The vulva (pl.: vulvas or vulvae) consists of the external female genitalia.
The vulva includes the mons pubis, labia majora, labia minora, clitoris, vulval vestibule, urinary meatus, vaginal opening, hymen, and Bartholin’s and Skene’s vestibular glands.
It includes the entrance to the vagina, which leads to the uterus, and provides a double layer of protection for this by the folds of the outer and inner labia.
Pelvic floor muscles, and other muscles of the urogenital triangle support the structures of the vulva.
Blood supply to the vulva comes from the three pudendal arteries.
The internal pudendal veins drain the vulva.
Afferent lymph vessels carry lymph away from the vulva to the inguinal lymph nodes.
The nerves that supply the vulva are the pudendal nerve, perineal nerve, ilioinguinal nerve and their branches.
Blood and nerve supply to the vulva contribute to sexual arousal that are helpful in the reproduction process.
Changes to the vulva take place at birth, childhood, puberty, menopause and post-menopause.
The vulva can be affected by many disorders, often resulting in irritation.
Disorders of the vulva include a number of infections and cancers.
There are several vulval restorative surgeries of the vulva, known as genitoplasties, and some of these are also used as cosmetic surgery procedures.
The vulva is made up of the following:
Mons pubis The mons pubis is the soft mound of fatty tissue at the front of the vulva, in the pubic region covering the pubic bone.
The “pubic mound” and is present in both sexes and acts as a cushion during sexual intercourse.
The mons pubis is more pronounced in the female.
Labia
The labia majora and the labia minora cover the vulval vestibule.
The outer pair of folds are the labia majora.
The labia majora contain and protect the other structures of the vulva.
The labia majora meet at the front of the mons pubis, and posteriorly at the urogenital triangle which is the anterior part of the perineum, between the pudendal cleft and the anus.
The labia minora are the two inner soft folds within the labia majora.
The labia minora are often pink or brownish black, related to the person’s skin color.
The grooves separating the labia majora and labia minora are called the interlabial sulci (folds).
The labia minora have more color than the labia majora and contain numerous sebaceous glands.
The labia minora meet again at the front to form the clitoral hood.[11]
The clitoris is located at the anterior junction of the inner labia is the highly erogenous sexual organ.
The visible portion of the clitoris is the glans, roughly the size and shape of a pea, and can vary in size from about 6 mm to 25 mm.
Its size can also vary when the clitoris is erect, when two regions of erectile tissue known as the corpora cavernosa fill with blood, engorging the shaft.
The clitoral glans contains many nerve endings, making it highly sensitive.
The only known function of the clitoris is to focus on sexual feelings.
The clitoral hood is a protective fold of skin, which varies in shape and size, and it may partially or completely cover the shaft and glans.
The hood may be partially or completely hidden within the pudendal cleft.
The area between the labia minora where the vaginal opening and the urinary meatus are located is called the vulval vestibule.
The meatus is below the clitoris and just in front of the vaginal opening, which is near to the perineum.
The term introitus term is more technically correct than opening, since the vagina is usually collapsed, with the opening closed.
The introitus is sometimes partly covered by a membrane called the hymen, and it usually rupture during the first episode of vigorous sex, and the blood produced by this rupture has been seen to signify virginity.
The hymen may also rupture spontaneously during exercise or be stretched by normal activities such as the use of tampons and menstrual cups, or be so minor as to be unnoticeable, or be absent.
The hymen may completely cover the vaginal opening, requiring a surgical procedure called a hymenotomy.
On either side of the back part of the vaginal opening are the two greater vestibular glands, the Bartholin’s glands.
Bartholin’s glands secrete a mucous vaginal lubricant.
The lesser vestibular glands, known as Skene’s glands, are found on the anterior wall of the vagina.
Pelvic floor muscles help to support the vulvar structures.
The voluntary, pubococcygeus muscle, part of the levator ani muscle partially constricts the vaginal opening.
Other muscles of the urogenital triangle support the vulvar area and they include the transverse perineal muscles, the bulbospongiosus, and the ischiocavernosus muscles.
The bulbospongiosus muscle decreases the vaginal opening, and play a role in the vaginal contractions of orgasm by causing the vestibular bulbs to contract.
The vulva is highly vascularized and blood supply is provided by the three pudendal arteries.
Venous return is via the external and internal pudendal veins.
The tissues of the vulva are drained by superficial inguinal lymph nodes located along the blood vessels.
The vulva is innervated by the ilioinguinal nerve which originates from the first lumbar nerve and gives branches that include the anterior labial nerves, which supply the skin of the mons pubis and the labia majora.
