Female ejaculation: An update on anatomy, history, and controversies.

Female ejaculation is a contentious topic. From a review of the literature, history indicates that it is not a modern concept; some females were aware of it in times past without understanding the role of the fluid or composition of the ejaculate. Over time, scholars experimented, mainly with anatomical studies, in an attempt to identify the source of the ejaculate and explore its physiological and anatomical benefits for the female sexual experience. Despite these studies, views about female ejaculation remain controversial and inconsistent, with no clear conclusion as to its function. This review discusses the history of studies of female ejaculation and presents various hypotheses from an anatomical and physiological perspective. After reviewing 44 publications from 1889 to 2019, it became apparent that clinical and anatomical studies conducted during recent decades provide substantial evidence in support of the female ejaculatory phenomenon. Anatomical studies have shown that the ejaculate originates in the paraurethral (Skene's) glands, but its composition has been debated. Female ejaculate differs from urine in its creatinine and urea concentrations. The fluid also contains prostate specific antigen (PSA) and could have antibacterial properties that serve to protect the urethra. While the specific function of female ejaculation remains a topic of debate, there is sufficient evidence to support the existence of the phenomenon.

The overlooked reproductive function of the human clitoris-News media responses to the published review.

A brief survey of how the news media reported and misreported on the publication of the review that revealed the overlooked empirical evidence for the reproductive function of the human clitoris.

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.

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. Clin. Anat. 32:136-145, 2019. © 2019 Wiley Periodicals, Inc.

The clitoral activation paradox - Claimed outcomes from different methods of its stimulation.

This article reviews clitoral structures, their functions and how they are activated during the stages of female life. The paradox that occurs is that different procedures of activation are claimed by some to favor 'noxious outcomes' to the physical and psychic health of women who use it to achieve sexual arousal/orgasm with or without penile vaginal intercourse. A number of the difficulties and inconsistencies in relation to these claims are explored. The proposed justification for the 'noxious outcomes' is that 'evolution' punishes sexual arousals other than by coitus because it is the only one that leads to gene propagation. In this context, however, the new, evolutionary interpretation of clitoral function in the fertile years as a fundamental proximate mechanism for facilitating female reproductive fitness makes such a justification improbable. The role of coital alignment technique (CAT) in the treatment of female orgasmic disorder is discussed in relation to its features of introital, clitoral and periurethral glans stimulation. Attempts to control female sexuality through various 'clitoridectomies' are examined, and unanswered questions about clitoral stimulation are listed. Clin. Anat. 31:650-660, 2018. © 2018 Wiley Periodicals, Inc.

Exceptionalism is not exceptional in relation to sexual and reproduction mechanisms: Contrasts of human and animal sexuality.

Speculation that the release of oxytocin by orgasm in the human female during coitus facilitates fertility by enhancing uterine sperm transport has been criticized as having no unequivocal empirical human evidence. However, a counter claim that this supports human "exceptionalism" as some form of uterine sperm transport occurs in other species. This is a misconception as it ignores that human uterine peristalsis, powered by contractions of the smooth muscle of the archimyometrium, facilitates sperm transport even without any systemic oxytocin involvement. Moreover, examination of various unique reproductive mechanisms in numerous animals also indicates that the claim is misjudged and rests on a biased interpretation of what "exceptionalism" means in this biological context. Ten chosen aspects of our sexuality are presented as being exceptional to humans. Clin. Anat. 30:940-945, 2017. © 2017 Wiley Periodicals, Inc.

The Physiology of Female Sexual Function and the Pathophysiology of Female Sexual Dysfunction (Committee 13A).

INTRODUCTION: The article consists of six sections written by separate authors that review female genital anatomy, the physiology of female sexual function, and the pathophysiology of female sexual dysfunction but excluding hormonal aspects. AIM: To review the physiology of female sexual function and the pathophysiology of female sexual dysfunction especially since 2010 and to make specific recommendations according to the Oxford Centre for evidence based medicine (2009) "levels of evidence" wherever relevant. CONCLUSION: Recommendations were made for particular studies to be undertaken especially in controversial aspects in all six sections of the reviewed topics. Despite numerous laboratory assessments of female sexual function, genital assessments alone appear insufficient to characterise fully the complete sexual response.

