The Female Prostate Revisited: Perineal Ultrasound and
Biochemical Studies of Female Ejaculate
Florian Wimpissinger, MD, FEBU,* Karl Stifter, PhD,
Wolfgang Grin, MD,
and Walter Stackl, MD*
*Department of Urology, Rudolfstiftung HospitalUrology, Vienna, Austria;
Institute for Perineometry and Sextherapy, Vienna, Austria;
Rudolfstiftung HospitalObstetrics and Gynecology, Vienna, Austria DOI: 10.1111/j.1743-6109.2007.00542.x A B S T R A C T Introduction. Many speculations have been made on the possible existence of a female prostate gland and female ejaculation. Despite several reports on the subject, controversy still exists around the female prostate and whether such a gland might be the source of uid emitted during orgasm (ejaculation). Aim. To investigate the ultrasonographic, biochemical, and endoscopic features in two women who reported actual ejaculations during orgasm. Main Outcome Measures. Perineal ultrasound studies, as well as biochemical characteristics of ejaculate and urethroscopy, have been performed in two women. Methods. Two premenopausal women44 and 45 years of agewho actually reported uid expulsion (ejaculation) during orgasm have been investigated. Ultrasound imaging, biochemical studies of the ejaculated uid, and endo- scopy of the urethra have been used to identify a prostate in the female. Ejaculated uid parameters have been compared to voided urine samples. Results. On high-denition perineal ultrasound images, a structure was identied consistent with the gland tissue surrounding the entire length of the female urethra. On urethroscopy, one midline opening (duct) was seen just inside the external meatus in the six-oclock position. Biochemically, the uid emitted during orgasm showed all the parameters found in prostate plasma in contrast to the values measured in voided urine. Conclusions. Data of the two women presented further underline the concept of the female prostate both as an organ itself and as the source of female ejaculation. Wimpissinger F, Stifter K, Grin W, and Stackl W. The female prostate revisited: Perineal ultrasound and biochemical studies of female ejaculate. J Sex Med 2007;4:1388 1393. Key Words. Female Prostate; Ultrasound; Female Orgasm; Female Ejaculation Introduction T he debate around female ejaculation and the existence of a female prostate dates back to 300 BC when the Greek anatomist Herophilos rst wrote about the female prostate [1]. The term female prostate itself was rst introduced by the Dutch physiologist Reijnier De Graaf in 1672 [1]. Even though most physiological and organic functions of the female arousal cycleand orgasm in particularhave been claried, the existence of the female prostate and female ejaculation still remains a matter of debate [24]. With a year-long experience on the topic [5], we wanted to look more deeply into the subject when two women who reported uid expulsion during orgasm agreed to undergo further investigation. Aims To investigate the ultrasonographic, biochemical, and endoscopic features in two women who reported ejaculation during orgasm. Methods In the two women who experienced ejaculation during orgasm, pelvic anatomy has been studied using high-denition perineal ultrasound (5 MHz) 1388 J Sex Med 2007;4:13881393 2007 International Society for Sexual Medicine and endosopically with a 4F cystoscope. The ejacu- lated uid collected during orgasm with masturba- tionat the sexual medicine ofce has beenevaluated biochemically at the hospital laboratory. The results were compared to the parameters of urine voided prior to sexual activity, as well as to the parameters usually found in normal male ejaculate. Main Outcome Measures The focus of the present study was to further clarify the anatomic features of paraurethral anatomy in women reporting ejaculation during orgasm, with new imaging techniques, especially high-denition perineal ultrasound. To dene the emitted uid as ejaculate, biochemical param- eters have been evaluated, mainly to rule out stress incontinence as the source of uid emission. Results Two premenopausal, karyotypically normal women 44 and 45 years of agewho reported to the Sexual Medicine Clinic because of frequent, signi- cant uid expulsions during orgasm have been subjected to further studies following informed consent. Both women are in stable, heterosexual relationships; one of them(44 years) gave birth to a daughter at 20 years of age. Biochemically, parameters of the examination of the uid emitted were clearly different than urine voided prior to sexual activity. Biochemical parameterswith special reference to prostate specic antigen (PSA)are shown in Table 1. The values show that the source of uid expulsion during orgasm is not urine, but is rather