Clitoral size in full-term infants

We have provided standards for clitoral length and width. These measurements are simple, reliable, and reproducible and should be included as part of the newborn physical examination.     

An Adolescent Girl with a Complaint of Clitoral Swelling

BackgroundWe present the case of an adolescent girl with prominent clitoral swelling as the first symptom when she presented to the emergency department, and who was subsequently diagnosed with nephrotic syndrome.CaseA 14-year-old adolescent girl was admitted with painless clitoral swelling. She denied recent masturbation, itching, or discharge. She was within the last few days of menstruation. Physical examination revealed clitoral edema without erythema or genital edema. Urine dipstick test and microscopic evaluation revealed protein 2+, blood 3+, abundant erythrocytes and 9–10 leukocytes. A few days later, additional clinical findings, such as pretibial and facial edema, were diagnosed as nephrotic syndrome.Summary and ConclusionThis case is a reminder that clitoral swelling is to be considered a sign in the diagnosis of nephrotic syndrome, even when it occurs alone.     

The Successful Measurement of Clitoral Pulse Amplitude Using a New Clitoral Photoplethysmograph: A Pilot Study

BackgroundAlthough the clitoris is more sensitive to stimulation and its innervation more conducive to sensory feedback than the vagina, the field of sexual psychophysiology, which uses psychophysiological methods including genital response measures to study sexual arousal, relies heavily on the measurement of vaginal, rather than clitoral, pulse amplitude.AimTo develop and test a new clitoral photoplethysmograph for the measurement of clitoral pulse amplitude (CPA).Methods2 versions of the new device, which differed in the orientation of the sensor and light source (parallel vs angled), were tested in 15 premenopausal, sexually functional women. Vaginal pulse amplitude (VPA) was assessed simultaneously. The women viewed a 3-minute erotic and an anxiety-inducing film segment with each clitoral sensor, interspersed with neutral video excerpts. In addition, they were asked to indicate their subjective level of sexual arousal during and after erotic video presentations.OutcomesThe main outcome measures are CPA, VPA, and subjective sexual arousal.ResultsThe clitoral photoplethysmograph successfully detected CPA. The quality of the signals was best for the angled sensor. Main effects of the film and the interaction between the film and epoch were stronger for the clitoral than for the vaginal device. In addition, CPA followed more closely changes in intensity of sexual films than VPA. Within- and between-subject correlations between genital response and subjective sexual arousal were higher for the clitoral than for the vaginal device.Clinical TranslationComparison of CPA with other genital blood flow measures in clinical samples is indicated and may contribute to improved physiological assessments of sexual response in women.Strengths and LimitationsOur sample was small and consisted of healthy volunteers. Future research could examine test-retest reliability, by including multiple recording sessions, and further explore the specificity of CPA by comparing sexual and non-sexual stimuli with positive valence.ConclusionThis study presents the first instrument to successfully measure CPA.Mechelmans DJ, Sachtler WL, von Wiegand TE, et al. The Successful Measurement of Clitoral Pulse Amplitude Using a New Clitoral Photoplethysmograph: A Pilot Study. J Sex Med 2020;17:1118–1125.     

Clitoral size in normal women.

OBJECTIVE: We sought to determine clitoral size in normal women and the possible effect of age, height, weight, parity, and oral contraceptive (OC) use. METHODS: Prospective measurement was made of clitoral dimensions in 200 consecutive normal women at routine gynecologic examination in an office setting. RESULTS: The mean (+/- standard deviation) transverse diameter of the glans clitoris was 3.4 +/- 1.0 mm. The longitudinal diameter of the glans was 5.1 +/- 1.4 mm. Total clitoral length including glans and body was 16.0 +/- 4.3 mm. The mean clitoral index was 18.5 mm2. Measurements of all diameters were normally distributed. Age, height, weight, or current use of OCs did not influence clitoral size, but parous women had significantly larger measurements. CONCLUSIONS: It is possible to obtain useful clitoral measurements in the office setting. Parity influences clitoral size, but age, height, weight, and OC use do not.     