The perineal nerve is one of the terminal branches of the pudendal nerve and this branches into the posterior labial nerves to supply the labia: the pudendal nerve branches include the dorsal nerve, which gives sensation to the clitoris.
The clitoris is populated by a large number of small nerves, a number that decreases as the tissue changes towards the urethra.
The density of nerves at the clitoral glans indicates it is the center of heightened sensation.
Nerves from the uterovaginal plexus supply the erectile tissue of the clitoris, and are joined underneath the pubic arch by the dorsal nerve of the clitoris.
The length of the labia minora varies significantly between women: while the labia majora completely enclose the labia minora in some women, in other women, they protrude and are clearly visible in an upright standing position.
There is a variation in the appearance of the vulva, lying in the significant differences in the size, shape, and color of the labia minora.
Other variations of the vulva include the appearance of Fordyce spots and clitoral phimosis.
The newborn’s vulva may be swollen or enlarged as a result of having been exposed, via the placenta, to her mother’s increased levels of hormones.
The newborn labia majora are closed.
These newborn vulva changes disappear over the first few months.
During childhood before puberty, the lack of estrogen can cause the labia to join firmly together.
This condition, labial fusion, and is rarely found after puberty when estrogen production has increased.
Puberty produces structural changes of the vulva becoming proportionately larger and more pronounced.
Pubarche, refers to the first appearance of pubic hair.
It develops, 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 a secondary sex characteristic.
Premature pubarche may sometimes indicate a later metabolic-endocrine disorder seen at adolescence.
This polyendocrine disorder is marked by elevated levels of androgen, insulin, and lipids, and may originate in the fetus.
Apocrine sweat glands secrete sweat into the pubic hair follicles, which can be broken down by bacteria on the skin and produces an odor: this is considered to act as an attractant sex pheromone.
The labia minora may grow more prominent and undergo changes in color at puberty.
At puberty, the first monthly period known as menarche marks the onset of menstruation.
In prepubertal girls, the vulva skin is thin, delicate, and is prone to irritation.
The production of the female sex hormone estradiol at puberty, causes the perineal skin to thicken by keratinizing, and reduces the risk of infection.
Estrogen also causes the laying down of fat in the development of the secondary sex characteristics, contributing 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.
In pregnancy, the vulva and vagina take on a bluish coloring due to venous congestion, which appears between the eighth and twelfth week and continues to darken as the pregnancy continues.
Estrogen is produced in large quantities during pregnancy and this causes the vulva to become enlarged as the vagina.
After childbirth, a vaginal discharge known as lochia is produced and continues for about ten days.
During menopause, hormone levels decrease, which causes changes in the vulva known as vulvovaginal atrophy: affecting the mons, the labia, and the vaginal opening and can cause pale, itchy, and sore skin.
During menopause 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 the genitourinary syndrome of menopause as a more comprehensive term.
The vulva provides entry to, and protection for the uterus.
It provides warmth and moisture that aids in its sexual and reproductive functions.
The vulva is heavily innervated and provides pleasure when properly stimulated.
The mons pubis provides cushioning against the pubic bone during intercourse.
Secretions are associated with the vulva, including urine from the urethral opening, sweat from the apocrine glands, menses (leaving from the vagina via the introitus, sebum from the sebaceous glands. alkaline fluid from the Bartholin’s glands, mucus from the Skene’s glands, vaginal lubrication from the vaginal wall and smegma.
Smegma is a white substance formed from a combination of dead cells, skin oils, moisture and naturally occurring bacteria, that forms in the genitalia.
In females, this thickened secretion collects around the clitoris and labial folds.
Female smegma can cause discomfort during sexual activity as it can cause the clitoral glans to stick to the hood, and is easily removed by bathing.
Aliphatic acids (copulins) are also secreted in the vagina, and are believed to act as pheromones.
Their fatty acid composition, and consequently their odor changes in relation to the stages of the menstrual cycle.
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 most erogenous areas of the vulva.
The labia majora are also somewhat erogenous.
Local stimulation can 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.
Sexual stimulation can result in widespread sexual arousal and, if maintained, can result in orgasm.
Stimulation to vulvar orgasm is optimally achieved by a massaging sensation: oral sex (cunnilingus), fingering, and tribadism, two women rubbing vulvas together.
Sexual arousal results in a number of physical changes in the vulva.
During arousal, the Bartholin’s glands produce more vaginal lubrication.
Vulval tissue is highly vascularized, and its arterioles dilate in response to sexual arousal and the smaller veins compress after arousal, so that the clitoris and labia minora increase in size.
