All right, so I think we'll get started. Welcome to the Augs Urogynecology webinar series. I'm Lauren Stewart, member of the Augs Education Committee and the moderator for today's webinar. Today's webinar is titled, Vulvar and Perineal Anatomy with Clinical Applications, and our speaker is Dr. Marlene Korten. Dr. Korten is professor of OBGYN at the University of Texas Southwestern Medical Center and Parkland Health and Hospital System in Dallas, Texas. She received her MD from UMDNJ Robert Wood Johnson Medical School in 1994. She completed her OBGYN residency at UT Southwestern, followed by a preceptorship in urogynecology and neurodynamics from 1998 to 2001. She obtained a master's in clinical science in 2012. For her entire career, Dr. Korten has focused on furthering the understanding of pelvic anatomy and teaching it to others. She founded and directs the Surgical Anatomy Center and Fresh Cadaver Dissection Course at UT Southwestern. She's organized and directed anatomy courses for both SGS and Augs and has authored many prize winning anatomy papers and videos. Dr. Korten is board certified in FPMRS, was a member of the editorial board of the FPMRS Journal and is an editor of Williams Gynecology. She served as chair of ACOG District 11 and Section 2 from 2012 to 2015. She is an ABOG specialty and female pelvic medicine and reconstructive surgery subspecialty certifying board examiner. She was the division director of the ABOG FPMRS division and is a member of the ABOG Board of Directors. She's also a member of the Maintenance of Certification Qualifying and Certifying Exam Committees for FPMRS. She's a member of the ACGME Review Committee for OBGYN. Dr. Korten is dedicated to promoting excellence in gynecologic surgery through acquisition of knowledge and advancement of research and education. As a reminder, the presentation will run about 45 minutes. The last 15 minutes of the webinar will be dedicated to Q&A. Before we begin, I just want to review a couple of housekeeping items. Augs designates this live activity for a maximum of one category one CME credit. To claim your CME credit, you must log into the Augs e-learning portal and complete the evaluation following the webinar. This webinar is being recorded and live streamed. A recording of the webinar will be made available via the Augs e-learning portal. Please use the Q&A feature to ask any questions of the speaker. We'll address them and answer them during the Q&A section at the end of the presentation. And then you can use the chat feature if you're having any technical issues. Augs staff is monitoring that behind the scenes and can assist you if there's any issues. Dr. Korten, you can begin. Thank you, Lauren, and thanks, everybody, for being here so late. I found over the last 20 years that the vulvar anatomy is one of the most difficult, at least it was one of the most difficult for me to get a grasp of, because unlike other pelvic compartments that you can enter, like the retropubic space, and find things and look at them, with the vulvar anatomy, all you see is the superficial anatomy and nothing deeper than that, unless you get into complications like anal central lacerations or periurethral lacerations during deliveries. So I don't have any financial relationships to disclose, and I thought that the objectives today would focus primarily on the vulvar anatomy, but on the clitoris and the dorsal nerve of the clitoris. I have a video towards the end of the slides that shows a dissection of the superficial space of the perineal triangle and how to trace the dorsal nerve all the way from the point that it enters the perineum until it reaches the glands of the clitoris. If we don't have time today to get to the perineal anatomy and the anal sphincter complex, we can do this another time, but I really think it may be worth going through the anterior perineal triangle in detail and allow you time to ask questions or perhaps share some interesting anecdotes, which we can all learn from. So Lauren, if I miss, if anybody posed a question during the presentation and I miss it, you can please let me know. But at the end of the day, the idea of knowing this anatomy or becoming familiar with it is to be able to integrate it into clinical practice. So if you go back to, these are just a boring drawing, but if you remember from medical school, the perineum is divided into an anterior triangle and a posterior triangle by drawing an arbitrary or imaginary line between the ischial tuberosities, right? Through the anterior triangle, you have the urethra and the vagina, the vaginal opening. So it's also known as the urogenital triangle. And in the posterior triangle, you have the anal opening. So it's also known as the anal triangle. But the female external genitalia or the vulvar structure, structures or the pudenda, whatever you want to call the female external genitalia is all found within the anterior triangle of the perineum. If we focus on the vestibule, which is that area here shaded in pink, we can go over the boundaries of the vestibules. And we all know that laterally the vestibule starts in the inner aspect of the labia minora, specifically what we know as the heart line, which is that area where the epithelium of the labia minora becomes nonkeratinized. So it looks very pink. And