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Female Ejaculation Orgasm Vs. Coital Incontinence: a Systematic Review

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Female Ejaculation Orgasm Vs. Coital Incontinence: a Systematic Review 1682 REVIEW Female Ejaculation Orgasm vs. Coital Incontinence: A Systematic Review Zlatko Pastor, MD*† *Obstetrics and Gynaecology Department, 2nd Medical Faculty, Teaching Hospital Motol, Charles University, Prague, Czech Republic; †Institute of Sexology, 1st Medical Faculty, Charles University, Prague, Czech Republic DOI: 10.1111/jsm.12166 ABSTRACT Introduction. Women may expel various kinds of fluids during sexual arousal and at orgasm. Their origins, quantity, compositions, and expulsion mechanisms depend on anatomical and pathophysiological dispositions and the degree of sexual arousal. These are natural sexual responses but may also represent symptoms of urinary incontinence. Aim. The study aims to clarify the etiology of fluid leakage at orgasm, distinguish between associated physiological sexual responses, and differentiate these phenomena from symptoms of illness. Methods. A systematic literature review was performed. EMBASE (OvidSP) and Web of Science databases were searched for the articles on various phenomena of fluid expulsions in women during sexual arousal and at orgasm. Main Outcome Measures. Articles included focused on female ejaculation and its variations, coital incontinence (CI), and vaginal lubrication. Results. Female ejaculation orgasm manifests as either a female ejaculation (FE) of a smaller quantity of whitish secretions from the female prostate or a squirting of a larger amount of diluted and changed urine. Both phenomena may occur simultaneously. The prevalence of FE is 10–54%. CI is divided into penetration and orgasmic forms. The prevalence of CI is 0.2–66%. Penetration incontinence occurs more frequently and is usually caused by stress urinary incontinence (SUI). Urodynamic diagnoses of detrusor overactivity (DOA) and SUI are observed in orgasmic incontinence. Conclusions. Fluid expulsions are not typically a part of female orgasm. FE and squirting are two different physi- ological components of female sexuality. FE was objectively evidenced only in tens of cases but its reported high prevalence is based mostly on subjective questionnaire research. Pathophysiology of squirting is rarely documented. CI is a pathological sign caused by urethral disorder, DOA, or a combination of both, and requires treatment. An in-depth appreciation of these similar but pathophysiologically distinct phenomena is essential for distinguishing normal, physiological sexual responses from signs of illness. Pastor Z. Female ejaculation orgasm vs. coital incontinence: A systematic review. J Sex Med 2013;10:1682–1691. Key Words. Female Ejaculation; Squirting; Orgasmic Incontinence; Coital Incontinence; Female Prostate; Urinary Incontinence Introduction These substantial differences are most likely due to varying research methodologies and sample selec- luid expulsion during female sexual arousal is tion. The studies on pathophysiology of squirting F well documented [1]. It is not typically associ- are limited, because of complicated method of ated with female orgasm but has been observed acquisition of data and samples that often result in in some women [2,3]. The prevalence has been methodologically inadequate research. Expulsions reported to be 10–54% [4–7], with the quantity of of various kinds and quantities of fluid from various fluid ranging from 1 mL [8] up to 900 mL [7,9–11]. locations at orgasm are erroneously considered the J Sex Med 2013;10:1682–1691 © 2013 International Society for Sexual Medicine Female Ejaculation Orgasm vs. Coital Incontinence 1683 same phenomenon. The term female ejacula- or describing types of CI, including the charac- tion (FE) was coined because of the similarities of teristics, quantity, and composition of the fluid FE with male orgasm. However, FE encompasses and mechanisms of leakage. Furthermore, papers various phenomena with different pathophysi- reporting urodynamic studies and therapies for CI ologic mechanisms [8,10]. Physiological signs of were included. Studies examining the quality of female arousal are sometimes mistaken for coital sexual life of incontinent women or other medi- incontinence (CI). Furthermore, while expulsion of cal conditions but without any mention of fluid fluid during sexual intercourse may signify a high leakage during sexual activities were excluded. level of arousal, it can also be a sign of urinary Terminology used was based on the patho- incontinence (UI). The fluid may originate from physiological mechanisms of expulsed fluids, and the vagina, urinary bladder, female prostate, or these expulsions were classified according to their from a combination of these sources. The develop- origins. Because of the heterogeneity of data, a ment of more precise research