Wikipedia

Vulva

For other uses, seeVulva (disambiguation).

Inmammals,thevulva(pl.:vulvasorvulvae) comprises mostly external, visible structures of the femalegenitalialeading away from the interior parts of thefemale reproductive tract,starting at thevaginal opening.For humans, it includes themons pubis,labia majora,labia minora,clitoris,vestibule,urinary meatus,vaginal introitus,hymen,and openings of the vestibular glands (Bartholin'sandSkene's). The folds of the outer and innerlabiaprovide a double layer of protection for the vagina (which leads to theuterus).Pelvic floor musclessupport the structures of the vulva. Other muscles of theurogenital trianglealso give support.

Vulva
Examples of different human vulvas
Details
PrecursorGenital tubercle,urogenital folds,labioscrotal swellings,urogenital sinus
SystemReproductive system,genitourinary system
ArteryInternal pudendal artery,superficial external pudendal artery,deep external pudendal artery,labial arteries, clitoral arteries
VeinInternal pudendal veins,external pudendal veins,labial veins, clitoral veins
NervePudendal nerve,perineal nerve,labial nerves,dorsal clitoral nerve,perineal branches of posterior femoral cutaneous nerve,genital branch of genitofemoral nerve
LymphSuperficial inguinal lymph nodes
Identifiers
Latinvulva, pudendum muliebre, pudendum femininum
MeSHD014844
TA98A09.2.01.001
TA23547
FMA20462
Anatomical terminology

Blood supply to the vulva comes from the threepudendal arteries.Theinternal pudendal veinsgive drainage.Afferent lymph vesselscarrylymphaway from the vulva to theinguinal lymph nodes.The nerves that supply the vulva are thepudendal nerve,perineal nerve,ilioinguinal nerveand their branches. Blood and nerve supply to the vulva contribute to the stages ofsexual arousalthat are helpful in thereproductionprocess.

Following the development of the vulva, changes take place at birth,childhood,puberty,menopauseand post-menopause. There is a great deal of variation in the appearance of the vulva, particularly in relation to the labia minora. The vulva can be affected by many disorders, which may often result inirritation.Vulvovaginal healthmeasures can prevent many of these. Other disorders include a number of infections andcancers.There are several vulval restorative surgeries known asgenitoplasties,and some of these are also used ascosmetic surgery procedures.

Different cultures have held different views of the vulva. Some ancient religions and societies have worshipped the vulva and revered the female as a goddess. Major traditions inHinduismcontinue this. In Western societies, there has been a largely negative attitude typified by the medical terminology ofpudenda membra,meaning parts to be ashamed of. There has been an artistic reaction to this in various attempts to bring about a more positive and natural outlook, such as work from British, American, and Japanese artists. While the vagina is a separate part of the anatomy, it has often been used synonymously with vulva.[1]

Structure

Labeled image of a vulva, showing external and internal views
Labeled illustrations of the gross anatomy of the vulva

The human vulva is made up of the following:

Mons pubis

Themons pubisis a soft mound offatty tissuein the pubic region covering thepubic bone.[2]Mons pubisis Latin for "pubic mound" and is present in bothsexesto act as a cushion duringsexual intercourse,and is more pronounced in the female.[3]The variant termmons veneris('mound of Venus') is used specifically for females.[4][3]

Labia

Thelabia minoraare the small inner pair of skin folds that protect the openings.[5]The large outer pair of folds are thelabia majora,which contain and protect the labia minora and other structures of the vulva.[5]The labia majora meet at the front of the mons pubis, and meet posteriorly at theurogenital triangle(the anterior part of theperineum) below theanus.[6][7]The labia minora are often pink or brownish black, relevant to the person's skin color.[8]

The grooves between the labia majora and minora are called theinterlabial sulci,or interlabial folds.[9]The labia minora meet posteriorly as the frenulum (fourchette).

Clitoris

Located at the anterior junction of the labia minora is theclitoris,a highlyerogenoussexual organ. The visible portions of the clitoris are theglansandfrenulum.Typically, the glans is roughly the size and shape of apea,and can vary in size from about 6 mm to 25 mm (less than an inch).[10]The size can also vary when the clitoris iserect,[7]which happens when two regions oferectile tissueknown as thecorpora cavernosa(along with thebulbsandcrura,which both constitute therootof the clitoris)[11]fill withblood,making theshaftengorged. The glans contains many nerve endings, which makes it highly sensitive.[10]The only known function of the clitoris is to focus on sexual feelings.[10]Theclitoral hoodis a protective fold ofskinand it may partially or completely cover the shaft and glans.[12]The hood may be partially or completely hidden within thepudendal cleft.[13]

Vestibule

The area between the labia minora where thevaginal introitusand theurinary meatus(openings of thevaginaandurethrarespectively) are located is thevestibule.The meatus is below the clitoris and atop the introitus. The introitus is sometimes partly covered by a membrane called thehymen.The hymen will usually rupture during the first episode of vigorous sex, and the blood produced by this rupture has been seen to signifyvirginity.However, the hymen may also rupture spontaneously during exercise or be stretched by normal activities such as the use oftamponsandmenstrual cups,or be so minor as to be unnoticeable, or be absent.[10]In some rare cases, the hymen may completely cover the introitus, requiring a surgical procedure called ahymenotomy.[14]Two greater vestibular glands known asBartholin's glandsopen into either side of the introitus and secrete a mucousvaginal lubricant.[15]The openings of the lesser vestibular glands, known asSkene's glands,are found on either side of the urethral meatus.