laterally, the boundaries, the hymen or the hymenal remnants or cabron poles, right? But anteriorly, the vestibule extends to the frenulum of the clitoris, which is that area where the medial folds of the labia minora contact the undersurface of the glands of the clitoris. And posteriorly, give me just one second to get rid of that, posteriorly, it ends by what we know as the foreshad, which properly is known as the frenulum of the labia minora, where the two labia minora come together posteriorly. In the vestibule, we have a little depression between the hymen and the foreshad, which is known as the vestibular fossa or the fossa navicularis. And you can see the openings of the bartholin glands at five and seven o'clock just outside or distal to the hymen. This is an area that is pretty important for gynecologists or for when they are evaluating patients with pain, with superficial dyspareunia or with pain, because, you know, localized vestibulitis, it's very commonly found here. Sometimes you see that erythema around the openings of the bartholin glands. But again, through the vestibules, you can see here, you have the openings of the urethra and the openings of the vagina. And relative to the urethra, you see the skin gland openings at five and seven o'clock. So if you look closely, when you're doing an exam, especially under anesthesia, you can almost always find the skin gland openings at five and seven o'clock on the distal or the external urethral opening. So some clinical correlations. The vestibule, again, highlighted here, includes that skin gland opening. And you can see in this patient, she has a skin gland abscess and it deviates, very classic, it deviates the urethra to the contralateral side. And you can see the opening on the right-sided picture, the opening on the right, pretty distinct, just outside of the external urethral opening. Another clinical application, it's the bartholin gland opening, and this is a left bartholin gland abscess. And you can see in this patient who has darker skin, more pigment, you can see that heart line very well demarcated right on the left. And then you can see that swelling on the vulva that sometimes can extend anteriorly and posteriorly. But the application or the importance of the heart line, I think, one of the most important, which I wasn't aware of when I was a resident, is that, you know, the recommendations are to make your incision for the incision and drainage within or inside of the heart line for several reasons. But one is aesthetics, right? You don't want to make a big incision where, you know, the patients may see a scar or have some pain on the vulva. And the other one is that that's the natural opening of the duct for the gland. It's within the heart line. So again, you know, if you have a, especially if you make a pretty big incision for marsupialization or for a gland excision, you want the patients not to see, to have a scar tissue or a scar in that area that's pigmented. So going back to the anterior triangle of the perineum, it's really, really interesting. I mean, it has three pouches or compartments or spaces, again, going back to medical school, right? The subcutaneous pouch is basically just the subcutaneous tissue, the fatty layer of the subcutaneous tissue in the abdomen is called campers. In the perineum, we also call it campers fascia, right? But it's really just the fatty layer of the subcutaneous tissue. And it's continuous with the thighs, continuous with the abdomen and with a posterior perineal triangle. So not that interesting. The deep space of that anterior triangle is mostly a continuation of the ischioanal fossa fat that extends deep to the perineal membrane. So again, it's continuous, that fatty tissue is continuous from posterior to anterior. And we'll see a little bit of that later. The superficial space of the anterior triangle is where most of the important structures in the vulva are located. And many consider this space an enclosed compartment. And that explains the findings here. I mean, if somebody asked you to describe these three patients with vulvar hematomas, it's pretty easy to see that they're unilateral. They're located on only one side of the vulva. They're not, you know, the hematoma is not spreading to the thigh and it doesn't seem to be spreading posteriorly or even anteriorly. Again, this suggests that this bleeding is happening from something that bled within the superficial space. Because if it was just from the subcutaneous tissue, like the campers fascia, it would be going everywhere because the fatty tissue is continuous anteriorly, posteriorly, and to the thigh too. So what are the boundaries then of the superficial space that make it an enclosed compartment? So if you remove the fatty layer, you have the membranous layer of the subcutaneous tissue. And in the perineum, we call it collis fascia, right? That's the old name or, you know, the proper name is the membranous layer, but we really know it as collis fascia. And then superiorly, the superficial space is bound by the perineal membrane. Now both collis and the perineal membrane are firmly attached to the ischiopubic brain laterally, and medially, they both attach to the urethra and the vagina. Posteriorly, they attach to each other over that muscle, what we know as the superficial