Meeting Paper
SGS Papers
Anatomy, histology, and nerve density of clitoris and associated structures: clinical applications to vulvar surgery

Presented in part in oral form at the 45th Annual Scientific Meeting of the Society of Gynecologic Surgeons, Tuscon, AZ, March 31–April 3, 2019.
https://doi.org/10.1016/j.ajog.2019.06.048Get rights and content

Background

A precise understanding of structures comprising the female external genitalia is essential in obstetric and gynecologic practice.

Objective

To further characterize the anatomy, histology, and nerve density of the clitoris and associated structures, and to provide clinical correlations to vulvar surgery.

Materials and Methods

Unembalmed female cadavers were examined. The length and width of the body, glans, and crura of the clitoris were measured. Distances from the glans to the urethra and from the dorsal surface of the clitoral body to the mid pubic arch were recorded. The path of the dorsal nerve of the clitoris was examined, and the nerve width was measured as it emerged from the lateral surface of crura and at the distal clitoral body. Distances from where the dorsal nerve emerged from the perineal membrane to the posterior surface of the membrane and to mid pubic arch were measured. Connective tissue layers associated with the clitoris were examined. Tissue was harvested from additional unembalmed cadavers, and nerve density of the 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.

Results

A total of 27 cadavers (aged 48–96 years) were examined, 22 grossly and 5 histologically. The median length and width of clitoral body were 29 mm (range, 13–59 mm) and 9 mm (range, 5–14 mm), respectively. The glans was 8 mm (range, 5–12 mm) long and 4 mm (range, 3–10 mm) wide. The length of the crura was 50 mm (range, 25–68 mm), and the width at the anterior portion was 9 mm (range, 2–13 mm). The closest distance from the glans to the urethra was 25 mm (range, 14–37 mm) and from the clitoral body to the mid pubic arch was 29 mm (range, 14–46 mm). The widths of the dorsal nerve at the lateral crura and at the distal clitoral body were 3 mm (range, 2–4 mm) and 1 mm (range, 1–2 mm), respectively. The distance from the dorsal nerve as it emerged from the perineal membrane to the mid pubic arch was 34 mm (range, 20–48 mm) and to the posterior surface of the membrane was 20 mm (range, 8–31 mm). The dorsal nerve and artery of the clitoris coursed adjacent to the medial surface of the inferior pubic ramus surrounded by a dense fibrous capsule adherent to the periosteum. The nerve and artery then coursed deep to dense connective tissue layers, which were contiguous with the suspensory ligament and fascia of the clitoris. Histologic examination revealed the presence of erectile tissue in the clitoral body, crura, and vestibular bulbs, but such tissue was absent in the 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 the proximal half of the labia minora.

Conclusion

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 the range of anatomic variations and awareness of the areas of increased nerve density is important during counseling and surgical planning. Although the dorsal nerve of the clitoris courses deep to dense connective tissue layers, inadvertent injury may occur in the 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.

Section snippets

Materials and Methods

Vulvar dissections and microscopic examination with nerve density assessment of the clitoris, labia, and VB were performed in unembalmed cadavers obtained from the Willed Body Program at University of Texas Southwestern Medical Center (UTSW) in Dallas. Cadavers were excluded if they had a history of gynecologic cancer or evidence of metastatic cancer to the vulva. This study was exempt from review by UTSW Medical Center Institutional Review Board in accordance with Code of Federal Regulations,

Results

A total of 22 adult female cadavers were examined grossly; 21 were of white ethnicity and 1 African American. Age was a median of 70 years (range, 48–89); body mass index was 21.5 kg/m2 (range, 13.3–34.3 kg/m2). The most common cause of death was metastatic cancer (n = 11), with breast cancer being the most common. Tissue from 5 additional cadavers (aged 52–96 years) was examined microscopically. Available medical histories and dissections revealed no evidence of prior vulvovaginal surgery or

Comment

In this cadaver study, we provide further characterization of the path and anatomic relationships of the DNC, and discuss possible clinical applications to obstetric and gynecologic procedures. As this nerve provides sensory innervation to the glans, injury may result in decreased sensation, pain syndromes, and possible sexual dysfunction. Similar to other descriptions, we found that after emerging from the PM, the DNC was consistently encased in a dense connective tissue sheath adherent to the

References (35)

  • A.J. Wein

    Campbell-Walsh urology

    (2016)
  • S.N. Fiona Lewis et al.

    Ridley’s the vulva

    (2009)
  • V. Puppo

    Anatomy and physiology of the clitoris, vestibular bulbs, and labia minora with a review of the female orgasm and the prevention of female sexual dysfunction

    Clin Anat

    (2013)
  • R.N. Pauls

    Anatomy of the clitoris and the female sexual response

    Clin Anat

    (2015)
  • M.A. Rees et al.

    The suspensory ligament of the clitoris: connective tissue supports of the erectile tissues of the female urogenital region

    Clin Anat

    (2000)
  • V.D. Marino et al.

    Anatomic study of the clitoris and the bulbo-clitoral organ

    (2014)
  • C.F. Moss et al.

    Dorsal clitoral nerve injury following transobturator midurethral sling

    J Pain Res

    (2016)
  • Cited by (30)

    • Surgical anatomy of the clitoris and surrounding vulvar structures

      2023, American Journal of Obstetrics and Gynecology
    • The Suspensory Ligament of the Clitoris: A New Anatomical and Histological Description

      2022, Journal of Sexual Medicine
      Citation Excerpt :

      The authors also described the macroscopic features of the ligament: the superficial component appeared fibro-adipose while the deep component was fibrous. Cross-references to clitoris supporting tissues were made in multiple studies: Poirier and Charpy in 1901,5 Zacharin in 1963,6 Bertolini in 1966,7 Milley and Nichols in 19708 and O'Connell in 19982 and finally Jackson in 2019.9 This new description of the suspensory ligament of the clitoris may give us useful new information for clitoris reconstruction surgery in female genital mutilation (FGM) and for metoidioplasty surgery.

    • Anatomical study of the clitoris and its implications on female genital mutilation and surgical repair

      2021, Journal of Plastic, Reconstructive and Aesthetic Surgery
      Citation Excerpt :

      The measurements of the clitoral glans, body, and crura were grossly consistent with those seen in previous results.3–5,7,8,16 Regarding dorsal nerve measurements, the study findings were consistent with those of two recent cadaveric studies by Kelling et al.7 and Jackson et al. (2019)4 . In our study, the dorsal nerve diameters were slightly smaller in proximal measurements: at the clitoral knee and at emergence from the crus.

    View all citing articles on Scopus

    The authors report no conflict of interest.

    Cite this article as: Jackson LA, Hare AM, Carrick KS, et al. Anatomy, histology, and nerve density of the clitoris and associated structures: clinical applications to vulvar surgery. Am J Obstet Gynecol 2019;221:519.e1-10.

    View full text