Professional Documents
Culture Documents
Review
Embryology and anatomy of the vulva: the female orgasm and womens
sexual health
Vincenzo Puppo *
Centro Italiano di Sessuologia (CIS), Via Regnoli 74, 40138 Bologna, Italy
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 16 December 2009
Received in revised form 3 August 2010
Accepted 13 August 2010
Sexual health is vital to overall well-being. Orgasm is a normal psycho-physiological function of human
beings and every woman has the right to feel sexual pleasure. The anatomy of the vulva and of the female
erectile organs (trigger of orgasm) is described in human anatomy textbooks. Female sexual physiology
was rst described in Dickinsons textbook in 1949 and subsequently by Masters and Johnson in 1966.
During womens sexual response, changes occur in the congestive structures that are essential to the
understanding of womens sexual response and specically of their orgasm. Female and male external
genital organs arise from the same embryologic structures, i.e. phallus, urogenital folds, urogenital sinus
and labioscrotal swellings. The vulva is formed by the labia majora and vestibule, with its erectile
apparatus: clitoris (glans, body, crura), labia minora, vestibular bulbs and corpus spongiosum.
Grafenberg, in 1950, discovered no G-spot and did not report an orgasm of the intraurethral glands.
The hypothetical area named G-spot should not be dened with Grafenbergs name. The female orgasm
should be a normal phase of the sexual response cycle, which is possible to achieve by all healthy women
with effective sexual stimulation. Knowledge of the embryology, anatomy and physiology of the female
erectile organs are important in the eld of womens sexual health.
2010 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Sexual health
Vulva
Clitoris
Female orgasm
G-spot
Contents
1.
2.
3.
4.
5.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The embryological development of the vulva . . . . . . . . . . . . . . .
The vulva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
The vestibule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.
The labia minora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.
The clitoris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4.
The vestibular bulbs and the female corpus spongiosum .
3.5.
The corpus spongiosum of the female urethra . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
1. Introduction
Orgasm is a normal psycho-physiological function of human
beings [1]. Women have the right to feel sexual pleasure: sexual
health is a global issue that is vital to overall well-being [2]. The
anatomy of the vulva and of the female erectile organs (trigger of
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
3
4
4
4
4
5
5
6
6
7
7
V. Puppo / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 38
V. Puppo / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 38
[(Fig._1)TD$IG]
V. Puppo / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 38
Fig. 1. I, The male penis. II III, The female erectile organs (without vestibular bulb). Modied from: Puppo V. La sessualita` umana e leducazione a fare lamore. Firenze: Loggia
de Lanzi, 2005. I - 1, Glans. 2, Correspondent part to the labia minora. 3, Scrotum. 4, Anus. II - 1, Glans. 2, Labia minora. 3, Labia majora. 4, Anus. 5, Frenulum. 6, Sulcus
nympholabialis. III - 1, Corpora cavernosa. 2, Septum. 3, Corpus spongiosum. 4, Kobelts venous plexus.
vided into pubovaginal, puboperineal and puboanal. This terminology was accepted in 1998 by the Federative Committee on
Anatomical Terminology [35,28]. The rhythmic contractions of
lower third of the vagina during orgasm are mainly due to the
contractions of the bulbocavernosus muscle [1,35].
3.5. The corpus spongiosum of the female urethra
The corpus spongiosum of the urethra is present in all
women, as in the male. It is a cavernous tissue rich in veins,
situated at submucosal level and among the muscular bundles of
the smooth muscular tunica of the urethral wall. It becomes
engorged, or erect, with sexual arousal and Grafenberg in
1950 wrote In the course of sexual stimulation the female
urethra begins to enlarge [4,17,29]. Female urethral sensibility
has been little investigated until now, though Dickinson wrote
in 1949 Indeed, the meatus is largely endowed with special
sensibility [5], and Grafenberg in 1950 described some cases of
female and male urethral masturbation [29].
Therefore the erectile structures are the same in female and in
male. The clitoris is the homologue of the two corpora cavernosa,
[(Fig._2)TD$IG]
Fig. 2. The female erectile organs (The female penis without labia minora)
Modied from: Puppo V. La sessualita` umana e leducazione a fare lamore. Firenze:
Loggia de Lanzi, 2005. 1, Body. 2, Glans. 3, Suspensory ligament. 4, Angle of clitoris.
