Helen E. O'Connell

ANATOMICAL RELATIONSHIP BETWEEN URETHRA AND CLITORIS

PURPOSE We investigated the anatomical relationship between the urethra and the surrounding erectile tissue, and reviewed the appropriateness of the current nomenclature used to describe this anatomy. MATERIALS AND METHODS A detailed dissection was performed on 2 fresh and 8 fixed human female adult cadavers (age range 22 to 88 years). The relationship of the urethra to the surrounding erectile tissue was ascertained in each specimen, and the erectile tissue arrangement was determined and compared to standard anatomical descriptions. Nerves supplying the erectile tissue were carefully preserved and their relationship to the soft tissues and bony pelvis was noted. RESULTS The female urethra, distal vaginal wall and erectile tissue are packed into the perineum caudal (superficial) to the pubic arch, which is bounded laterally by the ischiopubic rami, and superficially by the labia minora and majora. This complex is not flat against the rami as is commonly depicted but projects from the bony landmarks for 3 to 6 cm. The perineal urethra is embedded in the anterior vaginal wall and is surrounded by erectile tissue in all directions except posteriorly where it relates to the vaginal wall. The bulbs of the vestibule are inappropriately named as they directly relate to the other clitoral components and the urethra. Their association with the vestibule is inconsistent and, thus, we recommend that these structures be renamed the bulbs of the clitoris. CONCLUSIONS A series of detailed dissections suggest that current anatomical descriptions of female human urethral and genital anatomy are inaccurate.

The anatomy of the distal vagina: towards unity.

INTRODUCTION Factual presentations of sexual anatomy are required for educational purposes, for clinical and more general communication about sexual matters. To date, unambiguous, accurate and objective images with appropriate labeling to enhance specificity in communication have been lacking. AIM The aim of this presentation is to provide a comprehensive overview of anatomy of the distal vagina. We aim to simplify the anatomy to reduce the confusion of historical descriptions. In doing so, we aim to avoid sacrificing any of the specific detail. This would aid communication between clinicians, researchers, and the nonclinician regarding this anatomy. OUTCOME MEASURES AND METHODS: This article reviews the historical and current anatomical literature. Systematic dissection and photography, histological study, and magnetic resonance imaging have been used as the basis for this presentation. Digital technology has been used to label, color, and highlight photography to provide clarity and permit diagramatization of photography. No distortion has otherwise been used in presenting images from cadavers or anatomical research. RESULTS The anatomy of the distal vagina and surrounding structures is shown and described in detailed. The distal vagina, clitoris, and urethra form an integrated entity covered superficially by the vulval skin and its epithelial features. These parts have a shared vasculature and nerve supply and during sexual stimulation respond as a unit though the responses are not uniform. CONCLUSIONS Significant progress has been made in the field of female sexual anatomy and its pictorial representation. This may facilitate further progress in the related fields of female sexual health and education.

The suspensory ligament of the clitoris: Connective tissue supports of the erectile tissues of the female urogenital region

We aimed to define the gross anatomy of the supporting structures of the clitoris. We performed a dissection of the perineum of a series of 22 female and four male cadavers. Specific dissection of the clitoral and penile suspensory ligament complex was performed in four female and two male cadavers. Serial written observations and photography were used to document the findings. Our findings were then compared with the anatomical description of these structures in the historical and current anatomical literature. The suspensory ligament of clitoris consistently displayed two components: a superficial fibro‐fatty structure extending from a broad base within the mons pubis to converge on the body of the clitoris and extending into the labia majora; in addition there is a deep component with a narrow origin on the symphysis pubis extending to the body and the bulbs of the clitoris. The supporting structures of the clitoris are more substantial and complex than previously described. Their shape, extent, and orientation are different from analogous structures of the penis, the suspensory ligament of which was found as described in the literature. Clin. Anat. 13:397–403, 2000.

Decreased Viral Load and Symptoms of Polyomavirus-Associated Chronic Interstitial Cystitis after Intravesical Cidofovir Treatment

Interstitial cystitis causes disabling bladder pain and is usually diagnosed in the absence of infection. We describe a patient with interstitial cystitis who had high urinary levels of polyomavirus that decreased dramatically after initiation of intravesical cidofovir treatment; the patient also showed substantial improvement in symptoms. Another patient had milder symptoms of cystitis and intermittent polyomavirus shedding. Polyomaviruses, particularly BK virus, may cause some cases of interstitial cystitis.

