Beyond the G-spot: clitourethrovaginal complex anatomy in female orgasm

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Abstract

The search for the legendary, highly erogenous vaginal region, the Gräfenberg spot (G-spot), has produced important data, substantially improving understanding of the complex anatomy and physiology of sexual responses in women. Modern imaging techniques have enabled visualization of dynamic interactions of female genitals during self-sexual stimulation or coitus. Although no single structure consistent with a distinct G-spot has been identified, the vagina is not a passive organ but a highly dynamic structure with an active role in sexual arousal and intercourse. The anatomical relationships and dynamic interactions between the clitoris, urethra, and anterior vaginal wall have led to the concept of a clitourethrovaginal (CUV) complex, defining a variable, multifaceted morphofunctional area that, when properly stimulated during penetration, could induce orgasmic responses. Knowledge of the anatomy and physiology of the CUV complex might help to avoid damage to its neural, muscular, and vascular components during urological and gynaecological surgical procedures.

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Figure 1: Clitourethrovaginal (CUV) complex and its relationship to female anatomy.
Figure 2: Ultrasonographic coronal plane image taken at the top of the vulva during coitus in a healthy nulliparous woman.

References

  1. 1

    Jannini, E. A. et al. Female orgasm(s): one, two, several. J. Sex. Med. 9, 956–965 (2012).

    Article  Google Scholar 

  2. 2

    Jannini, E. A., Gravina, G. L., Buisson, O. & Foldes, P. A letter to the editor on the article by Burri et al. J. Sex. Med. 7, 2289–2292; author reply 2292–2284 (2010).

    Article  Google Scholar 

  3. 3

    Ladas, A. K., Whipple, B. & Perry, J. D. The G-spot and other discoveries about human sexuality (Holt, Reinehart & Winston, 1982).

    Google Scholar 

  4. 4

    Kinsey A. C., Pomeroy W. B., Martin C. E. & Gebhard, P. H. Sexual behaviour in the human female (W. B. Saunders, 1953).

    Google Scholar 

  5. 5

    Masters, W. H. & Johnson V. E. Human sexual response (Little Brown, 1966).

    Google Scholar 

  6. 6

    Hilliges, M., Falconer, C., Ekman-Ordeberg, G. & Johansson, O. Innervation of the human vaginal mucosa as revealed by PGP 9.5 immunohistochemistry. Acta Anat. (Basel) 153, 119–126 (1995).

    CAS  Article  Google Scholar 

  7. 7

    Song, Y. B., Hwang, K., Kim, D. J. & Han, S. H. Innervation of vagina: microdissection and immunohistochemical study. J. Sex Marital Ther. 35, 144–153 (2009).

    Article  Google Scholar 

  8. 8

    Pauls, R. et al. A prospective study examining the anatomic distribution of nerve density in the human vagina. J. Sex. Med. 3, 979–987 (2006).

    Article  Google Scholar 

  9. 9

    Buisson, O. & Jannini, E. A. Pilot echographic study of the differences in clitoral involvement following clitoral or vaginal sexual stimulation. J. Sex. Med. 10, 2734–2740 (2013).

    Article  Google Scholar 

  10. 10

    Buisson, O., Foldes, P., Jannini, E. A. & Mimoun, S. Coitus as revealed by ultrasound in one volunteer couple. J. Sex. Med. 7, 2750–2754 (2010).

    Article  Google Scholar 

  11. 11

    D'Amati, G. et al. Type 5 phosphodiesterase expression in the human vagina. Urology 60, 191–195 (2002).

    Article  Google Scholar 

  12. 12

    D'Amati, G. et al. Functional anatomy of the human vagina. J. Endocrinol. Invest. 26, 92–96 (2003).

    CAS  PubMed  Google Scholar 

  13. 13

    Jannini, E. A., d'Amati, G. & Lenzi, A. in Women's sexual function and dysfunction: study, diagnosis and treatment (eds Goldstein, I., Meston, C., Davis, S. & Traish, A.) 125–133 (Taylor & Francis, 2006).