Recreation and procreation: A critical view of sex in the human female.

This review deals critically with many aspects of the functional genital anatomy of the human female in relation to inducing sexual arousal and its relevance to procreation and recreation. Various controversial problems are discussed including: the roles of clitorally versus coitally induced arousal and orgasm in relation to the health of women, the various sites of induction of orgasm and the difficulty women find in specifically identifying them because of "'ambiguity problems" and "genital site pareidolia," the cervix and sexual arousal, why there are so many sites for arousal, why multiple orgasms occur, genital reflexes and coitus, the sites of arousal and their representation in the brain, and identifying aspects and functions of the genitalia with appropriate new nomenclature.

The pharmacology of the human female orgasm - its biological and physiological backgrounds.

The female orgasm has been examined over the years by numerous scientific disciplines yet it still has many secrets to be disclosed. Because its physiology, especially its neurophysiology, is sparingly understood its pharmacology is necessarily limited based mainly on the side effects of drugs. Few published studies have used a placebo group as controls. The paucity of focussed studies is well illustrated by the fact that there still is no approved medication to treat female orgasmic dysfunction. The present brief overview examines the most important aspects of its biology and especially its physiology highlighting the many questions that need answering if we are to have a comprehensive pharmacology of the female orgasm.

Can the controversy about the putative role of the human female orgasm in sperm transport be settled with our current physiological knowledge of coitus?

INTRODUCTION: Spermatozoal uptake, facilitated by uterine contractions induced by oxytocin at orgasm during coitus, has been a long term concept. Studies attempting its support, however, have been poorly examined especially in the context of the changes in the female genital tract activated by sexual arousal. AIM: To examine experimental support for the concept. METHODS: Using a variety of search engines, mainly peer reviewed articles and un-reviewed books were examined relating to sperm transport and function in the human female genital tract in the absence and presence of arousal to orgasm. MAIN OUTCOME MEASURES: Identifying evidence-based data to support authority-based opinion. RESULTS: All the experimental observations of sperm or model substitute's transport have been undertaken in women who were not sexually aroused. They fail to take into account that arousal creates vaginal tenting lifting the cervico-uterine complex into the false pelvis away from the ejaculated semen. This delays sperm uptake and transport making conclusions from these observations invalid in relation to transport during coitus. Studies injecting oxytocin have not used women in their sexually aroused state and used supraphysiological doses unlikely to be comparable with coitus and orgasm. The proposal that the transport of extra sperm by oxytocin-induced uterine contractions at orgasm is needed to facilitate fertility ignores possible harm from increased sperm numbers creating polyspermy and sperm enzyme release causing ovum degeneration, leading to decreased fertility. The role of sperm motility in their uptake from the vagina into the cervix as opposed to en bloc transfer through uterine archimyometrial-mediated transport in the absence of orgasm is at present unresolvable because of conflicting studies. CONCLUSION: The bulk of the reported evidence favors the conclusion that the female orgasm, with its concomitant central release of oxytocin, has little or no effective role in the transport of spermatozoa in natural human coitus.

Revisiting post-ejaculation refractory time-what we know and what we do not know in males and in females.

