Annual Meeting 2015
anatomy & physiology of female sexual dysfunctions
Nice, France, 10 June 2015
Bary Berghmans PhD MSc RPT clinical epidemiologist, health scientist, pelvic physiotherapist Pelvic care Center Maastricht Maastricht University Medical Center The Netherlands
Netter-Anatomy Atlas-2009 ovary fallopian tube
bladder abdomen
cervix pubic bone vagina urethra rectum clitoris Labium minus Labium majus
anus
vaginal orifice external urethra orifice G-spot female pelvic anatomy
understanding essential to treat FSD
internal and external genitalia internal: vagina, uterus, fallopian tubes, ovaries
external: vulva consists of labia, interlabial space, clitoris, vestibular bulbs
female pelvic anatomy: vagina
wall vagina 3 layers: – inner aglandular mucous membrane epithelium . mucous type, squamous cell epithelium, cyclic changes
– intermediary vascular muscularis layer . smooth muscle & extensive tree blood vessels, engorge during sexual arousal
– outer adventitial supportive mesh . fibrosa layer providing structural support to vagina female pelvic anatomy: vagina
vagina many ruggae needed for distensibility more prominent in lower third vagina (frictional tension during intercourse)
abundance of nerve fibers anterior distal vagina compared to proximal vagina female pelvic anatomy: vagina
during sexual arousal genital vasocongestion due to ↑ blood flow
vaginal canal lubricated secretions uterine glands, and transudation subepithelial vascular bed by intercellular channels
engorgement vaginal wall ↑ pressure inside capillaries and ↑ transudation plasma through vaginal epithelium Levin 1980 female pelvic anatomy: clitoris
‘small knob tissue located below symphysis pubis’ Kaplan 1974 erectile organ similar to penis, arising from genital tubercle. 3 parts: glans (emerging from labia minora), corpus (2-4 cm), crura (9-11cm) fused midline erectile bodies (corpora cavernosa) rising bilateral crura labia minora bifurcate to form upper prepuce anteriorly and lower frenulum posteriorly sexual stimulation → clitoral engorgement not erection
female pelvic anatomy: uterus
secretion mucous during sexual arousal→ lubrication vagina innervation uterus closely proximate bladder and vagina.
surgical procedures great impact
pelvic dissection → ↓ sexual health
hysterectomy → sexual dysfunctions: – ↓ desire, arousal, genital sensation, orgasmic dysfunction – result nerve and/or vascular injuries, loss ovarian estrogens and androgens – atrophy ovaries, fibrosis vaginal wall and clitoral cavernosal smooth muscle → ↓ genital arousal and orgasm
female sexual dysfunctions (FSD)
anorgasmia dysorgasmia dyspareunia vaginismus anaphrodisia relational anorgasmia
female sexual dysfunctions
age-related progressive highly prevalent, 30-50% US females Laumann 1999 risk factors: aging, hypertension, smoking, hypercholesterolemia Hsuch 1998 etiologic factors organic causes - perineal laceration - episiotomy - forceps vacuum - surgery
psychological causes - alteration body image - fear of intercourse - fear of infection Graziotin,2007 female sexual response Masters & Johnson 1966 desire excitation resolution
desire, arousal, orgasm Kaplan 1979 basis for DSM-IV definitions female sexual response
during sexual arousal:
clitoris, labia minora engorged with blood
increase length and diameter vagina and clitoris
labia minora increase in diameter 2-3 x → everted → exposing inner surface Berman 2002
increase in stem diameter of the clitoris removal of the clitoris increase in under the cap volume of the clitoris darkening and thickening of the swelling and opening of labia minora the labia minora activation the the glands of Bartholin expansion and flattening of the labia majora
B shelf A excitation
cap shortens
no marked change of labia majora volume the clitoris decrease and close maximum congestion labia minora and coloration of the thinning and labia minora close
C orgasm D resolution (rest) beginning of the elevation of the the uterus is high formation of the uterus seminal lake
removal of the clitoris under the cap
darkening of the labias increase in volume of the clitoris
formation of the orgasmic vaginal lubrication by swelling and opening of expansion of the two platform at the first third of transudation the labias posterior thirds of the vagina the vagina (tightening) B shelf A excitation
