Measurements of Female Genital Appearance in Chinese Adults Seeking Genital Cosmetic Surgery: a Preliminary Report from a Gynecological Center

IntUrogynecolJ DOI 10.1007/s00192-014-2584-6

ORIGINAL ARTICLE

Measurements of female genital appearance in Chinese adults seeking genital cosmetic surgery: a preliminary report from a gynecological center

Yujiao Cao & Qiang Li & Chuande Zhou & Fengyong Li & Senkai Li & Yu Zhou

Received: 11 July 2014 /Accepted: 10 November 2014 # The International Urogynecological Association 2014

Abstract Conclusions We presented an external genitalia database of Introduction and hypothesis Accurate and comprehensive Chinese female adults asking for cosmetic surgery. Although measurements of the external genitalia in female adults are the ranges of genital measurements vary, there is a propor- of great significance in surgery designs and for aesthetic tional relationship in female genital appearance, which should evaluation in genital plastic surgeries. The authors carried be heeded in surgical designs and genital aesthetic evaluation. out a 319-case study and provided baseline data and morphometric reference for plastic surgery involving the genital de- Keywords Female external genitalia . Plastic surgery . formity caused by trauma or burns and male-to-female trans- Anthropometry sexual operations. Methods Our study design recruited 319 women referred to the out-patient clinic from August 2010 to August 2013. From each individual we measured 16 parameters and assessed the Introduction significance of variations in age, height, weight, BMI, and marital status (as a proxy for parity). We tried to establish a Recent years have witnessed an astonishing rise in female female external genitalia database of the population presenting aesthetic genital surgery. The influence of the mass media on for cosmetic surgery and define the general proportions of perineal aesthetic trends could be an underlining factor of the female genitalia in Chinese adults from the data we obtained. sharp increase in female genital plastic and cosmetic surgeries. Results A wide range of values was noted in female genital On the contrary, accurate and detailed descriptions of female measurements especially in labia minora parameters. Four external genitals are rare, but this aspect is attracting the parameters, including clitoral prepuce length, clitoris to ure- attention of plastic surgeons. A previous study has noticed thra, labial length, and perineal body length had a proportional the great diversity of the female genital measurements, but relationship to some extent. The position of the clitoris and whether or not the phenomenon exists in a large-scale homo- urethral orifice was found to be regular in female adults. geneous group was not clarified [1]. An understanding of the Compared with unmarried women, perineal body length de- genital anatomy is essential for successful surgical approaches creased (P=0.048), while the apex to perineum (bilateral) and and cosmetic outcomes [2]. This question is particularly crit- labial length increased (P=0.005, 0.006, <0.0001) in those ical to plastic and urogynecological surgeons as they may who were married. Several parameters were statistically sig- frequently face genital restoration problems. One of those nificantly associated with age, height, weight, BMI, and mar- tremendous challenges is how to redistribute the excess tissue ital status. to form normal female genitalia in male-to-female transsexual operations. The foundation of the reconstruction is the correct recognition of normal female genitalia. Our goal is to define : : : : : specific and comprehensive measurements, to assess the pro- Y. Cao Q. Li (*) C. Zhou F. Li S. Li Y. Zh ou portions of the external genitalia of Chinese