transverse perineal. So most people, again, consider this space an enclosed compartment with a caveat. And that is that collis fascia is continuous with scarpus fascia in the abdomen, right? Again, it's all the membranous or the deeper layer of the subcutaneous tissue. So potentially, you can have spread of infection and blood to the anterior abdominal wall. So within that superficial space, the contents include the superficial perineal muscles, the vulvospongiosus medially, BS, the ischiocavernosus laterally, and the transverse perineal posteriorly. Now I say transverse perineal instead of superficial transverse perineal because women don't have a deep transverse perineal muscle. So in essence, you know, saying superficial is misleading because we don't have a deep transverse perineal muscle. So also in that compartment, you have the body and the cross of the clitoris, which is all kind of shaded in purple or blue here. And you also have the vestibular bulbs medially and bartholin gland. So all that, all those important structures are located within the superficial space of the anterior triangle. And of course, you have the nerves and the vessels that supply all the structures in the vulva and including the superficial space. And again, we all know that the pudendal nerve is the, and the pudendal vessels are the ones that supply the perineum. And specifically the perineal nerve and the dorsal nerve of the clitoris are the branches that go to the anterior compartment primarily. So this photo was the one on the right, remember the one on the right? This is a patient that presented to the emergency room after having vaginal intercourse with this hematoma that spread to the abdomen. So if you had to, you know, kind of imagine what's bleeding, it has to be something within the superficial space because it doesn't seem to be going to the other side, to the thigh, but it's spreading to the abdomen. And this is explained by the boundaries and the contents of the superficial space. So a little bit about the structures in actual cadaver, with actual cadaver dissections. This was an embalmed cadaver, and you can see a little bit of the muscles. I mean, it's difficult to see because everything looks kind of the same color. But on the left, you have the little bit of the vulva spongiosus and the instrument is pointing at it. In the middle, you have the ischial cavernosus, and on the right side, you can see the transverse perineal muscle, which actually is almost impossible to find in a cadaver dissection most of the time, but you can see it, you can see some fibers there pretty well. And remember, the vulva spongiosus medially, and then this transverse perineal contribute to the perineal body. Now, in this cadaver dissection, this was a fresh cadaver, unembalmed cadaver, and on the left side, you can see the erectile structures. They look very purple, right? And this is after removing the superficial muscles. So if you remove the vulva spongiosus, you're going to see the bulbs of the vestibules or the vestibular bulbs, just lateral to the base of the labia minora. And then just attached to the ischial pubic brain, as you see the cross of the clitoris in this case on the left. And you see also the super, the perineal membrane, and you see how attached or how firmly attached to the perineal membrane, the bulbs of the vestibular and the cross of the, the cross of the clitoris, very much associated with the inner surface of the ischial pubic ramus. So in that space, again, I mean, the remaining of the clitoral body, you don't see here because it's covered by the prebius of the clitoris, and labeled here is the glands of the clitoris, which is the only part of that structure that we see on external exam, right? Because the cross of the clitoris and the body are covered by muscle and by skin and subcutaneous tissue, and the body, it's covered by the prebius of the clitoris. Any questions so far about that, the superficial space and the contents? All right. So if we remove that prebius, that skin and subcutaneous tissue that you see in the midline at the top there, then we can, we can see the body of the clitoris, right? And take a look at it. I mean, it's formed from by the junction of the two crura. And if you look at the pubic symphysis, it's, it's forms about the mid, in the midsection of the, the pubic symphysis. Something else that kind of eluded me for years, I thought this, the body would start a lot lower, closer to the arch of the pubic, the pubic bones, but it actually starts pretty consistently about halfway between the top of the pubic symphysis and the bottom part of the pubic symphysis. And if we kind of transect that body, then kind of in the midline, you can see the two corpora cavernosa or the corpora cavernosa on each side, separated by the septum, by septum, like the septum of the corpora cavernosa. This anatomy is very similar to the penile anatomy, except that a lot smaller. And also we don't have a urethra going below the corpora cavernosa with spongy tissue associated with it. I don't know if you can see the pointer, but the urethra is several centimeters below the corpora cavernosa. And associated with it, you have the vestibular bulbs. And we can see, we'll see that a little later, but that's the difference between a cross-section of the