uterus contraction return of the uterus to its original position
return of the vagina to its original shape
rhythmic contractions anal sphincter of the orgasmic disappearance of the contraction platform orgasmic platform C orgasm D resolution (rest) female sexual response cycle
female sexual response cycle initiated by neurotransmitter–mediated vascular and nonvascular smooth muscle relaxation →
– increased pelvic blood flow – vaginal lubrication – clitoral and labial engorgement
Berman 2000 female sexual response cycle vasculogenic
clitoral & vaginal insufficiency – ↓ genital blood flow related to atherosclerosis iliohypogastric/pudendal arterial bed Goldstein 1998 ↓ pelvic blood flow due to aortailiac disease → – clitoral & vaginal wall smooth muscle fibrosis → vaginal dryness, dyspareunia Berman 1999 female sexual response cycle vasculogenic
1. atherosclerosis → clitoral cavernosal artery wall tickening, loss corporal smooth muscle & replacement fibrous connective tissue. possibly atherosclerotic changes in smooth muscle interfere with normal relaxation and dilitation responses to sexual stimulation
2. alterations circulating estrogen levels (menopause) → smooth muscle changes
3. traumata iliohypogastric/pudendal arterial bed and chronic perineal pressure (biking) → ↓ vaginal and clitoral blood flow
→ vasculogenic FSD Berman 2000 female sexual response cycle neurogenic
spinal cord injury more difficult orgasm (Viagra)
diseases central/peripheral nervous system (diabetis)
incomplete: regain capacity psychogenic arousal and vaginal lubrication Sipsky 1995 female sexual response cycle hormonal
dysfunction hypothalamic/pituitary axis, castration, premature ovarian failure, ↑ age, chronic birth control → hormonal FSD
↓ estrogen & testosteron → ↓ libido, vaginal dryness, lack sexual arousal, emotional lability, sleep disturbances
estrogen = ok → ↑ integrity vaginal mucosal tissue, ↑ vaginal sensation, vasocongestion, secretion → ↑ arousal
Berman 2000 female sexual response cycle hormonal
estrogen ≠ ok → ↓ clitoral intracavernosal, vaginal and urethral blood flow estrogen ≠ ok → clitoral fibrosis, thinner vaginal tissue, ↓vaginal submucosal vasculature
thus: ↓ estrogen → ↓ vaginal & clitoral tissue → hormonal FSD Berman 2000 female sexual response cycle hormonal
testosterone = ok → central & peripheral effects also in vagina vaginal epithelium responds to testosterone replacement like estrogen replacement androgens role in regulating vaginal smooth muscle relaxation and blood flow ↓ androgen receptor expression noted in vaginal sub-epithelium in women having estrogen replacement → persistent symptoms vaginal atrophy and dryness in menopausal women (impaired androgen responsiveness) → hormonal FSD
Berman 2000 female sexual response cycle musculogenic
pelvic floor muscles: levator ani, bulbocavernosus, ischiocavernosus (perineal membrane) voluntary contraction intensifies sexual arousal and orgasm perineal membrane involuntary rythmic contractions during orgasm levator ani modulates motor responses during orgasm and vaginal receptivity musculogenic FSD – overactive → vaginismus, dyspareunia, sexual pain – underactive → vaginal hypoanesthesia, coital anorgasmia, urinary incontinence during intercourse or orgasm Berman 2000 female sexual response cycle musculogenic
levator ani fixes vaginal neck, anorectal junction, vaginal fornices to sidewall pelvis (like a sling) during intercourse vaginal distension by erect penis evokes vaginolevator and vaginopuborectalis reflexes → levator ani contraction levator ani contracts also upon stimulation clitoris or cervix uteri → ↑ sexual response modulates motor responses during orgasm and vaginal receptivity levator ani subluxation and sagging → dysfunction, pelvic pain, dyspareunia, ↓ vaginal sensation, ↓ intensity orgasm
Berman 2000 female sexual response cycle psychogenic
emotional and relational issues affect sexual arousal self-esteem, body image, quality relationship depression, mood disorders ↔ sexual response medication (serotinin re-uptake inhibitors) ↓ desire, arousal, genital sensation, difficulty achieving orgasm → psychogenic FSD Berman 2000 pleasure orgasm intensity
shelf
excitation
resolution
cycle duration conclusion rehabilitation techniques