INTRODUCTION: The post-ejaculation refractory time (PERT), the period after a single ejaculation when further erections and ejaculations are inhibited, has been studied and well-documented in male rats. Since its first attribution in men by Masters and Johnson and its inaccurate delineation in their graphic sexual response model in 1966 it has been infrequently studied whereas scant attention has been paid to any such possible activity in women after female ejaculation. AIM: To critically review our current knowledge about PERT in rats and humans and describe and correct shortcomings and errors in previous publications and propose corrections. METHODS: Review of published literature. MAIN OUTCOME MEASURES: Identifying evidence-based data to support authority-based facts. RESULTS: The review exposes the extremely limited evidence-based data that our knowledge of PERT is based on. The paucity of data for most aspects of human PERT is remarkable; even the generally accepted statement that the duration of PERT increases with age has no published support data. CONCLUSIONS: Despite numerous studies in rats the mechanisms and site(s) of the activity are poorly understood. Dopaminergic and adrenergic pathways are thought to shorten PERT whereas serotonergic pathways lengthen its duration. Raising the brain serotonin levels in men using SSRIs helps reduce early or premature ejaculation. Rats have an absolute PERT (aPERT) during which erection and ejaculation is inhibited and a relative PERT (rPERT) when a stronger or novel stimulus can, whether such phases exist in men is unexamined. Apart from possible depressed activity in the amygdala and penile dorsal nerve and rejection of prolactin as a major factor in PERT little or no significant advance in understanding human male PERT has occurred. No evidence-based data on women's PERT after female ejaculation exists. New investigations in young and older men utilizing brain imaging and electromagnetic tomography are priority studies to accomplish.

Vaginal vasomotion--its appearance, measurement, and usefulness in assessing the mechanisms of vasodilatation.

INTRODUCTION: In a number of tissue microcirculations, the phenomenon of vasomotion occurs where only a proportion of the total number of capillaries present are open at the same time; they normally open and close in a random or chaotic order, partly determined by the metabolic state of their surrounding cells. AIM: A pilot to examine by photoplethysmography whether the vaginal microcirculation shows evidence of vasomotion and the effect when sexual arousal is induced. METHODS: The vaginal microcirculation in 14 healthy, premenopausal women was monitored by intravaginal infrared photoplethysmography using the vaginal pulse amplitude (VPA) as the index of blood content in the basal condition and during sexual arousal induced by video and/or clitoral stimulation. MAIN OUTCOME MEASURE: Analysis and interpretation of vaginal photoplethysmographic traces. RESULTS: The basal traces in all the sexually unaroused subjects (N = 14) showed at least two populations of their VPAs: a high amplitude VPA (h-VPA) with rapid ascending phase (short duration of systolic infill) and descending phase (short duration of diastolic outflow) among which were pseudorandomly scattered, low amplitude VPAs (l-VPA) with less acute ascending and descending phases; the l-VPAs were usually half the amplitude of the h-VPAs. On sexual arousal, the l-VPAs were converted into h-VPAs so that the l-VPAs decreased and in some cases practically disappeared, and the h-VPAs usually showed an increase; with cessation of the vasodilatory stimulus (N = 6), there was a slow recovery of the l-VPAs. The induction of orgasm did not appear to facilitate their recovery. Even during a short duration of sexual arousal (1 minute), the decrease in the l-VPAs (N = 6) was a more sensitive index of the occurrence of genital arousal than relying solely on changes in the maximum amplitude of the VPA. CONCLUSION: Because of vasomotion, the vaginal microcirculation can react to a vasodilatory stimulus with one of four theoretical photoplethysmographic responses, viz., Type 1 (full response), where there is a significant increase in the amplitude of the h-VPA signal and the number of l-VPAs are greatly reduced with a near corresponding increase in the h-VPAs; Type 2 (partial response), where the amplitude (and in some cases the number) of the h-VPAs increases but there is no decrease in the number of l-VPAs; Type 3 (partial response), where the amplitude of the h-VPAs changes little but the number of l-VPAs is reduced and the number of h-VPAs are correspondingly increased; and Type 4, where neither the amplitude of the h-VPAs (or their number) nor the number of the l-VPAs change significantly (a noneffective stimulus). This new analysis allows a more comprehensive and better discriminatory assessment of vaginal vasodilatation (genital arousal) and its return to the basal state in response to sexual arousal and now includes a new measure that is independent of an increase in the h-VPA maximum amplitude (Type 3 response).

Sexual arousal--its physiological roles in human reproduction.

The review examines the physiological roles of human sexual arousal in the mechanisms of reproduction in males and especially in females.