female adults Gynaecological Plastic Department, Plastic Surgery Hospital, presenting for cosmetic surgery, and to evaluate the signifi- Chinese Academy of Medical Sciences, No. 33 Ba-Da-Chu Road, Shi Jing Shan District Beijing 100144, People’sRepublicofChina cance of variations in age, height, weight, BMI and marital e-mail: [email protected] status, and therefore to provide morphometric reference for Int Urogynecol J plastic surgery involving male-to-female transsexual opera- SPSS for Windows, version 11.5 (Chicago, IL, USA). Com- tions and repairing the genital deformities caused by trauma or parisons between unmarried and married groups were con- burns. ducted using independent samples Student’s t tests. Spearman’s or Pearson’s correlations were used to assess correlations between measurement parameters and demo- Materials and methods graphic characteristics. Univariable and multivariable linear regressions were used to identify factors associated with mea- Our study design included 319 women who came to seek surement parameters. All reported p values were two-sided, cosmetic surgery, including vaginal tightening, labial reduc- and p values<0.05 were considered statistically significant. tion, and hymenoplasty at the out-patient clinic of the gyne- Results are presented as means±standard deviations. cological department at Plastic Surgery Hospital, Chinese Academy of Medical Science (CAMS), from August 2010 to August 2013. Ethical approval was obtained from the Results hospital ethics committee and all women gave written in- formed consent. Baselines of the patients consisting of age, In total, 319 women were recruited to this study. These wom- weight, height, BMI, and marital status were recorded. Inclu- en ranged in age from 18 to 64 years (mean±SD, 31.3±7.1; sion criteria were subjects over 18 years and Han nationality. median 32). Patients varied in height from 140 to 182 cm Exclusion criteria were as follows: previous vaginal and/or (mean±SD, 162.9±5.0; median 163), in weight from 41 to perineal gynecological or aesthetic surgical interventions, 75 kg (mean±SD, 55.3±6.3; median 55), and in BMI from stage >2 pelvic organ prolapse, urinary incontinence, and 15.8 to 29.3 kg/m [2] (mean±SD, 20.8±2.2; median 20.4). pregnancy. 43.3 % of them were single, and 56.7 % were married. All of We took the examinations using a standard gynecological the participants were of Han nationality, making this study a examination table before the surgery started, with patients in highly homogeneous one. The descriptive results are shown in the lithotomy position. A stainless steel vernier caliper steril- Table 2. ized by ethylene oxide was used to take the measurements. All From the data, we can see that the average clitoral prepuce measurements were straight-line distances measured with this length, distance from clitoris to urethra, and perineal body instrument. From each individual we obtained the 16 param- length are almost the same, which is half of labial length eters listed in Table 1, the locations of which are illustrated in (Table 3). The ratio of clitoral prepuce length/labia majora Figs. 1 and 2. All data were collected by the corresponding length is 0.34±0.09, which means that the average position of author to minimize the interobserver variability. An assistant the clitoris is on the upper third of the labia majora. Mean- recorded the data simultaneously. while, the ratio of clitoris to urethra/labia minora length is The 16 parameters were used as dependent variables, and slightly more than a half. This represents the position of the age, weight, height, and body mass index were considered urethra orifice being a little lower than the vertical midpoint of independent variables. Analysis of data was performed using the labia minora.

