffective transition to motherhood. However, it remains a most neglected phase in a woman's life. Furthermore, the transition to parenthood is a critical and potentially disrupting factor in a couple's relationship, which can be complicated by undiagnosed biological and psychosexual difficulties. Lack of recognition of the many biological and medical factors that can affect women's health and sexuality in the postpartum period is a common and persistent clinical omission worldwide. Communication difficulties exist between healthcare professionals and women and there are wording biases in describing female genitalia. This can further contribute to the diagnostic lack of attention and timely diagnosis and treatment of even very bothersome symptoms. Early diagnosis and treatment of common postpartum conditions is vital and quality care for new mothers should include psychological and emotional support, lactation assistance, early diagnosis and treatment of genital and sexual pain symptoms, pelvic floor rehabilitation and sexual health guidance. The inclusion of correct genital hygiene practices is a critical element of postpartum gynaecological counselling and can help improve overall genital and sexual health. In this review, we summarise the variability in global professional guidelines for postpartum care, identify common health problems faced by postpartum women and discuss appropriate postpartum care. We pay specific attention to prominent biological or medical factors that can impact the emotional and psychosexual wellbeing of women and couples. The aetiology, diagnosis and treatment of sexual dysfunction, in particular sexual pain disorders, is therefore discussed with a pragmatic approach. Finally, the role of intimate hygiene care is discussed with special attention given to cleanser ingredients with solid scientific evidence to help clinicians adopt a more tailored approach with their clinical recommendations.

Maintaining vulvar, vaginal and perineal health: Clinical considerations

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

Frequency and trends in usage of eponyms in gynecologic anatomical terminology: A cross-sectional culturonomics study

On average, gynecologic eponyms were used more than twice as frequently as their preferred anatomical synonyms in published printed sources between 2000 and 2019.

Anatomic relationships of the clitoral body, bulbs of the vestibule, and urethra

BACKGROUND

Although recent studies have enhanced our understanding of the anatomy of the clitoris and its somatic innervation, less emphasis has been placed on the anatomic relationships of the clitoris to its surrounding structures.

OBJECTIVE

This study aimed to further characterize the gross and histologic relationships of the clitoris, vestibular bulbs, and urethra.

STUDY DESIGN

Detailed dissections were performed in 30 unembalmed female cadavers. In 23 specimens, gross dissections were performed, and relationships of the clitoris, vestibular bulbs, and urethra were annotated. Histologic evaluation was performed in 7 specimens, in which tissues were harvested within 24 hours from death. Descriptive statistics were used for data analyses.

RESULTS

The clitoral body consisted of 2 components, the proximal body and the distal body. The distal body was oriented ≤90° from the proximal body, forming an outer and inner angle at the inflection point. A "septumlike" arrangement of fibroconnective and vascular tissues was noted between the inner angle of the clitoral body and the urethra. Neurovascular bundles coursed laterally along the clitoral body and the surfaces of the crura and vestibular bulbs. The vestibular bulbs approached each other over the ventral surface of the urethra, at the commissure of the vestibular bulbs. Each bulb was separated by fibrous tissue and did not merge along the midline. The vestibular bulbs approximated the clitoral body, but the erectile tissue of the vestibular bulbs was separated from the corpora cavernosa of the clitoral body by the tunica albuginea. The erectile tissue of the vestibular bulbs abutted the ventrolateral walls of the urethra but was separated from the urethral mucosa by an indiscrete layer of erectilelike tissue with dense stroma.

CONCLUSION

This study provided gross and histological confirmation of the relationships of the clitoris, vestibular bulbs, and urethra. Detailed knowledge of the anatomy of the clitoris is crucial for reducing surgical complications associated with periclitoral and distal urethral procedures, which may adversely affect sexual arousal and sexual function.

What is a vulva?

What exactly is a vulva? The question remains unresolved. Some sources consider the clitoris, labia, mons pubis, perineum, or vagina to be components of the vulva, while other sources do not. Indeed, disagreement exists among international anatomical and clinical societies with regard to what precise structures form the human vulva. The obfuscation regarding the anatomy of the vulva and, likewise, inconsistencies in vulva-related anatomical terminology have adversely affected communication, research, and healthcare. Therefore, this review was undertaken to provide a comprehensive and critical analysis regarding the past, present, and potential future of vulvar anatomy and vulva-related anatomical terminology. The review reveals that confusion regarding the specific gross anatomical structures that form the vulva has persisted for thousands of years. The review provides novel information regarding the etymology of vulva, contributes important historical context regarding vulva, and gives details regarding related anatomical terminology including clitoris, hymen, labia majora, labia minora, mons pubis, pudendum, pudendum femininum/muliebre, uterus, vagina, et cetera. The review highlights disagreement regarding what specific structures comprise a vulva, identifies sexual bias in anatomical terminology and among noteworthy anatomical resources, and offers novel perspectives regarding anatomical terminology-especially anatomical terminology that relates to the external genitalia. What specific anatomical structures comprise the vulva? This review provides a comprehensive and critical analysis regarding the past, present, and potential future of vulvar anatomy and vulva-related anatomical terminology.