clitoral body and a cross-section of the penile anatomy. So again, you can kind of see it in this photo, but you have the corpora cavernosa completely surrounded by a very dense connective tissue sheath. It's very thin, but very dense. That's called the tunica albugenia. And again, this is similar to the male anatomy. And then right on top, you can see the dorsal nerves and vessels of the clitoris. I mean, you can barely see them, but that's where they are located at approximately one o'clock on the left and 11 o'clock on the right. And again, we'll see that and you'll see it on the video, but very important from a clinical perspective, because if you damage the nerves, this nerves, you can have issues with sensation, decrease or impair sensation to the glands of the clitoris and the prepuce. So this is the dorsal, kind of a picture of the path of the dorsal nerve of the clitoris once it enters the perineal compartment. And it's labeled as a DNC here, but you can see how it perforates the perineal membrane pretty close, in pretty close proximity to the ischopubic ramus. And then it courses between the ramus and the cross of the clitoris, and it perforates the suspensory ligaments of the clitoris. And the deeper portion of that suspensory ligament is labeled here as the FLC. That's the fundiform ligaments, kind of the deeper part of the suspensory ligaments, or the connective tissue that supports the clitoral body and the remaining of the, and the glands of the clitoris as well. Now, if you follow the course of the nerve, you can see how it kind of courses really in really close proximity to the body of the clitoris. This is the one on the left. So it's coursing at 11 o'clock or 10 to 11 o'clock position to eventually penetrate the glands, which it supplies along. And you can see branches that go deep to the connective tissue. Those branches will supply the skin of the prepuce. And that's the whole sole purpose of the dorsal nerve of the clitoris. It's a branch of the pudendal nerve, which is a somatic nerve, and it supplies skin and non-vascular structure. So the glands of the clitoris doesn't consist of significant amounts of erectile tissue. It's mostly connective tissue and nerves that come from the dorsal nerve of the clitoris. And then it supplies the skin of the prepuce. And if you cut the suspensory ligament, this is a photo of the clitoral body pushed down after transecting the suspensory ligament. You can see the two dorsal nerves of the clitoris going at 11 o'clock on the right and one o'clock on the left. They are of significant size, anywhere between two and four millimeters in diameter. So pretty easy to see once you know where they are. But what about the erectile tissue of the clitoris, the corpora cavernosa, the corpus cavernosum, that it's the erectile tissue that forms the crura and the body of the clitoris? What is that supplied by? So that's supplied by the cavernous... They call the cavernous nerves. They're branches of the inferior hypogastric plexus. And remember, the inferior hypogastric plexus is a mixed plexus of parasympathetics and sympathetics. That course, the uterovaginal plexus is the plexus that goes to the uterus and the vagina, as the name implies. But there are branches that course through the paravaginal tissue and they pass under the pubic bone to supply the erectile structures of the perineum. And that is the corpora cavernosa. And as we will see later, the vestibular bulbs. So those branches, those distal branches that pass under the pubic bone to supply that tissue, they're called the cavernous nerves. So a lot of people, I mean, in the past 15 years since all this midurethral sling procedure started, specifically the retropubic ones, a lot of people have told me about anecdotes about women with sexual dysfunction after a sling or difficulty initiating voiding after a sling or having to stimulate the clitoris to initiate voiding. Things that, you know, I didn't have, nobody I think has an answer to it, but a common question is, can you injure the dorsal nerve of the clitoris with a regular sling? And the answer is no. If the sling was passed as is recommended, you know, if you pass a sling retropubically and not prepubically, and I've seen it happen that somebody's passed the sling kind of distal to the pubic bone and it's gone through the subcutaneous tissue in the labia. And in those cases you could, I guess, injure the dorsal nerve of the clitoris. But if it's passed as recommended, the entire path of the sling is proximal or above the perineal membrane. And as you can see both on the left and the right photos, the dorsal nerve is located pretty laterally and also distal to the perineal membrane. So it would be very difficult, if not impossible, to damage the dorsal nerve of the clitoris with sling, whether it's a retropubic midurethral sling or a pupal vaginal sling, it would be very, very difficult, if not impossible. But what about somebody who presents with erectile dysfunction or, you know, difficulty, you know, prolonged time to achieve an orgasm or any type of difficulty with orgasmic function? If you just think about what we just talked about, the cavernous nerve from the inferior hypogastric plexus that course through the paravaginal tissue, that can provide perhaps an answer to that. So this is