Treatment of Clitoral Keratin Pearls with Topical Estrogen Cream: Case Report

BackgroundKeratin pearls are intraepithelial accumulations of squamous cells and debris that can be an etiology of vulvovaginal irritation in pediatric patients and are often associated with clitoral adhesions. Historically, most cases have been managed with manual or operative lysis of adhesions.CaseTwo prepubertal girls presented to our clinic with chronic clitoral irritation and were found to have clitoral adhesions with keratin pearls. Both were managed with topical estrogen cream, which resulted in resolution of their symptoms.Summary and ConclusionKeratin pearls can form when the overlying clitoral epithelium becomes blocked by clitoral adhesions. Hypoestrogenism is thought to be implicated in adhesion development; thus, topical estrogen cream is a reasonable option in initial management. Our results demonstrate a noninvasive alternative to the initial treatment of clitoral keratin pearls.     

Ultrastructural Study of Clitoral Cavernous Tissue and Clitoral Blood Flow From Type 1 Diabetic Premenopausal Women on Phosphodiesterase-5 Inhibitor

Background

The effects of phosphodiesterase-type 5 (PDE5) inhibitors on the in vivo clitoral structure of women with diabetes have never been investigated.

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

BackgroundClitoral 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.AimsTo validate the technique clitoral artery Doppler measured in a sagittal section and explore arterial volume flow as a new parameter in clitoral Doppler.MethodsWe 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.OutcomesWe 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.ResultsThe 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 ImplicationsWe 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 & LimitationsThis 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.ConclusionWe 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.     

CASE REPORTS: Clitoral Atrophy: A Case Series

IntroductionClitoral atrophy is often a neglected cause of female arousal complaints and warrants treatment with localized treatments.AimThis is a case series of patients with clitoral atrophy in which localized estrogens were used to treat separate, distinct sexual complaints.MethodsWe report on three patients who were treated with localized estrogen tablets and cream for symptomatic clitoral atrophy despite a lack of data for use of these agents for the treatment of this diagnosis. The patients described here expressed understanding of the risks of vaginal hormonal therapy prior to treatment and at follow-up visits while on therapy.Main Outcome MeasuresPatient reports, physical examination, and vaginal pH.ResultsAll patients reported improvement or resolution of symptoms after the treatment with localized estrogen tablets and/or cream.ConclusionsLow-dose minimally absorbed local estrogen products can be used in combination with excellent tolerance and low side-effect profile to treat female sexual complaints. Amsterdam A, and Krychman M. Clitoral atrophy: A case series. J Sex Med 2009;6:584–587.     

Symptomatic Clitoromegaly: Case Report of a Clitoral Hemangioma

Background

Clitoromegaly is often a sign of an underlying disorder of sexual development. Isolated clitoromegaly might occur as a result of benign or malignant neoplasm.

Inhibition of Phosphodiesterase 4 Enhances Clitoral and Vaginal Blood Flow Responses to Dorsal Clitoral Nerve Stimulation or PGE1 in Anesthetized Female Rats

Introduction.Cyclic adenosine 3′5′ monophosphate (cAMP) is produced by adenylate cyclase after activation by, e.g., vasoactive intestinal polypeptide or prostaglandin E1 (PGE1). The cAMP‐degrading phosphodiesterase 4 (PDE4) is expressed in the vagina and clitoris, but no information is available on the functional role for PDE4‐related signals in the female neurovascular genital response.Aim.The aim of this study is to study the effect of inhibition of PDE4 with rolipram on nerve‐ and PGE1‐induced vaginal and clitoral blood flow responses of rat.Methods.Measure of clitoral and vaginal blood flow and blood pressure in anesthetized rats during activation of the dorsal clitoral nerve (DCN) before and after intraperitoneal administration of rolipram or sildenafil (phosphodiesterase type 5 inhibitors [PDE5]) and nitro‐L‐arginine (L‐NNA) (nitric oxide synthase inhibitor). Effect by topical administration of PGE1 on genital blood flow was also evaluated.Main Outcome Measure.Blood flow was recorded as tissue perfusion units (TPU) by a Laser Doppler Flowmeter. Mean arterial blood pressure (MAP) was recorded (cmH₂O) in the carotid artery. Blood flow responses are expressed as TPU/MAP. Unpaired t‐test and an analysis of variance were used.Results.Compared with control stimulations, rolipram (0.3 mg/kg) caused a twofold increase in peak blood flow (P < 0.05) and fourfold increase of the rate of clitoral blood flow during activation of the DCN (P < 0.05). Simultaneously, a twofold increase in peak blood flow and threefold increase in rate of blood flow were noted in the vagina (P < 0.05). Similar effects were noted for sildenafil (0.2 mg/kg) (P < 0.05). Inhibitory effects by L‐NNA (60 mg/kg) on blood flow responses to DCN activation were significantly lower for rats treated with rolipram than with sildenafil (P < 0.05). PGE1‐induced (10 μg) blood flow responses were significantly higher (P < 0.05) in rats treated with rolipram than with sildenafil.Conclusions.These findings suggest that the cAMP/PDE4 system may be of similar functional importance as the nitric oxide/cyclic guanosine monophosphate/PDE5 pathway for neurovascular genital responses of the female rat.     

