(144) Clitoral Anatomy and its Relation to Sexual Function after Apical Prolapse Repair using Pelvic MRI
Authors: Bowen S , Moalli P , Rogers R , Corton M , Andy U , Rardin C , Hahn M , Weidner A , Mazloomdoost D , Sridhar A , Gantz M 
Published: May 2023

Abstract

Introduction
The clitoris is the primary sexual organ involved in the physiological changes that occur during the female sexual response. Sparse research and contradictory evidence concerning clitoral anatomy and its role in female sexual function exist, especially in the context of pelvic floor disorders and their surgical correction. Comprehensive description of clitoral anatomy and how it relates to postoperative sexual function in women surgically treated for pelvic floor disorders is necessary to better understand the pathophysiological mechanisms of female sexual dysfunction following gynecologic surgery.

Objective
To identify characteristics of clitoral anatomy (size, location, shape) associated with female sexual function in women after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair, NTR) or transvaginal mesh (VM) hysteropexy for uterovaginal prolapse. We hypothesized that a smaller clitoris and clitoral components would correlate with poorer sexual function.

Methods
In this ancillary study of women enrolled in a randomized clinical trial, 30–42-month postoperative axial MRIs of 82 women surgically treated (41 NTR, 41 VM) were obtained at rest. The clitoral components (glans, body, crura) and vestibular bulbs were segmented to create 3D models of the “clitoral complex” (Figure 1). Using these models and computational morphometry, clitoral dimensions and position were computed with respect to a 3D pelvic coordinate system (Figure 2). After aligning, normalizing (scaling), and establishing corresponding points between models, statistical shape modeling was performed via Principal Component Analysis (PCA) to identify/quantify significant modes of anatomic variation of the clitoris. Participant data included demographics, medical history, sexual activity status, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). The relationships between clitoral measurements/shape and sexual function were evaluated using Spearman rank correlation.

Results
For this group of mostly postmenopausal women (80/82 [97.6%]), median (min-max) age was 65.3 (47-79), 15/82 (18.3%) were sexually active (SA), and 21/82 (25.6%) were not sexually active (NSA) postoperatively (46/82 [56.1%] did not respond). Among SA women, a smaller glans width correlated with overall poorer sexual function (lower PISQ-IR mean score) (r=0.74, p=0.002), frequent feelings of shame/fear with leakage of urine/stool during sex (r=0.69, p=0.004), and low sexual arousal (r=0.61, p=0.02). A smaller glans height correlated with dyspareunia (r=-0.64, p=0.02) and less intense orgasms postoperatively (r=0.64, p=0.01). A smaller glans volume correlated with low sexual arousal (r=0.60, p=0.02) and a clitoral complex farther away from participants’ midline (midsagittal plane) correlated with greater negative impact of incontinence/prolapse on sex life (r=-0.66, p=0.007). Among NSA women, a clitoris farther away from participants’ midline was associated with dyspareunia as a strong reason for sexual inactivity (r=0.49, p=0.03). From the PCA, 11 significant modes of shape variation were found. For SA women, Modes 5 and 8 correlated with leakage of urine/stool during sex (r=-0.65, p=0.009) and dyspareunia (r=-0.59, p=0.04), respectively (Figure 3). For NSA women, Mode 4 correlated with dyspareunia as a strong reason for sexual inactivity (r=0.46, p=0.04) (Figure 3).

Conclusions
Poorer sexual function was associated with a smaller clitoral glans (width, height, volume) among SA women and a clitoral complex positioned farther away from participants’ midline in SA and NSA women following prolapse surgery.

Disclosure
Yes, this is sponsored by industry/sponsor: Boston Scientific

Clarification
Industry funding only - investigator initiated and executed study