Muscles

Muscles underlying the vulva andperineum

Pelvic floor muscleshelp to support the vulvar structures. The voluntary,pubococcygeus muscle,part of thelevator animuscle partially constricts the vaginal opening.[16]Other muscles of theurogenital trianglesupport the vulvar area and they include thetransverse perineal muscles,thebulbospongiosus,and theischiocavernosusmuscles.[17]The bulbospongiosus muscle decreases the vaginal opening.[6]They play a role in thevaginal contractionsoforgasmby causing the vestibular bulbs to contract.[18]

Blood, lymph and nerve supply

The tissues of the vulva are highlyvascularisedand blood supply is provided by the threepudendal arteries.[19]Venous return is via theexternalandinternal pudendal veins.[20] The organs and tissues of the vulva are drained by a chain ofsuperficial inguinal lymph nodeslocated along theblood vessels.[21]

Theilioinguinal nerveoriginates from the first lumbar nerve and gives branches that include theanterior labial nerves,which supply the skin of the mons pubis and the labia majora.[22]Theperineal nerveis one of the terminal branches of thepudendal nerveand this branches into theposterior labial nervesto supply the labia.[22]The pudendal nerve branches include thedorsal nerve,which gives sensation to the clitoris.[22]The clitoral glans is seen to be populated by a large number of small nerves, a number that decreases as the tissue changes towards the urethra.[23]The density of nerves at the glans indicates that it is the center of heightened sensation.[23]Cavernous nervesfrom theuterovaginal plexussupply theerectile tissueof the clitoris.[24]These are joined underneath thepubic archby the dorsal nerve of the clitoris.[25] The pudendal nerve enters the pelvis through thelesser sciatic foramenand continues medial to the internal pudendal artery. The point where the nerve circles theischial spineis the location where apudendal blockoflocal anestheticcan be administered to inhibit sensation to the vulva.[26]A number of smaller nerves split off from the pudendal nerve. Thedeep branch of the perineal nervesupplies the muscles of the perineum and a branch of this supplies the bulb of the vestibule.[27][28]

Variations

The length of the labia minora varies significantly between women: while the labia majora completely enclose the labia minora in some women (top row), in other women, they protrude and are clearly visible in an upright standing position (bottom row). Colloquially, these variations of the labia are also referred to as "innies" and "outies".[29][30][31]

There is a great deal of variation in the appearance of the vulva.[10]Much of this variation lies in the significant differences in the size, shape, and color of the labia minora. Though called the smaller lips, they can often be of considerable size and may protrude outside the labia majora.[10][7]This variation has also been evidenced in a large display of 400 vulval casts called theGreat Wall of Vaginacreated byJamie McCartneyto fill the lack of information of what a normal vulva looks like. The casts taken from a large and varied group of women showed clearly that there is much variation.[32][10]Other variations of the vulva include the appearance ofFordyce spotsand clitoral phimosis (when the clitoral hood cannot retract past the glans).

Researchers from the Elizabeth Garret Anderson Hospital, London, measured multiple genital dimensions of 50 women between the ages of 18 and 50, with a mean age of 35.6:[33]

Measurements Mean[standard deviation]
Clitorallength (mm) 5.0–35.0 19.1 [8.7]
Clitoral glanswidth (mm) 3.0–10.0 5.5 [1.7]
Clitoris tourethra(mm) 16.0–45.0 28.5 [7.1]
Labia majoralength (cm) 7.0–12.0 9.3 [1.3]
Labia minoralength (mm) 20–100 60.6 [17.2]
Labia minora width (mm) 7.0–50.0 21.8 [9.4]
Perineumlength (mm) 15.0–55.0 31.3 [8.5]
Vaginallength (cm) 6.5–12.5 9.6 [1.5]
Tanner stage(n) IV 4.0 (8%)
V 46 (92%)
Color of the genital area compared to the surrounding skin (n) Same color 9 (18%)
Darker color 41 (82%)
Rugosityof the labia (n) Smooth (unwrinkled) 14 (28%)
Moderately wrinkled 34 (68%)
Markedly wrinkled 2 (4%)

Development

Prenatal development

Main article:Development of the reproductive system
Development of external genitals showinghomologuesfromindifferentto both sexes—female on right

In week three ofthe development of the embryo,mesenchymecells from theprimitive streakmigrate around thecloacal membrane.[34]Early in the fifth week, the cells form two swellings called the cloacal folds.[35]The cloacal folds meet in front of the cloacal membrane and form a raised area known as thegenital tubercle.[35][34]The urorectal septum fuses with the cloacal membrane to form theperineum.This division creates two areas one surrounded by the urethral folds and the other by the anal folds.[35][34]These areas become the urogenital triangle and the anal triangle.[36]The area between the vulva and the anus is known as the clinical perineum.[36]

