Query: supernumeray clitoris

title: Anatomy, Histology, and Nerve Density of Clitoris and Associated Structures: Clinical Applications to Vulvar Surgery.
abstract: Precise understanding of structures comprising female external genitalia is essential in obstetric and gynecologic practice.  To further characterize anatomy, histology, and nerve density of the clitoris and associated structures and to provide clinical correlations to vulvar surgery.  Unembalmed female cadavers were examined. Length and width of body, glans and crura of clitoris were measured. Distances from glans to urethra and from dorsal surface of clitoral body to mid pubic arch were recorded. Path of dorsal nerve of clitoris was examined and nerve width was measured as it emerged from lateral surface of crura and at distal clitoral body. Distances from where dorsal nerve emerged from perineal membrane to posterior surface of membrane and to mid pubic arch were measured. Connective tissue layers associated with clitoris were examined. Tissue was harvested from additional unembalmed cadavers and nerve density of labia minora, glans, and clitoral body were analyzed. Histological examination was performed on vulvar structures to clarify tissue composition. Descriptive statistics were used for data analyses.  27 cadavers (ages 48 to 96) were examined, 22 grossly and 5 histologically. Median length and width of clitoral body were 29 mm (range, 13 59 mm) and 9 (5 14) mm, respectively. Glans was 8 (5 12) mm long and 4 (3 10) mm wide. Length of crura was 50 (25 68) mm and width at anterior portion was 9 (2 13) mm. Closest distance from glans to urethra was 25 (14 37) mm and from clitoral body to mid pubic arch was 29 (14 46) mm. Widths of dorsal nerve at lateral crura and at distal clitoral body were 3 (2 4) mm and 1 (1 2) mm, respectively. Distance from dorsal nerve as it emerged from perineal membrane to mid pubic arch was 34 (20 48) mm and to posterior surface of membrane was 20 (8 31) mm. Dorsal nerve and artery of clitoris coursed adjacent to medial surface of inferior pubic ramus surrounded by a dense fibrous capsule adherent to periosteum. Nerve and artery then coursed deep to dense connective tissue layers, which were contiguous with suspensory ligament and fascia of clitoris. Histologic examination revealed presence of erectile tissue in clitoral body, crura and vestibular bulbs but such tissue was absent in glans and labia minora. Nerve density analysis revealed statistically significant greater density in the dorsal, compared with ventral half of the clitoral body. Although not statistically significant, there was increased nerve density in the distal compared to proximal half of the labia minora.  Precise knowledge of clitoral anatomy and associated neurovascular structures is essential to safely complete partial vulvectomies, clitoral and vulvar reconstructive procedures, anti incontinence surgeries and repair of obstetric lacerations. Understanding range of anatomic variations and awareness of areas of increased nerve density is important during counseling and surgical planning. Though the dorsal nerve of clitoris courses deep to dense connective tissue layers, inadvertent injury may occur in setting of deep dissection or suture placement. The dorsal nerve seems most vulnerable with surgical entry or lacerations that extend from the midline of the prepuce to the inferior pubic rami.

title: Androgen and estrogen receptor expression in the developing human penis and clitoris.
abstract: To better understand how the human fetal penis and clitoris grows and remodels, we undertook an investigation to define active areas of cellular proliferation and programmed cell death spatially and temporally during development of human fetal external genitalia from the indifferent stage (8 weeks) to 18 weeks of gestation. Fifty normal human fetal penile and clitoral specimens were examined using macroscopic imaging, scanning electron microscopy and immunohistochemical localization for the cellular proliferation and apoptotic markers, Ki67 and Caspase 3. A number of hot spots of cellular proliferation characterized by Ki67 localization are present in the penis and clitoris especially early in development, most notably in the corporal body, glans, remodeling glanular urethra, the urethral plate, the roof of the urethral groove and the fully formed penile urethra. The 12 fold increase in penile length over 10 weeks of growth from 8 to 18 weeks of gestation based on Ki67 labelling appears to be driven by cellular proliferation in the corporal body and glans. Throughout all ages in both the developing penis and clitoris Ki67 labeling was consistently elevated in the ventral epidermis and ventral mesenchyme relative to the dorsal counterparts. This finding is consistent with the intense morphogenetic activity/remodeling in the ventral half of the genital tubercle in both sexes involving formation of the urethral/vestibular plates, canalization of the urethral/vestibular plates and fusion of the urethral folds to form the penile urethra. Areas of reduced or absent Ki67 staining include the urethral fold epithelium that fuses to form the penile tubular urethra. In contrast, the urethral fold mesenchyme is positive for Ki67. Apoptosis was rarely noted in the developing penis and clitoris; the only area of minimal Caspase 3 localization was in the epithelium of the ventral epithelial glanular channel remodeling.