5, Vestibular bulb. 6, Crus. 7, Corpus spongiosum.
glans and prepuce of the male penis, and the male erection is
equivalent to the erection of all female erectile organs (vaginal
lubrication is a consequence of congestion) [35,17]. The female
external genitals are joined together even though separated by the
presence of the vaginal opening, and they represent the penis and
the scrotum of the male (Figs. 1 and 2) [35,8]. This has been
recognized for many years. In 1949 Dickinson wrote: Vulvo-vaginal
changes in excitement. Protrusion of erectile bulbs of vestibule.
Clitoris erection. Labial erection. [5]. Laqueur wrote that Realdus
Columbus, in 1559, named the love or sweetness of Venus
(amoris dulcedo) what he found in the nature, a female penis
[7,30].
4. Discussion
Addiego et al. in 1981 wrote: At the April, 1979, testing
session, the subject identied an erotically sensitive spot, palpable
through the anterior wall of her vagina. We subsequently named
this area the Grafenberg spot, in recognition of the person who
wrote of its existence and relationship to female ejaculation
(Grafenberg, 1950) [31]. Subsequently the Grafenberg spot (i.e.
intraurethral glands or female prostate) was seized on by the
popular media, which called it the G-spot. The G-spot is currently
an hypothesis: Grafenberg, in 1950, discovered no G-spot [29,32].
In his article he did not describe a vaginal spot, but the role of the
urethra in female orgasm (not the role of the vagina): the urethra,
on the anterior wall of the vagina, is a distinct erotogenic zone in
women [29].
Grafenberg described some cases of female urethral masturbation and the corpus spongiosum of the female urethra, stating that,
analogous to the male urethra, the female urethra also seems to
be surrounded by erectile tissues like the corpora cavernosa. He
did not report an orgasm of intraurethral glands, but wrote:
Involuntary expulsion of urine is reported in sex literature. In the
cases observed by us, the uid was examined and it had no urinary
character. I am inclined to believe that urine reported to be
expelled during female orgasm is not urine, but only secretions of
the intraurethral glands [29].
In 1950 Grafenberg wrote about the corpus spongiosum of
the female urethra: In the course of sexual stimulation the
female urethra begins to enlarge and can be felt easily. It swells
out greatly at the end of orgasm. The most stimulating part is
located at the posterior urethra, where it arises from the neck of
the bladder [29]. The so-called G-spot of the anterior vaginal
wall is located in Pawlicks triangle (which corresponds to
Lieutauds triangle in bladder) that has a smooth vaginal mucosa
and it is only a space with minor resistance [4].
V. Puppo / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 38
Hines in 2001 wrote: Grafenberg discusses no evidence for a Gspot. . . .[Some female patients], he says, derived sexual pleasure
from inserting objects, such as hat pins, into their urethras. Just how
later writers (i.e. 2) transformed these reports into evidence for a Gspot is unclear. . . . Women who fail to nd their G-spot, because they
fail to respond to stimulation as the G-spot myth suggests that they
should, may end up feeling inadequate or abnormal. [32].
Burri et al. in 2010 wrote: The existence of the G-spot seems to
be widely accepted among women, despite the failure of numerous
behavioral, anatomical, and biochemical studies to prove its
existence. . . .there is no physiological or physical basis for the Gspot. [33]. Besides, there are no ultrasonographic images or
anatomical pictures of the G-spot, and the female prostate has no
anatomical structure that can cause an orgasm [35]. The
hypothetical area named G-spot should not be dened with
Grafenbergs name.
G-spot amplication is a procedure that is not medically
indicated. The American College of Obstetricians and Gynecologists states: So-called vaginal rejuvenation, designer vaginoplasty, revirgination, and G-spot amplication are vaginal surgical
procedures being offered by some practitioners. Women should be
informed about the lack of data supporting the efcacy of these
procedures and their potential complications, including infection,
altered sensation, dyspareunia, adhesions, and scarring [34].
The importance of orgasm has been questioned: Orgasm and
resolution are not essential in Bassons model of the sexual
response cycle [35]. Basson et al. in 2005 wrote, Orgasm may or
may not be necessary for sexual satisfaction [36]. According to
Masters and Johnson, however: Physiologically sexual response
could be described as a cycle with four phases: excitement,
plateau, orgasm, and resolution (i.e. the period of return to the
unaroused state) . . . If there has been considerable excitement but
orgasm has not occurred, resolution takes a longer time . . . there is
sometimes a lingering sensation of pelvic heaviness or aching that
is due to continued vasocongestion, . . .this may create a condition
of some discomfort, particularly if high levels of arousal were
prolonged [1,37].