methodologies qualitative assessment was performed. In the final focusing on the urogenital area, such as magnetic analysis, a total 46 studies were evaluated, includ- resonance imaging (MRI), ultrasonography, endo- ing four reviews [1,3,16,17]. Five books were also scopy, urodynamic studies, and biochemical tests, included [5,18–21]. has enabled us to understand such phenomena based on anatomical and pathophysiological corre- lations [8,12–15]. Results Orgasmic fluid expulsions may constitute varying Aims types of physiological sexual response or UI. The fluids may have different origins, volumes, and The objectives of this systematic review are to mechanisms. They may also be a combination of provide a chronological summary of opinions and fluids (Figure 1). studies about fluid expulsions occurring during sexual activity and distinguish between the origins, Vaginal Lubrication Fluid mechanisms, and biochemical compositions of expelled fluids. By appreciating that fluid leakage As the most common and important “sexual fluid,” may occur not only at FE but also at squirting vaginal lubrication is a plasma transudate which or CI, inaccurate diagnoses can be avoided. A uro- diffuses across the vaginal wall due to the activities dynamic diagnosis for penetration or orgasmic of vasoactive intestinal peptide and neuropeptide incontinence is also clarified. Y [22]. The composition and quantity of lubrica- tion fluid change according to the intensity and length of sexual arousal. Insufficient lubrication is Methods reported in 3–43% women and occurs most com- The electronic databases OvidSP (EMBASE) and monly after menopause [23]. In contrast, increased Web of Science were searched according to the lubrication does not cause any problems and is fluid expulsion type, such as FE, squirting, vaginal considered a discharge rather than a gush, espe- lubrication, and CI. The key words for the titles and cially when a penis is inserted. Kinsey et al. sug- abstracts were as follows: “female ejaculation” gested that vaginal fluid may be forced out by AND “orgasm”; “female ejaculation” AND “fluid”; the contractions of perivaginal muscles and thus “female ejaculation” AND “female prostate”; resemble FE [19]. In addition, Perry and Whipple “vaginal lubrication” AND “orgasm”; “squirting” reported that women with FE have significantly AND “female ejaculation”, “coital incontinence”; stronger contractions of pubococcygeus muscles and “coital incontinence” AND “orgasm.” The and reach uterine orgasmic contractions more electronic database search yielded 413 articles from frequently [4]. 1948 through 2012. Only papers in English were used. The search was further refined to “human” Ejaculation Orgasm and “female” studies. Ejaculation orgasm is defined as a physiological response occurring as expulsion of various quanti- ties of fluids at orgasm that originate from the Main Outcome Measures urinary bladder (squirting), the female prostate The review focused on articles evaluating fluid (female ejaculation), or a combination of both, and expulsions occurring during female sexual activity may occur at the height of sexual arousal [8,10]. In J Sex Med 2013;10:1682–1691 1684 Pastor Figure 1 Summary of fluids released during sexual activities based on origins and mechanisms some cases, it may resemble orgasmic inconti- in the female prostate [28]. The ducts are not nence, which is a symptom of UI and requires visible on urethroscopy, and the fluid expulsions treatment. have not been demonstrated to be associated with urethroceles [13]. The presence of prostate- FE and Female Prostate specific antigen (PSA), prostatic specific acid phos- FE is an orgasmic expulsion of a smaller quantity phatase, fructose, and glucose are characteristic for of whitish fluid produced by the female prostate secretions from the female prostate [33]. Its glan- [8]. Opinions regarding the quantity of expelled dular cells contain moderate to strong expression fluid vary from 1 mL to 30–50 mL [7–9,11,24,25]. of androgenic receptors, which are not present Following the work of E. Gräfenberg regarding in cytoplasm [30]. The role and function of the the role of the urethra at sexual arousal [26], female prostate remain unclear. Some studies Addiego et al. hypothesized that this fluid may suggest an antimicrobial protective effect of pros- come from the female prostate, previously called tate secretions against urinary tract infections Skene’s paraurethral glands, given the presence of [34]. The female prostate can produce very scanty, prostatic acid phosphatase in female ejaculate [27]. milky fluid similar to the male semen during The female prostate is an exocrine organ of vari- vaginal or clitoral stimulation [8]. Most studies able size and location [28]. Studies suggest that consider orgasmic expulsions as FE and the fluid as one half to two thirds of women have a female female prostate
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