a photo of the retropubic space with a urethra in the middle, and then the sling on the right side of the patient going through the paravaginal, periurethral tissue. So that's exactly where the uterovaginal plexus fibers or the fibers that eventually form the cavernous nerves are located. So the bigger the needle or the bigger the hole that you open, let's say that you're doing a pupal vaginal sling and you have to place the whole finger through that tissue into the retropubic space, the greater the chances of disrupting fibers that eventually will supply the erectile tissue or the corpora cavernosa of the clitoris. So again, any questions about the path or the innervation to the clitoris? If not, I'll keep going and we can talk about it a little bit after the video. Clinical applications, when we do this bartholin gland excisions that nowadays we don't do a lot anymore because we have MRIs and we can assess whether this recurrent bartholin glands or masses have any chances of being malignant. So I think we are being less aggressive about bartholin gland excisions. And if any of you has done one, you can get into a lot of bleeding, especially when you get into the base of the gland. And as you can see here, that big blue in the middle, lateral to the labia is the vestibular bulb. And you can see that the bartholin gland is partially overlapped by that vestibular bulb. So getting deep in there can get you into a lot of bleeding because the vestibular bulb consists of erectile tissue, but the erectile tissue is basically vascular channels, lacuna filled with blood and surrounded by connective tissue septa. But you can also see some pretty big veins there, right? Just superficial to the perineal membrane. And those are internal pudendal nerve, internal pudendal branches, right? That drain eventually into the retrophobic space and eventually into the intraheliac vein. So the bleeding can be from the vestibular bulb injury, or it can be from injury in the venous, the multiple veins found in the space too. So if anybody asks you, which of the following was most likely enter if significant bleeding was encountered during a bartholin gland excision of these branches, what would you say? I know I can't see you guys, but we just talked about it. The vestibular bulb. Somebody, I mean, if the choice on A was the internal pudendal, then this would be a bad question because both could be possibility, right? Possibilities that you injure either the vestibular bulb or the internal pudendal vessels. But the external pudendals are by the mons of the pubis, right? Branches of the femoral vessel. So not a possibility or not a likely possibility in this case. So, and you can see, I mean, I'll just leave you those photos there because it's very difficult to find a bartholin gland during this dissections. But in this two cadavers, you can kind of see them partially, you know, overlapped by the vestibular bulbs. I always kind of, they always taught me when I was a resident to use a hemostat to break loculations when I was doing a bartholin gland abscess care. And, you know, I don't think that's a great idea. I mean, we see at least one or two cases of like vestibular anal fistulas because people get too aggressive with the loculations posteriorly. And you can get into a lot of bleeding too if you get deep into the vestibular bulbs or the vessels there. So I think it's probably best to do it, if you do it with a hemostat, be very gentle, but maybe using a Q-tip or something more blunt than a hemostat. And just another kind of clinical question from before we move on, but bleeding from the vestibular bulb most likely spread to which of the following spaces or compartment? Again, this is the vestibular bulb distal to the perineal membrane within the superficial space. Remember kind of an enclosed space, except that it goes to the anterior abdominal wall too because of the continuity of colis with the scarpus fascia of the anterior abdominal wall. So that kind of pretty much takes care of the non-clitoral clinical applications. And then we'll go over some clitoral and vestibular bulb clinical applications. And these are patients that some of you have shared with me and some are my own patients. This was a patient who was born with congenital adrenal hyperplasia and she had had the clitoral body resected twice because it was too long and then had a very redundant, I'll just show you the picture, a very redundant prep use and it bothered her a lot. So we did a prep use reduction for her and in doing so we excise a significant amount of that skin that covers the clitoral body. If you remember from the photos before, you can definitely damage the nerves that pass right over the clitoral body. If you go too deep with that dissection. Another clinical application, this was a courtesy photo from Dr. Handa. It's a pretty big periclitoral mass. And again, the question is, what's the best way to approach this so that we don't get into either the dorsal nerve or the cavernous nerve to the clitoris. This was somebody I saw a few weeks ago with the mass that was arising from the actual glands. So what kind of trouble can you get into when you resect these masses? And again, think back to the path of that dorsal nerve between the ischiopubic ramus and the cross of the clitoris and then