The normal vulva in medical textbooks

Beyond the tip of the iceberg: A meta-analysis of the anatomy of the clitoris

An understanding of ranges in clitoral anatomy is important for clinicians caring for patients including those who have had female genital mutilation, women seeking genital cosmetic surgery, or trans women seeking reconstructive surgery. The aim of this meta-analysis is to investigate the ranges in clitoral measurements within the literature. A meta-analysis was performed on Ovid Medline and Embase databases following the PRISMA protocol. Measurements of clitoral structures from magnetic imaging resonance, ultrasound, cadaveric, and living women were extracted and analyzed. Twenty-one studies met the inclusion criteria. The range in addition to the average length and width of the glans (6.40 mm; 5.14 mm), body (25.46 mm; 9.00 mm), crura (52.41 mm; 8.71 mm), bulb (52.00 mm; 10.33 mm), and prepuce (23.19 mm) was calculated. Furthermore, the range and average distance from the clitoris to the external urethral meatus (22.27 mm), vagina (43.14 mm), and anus (76.30 mm) was documented. All erectile and non-erectile structures of the clitoris present with substantial range. It is imperative to expand the literature on clitoral measurements and disseminate the new results to healthcare professionals and the public to reduce the sense of inadequacy and the chances of iatrogenic damage during surgery.

The International Society for the Study of Vulvovaginal Disease (ISSVD) Vulvar Awareness Day Campaign: Knowledge of Vulvovaginal Diseases Among Italian Obstetrics and Gynecology Residents

OBJECTIVES

The objective of this study is to investigate vulvovaginal disease (VVD) awareness in Italian obstetrics and gynecology (Ob/Gyn) residents.

MATERIALS AND METHODS

A 25-question survey on VVD basic knowledge (17 questions) and willingness to improve it (8 questions) was distributed through Ob/Gyn resident online group chats, from different Italian Universities in January 2023. A total number of 250 residents were invited to participate; 124 responses were obtained (response rate: 50%). Data were collected and analyzed using descriptive statistics through REDCap.

RESULTS

Overall, 87 of the 124 respondents (70%) fully completed the questionnaire and represented the study group. Residents were distributed among years of residency: 15% first year, 31% second year, 23% third year, 11% fourth year, and 20% fifth year. Most (60%) never attended a VVD clinic during residency, with an increasing percentage of attendance in later residency years (15% at first year vs 65% at fifth).Participants reported low knowledge of vulvar precancerous lesions and vulvoscopy but better knowledge of vaginitis, vulvar self-examination, and lichen sclerosus. Of the respondents, 50% were not satisfied with the education provided during residency, and more than 60% lacked confidence in managing VVD.All participants expressed a strong desire to improve their knowledge and skills, with 100% agreeing that every gynecologist should know the "basics" and 98% wanting to improve their knowledge through webinars (45%), lessons (34%), newsletters, and videos (19%).

CONCLUSION

Our findings indicate a significant need to improve VVD knowledge among Italian Ob/Gyn residents. Further efforts are necessary to provide information about VVD and comprehensive training programs in Italian Universities.

Dimensions, Ratios, Volumes, and Weights of the Fatty Parts of the Vulva (Mons Pubis and Labia Majora)

BACKGROUND

The anatomy of the fatty parts of the vulva, specifically the mons pubis and labia majora, has not been extensively studied.

OBJECTIVES

This study aimed to provide a comprehensive 3-dimensional picture of the mons pubis and labia majora by defining and measuring their dimensions. Furthermore, the study sought to calculate the different ratios, volumes, and weights of these structures.

METHODS

The study included 214 women, who were divided into 2 groups based on their BMI. The researchers defined 27 dimensions to describe the width, height, and length of the mons pubis and labia majora, and specified the measuring methodology.