At the same time, a pair of swellings on either side of the urethral folds known as the genital swellings develop into thelabioscrotal swellings.[35][34]Sexual differentiation takes place, and at the end of week six in the female, hormones stimulate further development and the genital tubercle bends and forms the clitoris.[35][34]Theurogenital sinuspersists as the vulval vestibule, vestibular glands and urethra. Theurethral foldsform the labia minora and the labioscrotal swellings form the labia majora.[37][38]

The uterovaginal canal or genital canal, forms in the third month of the development of the urogenital system. The lower part of the canal is blocked off by a plate of tissue, the vaginal plate. This tissue develops and lengthens during the third to fifth months and the lower part of the vaginal canal is formed by a process of desquamation or cell shedding. The end of the vaginal canal is blocked off by an endodermal membrane, which separates the opening from the vestibule. In the fifth month, the membrane degenerates but leaves a remnant called the hymen.[35]

Childhood

Thenewborn's vulva may be swollen or enlarged as a result of having been exposed, via theplacenta,to her mother's increased levels of hormones.[39]The labia majora are closed.[40]These changes disappear over the first few months.[39]During childhood before puberty, the lack of estrogen can cause the labia to become sticky and to ultimately join firmly together. This condition is known aslabial fusionand is rarely found after puberty when estrogen production has increased.[41]

Puberty

Pubertyis the onset of the ability to reproduce, and takes place over two to three years, producing a number of changes.[42][43]The structures of the vulva become proportionately larger and may become more pronounced.[44]Pubarche,the first appearance ofpubic hairdevelops, firstly on the labia majora, and later spreads to the mons pubis, and sometimes to the inner thighs and perineum. Pubic hair is much coarser than other body hair, and is considered asecondary sex characteristic.[45]Pubarche can occur independently of puberty.Premature pubarchemay sometimes indicate a latermetabolic-endocrine disorderseen at adolescence. The disorder sometimes known as apolyendocrine disorderis marked by elevated levels ofandrogen,insulin,andlipids,and may originate in the fetus. Instead of being seen as a normal variant it is proposed that premature pubarche may be seen as a marker for these later endocrine disorders.[46]

Apocrine sweat glandssecretesweatinto the pubic hair follicles. This is broken down by bacteria on the skin and produces an odor,[47]which some consider to act as an attractantsex pheromone.[48]The labia minora may grow more prominent and undergo changes in color.[49]At puberty, the first monthly period known asmenarchemarks the onset ofmenstruation.[50] In prepubertal girls, the skin of the vulva is thin and delicate, and its neutral pH makes it prone to irritation.[51]The production of the female sex hormoneestradiol(anestrogen) at puberty, causes the perineal skin to thicken bykeratinising,and this reduces the risk of infection.[52]Estrogen also causes the laying down of fat in the development of the secondary sex characteristics. This contributes to the maturation of the vulva with increases in the size of the mons pubis, and the labia majora and the enlargement of the labia minora.[44]

Pregnancy

Inpregnancy,the vulva and vagina take on a bluish coloring due to venous congestion. This appears between the eighth and twelfth week and continues to darken as the pregnancy continues.[36]Estrogen is produced in large quantities during pregnancy and this causes the vulva to become enlarged. The vaginal opening and the vagina are also enlarged.[53]Afterchildbirth,a vaginal discharge known aslochiais produced and continues for about ten days.[53]

Menopause

Duringmenopause,hormone levels decrease, which causes changes in the vulva known asvulvovaginal atrophy.[54]The decreased estrogen affects the mons, the labia, and the vaginal opening and can cause pale, itchy, and sore skin.[54]Other visible changes are a thinning of the pubic hair, a loss of fat from the labia majora, a thinning of the labia minora, and a narrowing of the vaginal opening. This condition has been renamed by some bodies as thegenitourinary syndrome of menopauseas a more comprehensive term.[54]

Function and physiology

Main article:Female reproductive system

The vulva has a major role to play in the reproductive system. It provides entry to, and protection for the uterus, and the right conditions in terms of warmth and moisture that aids in its sexual and reproductive functions. The vulva is richly innervated and provides pleasure when properly stimulated. The mons pubis provides cushioning against the pubic bone during intercourse.[10]

A number of different secretions are associated with the vulva, includingurine(from the urethral opening duringurinationthrough control of theexternal sphincter muscle),sweat(from the apocrine glands),menses(leaving from the vagina via the introitus),sebum(from thesebaceous glands), alkaline fluid (from the Bartholin's glands),mucus(from the Skene's glands), vaginal lubrication from thevaginal wallandsmegma.[36][10]Smegma is a white substance formed from a combination of dead cells, skin oils, moisture and naturally occurringbacteria,that forms in the genitalia.[55]In females, this thickened secretion collects around the clitoris and labial folds. It can cause discomfort duringsexual activityas it can cause the clitoral glans to stick to the hood, and is easily removed by bathing.[10]Aliphaticacids known ascopulinsare also secreted in the vagina.[48]These are believed to act aspheromones.Theirfatty acidcomposition, and consequently theirodorchanges in relation to the stages of themenstrual cycle.[48]