specifically on the right, that's where the nerve is most superficial and it courses between the clitoral body and the deepest part of the subcutaneous tissue, which is known as the clitoral fascia. So if somebody asks you between what two layers does the dorsal nerve of the clitoris course, it would be between the tunica albugenia, which surrounds the actual corpora cavernosa and then the clitoral fascia, which is kind of the deepest layer of that fundiform ligament or the subcutaneous tissue of the prepuce. So this little video, it doesn't have audio, but I can kind of say a few things when it's running. It's about five minutes and it was a dissection on an unembalmed cadaver. I found, I think it's useful if you ever have the opportunity to do, I mean, I know you attend cadaver dissections once in a while. You may want to ask, can I do a clitoral dissection and try to find the dorsal nerve and kind of trace it all the way. It's very useful because if you ever have to do one of these procedures, these mass excisions or clitoral hood excisions or reductions, you get an idea of how deep that nerve or how superficial, depending on how you look at it, that nerve is and how to best avoid it. So this patient, I think, was in her 40s and we're going to dissect the left side of the vulva, starting with. So we just see the labia minora. And the lateral folds of the labia minora form what we know as the hood of the clitoris. Then the medial folds attached to the glands at the frenulum. So you just make the incisions through the skin at 11 o'clock or one o'clock over the prepuce, just lateral to the labia minora. And you get into the superficial space or basically your subcutaneous tissue. If you're doing a labial fat pad, for example, this is kind of the tissue that you are harvesting, right? Always very useful to put analysis on the hymen because it puts the perineal membrane under tension. You can also excise the labia minora. And then you see kind of the deeper, the more membranous layer of the subcutaneous tissue. And you see kind of the connective tissue or the fascia that covers the cross. And that's the cross being held. You see how purple it looks. And you really have to separate it from the ischiopubic ramus and stay close to the ischiopubic ramus, the medial aspect of it. And eventually you'll find the nerve, which is pretty protected in connective tissue, but you see how deep it is in this area, right? And then it seems to be going deep, but it's actually going into the, fundiform ligament, which is the deeper part of the suspensory ligaments of the uterus. That's the suspensory. And then that deeper part is called the fundiform ligament. And you see how it's going deep to that fundiform ligament. That's what we call the outer elbow of the clitoral body. And then the nerve does get smaller or thinner as you go distally, because it gives branches to the prepuce. But really close to the body, right? So it depends on how much subcutaneous tissue you have on that prepuce. The nerve may be pretty close to the skin. This lady had a pretty healthy amount of subcutaneous tissue or pretty well-formed suspensory ligaments. So that's about the one o'clock position and that's the nerve on the left. So the one o'clock position, it's pretty consistent in all the dissections that we have done. It's a very consistent path. So eventually it just dives into the glands and that's, again, all it does. Supply the glands and you see the branches by the elbow that go to the prepuce. And again, if you kind of pull on the hymen, you can see the peroneal membrane really well, the vestibular bulbs. And then the right side, you can see the peroneal membrane the vestibular bulbs, the peroneal membrane. And deep to the peroneal membrane, that's the deep space of a triangle and continues with a ischial anal fossa posteriorly. And then vestibular bulb, that's the cross. And then you can see the suspensory ligament. And I don't know if you can appreciate almost the boomerang shape of that between the cross and the clitoral body has about 90 degree turn. The vestibule looks like it's pretty close, right? To the body. And it is. That's the suspensory ligament again. If we cut it, right adjacent to the pubic bone, then eventually you find this gap in the peroneal membrane just below the pubic symphysis. Then eventually you see the nerves in the middle are the cavernous nerves. And then cutting the labia allows you to see the proximity of the vestibular bulbs to the urethra. Also allows you to see that the vestibular bulbs and the crura are separate structures, even though they are adjacent to each other. And when you push on that erectile tissue, those lacuna filled with blood, you can see how the blood comes out. So the vestibular bulbs consist of more spongy tissue, similar to the tissue that surrounds the spongy urethra in males. And the erectile tissue and the clitoris is actually known as a corpus cavernosum. It's the lacuna are a little bit more dense, but also engorged with blood. So that's the end of the video. And if you guys have any questions, I think, or any stories that you wanna tell me, I would appreciate it. I think we probably don't have time to go through the posterior peroneal triangle and anal sphincter complex today, but we can do that at a different time. Any