RESULTS

The height of the mons pubis was approximately three-quarters of its length and half its width. The labia majora were wider and taller anteriorly than posteriorly, and their ratios decreased as they went posteriorly, from 4 to 2. The ratio of monal height to maximum labial height and to labial length was 3 and 1, respectively, whereas the ratio of monal width to the sum of maximum labial widths was nearly 1.5. The calculated volumes and weights of the mons pubis and labium majus were 200 mL, 30 mL, 180 g, and 27 g in Group 1, and 300 mL, 40 mL, 270 g, and 36 g in Group 2, respectively.

CONCLUSIONS

The dimensions, ratios, weights, and volumes defined and measured in this study can serve as the basis for any aesthetic measures involving the mons pubis and labia majora. Moreover, BMI and the different ratios should be considered in such measures.

Teaching vulval anatomy in the twenty-first century: The Australian experience

Anatomy has often been regarded as an immutable discipline where everything that needs to be known is known. This article focuses on the teaching of vulval anatomy, the diversification of gender in contemporary society, and the increasing popularity of the Female Genital Cosmetic Surgery (FGCS) industry. The binary language and singular structural arrangements contained in lectures and chapters on "female genital anatomy" are nowadays rendered exclusive and incomplete. A series of 31 semi-structured interviews with Australian anatomy teachers identified barriers and facilitators for teaching vulval anatomy to contemporary student cohorts. Barriers included lack of connection to contemporary clinical practice, time and technical difficulty involved in regularly updating online presentations, the crowded curriculum, personal sensitivity to teaching vulval anatomy, and reluctance to introduce inclusive terminology. Facilitators included lived experience, regular use of social media, and institutional initiatives toward inclusivity including the support of queer colleagues.

New context, new content-Rethinking genital anatomy in textbooks

It has been widely claimed that reductions in allocated teaching time and the widespread implementation of short-cut teaching methodologies have led to a shortfall in anatomy knowledge among graduating doctors. This decline in knowledge is evident in the failure of anatomy content to prepare graduates for contemporary clinical practice. The implications for postgraduate surgical training are addressed in the numerous extracurricular anatomy courses available to surgical candidates. This paper focuses on genital diversity and its relevance to non-surgical graduates, thus highlighting another potential impact of this knowledge shortfall on frontline clinic consultations. As the gender revolution and female genital cosmetic surgery industry flourish, nothing in contemporary anatomy textbooks addresses issues of diversification of female genitalia nor gives medical graduates a realistic view of what is normal regarding female genital appearance.

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.

Cosmetic labiaplasty on minors: a review of current trends and evidence

Cosmetic labiaplasty is a form of Female Genital Cosmetic Surgery (FGCS) that is performed with the deliberate intent to alter the appearance and morphology of the external genitalia in the absence of medical concerns. Over the last decade, there is an increasing demand for FGCS and the industry behind it is constantly growing. Adolescents comprise an extremely vulnerable population, with labiaplasties in this particular age group having also increased. However, labiaplasty has been widely contested due to the irrevocable alteration of a psychosexually significant body part on minors too young to consent. Besides, the changes that occur during pubertal development in the genital area can significantly alter pediatric surgical results. Genital anatomy is more diverse than we previously thought and there is evidence to suggest that the labia minora with their rich innervation play an important role in sexual arousal and pleasure. Education regarding the wide range of normal genital appearance suffices in most cases to dissolve concerns regarding body self-image. Mental health issues should always be explored and, if identified, the girl should be referred to an experienced professional for their resolution. Postponing labiaplasty until adulthood is strongly recommended to help adolescents achieve a well-informed decision regarding an irreversible procedure with possible adverse esthetic and functional outcomes.

The anatomical measurements of vulva in Indian women: A cross-sectional prospective study

OBJECTIVE

To measure the anatomical dimensions of the vulva in adult Indian women. To analyze their correlations with age, body mass index (BMI), parity, and mode of delivery.

METHODS

This cross-sectional study was conducted in a tertiary care university hospital in India, among 400 women aged 18 years and above. Various vulval measurements were taken, and Pearson's correction was applied to variables like age, BMI, parity, and mode of delivery.