In 1949 Dickinson wrote about long-term sequelae of female
sexual excitement without orgasm: Vulvo-vaginal changes in
excitement. Chronic or persisting alterations due to strong, long
continued and close-set repetition of excitation are the following:
(1) Inammation at mouth of duct of vulvo-vaginal gland. (2)
Prominent veins in certain locations about vulva. (3) Varicosities of
bulb, and of pars intermedia toward clitoris. (4) Varicosities in base
of broad ligament. (5) Varicosities in upper part of broad ligament.
(6) Enlargement of clitoris. (7) Labial enlargement. (8) Levator
thickening and irritability, followed by relaxation. (9) Hymen
gaping, worn, ironed out or disappearing. (10) Chronic bladder base
congestion, (11) Hemorrhoids. [5]. The evidence for these statements is unclear but physiologically, female sexual satisfaction is
based on orgasm and resolution [1,37,38].
5. Conclusion
Dickinson wrote: Exalting vaginal orgasm while decrying
clitoris satisfaction is found to beget much frustration. Orgasm is
orgasm, however achieved [5]. Masters and Johnson agreed.
Physiologically all female orgasms follow the same reex response
patterns, no matter what the source of sexual stimulation. An
orgasm that comes from rubbing the clitoris cannot be distinguished
physiologically from one that comes from intercourse or breast
stimulation alone [1,37]. Clitoral/vaginal/uterine orgasm, G/A/C/U
spot orgasm, are terms that should not be used by sexologists,
women and mass-media [3,4,38].
The female orgasm (and resolution) should be a normal phase of
the sexual response cycle, which is possible to achieve by all healthy
women with effective sexual stimulation, and aging alone does not
diminish female sexual interest or the potential of the woman to be
sexually responsive if her general health is good [1,37].
Clitoral bulbs, clitoral or clitorisurethrovaginal complex, urethrovaginal space, periurethral glans, genitosensory component of
the vagus nerve, and G-spot, are terms used by some sexologists but
they are not accepted or shared by experts in human anatomy
[3,4,38]. Findings from the disciplines of embryology, anatomy, and
physiology about the congestive structures of womens urogenital
areas, which are homologous to mens erectile organs, should form
the basis of the discourse about the biological basis womens orgasm.
References
[1] Masters WH, Johnson VE. Human sexual response. Boston: Little Brown;
1966 .
[2] Abdool Z, Thakar R, Sultan AH. Postpartum female sexual function. Eur J Obstet
Gynecol Reprod Biol 2009;145:1337.
[3] Williams PL, Bannister LH, Berry MM, et al. Grays anatomy, 38th ed., New
York: Churchill Livingstone; 1995.
[4] Testut L, Latarjet A. Traite dAnatomie Humaine, neuvie`me edition. Paris: G.
Doin & C. ie; 1972.
[5] Dickinson RL. Atlas of human sex anatomy, 2nd ed., Baltimore: Williams &
Wilkins; 1949.
[6] Mah K, Binik YM. The nature of human orgasm: a critical review of major
trends. Clin Psychol Rev 2001;6:82356.
[7] Laqueur T. Making sex: body and gender from the Greeks to Freud. Cambridge:
Harvard University Press; 1990.
[8] Van Turnhout AA, Hage JJ, Van Diest PJ. The female corpus spongiosum
revisited. Acta Obstet Gynecol Scand 1995;74:76771.
[9] Zaviacic M, Jakubovska V, Belosovi RM, Breza J. Ultrastructure of the
normal adult human female prostate gland (Skenes gland). Anat Embryol
2000;201:5161.
[10] Giuliano F, Clement P. Physiology of ejaculation: emphasis on serotonergic
control. Eur Urol 2005;48:40817.
[11] Zukerman Z, Weiss DB, Orvieto R. Does preejaculatory penile secretion originating from Cowpers gland contain sperm? J Assist Reprod Genet 2003;20:1579.
[12] Fetissof F, Arbeille B, Bellet D, Barre I, Lansac J. Endocrine cells in human
Bartholins glands. An immunohistochemical and ultrastructural analysis.
Virchows Arch B Cell Pathol Incl Mol Phatol 1989;57:11721.
[13] Sakamoto H, Ichikawa G, Shimizu Y, Kikuchi A, Yamamoto T. Extreme hypertrophy of the labia minora. Acta Obstet Gynecol Scand 2004;83:12256.