title: Case report: epidermoid inclusion cyst of the clitoris as a long term complication of female genital mutilation
abstract: BackgroundFemale genital mutilation is a common procedure in sub Saharan Africa that causes serious short and long term complications. Although physicians can overcome these complications sometimes, they can be very confusing to diagnose. In this report, we discuss the surgical management of a patient with an epidermal inclusion cyst of the clitoris as a long term complication of type III female genital mutilation.Case presentationA healthy 43 year old African woman who was a nonsmoker and nonalcoholic presented with a large genital mass causing difficulty in urination and sexual discomfort. The patient had three full term spontaneous vaginal deliveries without any complications. Perineal examination revealed a 6 x 10 cm, well circumscribed, mobile, nontender, rounded cystic swelling in the right periclitoral area that was obstructing the urinary meatus and vaginal introitus. A surgical procedure was performed for total excision of the clitoral mass. Pathological findings showed an epidermoid inclusion cyst.ConclusionsBesides increasing clinicians' awareness of female genital mutilation and its long term complications, public education campaigns should be designed to eradicate this practice.

title: The Clitoris An Appraisal of its Reproductive Function During the Fertile Years: Why Was It, and Still Is, Overlooked in Accounts of Female Sexual Arousal
abstract: Stimulating the clitoris activates the brain to instigate changes in the female genital tract, namely, the enhancement of vaginal blood flow that increases vaginal luminal pO2, vaginal transudate (lubrication) facilitating painless penile penetration and partial neutralization of the basal luminal acidic pH, vaginal tenting, and ballooning delaying sperm transport and allowing semen de coagulation and capacitation (sperm activation) factors to act until arousal ends (often by orgasm induction) All these genital changes taken together are of major importance in facilitating the possibility of reproductive success (and thus gene propagation) no matter how or when the clitoris is stimulated they reveal its overlooked reproductive function. Of course, also commensurate with these changes, is its activation of sexual pleasure. The clitoris thus has both procreative (reproductive) and recreative (pleasure) functions of equal importance. Clitoridectomy creates not only sexual disability but also a reproductive disability.  2019.

title: Anatomical Dissection of the Dorsal Nerve of the Clitoris.
abstract: The clitoris is the primary somatosensory organ of female sexual response. Knowledge of its neural anatomy and related landmarks is essential for safe genital surgery.  To describe the distal course of the dorsal nerves of the clitoris and associated structures.  Clitorises of 10 fresh cadavers were dissected. Measurements of the dorsal nerves, suspensory ligament, clitoral body, clitoral hood, and clitoral glans were obtained. The course of the dorsal nerves was examined.  The dorsal nerves of the clitoris were larger than expected, ranging from 2.0 3.2 mm in diameter, on average, along their course in the clitoral body. In 9 of 10 specimens, the dorsal nerves could be traced to within 6 mm of the glans. They traveled deep to a superficial clitoral fascia but superficial to the tunica albuginea, were variably located between 10 and 2 o'clock, and were separated by the deep suspensory ligament of the clitoris. The mean length of the descending clitoral body, from the angle to the base of the glans, was 37.0 mm. The mean distance from the pubic rim to the deep suspensory ligament was 37.7 mm.  The clitoral body is substantial in length, mostly lying superficially under the clitoral hood and mons pubis. The dorsal nerves of the clitoris are large and superficial, terminating at or near the base of the clitoral glans. Knowledge of this anatomy is critical prior to performing surgery near the clitoris.

title: Development of the human penis and clitoris.
abstract: The human penis and clitoris develop from the ambisexual genital tubercle. To compare and contrast the development of human penis and clitoris, we used macroscopic photography, optical projection tomography, light sheet microscopy, scanning electron microscopy, histology and immunohistochemistry. The human genital tubercle differentiates into a penis under the influence of androgens forming a tubular urethra that develops by canalization of the urethral plate to form a wide diamond shaped urethral groove (opening zipper) whose edges (urethral folds) fuse in the midline (closing zipper) In contrast, in females, without the influence of androgens, the vestibular plate (homologue of the urethral plate) undergoes canalization to form a wide vestibular groove whose edges (vestibular folds) remain unfused, ultimately forming the labia minora defining the vaginal vestibule. The neurovascular anatomy is similar in both the developing human penis and clitoris and is the key to successful surgical reconstructions.

title: Clarification of the Innervation of the Bladder, External Urethral Sphincter and Clitoris: A Neuronal Tracing Study in Female Mongrel Hound Dogs
abstract: Many studies examining the innervation of genitourinary structures focus on either afferent or efferent inputs, or on only one structure of the system. We aimed to clarify innervation of the bladder, external urethral sphincter (EUS) and clitoris. Retrograde dyes were injected into each end organ in female dogs. Spinal cord, mid bladder, and spinal, caudal mesenteric, sympathetic trunk and pelvic plexus ganglia were examined for retrograde dye labeled neurons. Neurons retrogradely labeled from the bladder were found primarily in L7 S2 spinal ganglia, spinal cord lateral zona intermedia at S1 S3 levels, caudal mesenteric ganglia, T11 L2 and L6 S2 sympathetic trunk ganglia, and pelvic plexus ganglia. The mid bladder wall contained many intramural ganglia neurons labeled anterogradely from the pelvic nerve, and intramural ganglia retrogradely labeled from dye labeling sites surrounding ureteral orifices. Neurons retrogradely labeled from the clitoris were found only in L7 and S1 spinal ganglia, L7 S3 spinal cord lateral zona intermedia, and S1 sympathetic trunk ganglia, and caudal mesenteric ganglia. Neurons retrogradely labeled from the EUS were found in primarily at S1 and S2 spinal ganglia, spinal cord lamina IX at S1 S3, caudal mesenteric ganglia, and S1 S2 sympathetic trunk ganglia. Thus, direct inputs from the spinal cord to each end organ were identified, as well as multisynaptic circuits involving several ganglia, including intramural ganglia in the bladder wall. Knowledge of this complex circuitry of afferent and efferent inputs to genitourinary structures is necessary to understand and treat genitourinary dysfunction.