RESULTS

Mean length of glans of clitoris was 5.2 ± 1.43 mm, the labia minora width was 2.6 ± 0.74 cm, length of introitus was 1.3 ± 0.59 cm, and perineal body length was 2.3 ± 0.60 cm. The range of some measurements was extensive, for example labia minora width ranged from 0.7 to 4.9 cm. Normal centile curves were constructed for vulval measurements according to age groups. Statistically significant positive correlations of age, BMI, and obstetrical history were seen with labia minora width (r = 0.165, P = 0.001; r = 0.284, P < 0.001; r = 0.246, P < 0.001, respectively).

CONCLUSION

The centile curves can be used as a reference for the Indian population of different ages. These can be used when counseling women coming for female genital cosmetic surgery.

Scrotal Labia - An Uncommon Presentation of Vulvar Lichen Simplex Chronicus

Lichen simplex chronicus (LSC) of the vulva is an acquired, persistent, severely itchy dermatosis usually located in easily reachable areas of the body like the extremities, nape of the neck, and genitalia. It also has a strong association with atopy and is said to be initiated and perpetuated by the itch–scratch–itch cycle. Two cases of rugose labia as the sole presentation of LSC of vulva are being presented.

Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature

BACKGROUND

Secondary vaginal stenosis may occur after reconstruction of genital malformations in childhood or after failed vaginal aplasia repair in adults.

AIM

This study focusses on the results of the surgical treatment of these patients in our multidisciplinary transitional disorders/differences of sex development team of pediatric surgeons and gynecologists.

METHODS

A retrospective analysis was carried out on adult and female identified disorders/differences of sex development patients with vaginal stenoses treated between 2015 and 2018 in a single center with revision vaginoplasty. The underlying type of malformation, the number and surgical techniques of vaginoplasties in infancy, techniques of revision of the stenotic vagina, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. A review of literature with regard to recommended surgical techniques of revision vaginoplasties was accomplished.

OUTCOMES

To describe the surgical technique, the main outcome measures of this study are vaginal calipers after revision vaginoplasty as well as ability for sexual intercourse.

RESULTS

Thirteen patients presented with vaginal stenosis with a median age of 19 years (range 16-31). All patients had one or more different types of vaginoplasties in their medical history, with a median age at first vaginoplasty of 15 months (0-233). Underlying anatomical conditions were urogenital sinus (n = 8), vaginal agenesis (n = 2), persistent cloacae (n = 2), and cloacal exstrophy (n = 1). The main symptoms were disability of sexual intercourse in 13 patients due to stenotic vaginal tissue. The most frequently performed surgical technique was partial urogenital mobilization with a perineal or lateral flaps (n = 10), followed by bowel vaginoplasty (n = 2), in 1 patient a revision vaginoplasty failed due to special anatomical conditions. In a median follow-up of 11 months, all but one patient presented with physiological vaginal length and width, and normal sexual intercourse in those with a partnership.

CLINICAL IMPLICATIONS

Perineal flap with partial urogenital mobilization should be considered as a treatment of choice in severe cases of distal vaginal stenosis and after multiple failed former vaginoplasties, while bowel vaginoplasty should be reserved only for cases of complete cicatrization or high located stenosis of the vagina.

STRENGTHS & LIMITATIONS

The strength of this study is the detailed description of several cases while the retrospective character is a limitation.

CONCLUSION

In patients after feminizing genital repair, perineal flap with partial urogenital mobilization provides a normal anatomical outcome and allows unproblematic sexual intercourse. Ellerkamp V, Rall KK, Schaefer J, et al. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021;18:1797-1806.

The Adolescent and Genital Dissatisfaction

Genital dissatisfaction in healthy young women is on the rise. Pubic hair removal reveals genital tissue previously hidden, while social trends promote the absence of any protruding genital tissue as the feminine ideal. Information with regard to the natural diversity of external genitalia anatomy, and lifestyle changes to improve physical symptoms related to labial tissue may suffice to reassure a distressed adolescent. Female genital cosmetic surgery is rarely supported, before attaining genital maturity. However, genital dissatisfaction may lead to significant embarrassment and anxiety, requiring formal psychological counselling. Sexual education needs to counterbalance perceived normal anatomy, portrayed in pornography or female genital cosmetic surgery advertisements.