questions so far about the anatomy on the anterior triangle? Any stories you wanna share? I actually had a quick question about the superficial peroneal space and the Bartholin glands. It seemed like in one of the pictures that you showed, the Bartholin's gland is completely enclosed within that superficial peroneal space, but then there must be some connection with the labia minora as well, just based on those vulvar hematoma pictures. Like I've seen a few patients with Bartholin gland cysts that seem to extend into the labia minora anteriorly as well. Are those just not Bartholin gland cysts or is that anatomically possible? I think it is, right? Because the Bartholin gland, it's really interesting. The Bartholin gland itself, let me see if we can, well, the pictures are pretty far, but maybe you can kind of see. Do you see my arrow pointing at it? Yes, yeah. Yeah, it's kind of in this area right here in the superficial space, the gland, right? But then the duct takes that gland, it connects the gland to the vestibule. In this case, it would be like the five o'clock position. So the gland abscess or cyst can definitely expand the duct too, or go through the path of the duct into the more superficial areas, like the labia minora and eventually the vestibule. Some of them extend really anteriorly, some of them extend somewhat posteriorly, this abscesses or cyst. And like I said, at least once a year, I see a patient with a fistula between kind of the vestibular area and the anus, which are very kind of difficult to treat because sometimes they go through the anal central muscle. I saw a poor, like, I think she was 32, had just gotten married, no babies, and had a cloacal type defect, like a chronic fourth degree laceration. Colorectal had already done two procedures, including an advancement lab, and it was a mess. And they were planning to do like a gracilis muscle interposition, kind of do an anal sphincter, try to recreate an extra anal sphincter muscle with a gracilis muscle, a superficial sphincter. So, I mean, we reconstructed the perineal muscle, but of course she had no anal sphincter left anteriorly, and eventually we did a interstitium on her. And so far she's continent, but you know she's going to have problems in the future. And that all started with a bartholing gland that was probably treated too aggressively, or one that extended pretty deep into the posteriorly, and it got into the anus. The abscess broke into the anal wall. Yeah, I remember we had a patient like that when I was a resident who, it turns out the etiology of her, it wasn't really a bartholin gland abscess. It was a perianal abscess from undiagnosed inflammatory bowel disease. So that's sort of what I always think of when I hear about those fistula, but I suppose that can happen from too aggressive of treatment of the bartholin cyst as well. Just scary. There's another question in the chat about the clitoral prep use reduction. And the question is, could you please describe your technique and do you favor reduction or resection of the lateral redundant tissue to minimize resection of dorsal tissue? Yes, very important, right? So I don't like, I don't advertise for labial reductions or clitoral hood reductions in general. It has to be, you know, how it is, right? The patients come in, they already have thought about it for years. They usually have seen multiple gynecologists that don't feel comfortable. We're talking about just labial minora reduction here. But as you know, a lot of women with asymmetric labia minora also have redundant prep use on one side. And I think a lot of people say, why not remove some of that prep use, right? So that it doesn't, after we remove or do a labial reduction, the prep use doesn't look overwhelmingly large compared to the other side. So something like this, like this lady had a mass right there on the lateral aspect of the prep use, but yeah, if you had to do something like that, I would maybe take a wedge as lateral as possible so that you are avoiding that area between one o'clock and, the two o'clock and 10 o'clock, I would say, you know, if you stay more lateral than that, there are not a lot of, I mean, you're not gonna get through the main nerve if you get into anything, would be branches of it, right? That go to the prep use, but the nerves are consistently found at like between a two o'clock and a 10 o'clock going over the whole body. But also, you know, keeping in mind how deep or the location of the path of the nerve along the prep use. Like this lady, the only reason we did this kind of incision like this is because we had to excise, you know, a lot of prep use skin. So just taking it laterally wouldn't have worked. And this is just because of the underlying issues that she had. She had a clitoral megaly and a GYN oncologist had resected, in the operative report, it said one centimeter of the clitoral body. Then somebody else did another, you know, resection of the clitoral body, so they removed more. She had a very long clitoral body, looked like a mini phallus. And if you think about it, then you would have all that excess prep use that was covering the original clitoral body. And she wanted removed. Actually, this recurred. I just, a few months ago, we did another reduction and we removed the tip of the gland that