[14] Pardo J, Sola` V, Ricci P, Guilloff E. Laser labioplasty of labia minora. Int J
Gynaecol Obstet 2006;93:3843.
[15] Catania L, Abdulcadir O, Puppo V, Baldaro Verde J, Abdulcadir J, Abdulcadir D.
Pleasure and orgasm in women with female genital mutilation/cutting (FGM/
C). J Sex Med 2007;4:166678.
[16] Shak A, Shak AA, Ahmed I. Response of the labia majora and minora to
clitoral stimulation. Int J Gynaecol Obstet 2004;86:4012.
[17] Yang CC, Cold CJ, Yilmaz U, Maravilla KR. Sexually responsive vascular tissue of
the vulva. BJU Int 2006;97:76672.
[18] Connell K, Guess MK, La Combe J, et al. Evaluation of the role of pudendal nerve
integrity in female sexual function using noninvasive techniques. Am J Obstet
Gynecol 2005;192:17127.
[19] Catala M. Control of the development of Onufs spinal nucleus. Prog Urol
2002;12:3403.
[20] Shak A. Response of the urethral and intracorporeal pressures to cavernosus
muscle stimulation: role of the muscle in erection and ejaculation. Urology
1995;46:858.
[21] Toesca A, Stol VM, Cocchia D. Immunohistochemical study of the corpora
cavernosa of the human clitoris. J Anat 1996;188:51320.
[22] Goldstein AT, Burrows LJ. Surgical treatment of clitoral phimosis caused by
lichen sclerosus. Am J Obstet Gynecol 2007;196:. 126.e14.
[23] Johnson RD, Kitchell RL. Mechanoreceptor response to mechanical and
thermal stimuli in the glans penis of the dog. J Neurophysiol
1987;57:181336.
[24] Halata Z, Munger BL. The neuroanatomical basis for the protopathic sensibility
of the human glans penis. Brain Res 1986;371:20530.
[25] Verkauf BS, Von Thron J, OBrien WF. Clitoral size in normal women. Obstet
Gynecol 1992;80:414.
[26] Medina CA. Clitoral priapism: a rare condition presenting as a cause of vulvar
pain. Obstet Gynecol 2002;100:108991.
[27] Arntzen BW, de Boer CN. Priapism of the clitoris. BJOG 2006;113:7423.
[28] Kearney R, Sawhney R, DeLancey JO. Levator ani muscle anatomy evaluated by
origin insertion pairs. Obstet Gynecol 2004;104:16873.
[29] Grafenberg E. The role of urethra in female orgasm. Int J Sexol 1950;III:1458.
[30] Stringer MD, Becker I. Colombo and the clitoris. Eur J Obstet Gynecol Reprod
Biol 2010;151:1303.
[31] Addiego F, Belzer EG, Comolli J, Moger W, Perry JD, Whipple B. Female
ejaculation: a case study. J Sex Res 1981;17:1321.
[32] Hines TM. The G-spot: a modern gynecologic myth. Am J Obstet Gynecol
2001;185:35962.
V. Puppo / European Journal of Obstetrics & Gynecology and Reproductive Biology 154 (2011) 38
[33] Burri AV, Cherkas L, Spector TD. Genetic and environmental inuences on
self-reported G-spots in women: a twin study. J Sex Med 2010;7:184252.
[34] American College of Obstetricians and Gynecologists (ACOG). Committee
opinion No. 378: vaginal rejuvenation and cosmetic vaginal procedures.
Obstet Gynecol 2007;110:7378.
[35] Rosen RC, Barsky JL. Normal sexual response in women. Obstet Gynecol Clin
North Am 2006;33:51526.
[36] Basson R, Brotto LA, Laan E, Redmond G, Utian WH. Assessment and management of womens sexual dysfunctions: problematic desire and arousal. J Sex
Med 2005;2:291300.
[37] Masters WH, Johnson VE, Kolodny RC. Masters and Johnson on sex and human
loving. Boston: Little Brown; 1986.
[38] Puppo V, Mannucci A, Abdulcadir J, Puppo G. Clarications about some
theories in sexology and about a correct sexual terminology. In: Oral Presentation-9th Congress of the European Federation of Sexology; 2008 [Abstract
in: Sexologies 2008; 17(Suppl. 1), T10-O-25: S147. Full text (video) in: Vaginal
orgasm and G-spot dont exist-sex education: from EFS congress 2008. Available at: http://www.youtube.com/watch?v=E52HiDw5bhM (accessed 08.07.
2008)].