What is the anatomical basis of labiaplasty? A review of normative datasets for female genital anatomy

BACKGROUND

Despite increasing numbers of labiaplasties being performed, there is little quantitative information on normal labial diversity to guide medical education, patient education and surgical treatment.

AIM

This scoping review will determine what is known in the published literature about the anatomical basis of normal for labia and female genital cosmetic surgery (FCGS).

MATERIALS AND METHODS

The scoping review identified ten population-based studies that recorded labial dimensions by searching three electronic databases utilising a Preferred Reporting Items for Systematic Reviews and Meta-Analyses search strategy. Strict inclusion and exclusion criteria were applied and then reference lists were scrutinised until no further articles that met the criteria were located.

RESULTS

These studies showed significant variation in labial length (range 5-100 mm) and width (range 1-60 mm). Labia minora were wider in pre-menopausal women than in post-menopausal women, protruding labia minora were more common than not, and asymmetry between right and left labia was common. Variation in recruitment, inclusion and exclusion criteria, and measurement did not allow for summation of the data sets.

CONCLUSION

This information could usefully be added to medical textbooks and teaching to ensure that medical graduates are sufficiently informed about normal variation in female genital anatomy to assess and advise women seeking FGCS.

Female genital cosmetic surgery: a cross-sectional survey exploring knowledge, attitude and practice of general practitioners

OBJECTIVE

To explore general practitioner's (GP) knowledge, attitudes and practice regarding female genital cosmetic surgery (FGCS) in Australia.

DESIGN

Cross-sectional survey.

SETTING

Australia.

SAMPLE

GPs who attended a women's health seminar and GPs who subscribed to a non-governmental, national health professional organisation database that provides education to primary care professionals.

METHOD

A national online survey of GPs was conducted for the 10-week period, starting 1 week prior and 2 months after a Women's Health seminar was held in Perth on 8 August 2015. 31 questions prompted GPs' knowledge, attitudes and practice in managing patients asking about FGCS.

RESULTS

The survey was fully completed by 443 GPs; 54% had seen patients requesting FGCS. Overall, 75% (95% CI 71% to 79%) of GPs rated their knowledge of FGCS as inadequate and 97% (95% CI 94% to 99%) had been asked by women of all ages about genital normality. Of those who had seen patients requesting FGCS, nearly half (44%, 95% CI 38% to 51%) reported they had insufficient knowledge of risks of FGCS procedures and 35% (95% CI 29% to 41%) reported seeing females younger than 18 years of age requesting FGCS. Just over half (56%, 95% CI 51% to 60%) of the GPs felt that women should be counselled before making a referral for FGCS. More than half the GPs suspected psychological disturbances in their patients requesting FGCS such as depression, anxiety, relationship difficulties and body dysmorphic disorder.

CONCLUSIONS

GPs see women of all ages presenting with genital anatomy concerns and in those who request FGCS, GPs often suspected a range of mental health difficulties. GPs require greater education to support their patients who request FGCS.

The Normal Vulva, Vulvar Examination, and Evaluation Tools

The appearance of the female external genitalia is key for understanding and diagnosing many diseases that women of all ages encounter. Alas, the normal appearance of the vulva is an elusive concept, scarcely represented in textbooks, and the growing number of vulvar cosmetic surgery calls for a review of the normal appearance of the vulva and its diversity. In this paper I will review vulvar embryology, anatomy, the current literature discussing vulvar appearance, and describe meticulous vulvar examination, including the diagnostic tools.

Post-coital genital injury in healthy women: A review

Female genital injury following penile sexual intercourse in healthy women is a matter of importance and debate in many parts of society. However, the literature on the subject is sparse. There are a few studies regarding minor injury that does not require treatment in adult, pre-menopausal women, a single study of adolescent women, and none regarding post-menopausal women. Larger lesions requiring treatment are described casuistically. The purpose of this article is to provide a short, easy-to-read review of the literature regarding the prevalence and nature of female genital injury following consensual sexual intercourse in otherwise healthy women.