Sexual stimulation and arousal

Main articles:Human sexual response cycleandSexual arousal
Further information:Orgasm § Females
A vulva with receding labia majora, developing clitoral erection, engorgement of the labia minora, and increased vaginal lubrication

The clitoris and the labia minora are both the mosterogenous areasof the vulva. The labia majora are also somewhat erogenous.[56]Localstimulationcan involve the clitoris, vagina and other perineal regions. The clitoris (especially the glans) is the human female's most sensitive erogenous zone and generally the primary anatomical source of human female sexual pleasure.[57]Sexual stimulation of the clitoris (by a number of means) can result in widespread sexual arousal and, if maintained, can result inorgasm.Stimulation to vulvar orgasm is optimally achieved by a massaging sensation,[44]such asoral sex(cunnilingus),fingering,andtribadism(two women rubbing vulvas together).

Sexual arousal results in a number of physical changes in the vulva. During arousal, theBartholin's glandsproduce morevaginal lubrication.Vulval tissue is highlyvascularised;arterioles dilate in response to sexual arousal and the smaller veins will compress after arousal,[27][58]so that the clitoris and labia minora increase in size. Increasedvasocongestionin the vagina causes it to swell, decreasing the size of the vaginal opening by about 30%.Clitoral erectiontakes place, which retracts the clitoral hood, causing the glans to appear. The labia majora have swollen from blood flow,[59]and slightly separated, revealing a thick and engorged labia minora.[60]The labia minora sometimes change considerably in color, going from pink to red in lighter skinned women who have not borne a child, or red to dark red in those who have.

During orgasm, rhythmicmuscle contractionsoccur in the outer third of the vagina, as well as the uterus and anus. Contractions become less intense and more randomly spaced as the orgasm continues. The number of contractions that accompany an orgasm vary depending on its intensity. An orgasm may be accompanied byfemale ejaculation,causing liquid from theSkene's glandsto be expelled through the urethra. The pooled blood begins to dissipate, although at a much slower rate if an orgasm has not occurred. The vagina and its opening return to their normal relaxed state, and the rest of the vulva returns to its normal size, position and color.[61][10]

Distance between vagina and clitoral glans

The distance between theclitoral frenulumand theurinary meatuslocated above thevaginal openingis called the clitoral-urinary meatus distance or CUMD. In the 1920s,Marie Bonaparteconducted surveys among women to find out whether they get an orgasm duringcoitus.The causes of lack of sexual arousal were known to be aversion or psychological inhibitions. Among the test subjects, there were women who, with a man they loved and desired, "felt the greatest pleasure at certain tender touches", but were nevertheless not sufficiently aroused during coitus. Bonaparte examined the distance between the clitoris and the vagina in 200 women. In 69% of the women, the CUMD was 1.25 to 2.25 cm, most of whom experienced the sexual act as satisfying. In 10% of the women, the CUMD was 2.5 cm; 21% measured 2.75 to 3.5 cm. All the women with a large gap stated that they did not experience satisfying pleasure from penile penetration, although some were very sensitive to "precise stroking by the man". Bonaparte concluded from this an anatomical causal connection between a large CUMD and "vaginal frigidity" explaining why only women with the clitoral glans close to the vagina (so that it is continuously touched by the penis) were able to experience "the highest sexual pleasure" during coitus.[62][63]

  • Glans clitoridis with small distance to the opening
  • Contact of the clitoral glans with the penis with small CUMD
  • Glans clitoridis with medium distance to the opening
  • Lack of contact of the clitoral glans with the penis
  • Classification of the 200 women into CUMD categories
  • Selection of women studied and interviewed

A study byCarney Landisand colleagues in 1940 includes statements to this effect: "On the physical side orgasm capacity is related to clitoris-meatus distance". (Landis et al. 1940).[64][65]

In 2011,Kim Wallen[66]andElisabeth Lloydreviewed Bonaparte's research and confirmed an inverse correlation between CUMD and orgasm through intercourse.[67][68][69][70] In methods taught since the 1970s byBetty Dodson,thesexual arousalof the woman during vaginal intercourse is to be ensured by the woman independently stimulating her clitoris continuously with herhandsor possibly with avibrator.[71][72]According to Kim Wallen, the CUMD says nothing about a happy sex life, rather that a large gap gives couples an opportunity "to be a bit more inventive in how they have sex".[68]