Type 2 Cesarean Scar Pregnancy Successfully Treated via Hysteroscopy-Assisted Laparoscopy

Study ObjectiveTo evaluate the efficacy of hysteroscopy-assisted laparoscopy as a treatment strategy for type 2 cesarean scar pregnancy at gestational age >8 weeks.DesignRetrospective case series (Canadian Task Force classification II-3).SettingA tertiary hospital.PatientsEight women with type 2 cesarean scar pregnancy at a gestational age >8 weeks.InterventionsAll patients underwent hysteroscopy-assisted laparoscopic resection and isthmus repair of cesarean scar pregnancy.Measurements and Main ResultsAll patients underwent removal of the cesarean scar pregnancy and complete repair of the uterine scar defect. The median operative time was 123.0 minutes (range, 100–168 minutes), median blood loss was 65.0 mL (range, 20–100 mL), and median length of hospital stay was 9.1 days (range, 8–12 days). There were no adverse reactions. The mean time to serum β-human chorionic gonadotropin (β-HCG) resolution was 22.9 days (range, 14–30 days), and menstruation resumed after 9 to 15 days with serum β-HCG returning to nondetectable levels. There was no recurrence of cesarean scar pregnancy at long-term follow-up.ConclusionHysteroscopy-assisted laparoscopy may be an effective treatment for patients with type 2 cesarean scar pregnancy at gestational age >8 weeks.     

Umbilical Cord Avulsion in Waterbirth

Umbilical cord avulsion (or “cord snapping”) is often cited as a risk associated with waterbirth. This article discusses a case study in which a cord avulsed during a waterbirth and uses it as a basis to explore the incidence, etiology, and associated risk factors of umbilical cord avulsion. The diagnosis, clinical presentation, and management of cord avulsion in waterbirth is presented along with a thorough review of the literature and relevant professional standards. This article offers recommendations for clinical practice to minimize the risk of a cord avulsion and highlights the need for additional research and provider education to ensure optimal care of women and newborns.     

Eczema Herpeticum in Pregnancy Successfully Treated with Acyclovir

Summary: A woman with eczema herpeticum due to herpes simplex virus type 1 presented at 35 weeks' gestation and was successfully treated with intravenous acyclovir, with subsequent vaginal delivery of a healthy female infant.     

REVIEWS: The Clitoral Complex: A Dynamic Sonographic Study

IntroductionThe existence of the G-spot remains controversial partly because no appropriate structure and innervation have been clearly demonstrated in this pleasurable vaginal area. Using sonography, we wanted to visualize the movements of the clitoris and its anatomical relationship with the anterior wall of the vagina during voluntary perineal contraction and vaginal penetration without sexual stimulation.AimThe aim of this presentation is to provide a dynamic sonographic study of the clitoris and to describe the movements of the quiescent clitoral complex during a voluntary perineal contraction. We aim to visualize the mechanical consequences of the pressure of the anterior vaginal wall with women who claim to have a special sensitivity of the G-spot area and vaginal orgasm. Histology and immunohistochemistry of the G-spot and other female genital tissues are beyond the scope of this study and have not been discussed.MethodThe ultrasounds were performed in five healthy volunteers with the Voluson® General Electric® Sonography system (GE Healthcare, Zipf, Austria), with a 12-MHz flat probe, and with a vaginal probe. We used functional sonography of the quiescent clitoris with voluntary perineal contractions and with finger penetration without sexual stimulation.Main Outcome MeasuresWe focused on the size of the clitoris (raphe, glans, and clitoral bodies) and of the length of the movements of the clitoris during voluntary perineal contractions.ResultsThe coronal planes during perineal contraction and finger penetration demonstrated a close relationship between the root of the clitoris and the anterior vaginal wall.ConclusionsWe suggest that the special sensitivity of the lower anterior vaginal wall could be explained by pressure and movement of clitoris' root during a vaginal penetration and subsequent perineal contraction. The G-spot could be explained by the richly innervated clitoris. Foldes P, and Buisson O. The clitoral complex: A dynamic sonographic study. J Sex Med 2009;6:1223–1231.