Sexual arousal and orgasm in subjects who experience forced or non-consensual sexual stimulation -- a review.

The review examines whether unsolicited or non-consensual sexual stimulation of either females or males can lead to unwanted sexual arousal or even to orgasm. The conclusion is that such scenarios can occur and that the induction of arousal and orgasm does not indicate that the subjects consented to the stimulation. A perpetrator's defence simply built upon the fact that evidence of genital arousal or orgasm proves consent has no intrinsic validity and should be disregarded.

Disorders of orgasm in women.

INTRODUCTION: Orgasm is a sensation of intense pleasure creating an altered consciousness state accompanied by pelvic striated circumvaginal musculature and uterine/anal contractions and myotonia that resolves sexually-induced vasocongestion and induces well-being/contentment. In 1,749 randomly-sampled U.S. women, 24% reported an orgasmic dysfunction. AIM: To provide recommendations/guidelines concerning state-of-the-art knowledge for management of orgasmic disorders in women. METHODS: An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Disorders of Orgasm in Women Committee, there were four experts from two countries. MAIN OUTCOME MEASURE: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. RESULTS: Female Orgasmic Disorder, the second most frequently reported women's sexual problem is considered to be the persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase that causes marked distress or interpersonal difficulty (DSM-IV). Empirical treatment outcome research is available for cognitive behavioral and pharmacological approaches. Cognitive-behavioral therapy for anorgasmia promotes attitude and sexually-relevant thought changes and anxiety reduction using behavioral exercises such as directed masturbation, sensate focus, and systematic desensitization treatments as well as sex education, communication skills training, and Kegel exercises. To date there are no pharmacological agents trials (i.e., bupropion, granisetron, and sildenafil) proven to be beneficial beyond placebo in enhancing orgasmic function in women diagnosed with Female Orgasmic Disorder. CONCLUSIONS: More research is needed in understanding management of women with orgasmic dysfunction.

Women's orgasm.

An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment. Women's orgasms can be induced by erotic stimulation of a variety of genital and nongenital sites. As of yet, no definitive explanations for what triggers orgasm have emerged. Studies of brain imaging indicate increased activation at orgasm, compared to pre-orgasm, in the paraventricular nucleus of the hypothalamus, periaqueductal gray of the midbrain, hippocampus, and the cerebellum. Psychosocial factors commonly discussed in relation to female orgasmic ability include age, education, social class, religion, personality, and relationship issues. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Cognitive-behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. To date there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women.

The physiology of sexual arousal in the human female: a recreational and procreational synthesis.

Changes induced by human sexual arousal serve reproductive and recreational functions. The current sexual phase model (desire, excitation, orgasm, and resolution) conveys little about this duarchy. Lack of spontaneous sexual desire in a third of nonclinic females indicates that the D phase needs splitting into D1 (the spontaneous [endogenous] activation of desire) and D2 (desire activated by sexual excitation at and during the E phase). Attempts to link D1 with reproduction by studies monitoring it over the menstrual cycle revealed a D1 peak just before or at ovulation, but its reliability is criticized because of the poor identification of the time of ovulation. Sexual arousal initiates enhanced genital blood flow, leading to the formation of a neurogenic transudate, lubricating the vagina, partly buffering its acidity, and increasing its oxygen tension all features that enhance spermatozoal function and survival. Orgasm occurs with vaginal and uterine contractions. The latter have been misinterpreted as powering rapid sperm transport to facilitate fertilization, but such fast transport would lead to the tubal deposition of noncapacitated, incompetent spermatozoa. Vagino-cervico elevation, however, delays rapid sperm transport and allows the initiation of decoagulation and sperm capacitation before the elevation resolves. The fastest transport of spermatozoa from cervix to the fallopian tubes occurs in the nonaroused female by uterine/subendometrial smooth muscle peristalsis. There is some evidence that even this may be reduced for a time after coitus, adding to the transport delay. If a number of the changes induced by sexual arousal are inadequately expressed, sexual as well as reproductive dysfunctions could arise.