Clinical significance

Main article:Vulvar disease

Irritation

Irritation anditchingof the vulva is calledpruritus vulvae.This can be a symptom of many disorders, some of which may be determined by apatch test.The most common cause of irritation isthrush,a fungal infection.Vulvovaginal healthmeasures can help to prevent many disorders including thrush.[73]Infections of the vagina such asvaginosisand of the uterus may producevaginal discharge,which can be anirritantwhen it comes into contact with the vulvar tissue.[74][75]Inflammation asvaginitis,vulvovaginitisandvulvitiscan result from this causing irritation and pain.[76]Ingrown hairsresulting from pubic hair shaving can causefolliculitiswhere thehair folliclebecomes infected; or give rise to an inflammatory response known aspseudofolliculitis pubis.[77]A less common cause of irritation isgenital lichen planus,another inflammatory disorder. A severe variant of this isvulvovaginal-gingival syndrome,which can lead to narrowing of the vagina,[78]or vulva destruction.[79]Many types of infection and other diseases including somecancersmay cause irritation.[80][81]

Sexually transmitted infections

Main article:Sexually transmitted infection
Water warts ofmolluscum contagiosum
Pubic hair with crab lice

Vulvar organs and tissues can become affected by differentinfectious agentssuch asbacteriaandviruses,orinfestedbyparasitessuch asliceandmites.Over thirty types ofpathogencan besexually transmitted,and many of these affect the genitals. MostSTIsdo not produce symptoms or symptoms may be mild and not be indicative of an STI.[82]The practice ofsafe sexcan greatly reduce the risk of infection from many sexually transmitted pathogens.[83]The use ofcondoms(either male orfemale condoms) is one of the most effective methods of protection.[82]

Bacterialinfections include:chancroid– characterised bygenital ulcersknown aschancres;granuloma inguinaleshowing as inflammatorygranulomasoften described as nodules;syphilis–the primary stage classically presents with a single chancre, a firm, painless, non-itchy ulcer, but there may be multiple sores;[84]andgonorrheathat very often presents no symptoms but can result in discharge.[85]

Viral infectionsincludehuman papillomavirus infection(HPV) – this is the most commonSTIand has many types.[86]Genital HPV can causegenital warts.There have been links made between HPV and vulvar cancer, though HPV most often causescervical cancer.[87]Genital herpesis mostlyasymptomaticbut can present with smallblistersthat break open intoulcers.[88]HIV/AIDSis mostly transmitted through sexual activity, and the vulva in some cases can be affected by sores.[89] A highly contagious viral infection ismolluscum contagiosum,which is transmissible on close contact and causes waterwarts.[90][91]

Parasiticinfections includetrichomoniasis,pediculosis pubis,andscabies.Trichomoniasis is transmitted by aparasiticprotozoanand is the most common non-viral STI.[92]Most cases are asymptomatic but may present symptoms of irritation and adischargeof unusualodor.[93]Pediculosis pubis,commonly calledcrabs,is a disease caused by thecrab louseanectoparasite.[81]When the pubic hair is infested, the irritation produced can be intense.[81]Scabies,also known as the "seven year itch", is caused by another ectoparasite, themiteSarcoptes scabiei,giving intense irritation.[81]

Cancer

Main article:Vulvar cancer

Malignanciescan develop in the glabrous and hair-bearing parts of the vulva.[27][94]Based on the cellular origin andhistology,vulvar cancers are classified intosquamous cell carcinomas,melanomas,basal cell carcinomas,adenocarcinomas,sarcomasand invasiveextramammary Paget's disease.[94]Squamous cell carcinomas represent the most common variant of vulvar cancers and account for approximately 75%.[94]These are usually found in the labia, particularly the labia majora.[95]The second most common vulvar cancer isbasal cell carcinoma,which rarely spreads to regional lymph nodes or distant organs.[94]The third most common subtype is vulvarmelanoma.Studies have shown that vulvar melanomas appear to have a different tumor biology and mutational characteristics compared to skinmelanomas,which has a direct impact on the medical treatment of vulvar melanomas.[96][97]

Signsand symptoms of vulvar cancer can include:itching,orbleeding;skin changes including rashes, sores, lumps orulcers,and changes in vulvar skin coloration.Pelvic painmight also occur especially duringurinatingand sex.[80]However, a significant proportion remains asymptomatic in early disease stages, often delaying its diagnosis.[94]As such, 32% of women with vulvar melanoma already have regional involvement or distant metastases at the time of diagnosis, which significantly impacts prognosis.[96]

Surgery (with or without removal of regional lymph nodes) is usually the primary treatment modality. Typically, a wide-local excision is performed, in which the tumor is excised including a safety-margin of healthy tissue to ensure its entire removal, which is confirmed by a pathologist.[94]In more advanced disease, a (partial)vulvectomymay need to be performed in order to remove some or all of the vulva.[98]Advanced-stage melanomas can be treated withcheckpoint inhibitors.[99]

Other

Labial fusion,also calledlabial adhesion,is the fusion of the labia minora. This affects a number of young girls and is not considered unduly problematic. The condition can usually be treated usingcreams,or it may right itself with the release of hormones at the onset of puberty.[41][100]

Clitor Omega lyis an enlarged clitoris caused by eitheranabolic steroidsor anintersexcondition.