title: Retrospective Study of the Prevalence and Risk Factors of Clitoral Adhesions: Women's Health Providers Should Routinely Examine the Glans Clitoris
abstract: The glans clitoris is covered by a prepuce that normally moves over the glans surface and can be retracted beyond the corona. Clitoral adhesions, ranging from mild to severe, occur when preputial skin adheres to the glans. Physical examination consistent with clitoral adhesions is based on the inability to visualize the entire glans corona. In this closed compartment, the space underneath the adherent prepuce and clitoris can become irritated, erythematous, or infected and can result in sexual dysfunction.  To determine the prevalence of clitoral adhesions in a sexual medicine practice and assess risk factors associated with clitoral adhesions.  This research involved retrospective examinations of vulvoscopy photographs taken from August 2007 to December 2015. Clitoral adhesions were considered absent when preputial retraction enabled full glans corona visualization. The study group consisted of women with mild, moderate, or severe clitoral adhesions based on more than 75% 25% to 75% or less than 25% glans clitoris exposure without full corona visualization, respectively. 2 independent reviewers evaluated photographs; a 3rd analyzed study group health record data.  Prevalence of severity of clitoral adhesions.  Of the 1,261 vulvoscopy photographs, 767 (61% were determined adequate for assessment and 614 photographs represented individual patients. The study group with clitoral adhesions consisted of 140 women (23% of whom 44% 34% and 22% demonstrated mild, moderate, and severe clitoral adhesions, respectively. In the study group, 14% presented with clitorodynia. Risk factors included a history of sexual pain, yeast infection, urinary tract infection, blunt perineal or genital trauma, lichen sclerosus, low calculated free testosterone, and other sexual dysfunctions including persistent genital arousal disorder.  Women with sexual dysfunction should routinely undergo clitoral physical examination. If the glans corona is not fully visualized, then clitoral adhesions should be suspected. Education, counseling, and/or referral for sexual pain management should be considered. Aerts L, Rubin RS, Randazzo M, et al. Retrospective Study of the Prevalence and Risk Factors of Clitoral Adhesions: Women's Health Providers Should Routinely Examine the Glans Clitoris. Sex Med 2018;6:115 122.

title: Os clitoris in dogs: 17 cases (2009 2017)
abstract: Medical records of 17 client owned dogs diagnosed with os clitoris on physical examination or diagnostic imaging were reviewed to describe the clinical signs and surgical management of this condition. All dogs were phenotypically female. The most common presenting complaints included an enlarged clitoris (n 10) urinary tract infection (n 5) and licking of the vulva (n 3) Other frequently reported clinical signs included vaginal discharge and/or lower urinary tract signs such as pollakiuria. Ten dogs were surgically managed with os clitorectomy. Concurrent related procedures included gonadohysterectomy (n 7) and episioplasty (n 3) Clitorectomy in the surgically managed dogs created a more normal female anatomy and resolved clinical signs associated with the exposed clitoris.

title: Victorian Medicine Was Not Responsible for Repressing the Clitoris: Rethinking Homology in the Long History of Women's Genital Anatomy
abstract: Narratives about female sexual pleasure frequently make recourse to teleological views of historical development that posit the present as relatively more enlightened than past repressive attitudes. The teleology usually takes the form of recognizing early modern accounts of the clitoris but denying the vast array of nineteenth century sources that had significantly more holistic views about female pleasure than is often imagined. Any scholar who has studied many nineteenth century texts about sexuality across French, British, US, German, and Italian cultures cannot help notice that female sexual pleasure in fact was heavily represented in medical thought throughout this time. This article suggests an alternative account of how the clitoris became maligned in the twentieth century. Several factors were involved, some of them occurring over a long historical process and some particular to interwar gender culture. Anatomical ideas about female genitalia were divided from the very beginning of their history, in what might be characterized as the Galenic versus Hippocratic models. Divergent views about the importance of the clitoris have been a constant feature of the long history of medical attempts to account for women's sexual pleasure. This article discusses how the clitoral vaginal dichotomy was generated in Europe and the United States only in the early twentieth century and how it was contested in the period between 1950 and 1973. The final section considers what is now understood scientifically about female genitalia and how these new understandings might inform feminist thinking about women's pleasure in ways that do not rely on historical myths about Victorian repression.