Table 1 Name and landmarks of parameters of female genitalia

Parameter Starting point Ending point

Clitoral prepuce length Skin fold of the clitoral root The tip of the clitoral glans Clitoral glans length Length of the clitoral glans seen slightly retracting the prepuce Clitoral glans width The greatest transverse diameter of the clitoral glans Clitoris to urethra Clitoris glans 12’clock point of the urethral orifice Urethra to vagina 6’clock point of the urethral orifice 12’clock point of the introitus Vagina to perineum Hymenal mark Juncture of skin and mucosa Perineal body length Juncture of skin and mucosa Anterior anal margin Labia minora length Clitoris glans Juncture of skin and mucosa Apex to clitoris glansa Apex of the labia minora Clitoris glans Apex to perineuma Apex of the labia minora Juncture of skin and mucosa Labia minora widtha Sulcus nympholabialis Apex of the labia minora Labia majora length Skin fold of the clitoral root Juncture of skin and mucosa Labia majora width Sulcus nympholabialis Borderline without hair or skinfold a Parameters are bilateral IntUrogynecolJ

Fig. 1 Location of 12 of the parameters

We assessed the occurrence of asymmetry in bilateral labia marital status in women under 35 years, and obtained the minora, which was close to one third (as shown in Table 4). same result (Table 6). The width difference of more than 5 mm accounted for 33.9 % Clitoral prepuce length, clitoral glans length, and of all the individuals. clitoral glans width correlated positively with weight Compared with the unmarried, perineal body length de- (r=0.193, 0.212, 0.198) and age (r =0.116, 0.244, creased while clitoral glans length, clitoral glans width, apex 0.274) respectively. Multivariable linear regression anal- to perineum (bilateral) and labial length increased in those ysis showed that labial minora length was associated married (Table 5). Since the significance can be explained by with height and weight, whereas labial majora length age differences, we analyzed the parameters of different was associated with weight. Int Urogynecol J

surgery, we need to have a comprehensive knowledge of female vulvovaginal anatomy and its physiological changes. The first description of female genital anatomy can be traced to the year 1899, when Waldeyer reported that normal labia minora measured 2.5 to 3.5 cm in width [3]. There have been several studies on the an- thropometric measurements of the anatomy of external genitalia in prepubertal girls [2]andwomen[1, 4, 5]. Lloyd et al. measured 50 premenopausal women and demonstrated that for external measurements there was no statistically significant association with age, parity or history of sexual activity [1]. Seitz et al. evaluated mons pubis measurements of 28 women of normal weight and concluded that the data were dependent on body size/ weight and age [5]. To the best of our best knowledge, this article is the first to study genital appearance in the Chinese population. We were only able to study Chi- nese female adults, which limited our ability to gener- alize the results to other races, but provided avenues for further studies. We are not sure whether there are racial Fig. 2 A depiction of part of the female external genitalia measurements. differences in the measurements of the external genita- 1 2 3 4 Clitoral prepuce length, clitoris to urethra, vagina to perineum, lia, but this issue on labia minora has been raised perineal body length, 5 apex to clitoris glans, 6 apex to perineum, 7 labia minora length before [6]. Therefore, multi-center cooperation is needed to evaluate the genital differences in various races and ethnicities. In our sample, we recruited 319 physically and psy- Discussion chologically healthy Chinese women, comprising a large-scale homogeneous group. All the measurements The main issue of this study is to report values of were collected from living bodies, which reflects the female genitalia measurements of patients presenting morphology of female external genitalia as exactly as for cosmetic gynecological surgery. For a better under- possible. Among the 16 parameters, the measurement of standing of the genital reconstruction and aesthetic the width of the labia majora is complicated by the

Table 2 Measurements of female genitalia Parameter Range Minimum Maximum Mean SD

Clitoral prepuce length 25 15 40 25.66 4.415 Clitoral glans length 9 1 10 5.04 1.742 Clitoral glans width 6 2 8 4.14 1.222 Clitoris to urethra 25 15 40 24.95 4.366 Urethra to vagina 3 2 5 2.90 .396 Vagina to perineum 15 5 20 13.82 2.286 Perineal body length 50 10 60 24.56 4.203 Labia minora length 33 35 68 47.99 5.821 Apex to clitoris glans (left) 35 15 50 28.37 6.991 Apex to clitoris glans (right) 45 15 60 28.77 7.252 Apex to perineum (left) 45 25 70 47.75 10.111 Apex to perineum (right) 69 6 75 49.73 10.960 Labia minora width (left) 42 3 45 19.92 8.462 Labia minora width (right) 42 3 45 21.26 8.709 Labia majora length 69 21 90 75.71 5.216 Labia majora width 70 15 85 20.53 4.108 IntUrogynecolJ