Vulvodyniais chronic pain in the vulvar region. There is no single identifiable cause.[101]A subtype of this isvulvar vestibulitisbut since this is not thought to be an inflammatory condition it is more usually referred to asvestibulodynia.[102]Vulvar vestibulitis usually affects pre-menopausal women.[102]

Pudendal nerve entrapmentcan cause sharp pain or numbness in the vulva. This condition can be caused by activities such ascycling,giving birth, or prolonged sitting.

A number ofskin disorderssuch aslichen sclerosus,andlichen simplex chronicuscan affect the vulva.Crohn's diseaseof the vulva is an uncommon form ofmetastaticCrohn's disease, which manifests as a skin condition showing ashypertrophiclesions or vulvarabscesses.[103]Papillary hidradenomasarenodulesthat can ulcerate and are mostly found on the skin of the labia or of the interlabial folds. Another more complex ulcerative condition ishidradenitis suppurativa,which is characterised by painful cysts that can ulcerate, and recur, and can become chronic lasting for many years.[104][105]Chronic cases can develop intosquamous cell carcinomas.[105]An asymptomatic skin disorder of the vulval vestibule isvestibular papillomatosis,which is characterised by fine, pink projections from either the epithelium of the vulva or from the labia minora.Dermatoscopycan distinguish this condition from genital warts.[106]A subtype ofpsoriasis,anautoimmune disease,isinverse psoriasisin which red patches can appear in theskin foldsof the labia.[107]

Childbirth

The vulvar region is at risk for trauma duringchildbirth.[108] During childbirth, the vagina and vulva must stretch to accommodate the baby's head (approximately 9.5 cm (3.7 in)). This can result in tears known asperineal tearsin the vaginal opening, and other structures within theperineum.[109]Anepisiotomy(a pre-emptive surgical cutting of the perineum) is sometimes performed to facilitate delivery and limit tearing. A tear takes longer to heal than an incision.[110]Tears and incisions may be repaired usingsuturesthat may be layered.[111][36]Among the methods of hair removal evaluated for pre-surgeries, pubic hair shaving known asprepping,was seen to increase the risk of surgical site infections.[112][110]No advantages have been demonstrated in the routine shaving of pubic hair prior to childbirth.[113]

Surgery

Main articles:GenitoplastyandCosmetic surgery

Genitoplastiesareplastic surgeriesthat can be carried out to repair, restore or alter vulvar tissues,[114]particularly following damage caused by injury orcancer treatment.These procedures includevaginoplastyandvulvoplasty,which can also be performed as acosmetic surgery.Other cosmetic surgeries to change the appearance of external structures includelabiaplasties.[115]Some of these procedures, vaginoplasties and vulvoplasties, are also carried out assex reassignment surgeries.[116][117]

The use of cosmetic surgeries has been criticized by clinicians.[118][119]TheAmerican College of Obstetricians and Gynecologistsrecommends that women be informed of the risks of these surgeries. They refer to the lack of data relevant to their safety and effectiveness and to the potential associated risks such asinfection,altered sensation,dyspareunia,adhesions,andscarring.[120]There is also a percentage of people seeking cosmetic surgery who may be suffering frombody dysmorphic disorderand surgery in these cases can be counterproductive.[121]

Society and culture

See also:Vagina § Society and culture,andVulva activism

Altering the female genitalia

Further information:Genital modification and mutilation
Thelabia pridemovement opposes the ideals of female cosmetic genital surgeries: The Muff March in London, 2011

In somecultural practices,particularly in the AfricanKhoikhoiandRwandacultures, the labia minora are purposefully stretched by repeated pulling on them and sometimes by attaching weights.[122][123][10]Labia stretchingis a recognised, familial cultural practice in parts of Eastern and Southern Africa.[122][124][125]This is a desired and encouraged practice by the women (starting at puberty) in order to promote better sexual satisfaction for both parties.[126][10]The achieved extensions can hang down below the labia majora for up to seven inches.[10]Children in the African diaspora practise this too, so it occurs within immigrant communities in, for example, Britain, where aBBC Newsreport labelled it a hidden form ofchild abuse.[127]The girls are subject to familial and social pressure to conform.[128]

In some cultures, including modern Western culture, women have shaved or otherwiseremoved the hairfrom part or all of the vulva. When high-cut swimsuits became fashionable, women who wished to wear them would remove the hair on either side of their pubic triangles, to avoid exhibitingpubic hair.[129]Other women prefer to retain their vulva hair. The removal of hair from the vulva is a fairly recent phenomenon in the United States, Canada, and Western Europe, usually in the form ofbikini wa xingorBrazilian wa xing,but has been prevalent in many Eastern European and Middle Eastern cultures for centuries, usually due to the idea that it may be more hygienic, or originating in prostitution and pornography.[130][131]Hair removal may include all, most, or some of the hair.[132]French wa xingleaves a small amount of hair on either side of the labia or a strip directly above and in line with the pudendal cleft called alanding strip.[132]Islamteaching includesMuslim hygienical jurisprudenceapracticeof which is the removal of pubic hair.[133]

Vulva piercings include theclitoral hood piercingabove and thelabia piercing
Derived from traditional symbols, Hanabira scarification is intended to decorate the pubic area

Several forms ofgenital piercingscan be made in the vulva, and include theChristina,Princess Albertina,Isabella,Nefertiti,fourchette,andlabia piercings.Piercings are usually performed for aesthetic purposes, but some forms like theclitoral hood piercing(or rarelyglans piercing) might also enhance pleasure during sex. Though they are common intraditional cultures,intimate piercings are a fairly recent trend in Western society.[134][135][136]Other forms of permanent modifications of the vulva for cultural, decorative or aesthetic reasons aregenital tattoosorscarification(so-called "Hanabira" ).

