Comprehensive Anatomy of the Clitoris for the Pelvic Surgeon Approximately half a century ago, Masters and Johnson identified the clitoris and its components as the center of sexual satisfaction in the female. Yet most of the details in this area have remained a mystery. Despite our awareness, many surgeons are not familiar with the intricacies of the clitoris and its nerve supply. Gratification and orgasmic function appear to be associated with the intricate assembly of nerve endings in the clitoral glands. This critical structure is homologous to the penile glands in men. Loss or disruption of the clitoral innervation during benign or oncologic gynecology surgery may be the etiology of alteration of sexual function postoperatively. Thus, the pelvic surgeon should be familiar with its complex anatomy to avoid potential damage, which could be irreversible. The glands clitoris is located within the vulva, a collective term for the external genital organs as seen here. Nevertheless, the clitoris is also a buried structure, with further significant tissue located beneath the vulva and vagina. A flap may be cut to expose the underlying anatomy by incising from the top of the mons through the interlabial sulci. Ninety-five percent of the tissue beneath the skin of the labia is fat through which nerves travel. The glands clitoris is a short, cylindrical, erectile organ at the superior portion of the vestibule, with a width less than one centimeter. The normal adult glands clitoris has an average length of one and a half to two centimeters and is densely populated by thousands of terminal sensory nerve fibers. The body of the clitoris is positioned beneath the skin surface. As seen here in our cadaver specimen, the body is composed of conjoined corpora cavernosa, which branch near the base of the clitoral body and become known as crura. We will see these on the following two slides. The ischiocavernosus muscle lies directly along the superior ischial ramus, partly overlying the corpora cavernosum clitoris, or cruce. As highlighted in blue here in our cadaver specimen, you can see the location of one side of the two cylindrical corpora cavernosa that compose the clitoral body. These are known individually as crura. The crura are surrounded by a fibrous sheath, as we see here on microscopy, known as the tunica. It is discriminated from the tunica albigenia in the male penis, as the female sheath does not impede venous drainage. Along with the previously seen thin-walled vascular channels called crura, the bulb functions as erectile tissue as well. Upon closer look at this image, one can see the umbrella-like mass of cavernous tissue emanating from the bulb in the center, which covers the urethra. A tough membrane encompasses the clitoral cruce, the bulb, and the body of the clitoris, which are all retracted toward the anatomical left in our cadaver specimen seen here. These structures lie beneath Coleus fascia. Now that we have reviewed the components of the clitoris, let us proceed by discussing its surrounding structures. The clitoral body lies deep to the glands clitoris and is suspended from the pubic symphysis by a ligament. In our cadaver specimen, the suspensory ligament is thick and robust, as demonstrated by the smooth pickups placed behind it here. Superimposed upon this ligament is a branch of the dorsal clitoral nerve. In a different cadaver specimen, the suspensory ligament is bifurcated but still seen clearly as an attachment between the clitoral body and the pubic symphysis bone. Innervation of the clitoris and surrounding vulva is critically important for the pelvic surgeon due to the potential for nerve injury during procedures such as vaginal hysterectomy, placement of a suburethral sling, and other prolapse repairs. The mons and upper labia are supplied by the iliohypogastric and ilioinguinal nerves, as detailed by the red and green colors. The purple, cruel areas are supplied by the posterior femoral cutaneous nerve. The remainder of the vulva, including the clitoris, is supplied by the pudendal nerve, seen in orange. The neural supply to the clitoris and surrounding vulva emanates from the pudendal nerve as it emerges from Alcock's canal beneath the ischial tuberosity. In summary, the iliohypogastric, ilioinguinal, and posterior femoral cutaneous nerve also supply portions of the vulva as depicted here in our illustration. Once again, we see this plexus of nerves retracted in our cadaver specimen with a Kelly clamp, while the clitoral glands is retracted toward the anatomical right by smooth pickups. Although not part of the external genitalia and perineum, the muscles of the inner thigh are important to the gynecologic surgeon, given their proximity to the vasculature and nerves supplying the clitoris. Now to reorient ourselves to the surrounding anatomy, let's first view the clitoral glands and body back at the midline as held in place by smooth pickups here in our cadaver specimen. Next, it will be retracted toward the anatomical left by an Alice clamp in order to view the muscles of the inner right thigh. The cruel area of the clitoris is prominently seen and felt by the adductor longus muscle and its tendon, starting in the left upper portion of our drawing and ending in the superior portion of the midline at the pubic rami. The adductor longus and its tendon, as seen here, extend outward from the pubic ramus and cover the obturator space beneath. The bulbocavernosis muscle is immediately lateral to the outer wall of the vagina. The ischiocavernosis lies along the margin of the pubic ramus. The complexity of the clitoris has now been described. Let us review the key points. The clitoris, which has no glandular structures, is covered by thinly keratinized, stratified squamous epithelium. The loose fibrous sheath encapsulates the corpora cavernosa, or cura, which contain an abundance of nerves. Beneath the ischiocavernosis muscle is the corpus cavernosum clitoris. The two corpora unite at the lowest margin of the symphysis pubis to form the body of the clitoris. Remember that the most distal portion of the clitoral body is the glands, exposed here with smooth pickups, but normally protected by the clitoral hood. The bulb is the highly vascularized area deep to collis fascia, between the glands of the clitoris and the urethra, as retracted here. The clitoral complex is supported superiorly by the suspensory ligament, between the symphysis pubis and the glands and body, seen here. All structures are innervated primarily by the pudendal nerve, and the highly vascularized bulb is located nearby. Thank you for watching!

clitoris

anatomy

pelvic surgeons

sexual satisfaction

gynecology surgery