Int J Womens Health Wellness ISSN: 2474-1353

• Introduction
• Case
• Discussion
• References

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International Journal of Women's Health and Wellness

¹Department of Urology, Ataturk Training and Research Hospital, Ankara, Turkey
²Department of Gynecology and Obstetrics, Fatih University, School of Medicine, Istanbul, Turkey
³Department of Urology, Gazi University, School of Medicine, Ankara, Turkey
⁴Department of Urology, Turgut Ozal University, School of Medicine, Ankara, Turkey
⁵Department of Urology, Behcet Uz Training and Research Hospital, İzmir, Turkey

Introduction

In women, orgasm is defined as giving a feeling of happiness and fulfillment after sexual stimulation which is decreasing of vasocongestion; rhythmic contractions of uterus, anus and vagina muscles surrounding the pelvic region, also defined as a state of short term intense pleasure. Sexuality takes an important role and has an impact on the quality of life of the couples [1]. Sexual function in women affected by psychological, environmental and physiologic (hormonal, vascular, neurologic and anatomic) factors [2]. Recent literature indicates that 40-45% of woman experienced at least one sexual dysfunction [3].

The clitoris plays an important role at the primary erogenous response by the disciplines of embryology, anatomy and physiology [4]. Glans and the body of the clitoris are visible in normal, but in some cases a skin, likely the prepuce in men, covers the clitoris [4]. Some women may reflect this situation as a reason of anorgasmia. We represent a case aiming to assess the various reasons of women anorgasmia discussing with the current literature.

Case

A 35 year old woman, married for ten years and having 2 children with vaginal delivery admitted to obstetrics and gynecology clinic with primary anorgasmia from the beginning of her marriage. She had a regular sexual life with her husband (at least twice a month), but she had never experienced an orgasm during her marriage. She had graduated from university and has a normal socioeconomic status. She had not experienced any sexual intercourse before her marriage. During her marriage she had no argument with her husband about this situation. Urology consultation was obtained after the vaginal examination. Patient was evaluated with urogynecologic examination and Female Sexual Function Index (FSFI). At the physical examination we determined a skin lying from anterior labial commissure to the top of the glans clitoris. Despite retracting this skin, the clitoris could not be seen. Behavioral therapy (coital alignment technique), sildenafil citrate, tibolon and vacuum therapy administered for three months respectively but there were no change at her FSFI score and complaints. We performed vestibuloplasty and excised half of this clitoral skin to expose the glans clitoris out. The patient experienced a satisfactory orgasm at the second month after the operation. In two years of follow-up she had no anorgasmia and her FSFI rates increased markedly. Informant consent obtained from the patient to report her data but the patient did not give permission to take any picture or drawing her operative area.

Discussion

Sexual satisfaction is an important part of the daily life that affects both men and women. Almost 40-45% of the women experiences sexual dysfunction once in a lifetime [3]. Primary anorgasmia is found at 5-10% of the women [5]. Highlighted as the most intense point of the ultimate female sexual arousal; orgasm was evaluated in many sides like; etiological, clinical, physiological, psychological and sociological. Some studies reported anorgasmia rates at 26.3% in women [3]. Sexual problems may cause several difficulties in marriage, that 67% of divorces are related to sexual disorders in current reports [5].

Sexual disorders in women classified into four main branches; lubrication insufficiency, anorgasmia, dyspareunia and vaginismus [2]. Anorgasmia is also classified as persistent, recurrent delay or absence of orgasm following a normal sexual excitement phase, resulting in distress or interpersonal difficulties [6]. Clitoris is an important part of external genitalia and has a significant role at the sexual function of women. Clitoris is localized under the urogenital diaphragm, in front of symphysis pubis and anterior perineal region and the roots of clitoris are located in contact with the ischiopubic ramus [4]. Embryologic, anatomic and physiologic findings showed that clitoris plays an important role in female orgasm [4]. According to some authors, it is one of the erectile tissues in woman and could be named as female penis [4]. The glans and the body of the clitoris are visible but sometimes they can be covered by a prepuce like skin [4]. So that, women, like in our case, could not have a satisfactory orgasm because absence stimulation of clitoris. Orgasm is known to develop on the ground of peripheral sexual stimulation, as a result of physiological changes in cerebral neural activity. Neuroanatomical studies have shown that pudendal nerve branches innervating the clitoris that include the clitoral corpus cavernous nerve, the peripheral nerve and the dorsal nerve of clitoris, which is likely that this fine innervation of the clitoris and external genitalia transmits the sensorial stimulation that influences the vasocongestive events of clitoral sexual arousal [7].

First line we suggested “Coital Alignment” technique as behavioral therapy that was hypothesized with high frequency of female orgasm and partner simultaneity [8]. For women, sildenafil initially was used "off label" as a primary treatment for female sexual dysfunction (FSD) since 1998 [9]. After failure of behavioral therapy we suggested sildenafil 25 mg and tibolon 2.5 mg for daily for a month but, she had showed no response to sildenafil. We also recommended a vacuum erection device which increases blood flow to the clitoris has been approved by the US Food and Drug Administration (FDA) for a month. Mechanical devices may work through vibratory stimulation or by causing clitoral vascular engorgement using a vacuum system [10]. She did not show any response to all these therapies and there were no increase at the FSFI scores in three month period. We excised a half of the prepuce in order to expose the glans clitoris. Sexual satisfaction and FSFI scores were started to increase at second month after the operation. Sexual satisfaction still remained at the same level at the two years of follow-up. This delay at satisfaction may be due the late onset of sexual intercourse after operation.

Anatomical or physiological factors inhibiting the arousal of clitoris are adversely affecting the clitoris to achieve orgasm. In cases where other treatment methods have failed at women with primary anorgasmia, clitoris examination should be performed. Vestibuloplasty could provide a treatment success increasing the sensitivity of clitoris in anorgasmia at appropriate patients. This is the first report about excision of the clitoral skin in order to expose the glans clitoris to increase the sexual satisfaction in women.

References

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