Female genital surgery includeslaser resurfacingof the labia to remove wrinkles,labiaplasty(reducing the size of the labia) andvaginoplasty.In September 2007, theAmerican College of Obstetricians and Gynecologists(ACOG) issued a committee opinion on these and other female genital surgeries, including "vaginal rejuvenation", "designer vaginoplasty", "revirgination", and "G-spotamplification ". This opinion states that the safety of these procedures has not been documented. The ACOG and theISSVDrecommend that women seeking these surgeries need to be informed about the lack of data supporting these procedures and the potential associated risks such as infection, altered sensation,dyspareunia,adhesions,and scarring.[120][137]

With the growing popularity of female cosmetic genital surgeries, the practice increasingly draws criticism from an opposition movement ofcyberfeministactivist groups and platforms, called thelabia pride movement.The major point of contention is that heavy advertising for these procedures, in combination with a lack of public education, fosters body insecurities in women with larger labia in spite of the fact that there is normal and pronounced individual variation in the size of labia. The preference for smaller labia is a matter of a fashion fad and is without clinical or functional significance.[138][139]

Female genital mutilation

The most prevalent form of non-consensualgenital alterationis that offemale genital mutilation.This mostly involves the partial or complete removal of the vulva.[140]Female genital mutilation is carried out in thirty countries in Africa and Asia with more than 200 million girls being affected, and some women (as of 2018).[140]Nearly all of the procedures are carried out on young girls. The practices are also carried out globally among migrants from these areas. Female genital mutilation is claimed to be mostly carried out for cultural traditional reasons.[140]According to the research conducted underIn the Name of Tradition,FGM/C is more common inSunnicountries and less common inShiasocieties.[141][142][143][144]

FGM/C can have harmful effects on their physical and mental health. Various official and unofficial research reports also confirm these complications. In its various reports, theWorld Health Organizationhas considered FGM/C as an action that endangers women's health in various ways. This organization stated in a report published in January 2023 that FGM/C has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and it interferes with the natural functions of girls' and women's bodies. Although all forms of FGM/C are associated with increased risk of health complications, the risk is greater with more severe forms of FGM/C.[145][146][147]

The American National Library of Medicine also stated in an article in 2018 that the consequences of FGM/C have both physiological and psychological complications, including short- and long-term complications. The method in which the procedure is performed may determine the extent of the short-term complications. If the process was completed using unsterile equipment, no antiseptics, and no antibiotics, the victim may have increased risk of complications. Primary infections include staphylococcus infections, urinary tract infections, excessive and uncontrollable pain, and hemorrhaging. Infections such as human immunodeficiency virus (HIV), Chlamydiatrachomatis,Clostridium tetani, and herpes simplex virus (HSV) 2 are significantly more common among women who underwent Type 3 mutilation compared with other categories.[148][149][150]

Etymology

An 1822 illustration of agynaecological examination

The wordvulvaisLatinfor "womb". It derives from the 1540s in referring to the womb and female sexual organs, from the earliervolveremeaning to turn, roll or revolve, with further derivatives such as used involvox,andvolvulus(twisted bowel).[151][152]The naming of the female (and male) genitals aspudenda membra,meaning parts to be ashamed of, dates from the mid-17th century.[153]The naming influenced the general perception of the vulva and this is shown in depictedgynaecologicalprocedures. The examiner shown in theObstetrical examinationdated 1822, is adopting the compromise procedure where the woman's genitals cannot be seen.[154][155]

Terminology

In 2021, a study in the UK showed that few are able to label the structure of the vulva correctly.[156][157][158]

There are manysexual slangterms used for the vulva.[152][159]Cunt,a medieval word for the vulva and once the standard term, has become avulgarism,and in other uses one of the strongest offensive and abusiveswear wordsin English-speaking cultures. The word has been replaced in normal usage by a feweuphemismsincludingpussy(vulgar slang) andfanny(UK), which used to be a commonpet name.[160][152]In the UK, these terms have other non-sexual meanings that lend themselves todouble entendres,such aspussy,which is used as aterm of endearmentfor a pet cat, "pussy cat".[161][162][163]In North American informal use, the termpussycan also refer to a weak or effeminate man,[164]andfannyis a term used for thebuttocks.[165][152]Other slang terms aremuff,snatch,andtwat.[166][167]Vaginais often incorrectly used as a synonym for vulva since it is separate from that anatomy.[1]

Religion and art

Main article:Vagina and vulva in art
Japanese artistMegumi Igarashiwith vulva portrayal