was completely disconnected from the clitoral body, pretty close to the pubic bone, based on the MRI and the exam. I mean, they had left a little piece of gland, but it was completely disconnected from the body. And then she had recurrence of this excess skin. I don't know why. But this is something that I don't advocate doing. This is a very delicate area, but if you are gonna do it, if, you know, the more lateral you stay here, and also it helps if you stay pretty laterally, because you're not gonna see, they're not gonna see any scar tissue. If you go between the prep use and the labia majora, I don't know if you can see the pointer, but you go into that interlabial fold, or in this case, the fold between the prep use and the labia majora, and you're less likely to see a scar tissue or any issues if you stay pretty laterally. And then don't go deep. The only, I mean, the main problems, I think, the only reason you would have to go very deep with this clitoral hood resections would be if you encounter bleeding, and then you put some deep sutures, potentially you can entrap the nerve. But as long as you just take the skin and maybe a little bit of the more superficial subcutaneous tissue, you shouldn't be too close to the nerve. The other times that I've seen some avulsions or fractures of the clitoral nerve is in, and Loren and I were talking about open fractures of the pelvis in motor vehicle accidents. So the patients usually present with, like if somebody told you, I don't have sensation over the glands and the prep use, you know, it feels like I don't have the same, I don't feel anything. On the prep use, then you think that's probably, you know, the dorsal nerve. Of course, you would have to injure it on both sides to have complete absence of sensation. If you think about it, and that would be difficult to do. But with somebody like this, where we did it over, you know, the incision went all the way over the prep use. If you, you know, if we got into bleeding and we got a bunch of deep sutures, or we were too aggressive with the dissection or the excision of subcutaneous tissue, you can potentially get both of them. So, yeah. Wow. We have a few more questions in the chat that maybe we can get to. Dr. Fenner is asking if you think that there's nerve supply to parts of the clitoris from the ilioinguinal and genital femoral nerves? Wow, that's a, who was that? Dr. Fenner. Dr. Fenner, of course. Yeah, very smart question. And you can kind of see it there. I don't know if you have any, if those branches extend to the glands, but they definitely, definitely supply the proximal part of the prep use. That's a great question. I mean, people don't even think about it. Can you see my arrow here pointing? Yes. So these little nerves that are going this way, they are branches. They could be the inguinal branches of the ilioinguinal nerve that go to the mons and the upper part of the labia majora and probably the prep use too. Or they could be also branches from the genital branch of the genital femoral nerve, right? That goes through the inguinal canal. And then you have that genital branch supply part of the labia majora, the upper part of the labia majora and most likely the prep use too. Cause I don't know, let me see if I can show some pictures, but that prep use is pretty close to the mons and those nerves supplied or all that area. So definitely, yeah, that's a great question. The genital branch of the genital femoral, which comes from the lumbar plexus like L1, L2 or the inguinal branch of the ilioinguinal, which it's like, I don't know what is it, T12, L1, right? Also part of the lumbar plexus, but that's a great question. And if they ask you that on an exam, it's a fair question. And then the rest of the labia majora skin and parts of the labia minora or most of it is supplied by the posterior labial branches of the perineal nerve. It's a little confusing, but the perineal nerve is the largest branch of the pudendal and it supplies most of the labia majora skin and most of the labia minora epithelium, right? Or the skin. And they're called the posterior labial branches. And then the branches that come from anteriorly, they're called the anterior labial branches. They come exactly from those two nerves that we just talked about, the ilioinguinal and maybe the genital femoral. It's a great question. That's great. Thank you so much. I think we probably should wrap up now. We have just about two minutes left. On behalf of AUGS, I'd like to thank Dr. Korten today for this amazing webinar. Be sure to register for our upcoming webinars in collaboration with ALAPP. We're presenting a Spanish speaking webinar on September 27th, discussing the different procedures used in different parts of Latin America. And on October 18th, we have Dr. Garter who will be presenting a talk titled combined rectopexy and sacrocopopexy for multi-compartment pelvic floor prolapse, better outcomes question mark. Follow AUGS on Twitter and Instagram or check our website for information on all upcoming webinars. Thank you all for joining and have a great evening. Thank you very much. Thank you so much, Dr. Korten.

vulvar anatomy

perineal anatomy

clinical applications

superficial space

anterior triangle

clitoris

innervation

bartholin gland excisions

cadaver dissections