    Google Scholar 

  14. 14

    Shafik, A., El-Sibai, O., Shafik, A. A., Ahmed, I. & Mostafa, R. M. The electrovaginogram: study of the vaginal electric activity and its role in the sexual act and disorders. Arch. Gynecol. Obstet. 269, 282–286 (2004).

    Article  Google Scholar 

  15. 15

    Shafik, A., Shafik, A. A., Sibai, O. E. & Shafik, I. A. Identification of a vaginal pacemaker: an immunohistochemical and morphometric study. J. Obstet. Gynaecol. 27, 485–488 (2007).

    CAS  Article  Google Scholar 

  16. 16

    O'Connell, H. E., Hutson, J. M., Anderson, C. R. & Plenter, R. J. Anatomical relationship between urethra and clitoris. J. Urol. 159, 1892–1897 (1998).

    CAS  Article  Google Scholar 

  17. 17

    O'Connell, H. E., Eizenberg, N., Rahman, M. & Cleeve, J. The anatomy of the distal vagina: towards unity. J. Sex. Med. 5, 1883–1891 (2008).

    Article  Google Scholar 

  18. 18

    Yang, C. C., Cold, C. J., Yilmaz, U. & Maravilla, K. R. Sexually responsive vascular tissue of the vulva. BJU Int. 97, 766–772 (2006).

    Article  Google Scholar 

  19. 19

    Zaviacic, M. & Ablin, R. J. The female prostate. J. Natl Cancer Inst. 90, 713–714 (1998).

    CAS  Article  Google Scholar 

  20. 20

    Zaviacic, M. & Ablin, R. J. The female prostate and prostate-specific antigen. Immunohistochemical localization, implications of this prostate marker in women and reasons for using the term prostate” in the human female. Histol. Histopathol. 15, 131–142 (2000).

    CAS  PubMed  Google Scholar 

  21. 21

    Zaviacic, M. et al. Immunohistochemical localization of human protein 1 in the female prostate (Skene's gland) and the male prostate. Histochem. J. 29, 219–227 (1997).

    CAS  Article  Google Scholar 

  22. 22

    Grafenberg, E. The role of the urethra in female orgasm. Int. J. Sexol. 3, 145–148 (1950).

    Google Scholar 

  23. 23

    O'Connell, H. E., Sanjeevan, K. V. & Hutson, J. M. Anatomy of the clitoris. J. Urol. 174, 1189–1195 (2005).

    Article  Google Scholar 

  24. 24

    Maravilla, K. R. et al. Noncontrast dynamic magnetic resonance imaging for quantitative assessment of female sexual arousal. J. Urol. 173, 162–166 (2005).

    Article  Google Scholar 

  25. 25

    Suh, D. D., Yang, C. C., Cao, Y., Garland, P. A. & Maravilla, K. R. Magnetic resonance imaging anatomy of the female genitalia in premenopausal and postmenopausal women. J. Urol. 170, 138–144 (2003).

    Article  Google Scholar 

  26. 26

    Buisson, O., Foldes, P. & Paniel, B. J. Sonography of the clitoris. J. Sex. Med. 5, 413–417 (2008).

    Article  Google Scholar 

  27. 27

    Foldes, P. & Buisson, O. The clitoral complex: a dynamic sonographic study. J. Sex. Med. 6, 1223–1231 (2009).

    Article  Google Scholar 

  28. 28

    Schultz, W. W., van Andel, P., Sabelis, I. & Mooyaart, E. Magnetic resonance imaging of male and female genitals during coitus and female sexual arousal. BMJ 319, 1596–1600 (1999).

    CAS  Article  Google Scholar 

  29. 29

    Lavoisier, P., Aloui, R., Schmidt, M. H. & Watrelot, A. Clitoral blood flow increases following vaginal pressure stimulation. Arch. Sex. Behav. 24, 37–45 (1995).

    CAS  Article  Google Scholar 

  30. 30

    Kukkonen, T. M. et al. Convergent and discriminant validity of clitoral color Doppler ultrasonography as a measure of female sexual arousal. J. Sex Marital Ther. 32, 281–287 (2006).