Some cultures have long celebrated and even worshipped the vulva. During theUruk period(c.4000–3100 BC), the ancientSumeriansregarded the vulva as sacred[168][169]and a vast number ofSumerian poemspraising the vulva ofInanna,the goddess of love, sex, and fertility, have survived.[169]InSumerian religion,the goddessNinimmais the divine personification of the vulva.[170][171]Vaginal fluid is always described in Sumerian texts as tasting "sweet"[169]and, in a Sumerian bridal hymn, a young maiden rejoices that her vulva has grown hair.[169]Clay models of vulvas were discovered in the temple of Inanna atAshur.[172]

Some majorHindutraditions such asShaktism,a goddess-centered tradition, revere the vulva and vagina under the nameyoni.[173][174]ThegoddessasDeviis worshipped as the supreme deity.[175]The yoni is a representation of the female deity and is found in many temples as a focus forprayer and offerings.[174]It is also represented symbolically as amudrainspiritual practices,includingyoga.[176]

Sheela na gigsare figurative carvings of naked women displaying an exaggerated vulva. They are found in ancient and medieval European contexts. They are displayed on many churches, but their origin and significance is debatable. A main line of thinking is that they were used to ward offevil spirits.Another view is that the sheela na gig was a divine assistant in childbirth.[177][178]Starr Goode explores the image and possible meanings of the Sheela na gig andBauboimages in particular, but writes also about the recurring image worldwide. Through hundreds of photographs, she demonstrates that the image of a female displaying her vulva is not specific to European religious art or architecture, but that similar images are found in the visual arts and in mythical narratives ofgoddessesandheroinesparting their thighs to reveal what she calls, "sacred powers". Her theory is that "the image is so rooted in our psyches that it seems as if the icon is the original cosmological center of the human imagination".[179]

L'Origine du monde,an oil painting byGustave Courbet

L'Origine du monde(Origin of the World), painted byGustave Courbetin 1866, was an earlyRealistpainting of a vulva that only became exhibited many years later.[180]The painting was commissioned byOttomandiplomatHalil Şerif Paşa.The woman used as the model for the painting was probably Halil's loverConstance Quéniaux.[181]However, another potential model isMarie-Anne Detourbay,who was also a lover of Halil Şerif Pasha.[182]

Japanese sculptor andmangaartistMegumi Igarashihas focused much of her work on painting and modelling vulvas and vulva-themed works. She has used molds to createdioramas– three-dimensional models of her vulva with the hope of demystifying the female genitals.[183]

Anart installationcalledThe Dinner Partybyfeminist artist,Judy Chicago,portrays a symbolic history of famous women. The dinner plates each depict an elaborate vulval form and they are arranged in a triangular vulva shape.[184]Another installation was made by British artistJamie McCartneywho used the casts of four hundred vulvas to createThe Great Wall of Vaginain 2011. The casts are life-size. Explanations written by the project's sexual health adviser accompany these. The purpose of the artist was to "address some of the stigmas and misconceptions that are commonplace".[185][32]

Other animals

As a rule, only the external female genitals ofplacental mammalsare referred to as the "vulva", although the term is also used in the scientific literature for functionally comparable structures in other animal groups such asmarsupials[186]and roundworms (Nematoda).[187]

For comparison,birds,reptiles,amphibians,someaquatic animals,and themonotremeshave acloaca.An organ system like a vulva does not exist.

The vulva of a placental mammal consists of the following along with its variations:

  • Clitoris: Made up of the root, glans and body and is usually retracted into aprepuce.Inside the clitoris of many non-human placentals is thebaubellum,a small bone that possibly has origins incopulation.In horses and dogs, the clitoris is contained in clitoralfossa,which is a small pouch of tissue.[188][189]
  • Labia: A small, thin pair of lip-like structures that protect the vestibule. They are known as thelabia vulvaeor simplylabiaincarnivoransandungulatesand as thelabia minorainprimates.[190][191][192][193]Thelabia majoraonly exist in primates (including humans).Afrotheriansdo not have distinguishable labia.[194]
  • Vestibule/vulvar opening: In humans, othergreat apes,and somerodents,the vestibule is a flat and short external space that contains separate urethral and vaginal openings. In most other placentals, the urethra and vagina join as an internal vestibule (urogenital sinus), hence both urine and offspring exit through an orifice called thevulvar opening.[194][195][196]

Duringestrus,the clitoris of amare(female horse) everts as the labia contracts by opening and closing. This is colloquially known as "winking".[197]Throughout the menstrual cycle, some femaleprimates' vulvar and anal regions will swell (sexual swelling) to attract a male, though the fundamental reason for this function is up for debate.[198]

The vulva of aspotted hyenahas a large clitoris known as apseudo-penisfor copulating, giving birth and urinating, as well as fused labia (pseudo-scrotum). This can make it difficult to correctlysexthe species.

Additional images

  • Vulva hand sign used as ayogicmudra
  • Attic red-figure lid depicting three vulvae and a winged penis

See also

References

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