In order to discuss the various surgical techniques, it is extremely important to understand the changes that have to be made, and why. In our routine practice, we quite often find a lack of basic knowledge of the anatomical structures in the genital area or confusion about the terms used to describe them.
Here is a brief overview of the main structures:
The pelvic floor consists of sheets of muscle and connective tissue, stretched like a muscular hammock across the circular pelvis. Its main function is to ensure that the organs in the pelvis and abdomen remain in the right place. The pelvic floor therefore prevents the bladder, uterus (womb), ovaries, intestines, etc. from “slipping down”. Openings in the centre allow the intestine, vagina, and urethra to pass through. A connective tissue layer called the perineum lies between the anus and the lower end of the vagina. Fasciae and tendons of the pelvic floor radiate into the perineum, forming an important mechanical junction.
The vulva (pudendum) includes all of the following structures of the female external genitalia:
- labia majora (outer labia, outer vaginal lips)
- labia minora (inner labia, inner vaginal lips)
- vaginal opening (introitus)
- urinary meatus
- mons pubis
The anatomical term vulva is often confused with the term vagina, not least in the media.
Labia majora (outer labia, outer vaginal lips)
The labia majora (outer labia) are a pair of prominent skin folds that lie in a gentle curve around the labia minora (inner labia). They extend from the mons pubis to the perineum. They are joined at the front and back by bridges of tissue, and merge almost seamlessly into the mons pubis.
The relatively firm skin is the female equivalent of the scrotum in men and is hairy. It contains sebaceous glands, sweat glands, and scent glands.
Abundant fatty tissue lying beneath the skin of the outer labia affords mechanical protection for the external genital area but also helps to cover the inner labia and to close the vaginal opening.
The loss of fatty tissue with advancing age (fat atrophy) means the loss or at least a reduction of the normal functions, and the outer labia can start to sag. The skin may also stretch during a woman’s lifetime and lead to a visible enlargement (hypertrophy) of the outer labia.
Labia minora (inner labia, inner vaginal lips)
The labia minora (inner labia) are two narrow folds of skin that differ widely in shape and size from woman to woman. Ideally, they should be completely covered by the labia majora. Their function is to close the vaginal opening to protect it against infection and prevent the vagina from drying out.
The inner labia run downwards between the outer labia from the mons pubis to the perineum. Above the clitoris they cover the clitoral shaft, which arches outwards like a half cylinder. This upper segment forms the clitoral prepuce. The lower part of the clitoral prepuce covers the tip of the clitoris and is known as the clitoral hood.
There is great variation in the shape and length of the clitoral hood. Sometimes it covers only the upper part of the tip and sometimes it covers the entire tip, hanging over it like a curtain.
The skin of the inner labia is considerably thinner than that of the outer labia. It is hairless and does not contain any fatty tissue.
With increasing age, but even at in young women, the inner labia can grow excessively and visibly protrude beyond the shelter of the outer labia. Apart from the unsightly appearance, there may also be functional impairment.
At what point do we say that there is enlargement (hypertrophy) of the labia minora? There is no internationally recognised definition. When their height exceeds 2 cm from the base at the interlabial fold, the inner labia generally start to be visible beyond the shelter of the outer labia and are more often associated with detrimental physical and psychological effects. When they measure more than 2 cm in height, therefore, the labia minora can be described as enlarged (hypertrophic).
The clitoris is the only organ in the human body that serves exclusively for sexual pleasure. It is a three-dimensional structure in the shape of an inverted Y with the two arms joining in the midline of the pubis.
The tip of the clitoral shaft (the glans) is the only part of the clitoris that is visible externally. In lay terms, this visible part is called the clitoris, even though it is really only a small part of the whole anatomical structure that is in fact the clitoris. The tip is often described as being the size and shape of a pea. The nerve supply consists of two nerves that run directly to the clitoris and give off many smaller branches.
The mons pubis is a softly rounded area that extends between the lower abdomen and the start of the outer labia, reaching the inguinal folds on each side. It is filled with abundant fatty tissue.
The skin of the mons pubis is relatively thick and hairy. The volume, and therefore the size, of the mons pubis increases in obesity; the mons pubis may descend with age, especially in obese people.
The vagina is an approximately 10-cm long tube consisting of muscle lined by a layer of folded skin. The front and back walls of the vagina touch when relaxed. The biological function of the vagina is to take up sperm. It allows sexual intercourse and also functions as the birth canal. The term vagina is often wrongly used to describe the female external genitalia. The vagina is actually a part of the female internal genitalia. The most sensitive part of the vagina is the roughly coin-sized area found on the front wall about a finger’s breadth below the urethral opening. It is known as the G spot.
The hymen is a crescent-shaped or ring-shaped membrane or skin fold that incompletely covers the vaginal opening at about the level of the urethral opening. With the first sexual intercourse, the hymen undergoes a (usually) star-shaped tear. It is of particular significance to Muslim women prior to marriage, as an intact hymen proves that the woman has not had sexual intercourse.