Conjoint Urological Society of Australia and New Zealand (USANZ) and Urogynaecological Society of Australasia (UGSA) Guidelines on the management of adult non-neurogenic overactive bladder

Due to the myriad of treatment options available and the potential increase in the number of patients afflicted with overactive bladder (OAB) who will require treatment, the Female Urology Special Advisory Group (FUSAG) of the Urological Society of Australia and New Zealand (USANZ), in conjunction with the Urogynaecological Society of Australasia (UGSA), see the need to move forward and set up management guidelines for physicians who may encounter or have a special interest in the treatment of this condition. These guidelines, by utilising and recommending evidence‐based data, will hopefully assist in the diagnosis, clinical assessment, and optimisation of treatment efficacy. They are divided into three sections: Diagnosis and Clinical Assessment, Conservative Management, and Surgical Management. These guidelines will also bring Australia and New Zealand in line with other regions of the world where guidelines have been established, such as the American Urological Association, European Association of Urology, International Consultation on Incontinence, and the National Institute for Health and Care Excellence guidelines of the UK.

A Case Control Study Reveals that Polyomaviruria Is Significantly Associated with Interstitial Cystitis and Vesical Ulceration.

Objectives To investigate whether polyomaviruses contribute to interstitial cystitis pathogenesis. Subjects and Methods A prospective study was performed with 50 interstitial cystitis cases compared with 50 age-matched, disease-free controls for the frequency of polyomaviruria. Associations between polyomaviruria and disease characteristics were analysed in cases. Polyomavirus in urine and bladder tissue was detected with species (JC virus vs. BK virus) specific, real-time PCR. Results Case patients were reflective of interstitial cystitis epidemiology with age range from 26–88 years (median 58) and female predominance (41/50 F). There was a significant increase in the frequency of polyomavirus shedding between cases and controls (p<0.02). Polyomavirus shedding, in particular BK viruria, was associated with vesical ulceration, a marker of disease severity, among interstitial cystitis cases after adjustment for age and sex (OR 6.8, 95% CI 1.89–24.4). There was a significant association among cases between the presence of BK viruria and response to intravesical Clorpactin therapy (OR 4.50, 95% CI 1.17–17.4). Conclusion The presence of polyomaviruria was found to be associated with the ulcerative form of interstitial cystitis. Clorpactin, which has anti-DNA virus activity, was more likely to improve symptoms in the presence of BK viruria. These data from this pilot study suggest associations between polyomaviruria and interstitial cystitis warranting further investigation.

Stimulated smooth muscle neosphincter in male intrinsic sphincter deficiency: Proof of principle studies in a rabbit model

Intrinsic sphincter deficiency (ISD) causes significant disability and impairment of quality of life despite a range of treatment options. We investigated a novel method to improve sphincter function that does not appear to have been previously attempted, that is, transplantation to create a smooth muscle cuff, that subsequently becomes innervated, around the urethra.

Re-innervation of smooth muscle that is transplanted to provide urethral sphincter augmentation

A number of methods to augment the resistance of the outlet of the urinary bladder and to improve continence have been developed, including the artificial urinary sphincter and the placement of skeletal muscle around the urethra. It has been recently shown in a rabbit model that transplantation of smooth muscle around the proximal urethra reduces incontinence caused by internal sphincter deficiency. In the present work we have investigated the re-innervation of a peri-urethral smooth muscle transplant, and whether re-innervating axons have an appropriate effect when they are stimulated. Detrusor muscle from the dome of the bladder was transplanted to encircle the proximal urethras of rats. Rats tolerated the surgery and transplantation without any signs of compromised health. At 8 weeks the new sphincter was intact and easily recognised. The transplant contracted in response to transmural stimulation (1-5Hz for up to 5min) in a similar way to freshly removed detrusor strips. Contractions were graded with stimulus frequency, they peaked at about 10s and faded to a lower tension that was maintained. The amplitudes of sustained contractions of the transplants were reduced to about 10% by hyoscine and were almost abolished by tetrodotoxin. Histological examination revealed healthy, vascularised smooth muscle in the transplants, similar in appearance to freshly dissected detrusor. Re-innervation was confirmed immunohistochemically for transplanted detrusor muscle and transplants of dartos muscle. We conclude that smooth muscle transplanted to form a new sphincter around the urethra becomes functionally re-innervated and has potential to be used for sphincter augmentation.