Increased vasocongestion in the vagina causes it to swell, decreasing the size of the vaginal opening by about 30%.
Clitoral erection takes place with sexual,arousal which retracts the clitoral hood, causing the glans to appear.
The labia majora swell from blood flow, and slightly separated, revealing a thick and engorged labia minora.
The labia minora sometimes change considerably in color with arousal 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, there are rhythmic muscle contractions that occur in the outer third of the vagina, as well as the uterus and anus.
These contractions become less intense and more randomly spaced as the orgasm continues.
The number of contractions that accompany an orgasm vary with its intensity.
An orgasm may be accompanied by female ejaculation, which is caused by liquid from the Skene’s glands to be expelled through the urethra.
After orgasm the vagina and its opening return to their normal relaxed state, vascularization diminishes, and the rest of the vulva returns to its normal size, position and color.
Distance between vagina and clitoral glans The distance between the frenulum at the clitoral glans from the urinary meatus located above the vaginal opening is called the clitoral-urinary meatus distance or CUMD.
In 69% of the women studied, 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.
The anatomical causal connection between a large CUMD and vaginal frigidity explains 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.
Researchers and confirmed an inverse correlation between CUMD and orgasm through intercourse.
The sexual arousal of the woman during vaginal intercourse is to be ensured by the woman independently stimulating her clitoris continuously with her hands or possibly with a vibrator.
Irritation and itching of the vulva is called pruritus vulvae, can be a symptom of many disorders.
The most common cause of irritation is thrush, a fungal infection.
Infections of the vagina such as vaginosis and of the uterus may produce vaginal discharge, which can be an irritant when it comes into contact with the vulvar tissue.
Inflammation as vaginitis, vulvovaginitis and vulvitis can result from this causing irritation and pain.
Ingrown hairs resulting from pubic hair shaving can cause folliculitis where the hair follicle becomes infected, and give rise to an inflammatory response known as pseudofolliculitis pubis.
A less common cause of irritation is
Genital lichen planus an inflammatory disorder and a variant of the vulvovaginal-gingival syndrome, can lead to narrowing of the vagina, or vulva destruction.
Vulvar organs and tissues can become affected by different infectious agents such as bacteria and viruses, or infested by parasites such as lice and mites.
Over thirty types of pathogen can be sexually transmitted, and many of these affect the genitals.
The practice of safe sex can greatly reduce the risk of infection from many sexually transmitted pathogens:condoms (either male or female condoms) is one of the most effective methods of protection.
Bacterial infections include: chancroid – characterized by genital ulcers known as chancres; granuloma inguinale showing as inflammatory granulomas often described as nodules; syphilis –the primary stage classically presents with a single chancre.
Gonorrhea that very often presents no symptoms but can result in discharge.
Viral infections include human papillomavirus infection (HPV) – this is the most common STI.
Genital HPV can cause genital warts.
There have been links made between HPV and vulvar cancer, though HPV most often causes cervical cancer.
Genital herpes is mostly asymptomatic but can present with small blisters that open into ulcers.
HIV/AIDS is mostly transmitted through sexual activity, and the vulva in some cases can be affected by sores.
A contagious viral infection is molluscum contagiosum, which is transmissible on close contact causes warts.
Parasitic infections include trichomoniasis, pediculosis pubis, and scabies.
Trichomoniasis is transmitted by a parasitic protozoan and is the most common non-viral STI affecting the vulva.
Most cases of trichomoniasis are asymptomatic but may present symptoms of irritation and a discharge of unusual odor.
Pediculosis pubis, commonly called crabs, is a disease caused by the crab louse an ectoparasite.
When the pubic hair is infested, the irritation produced can be intense.
Scabies, (seven year itch) is caused by another ectoparasite, the mite Sarcoptes scabiei, giving intense irritation.
Vulvar cancers are classified into squamous cell carcinomas, melanomas, basal cell carcinomas, adenocarcinomas, sarcomas and invasive extramammary Paget’s disease.
Squamous cell carcinomas represent the most common variant of vulvar cancers and account for approximately 75%.
Squamous cell carcinomas are usually found in the labia, particularly the labia majora.
The second most common vulvar cancer is basal cell carcinoma, which rarely spreads to regional lymph nodes or distant organs.
The third most common subtype is vulvar melanoma.
Studies have shown that vulvar melanomas appear to have a different tumor biology and mutational characteristics compared to skin melanomas, which has a direct impact on the medical treatment of vulvar melanomas.