Table 3 Proportion relationship of the measurements N Minimum Maximum Mean SD

Clitoral prepuce length/clitoris to urethra 319 0.50 2.33 1.0575 0.25576 Clitoral prepuce length/perineal body length 319 0.44 2.50 1.0692 0.24383 Apex to clitoris glans/apex to perineum (left) 319 0.31 1.00 0.6005 0.11158 Apex to clitoris glans/apex to perineum (right) 319 0.33 5.00 0.5987 0.27469 Clitoral prepuce length/labia majora length 319 0.21 1.62 0.3421 0.09134 Clitoris to urethra/labia minora length 319 0.33 0.80 0.5229 0.08577

difficulty in determining the precise border of the labia from the clitoral complex to the vaginal lumen on majora, which is a common issue in soft tissue mea- pelvic MRI. Such findings support clitoral characteris- surements. The perineal body length is consistent with tics having an impact on female sexual symptoms. Our the parameter that has been standardized according to study suggested married women had larger clitoris glans the pelvic organ prolapse quantification system by parameters (P=0.0002, 0.0001) than unmarried ones. Bump et al. [7]. We found that clitoral prepuce length, clitoral glans Themeantransversediameteroftheglanswas4.1± length, and clitoral glans width correlated positively 1.2 mm, and clitoral glans length was 5.0±1.7 mm. The with weight and age respectively. The result is different results closely mirror those of previous studies on cli- from the findings of Lloyd et al., that clitoral dimen- toris size. Dickson and Pierson [8] found the mean sions were not significantly associated with age, parity, width to be 4.4 mm, and the mean length to be ethnicity, hormonal use, or a history of sexual activity 5.5 mm in Americans. In a white population study, [1].. We assume that small sample size may account for Verkauf et al. [9] found the corresponding data to be their lack of significant findings. 3.4±1.0 mm and 5.1±1.4 mm respectively. Since in We did not select subjects for labial reduction surgery female genital aesthetic surgery, the position of the from other patients. This is a possible bias for the data clitoral body and length of the prepuce should be taken of labia minora width, the mean±SD of which is 19.9± into account when reconstructing a neo-vulva [10], these 8.5 (right) and 21.3±8.7 (left). However, the result is data can provide objective references for aesthetic sur- consistent with Lloyd’s[1] data (21.8±9.4). In addition, gery related to the structure of the clitoris. a prospective study indicated that women seeking labial Master and Johnson described women with a long reduction surgery had normal-sized labia minora of thin shaft surmounted by a relatively small glans, or a (26.9±12.8) mm (right), and (24.8±13.1) mm (left) short thick shaft with a rather large glans, with frequent [15]. Therefore, our study can provide reliable data in variations and combinations [11]. Verkauf’sdatadidnot the measurement of labia minora in the Chinese show significant changes or progressive growth in cli- population. toral size in women of reproductive age [9]. Neverthe- Compared with the unmarried women, apex to peri- less, Huffman et al. concluded an increase in clitoral neum (bilateral) and labial length increased in those size in normal female subjects, from childhood to the who were married. This phenomenon is related to the fourth decade of life to the postmenopausal years [12]. decrease in the perineal body length in married women, Several studies [13, 14] also support clitoral tissue be- because measurement of the above parameters ended in ing responsive to serum hormones. A recent study [14] juncture of the skin and mucosa, which is the starting in women matched by age and body mass index re- point for perineal body length. In previous studies it vealed that women with self-reported anorgasmia had a was suggested that hormone changes in pregnancy and significantly smaller clitoral glans and greater distance childbirth might lead to vaginal laxity and laceration of the perineum [16–18]. We admitted that the best way to analyze the effects of childbirth was to record the parity Table 4 The situation of labial asymmetry of the subjects recruited. However, because of the specific situation in China, where a one-child policy is Width difference/smaller labial width (%) Percentage (%) strictly applied, we can hardly analyze correlations between measurements and gravidity and parity. Thus, we 20 35.7 used marital status as a surrogate for parity. Generally 25 29.5 speaking, unmarried people are nonparous, presenting 30 23.8 one type of vulva anatomy. The fact is that a small Int Urogynecol J

Table 5 Difference between the unmarried and married women Parameter Unmarried Married P

N Mean (SD) N Mean (SD)