    Article  Google Scholar 

  31. 31

    Gerritsen, J. et al. The clitoral photoplethysmograph: a new way of assessing genital arousal in women. J. Sex. Med. 6, 1678–1687 (2009).

    Article  Google Scholar 

  32. 32

    Meston, C. M., Rellini, A. H. & McCall, K. The sensitivity of continuous laboratory measures of physiological and subjective sexual arousal for diagnosing women with sexual arousal disorder. J. Sex. Med. 7, 938–950 (2010).

    Article  Google Scholar 

  33. 33

    Jannini, E. A., Simonelli, C. & Lenzi, A. Disorders of ejaculation. J. Endocrinol. Invest. 25, 1006–1019 (2002).

    CAS  Article  Google Scholar 

  34. 34

    Singer, J. & Singer, I. Types of female orgasm. J. Sex Res. 8, 255–267 (1972).

    Article  Google Scholar 

  35. 35

    Meston, C. M., Levin, R. J., Sipski, M. L., Hull, E. M. & Heiman, J. R. Women's orgasm. Annu. Rev. Sex Res. 15, 173–257 (2004).

    PubMed  Google Scholar 

  36. 36

    Jannini, E. A. et al. Who's afraid of the G-spot? J. Sex. Med. 7, 25–34 (2010).

    Article  Google Scholar 

  37. 37

    Millet, K. Sexual politics (Doubleday, 1969).

    Google Scholar 

  38. 38

    Lloyd, E. A. The case of the female orgasm: bias in the science of evolution (Harvard University Press, 2005).

    Google Scholar 

  39. 39

    Whipple, B., Gerdes, C. & Komisaruk, B. R. Sexual response to self-stimulation in women with complete spinal cord injury. J. Sex Res. 33, 231–240 (1996).

    Article  Google Scholar 

  40. 40

    Komisaruk, B. R., Gerdes, C. A. & Whipple, B. 'Complete' spinal cord injury does not block perceptual responses to genital self-stimulation in women. Arch. Neurol. 54, 1513–1520 (1997).

    CAS  Article  Google Scholar 

  41. 41

    Komisaruk, B. R. et al. Brain activation during vaginocervical self-stimulation and orgasm in women with complete spinal cord injury: fMRI evidence of mediation by the vagus nerves. Brain Res. 1024, 77–88 (2004).

    CAS  Article  Google Scholar 

  42. 42

    Komisaruk, B. R., Beyer-Flores, C. & Whipple, B. The science of orgasm (Johns Hopkins University Press, 2006).

    Google Scholar 

  43. 43

    Gravina, G. L. et al. Measurement of the thickness of the urethrovaginal space in women with or without vaginal orgasm. J. Sex. Med. 5, 610–618 (2008).

    Article  Google Scholar 

  44. 44

    Battaglia, C. et al. 3-D volumetric and vascular analysis of the urethrovaginal space in young women with or without vaginal orgasm. J. Sex. Med. 7, 1445–1453 (2010).

    Article  Google Scholar 

  45. 45

    Oakley, S. H. et al. Clitoral size and location in relation to sexual function using pelvic MRI. J. Sex. Med. 11, 1013–1022 (2014).

    Article  Google Scholar 

  46. 46

    Rees, M. A., O'Connell, H. E., Plenter, R. J. & Hutson, J. M. The suspensory ligament of the clitoris: connective tissue supports of the erectile tissues of the female urogenital region. Clin. Anat. 13, 397–403 (2000).

    CAS  Article  Google Scholar 

  47. 47

    King, R., Belsky, J., Mah, K. & Binik, Y. Are there different types of female orgasm? Arch. Sex. Behav. 40, 865–875 (2011).

    Article  Google Scholar 

  48. 48

    Laan, E., Rellini, A. H. & Barnes, T. Standard operating procedures for female orgasmic disorder: consensus of the International Society for Sexual Medicine. J. Sex. Med. 10, 74–82 (2013).