Vulvar cancer signs and symptoms can include: itching, or bleeding; skin changes including rashes, sores, lumps or ulcers, and changes in vulvar skin coloration, pelvic pain might also occur especially during urinating and sex.
A significant proportion of patients with vulvar cancer remains asymptomatic in early disease stages, often delaying its diagnosis.
As such, 32% of women with vulvar melanoma already have regional involvement or distant metastases at the time of diagnosis, which significantly impacts prognosis.
Surgery, with or without removal of regional lymph nodes, is usually the primary treatment modality for vulva cancers.
Advanced-stage melanomas can be treated with checkpoint inhibitors.
Labial fusion /labial adhesion, is the fusion of the labia minora affects a number of young girls.
Vulvodynia is chronic pain in the vulvar region, with no single identifiable cause.
Pudendal nerve entrapment can cause sharp pain or numbness in the vulva, and can be caused by activities such as cycling, giving birth, or prolonged sitting.
Skin disorders such as lichen sclerosus, and lichen simplex chronicus can affect the vulva.
Crohn’s disease of the vulva manifests as a skin condition showing as hypertrophic lesions or vulvar abscesses.
Papillary hidradenomas are nodules that can ulcerate and are found on the skin of the labia or of the interlabial folds.
Hidradenitis suppurativa, characterized by painful cysts that can ulcerate, and recur, and can become chronic lasting for many years, and can develop into squamous cell carcinomas.
A subtype of psoriasis, an autoimmune disease, is inverse psoriasis in which red patches can appear in the skin folds of the labia.
During childbirth, the vagina and vulva are stretched to accommodate the baby’s head (approximately 9.5 cm (3.7 in)).
Such stretching can result in tears known as perineal tears in the vaginal opening, and other structures within the perineum.
An episiotomy, a pre-emptive surgical cutting of the perineum, is sometimes performed to facilitate delivery and limit tearing.
Tearing takes longer to heal than an incision.
No advantages have been demonstrated in the routine shaving of pubic hair prior to childbirth.
Genitoplasties are plastic surgeries that can repair, restore or alter vulvar tissues, particularly following damage caused by injury or cancer treatment.
These procedures include vaginoplasty and vulvoplasty, which can also be performed as a cosmetic surgery.
Other cosmetic surgeries change the appearance of external structures include labiaplasties.
Vaginoplasties and vulvoplasties, are also carried out as sex reassignment surgeries.
Risks of these surgeries include: infection, altered sensation, dyspareunia, adhesions, and scarring.
A percentage of people seeking vulvar cosmetic surgery who may be suffering from body dysmorphic disorder and surgery in these cases can be counterproductive.
In some cultural practices, particularly in the African, the labia minora are purposefully stretched by repeated pulling on them and sometimes by attaching weights: promote better sexual satisfaction for both parties: in order to promote better sexual satisfaction for both parties.
In some cultures, including modern Western culture, some women shave the hair from part or all of the vulva, to avoid exhibiting pubic hair.
Vulva piercings include the clitoral hood piercing above and the labia piercing
Piercings are usually performed for aesthetic purposes, but some forms like the clitoral hood piercing might also enhance pleasure during sex.
Other forms of permanent modifications of the vulva for cultural, decorative or aesthetic reasons are genital tattoos or scarification.
Female genital surgery includes laser resurfacing of the labia to remove wrinkles, labiaplasty as in reducing the size of the labia and vaginoplasty.
American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion on these and other female genital surgeries, that the safety of these procedures has not been documented.
There is the lack of data supporting these procedures and the potential associated risks such as infection, altered sensation, dyspareunia, adhesions, and scarring.
Female genital mutilation. involves the partial or complete removal of the vulva, and is carried out in thirty countries in Africa and Asia with more than 200 million girls being affected, and some women (2018).
Nearly all of the procedures are carried out on young girls., and mostly carried out for cultural traditional reasons.
FGM/C can have harmful effects on physical and mental health.
Primary infections include staphylococcus infections, urinary tract infections, excessive and uncontrollable pain, and hemorrhaging.
Infections such as human immunodeficiency virus (HIV), Chlamydia trachomatis, Clostridium tetani, and herpes simplex virus (HSV) 2 are significantly more common among women who underwent mutilation surgery.
Inflammatory skin diseases that affect hair bearing skin elsewhere may also occur on the vulva and include psoriasis and allergic diseases.
Prone to skin infections secondary to its constant exposure to moistness and secretions.
Subject to inflammation related to blood abnormalities, renal insufficiency, diabetes, and impaired nutrition.