Clitoral glans length 138 4.6 (1.7) 181 5.4 (1.7) 0.0002 Clitoral glans width 138 3.8 (1.1) 181 4.4 (1.2) 0.0001 Perineal body length 138 25.1 (3.1) 181 24.2 (4.9) 0.048 Labia minora length 138 46.3 (5.1) 181 49.2 (6.1) <0.0001 Apex to perineum (left) 138 45.5 (10.5) 181 49.5 (9.5) 0.0005 Apex to perineum (right) 138 47.3 (11.1) 181 51.5 (10.6) 0.0006 number of the unmarried patients were parous, and a that the patients presenting for different reasons may have few married patients were nonparous, which made the critical and meaningful deviations, we have improved the data mixed. However, we also found differences be- study design and have begun to conduct a more detailed tween them. Therefore, our data can explain this prob- investigation into the Chinese population. We hope that the lem from the external genitalia aspect. revised study can provide more information about female However, we recognize that we were limited by a lack of external genitalia in the future. sufficient and detailed demographic information, including gravidity, parity, and sexual activity. We were also restricted with regard to the recruitment of patients presenting for cos- Conclusions metic surgery and were aware of the inherent selection bias in a study of this nature. The subjects were from a non- Although the normal ranges of genital measurements vary, generalized population, which may not represent normal fe- there is a proportional relationship in female genital appear- male genitalia. Nevertheless, we assumed that patients who ance in the Chinese population. Clitoral size, labial minora asked for vaginal tightening surgery and hymenoplasty may and majora size, and perineal body length correlated with represent normal people to some degree. Therefore, the data demographic information to varying degrees, which should we present have considerable reference to reconstructive sur- be heeded in any reconstructive or cosmetic genitalia surgery. gery designs. We admitted that our study was limited by As a preliminary report, this study provided a clinical tool for lacking inter- and intra-observer reliability. If we took the female genital measurements and aesthetic evaluation. average of three times the measurements as the last data, it would better to diminish the clinical measurement error. But unlike blood pressure, the female external genitalia arein an Acknowledgements We would like to thank Professor Li Wang for the intimate part of the body; thus, repeated and time-consuming biostatistical work and assistance. measurement may cause patients’ discomfort and refusal, Ethics approval The project was approved by the plastic surgery which we once encountered. Furthermore, the 319-case data hospital ethics committee. Data were selected from the patient case notes were weakened by no sub-grouping of the patients according accessible only to the authors. All data collected were de-identified to to the reason for cosmetic surgery. Therefore, we cannot preserve patient confidentiality. The result did not have an impact on any analyze correlations between the reasons for attending and aspect of patient management. Patient consent to publish medical photo- graphs was obtained. particular special morphological deviations. Since we realized Funding This work is supported by the Innovation Fund for Postgrad- Table 6 Difference between the unmarried and married women under uates at Peking Union Medical College (no.: 5201020104). 35 years old Conflict of interest The authors declare that they have no conflict of Parameter Unmarried Married P interest.

N Mean (SD) N Mean (SD)

Clitoral glans length 138 4.6 (1.7) 84 5.2 (1.7) 0.0251 References Clitoral glans width 138 3.8 (1.1) 84 4.2 (1.3) 0.0347 Perineal body length 138 25.1 (3.1) 84 23.8 (3.7) 0.0048 1. Lloyd J, Crouch NS, Minto CL, Liao LM, Creighton SM (2005) Labia minora length 138 46.3 (5.1) 84 48.9 (5.1) 0.0004 Female genital appearance: ‘normality’ unfolds. BJOG 112:643–646 Apex to perineum (left) 138 45.5 (10.5) 84 50.3 (9.2) 0.0006 2. Akbiyik F, Kutlu AO (2010) External genital proportions in prepu- Apex to perineum (right) 138 47.3 (11.1) 84 51.9 (9.5) 0.0019 bertal girls: a morphometric reference for female genitoplasty. J Urol 184:1476–1481 IntUrogynecolJ

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