    Article  Google Scholar 

  49. 49

    Fayyad, A. M. et al. Symptomatic and quality of life outcomes after site-specific fascial reattachment for pelvic organ prolapse repair. Int. Urogynecol. J. Pelvic Floor Dysfunct. 19, 191–197 (2008).

    Article  Google Scholar 

  50. 50

    Dua, A., Jha, S., Farkas, A. & Radley, S. The effect of prolapse repair on sexual function in women. J. Sex. Med. 9, 1459–1465 (2012).

    Article  Google Scholar 

  51. 51

    Brandner, S., Monga, A., Mueller, M. D., Herrmann, G. & Kuhn, A. Sexual function after rectocoele repair. J. Sex. Med. 8, 583–588 (2011).

    Article  Google Scholar 

  52. 52

    Pauls, R. N. & Karram, M. M. Sexual function following anti-incontinence surgery. Minerva Urol. Nefrol. 60, 113–122 (2008).

    CAS  PubMed  Google Scholar 

  53. 53

    Lau, H. H., Su, T. H., Su, C. H., Lee, M. Y. & Sun, F. J. Short-term impact of tension-free vaginal tape obturator procedure on sexual function in women with stress urinary incontinence. J. Sex. Med. 7, 1578–1584 (2010).

    Article  Google Scholar 

  54. 54

    Achtari, C. et al. Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings. Int. Urogynecol. J. Pelvic Floor Dysfunct. 17, 330–334 (2006).

    Article  Google Scholar 

  55. 55

    Goldstein, I. & Berman, J. R. Vasculogenic female sexual dysfunction: vaginal engorgement and clitoral erectile insufficiency syndromes. Int. J. Impot. Res. 10 (Suppl. 2), 84–90 (1998).

    Google Scholar 

  56. 56

    Caruso, S. et al. Clitoral blood flow changes after surgery for stress urinary incontinence: pilot study on TVT versus TOT procedures. Urology 70, 554–557 (2007).

    Article  Google Scholar 

  57. 57

    Pauls, R. N. Impact of gynecological surgery on female sexual function. Int. J. Impot. Res. 22, 105–114 (2010).

    CAS  Article  Google Scholar 

  58. 58

    Mokate, T., Wright, C. & Mander, T. Hysterectomy and sexual function. J. Br. Menopause Soc. 12, 153–157 (2006).

    Article  Google Scholar 

  59. 59

    Komisaruk, B. R., Frangos, E. & Whipple, B. Hysterectomy improves sexual response? Addressing a crucial omission in the literature. J. Minim. Invasive Gynecol. 18, 288–295 (2011).

    Article  Google Scholar 

  60. 60

    Feldner, P. C. Jr et al. Sexual function after anterior vaginal wall prolapse surgery. Clinics (Sao Paulo) 67, 871–875 (2012).

    Article  Google Scholar 

  61. 61

    Leiblum, S. R. Redefining female sexual response. Contemp. Ob. Gyn. 45, 120–126 (2000).

    Google Scholar 

  62. 62

    Basson, R. Human sex-response cycles. J. Sex Marital Ther. 27, 33–43 (2001).

    CAS  Article  Google Scholar 

  63. 63

    Levine, S. B. The nature of sexual desire: a clinician's perspective. Arch. Sex. Behav. 32, 279–285 (2003).

    Article  Google Scholar 

  64. 64

    Berg, R. C. & Denison, E. Does female genital mutilation/cutting (FGM/C) affect women's sexual functioning? A systematic review of the sexual consequences of FGM/C. Sex. Res. Soc. Policy 9, 41–56 (2011).

    Article  Google Scholar 

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Acknowledgements

Figure 1b is a modification of an original image created by Laurent Buffo.

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All authors made substantial contributions to each stage of the preparation of this manuscript for submission.

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Correspondence to Emmanuele A. Jannini.

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Jannini, E., Buisson, O. & Rubio-Casillas, A. Beyond the G-spot: clitourethrovaginal complex anatomy in female orgasm. Nat Rev Urol 11, 531–538 (2014). https://doi.org/10.1038/nrurol.2014.193

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