Clitoral anatomy linked to sexual function after vaginal surgery

Clitoral anatomy linked to sexual function after vaginal surgery | Image Credit: © Georgii - © Georgii - stock.adobe.com.

There is a link between postoperative sexual function following vaginal surgery and clitoral glans size, position, and shape, according to a recent study published in JAMA Surgery.¹

Sexual function and quality of life are negatively impacted in millions of women with pelvic organ prolapse (POP). The risk of undergoing surgery for POP in women is 13%, and 80% to 90% of surgeries are performed transvaginally.² Changes to nearby anatomy during surgery such as the clitoris may cause sexual dysfunction despite aims to restore vaginal support.¹

According to investigators, “little research exists on how in vivo clitoral anatomy relates to sexual function, particularly after gynecologic surgery.” Therefore, a study was conducted to identify anatomical clitoral features linked to postoperative sexual function in patients.

Magnetic resonance imaging (MRI) data was obtained from the Defining Mechanisms of Anterior Vaginal Wall Descent (DEMAND) study, a prospective study including 88 women recruited from June 2014 to May 2018. Participants in the DEMAND study underwent MRIs at 30 to 42 months post operation.

The MRI protocol included the use of 3-T scanners with a pelvic phased array coil to obtain axial T2-weighted postoperative MRIs. From these MRIs, the clitoral complex was manually segmented for further investigation. Dimensional and position measurements were performed by a Mathematica, version 12.2.2.0 (Wolfram Research) algorithm.

Statistical shape modeling was utilized to assess clitoral shape. This involved aligning patient-specific models to a template model, then exporting coregistered models. Afterward, shape variation was explained using a principal component analysis.

The Pelvic Organ Prolapse/Sexual Incontinence Questionnaire, International Urogynecological Association Revised (PISQ-IR) was used to measure sexual activity and function at baseline and follow-up. Item 1 asked patients whether they were sexually active (SA) or not sexually active (NSA) at all.

Sexual function measures in SA women included dyspareunia, PISQ-IR summary score, PISQ-IR subscale scores, and individual PISQ-IR items for incontinence during sexual activity, sexual arousal, pain during sexual intercourse, and orgasm intensity. The link between PISQ-IR summary, subscale, and item scores with clitoral dimensions, positions, and shape was reported as the primary outcome.

There were 82 women aged a median 65 years included in the final analysis. Imaging was performed at 30 to 42 months postoperatively for 75 participants, before 30 months for 6, and at 48 months for 1. Participants had a median body mass index of 28 and a median vaginal parity of 3.

Of participants, 3.7% were American Indian or Alaskan Native, 7.3% Black, 1.2% multiracial, 81.7% White, 6.1% other race, 11.5% Hispanic, and 88.5% non-Hispanic. Postmenopausal status was reported in 97.6%, being married or living with a partner in 63.4%, and having stage 3 or stage 4 POP in 75.6%.

No association was found between clitoral position and postoperative sexual function in SA women. However, a correlation was reported between a more laterally positioned clitoral complex with postoperative dyspareunia causing sexual inactivity and an increased impact of POP and pain with sexual inactivity in NSA.

There were 11 principal components (PCs) of clitoral shape variation accounting for 86.7% of shape variance among participants. Nine of these were linked to postoperative sexual activity status and function. After surgery, PC4 was linked to dyspareunia, PC5 to urine leakage during sexual activity, and PC8 to changes in orgasm intensity among SA women.

In NSA women, PC10 was linked to an impact of POP on sexual inactivity postoperatively. Variations in PC10 were observed for clitoral glans and body, with a more posteriorly positioned glans and anteriorly oriented clitoral body linked to a stronger agreement for POP as a reason for sexual inactivity.

These results indicated a correlation between clitoral size and position and reduced postoperative sexual function. Investigators recommended further research to “assess how clitoral anatomy and sexual function differ by the type of vaginal surgery performed.”

Reference

1. Bowen ST, Moalli PA, Rogers RG, et al. Postoperative sexual function after vaginal surgery and clitoral size, position, and shape. JAMA Surgery. 2025. doi:10.1001/jamasurg.2024.6922
2. Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014;123(6):1201-1206. doi:10.1097/AOG.0000000000000286