similar to male ejaculate. Perineal ultrasound imaging showed a hyperin- tense structure surrounding the entire length of the urethra with the anterior wall of the vagina adjacent dorsally (Figure 1). This picture closely resembles that of the male prostate. On urethroscopy with a 4F endoscope, an open- ing was identied in the distal part of the urethra in the six-oclock position. Passage into this opening Table 1 Comparison of different biochemical parameters in female ejaculate and voided urine compared to male ejaculate W1: female ejaculate W1: voided urine W2: female ejaculate W2: voided urine Male ejaculate PSA (ng/mL) 213.49 0.80 105.00 0.16 1102,211 [27] PAP (U/L) 329 42 <1 PSAP (U/L) 271 37 860.0 178 Glucose (mg/dL) 127 30 100 31 0.429.5 [28] Creatinine (mg/dL) 33.0 178.0 30.0 225.0 BUN 1,474 363 K (mMol/L) 8.6 37.3 31 5.024.8 [28] Na (mMol/L) 46 203 129 23.651.2 [28] Cl (mMol/L) 37 148 144 43 W1 = woman 1; W2 = woman 2; PSA = prostate specic antigen; PAP = prostatic acidic phosphatase; PSAP = prostate specic acid phosphatase; BUN = blood urea nitrogen; K = potassium; Na = sodium; Cl = chloride; = no parameters available. a b Figure 1 Perineal ultrasound of the female prostate. (a) median aspect (b) sagittal aspect. B = bladder; U = urethra; P = prostate; V = vagina. The Female Prostate 1389 J Sex Med 2007;4:13881393 was possible; however, the duct ended blindly after 2 cm. Endoscopically, no diverticulum or other pathologies of the urethra have been found. Discussion Orgasm Intensity It seems that female orgasm with uid emission is more intense than an orgasm without ejaculationin women who do experience such phenomena [6]. This nding has been conrmed by both women reported in this study. Is female ejaculation the cause or the effect of more intense orgasmsa similar question just raised in a study on lubrication difculties [7]? With female orgasm and arousal difculties being highly prevalent [8], a possible link to ejaculations would be an interest- ing eld of future studies. Anatomy Perineal ultrasound has been used to study para- urethral anatomy without artefacts that occur in any form of endoluminal ultrasound investigation (distortion and compression). From an anatomic point of view, we found glandlike structures sur- rounding the female urethra of the two female subjects who had frequent ejaculations during orgasm. Comparing these ndings with previous data from the literature, we agree with De Graafs description of a gland similar to the male prostate rather than with Skenes concept of pure female paraurethral glands [9]. In this respect, some authors even believe that Skenes work hindered further studies of a female prostate for many years [10]. Historically, Reinjer de Graaf was the rst to study the female prostate as early as 1672 [1]. Alex- ander Skene reported on paraurethral glands in 1880, leading to the terminology Skenes glands of a female organ that seems to be the same as the male prostate (and that had been described by De Graaf in the rst place). Later on, J.W. Huffman was the rst to disagree with several conclusions drawn by Skene. Ultrastructural and immunohis- tochemical work in the 1980swith special refer- ence two PSA stainingfurther strengthened the concept of the existence of the female prostate. Taking anatomical data of Huffmans revolu- tionary wax models [11] into account (Figures 2 and 3), M. Zaviacic found different types of female prostates according to his pathoanatomic cross- sectional studies: anterior (meatal) type, posterior type, the prostate distributed over the hole length of the female urethra, the rudimentary female prostate, and rare middle and dumbbell congu- rations [10,12]. J.W. Huffmans description of a female pro- state with ductal tissue predominating has been strengthened by later observations [13,14]. This Figure 2 Huffmans wax model, longi- tudinal aspect. Figure 3 Huffmans wax model, anterior aspect. 1390 Wimpissinger et al. J Sex Med 2007;4:13881393 lobulated appearance of the gland is similar to the prostate of the male before puberty [13]. Termina- tion of hormonal stimuli in the female embryo, together with a different anatomic development of the urethra (and adjacent anterior vaginal wall), stops the full development of the gland. According to ultrasonography, the subject stu- died exhibits a paraurethral gland that is distrib- uted over the hole length of the female urethra (Figure 1). This type of distribution has been found in about 6% of Zaviacics autopsy material [11]. The ultrasonographic appearance of the struc- ture surrounding the female urethra just like the male prostate is supported by numerous histologic and ultrastructural studies that found PSA-positive glands and stroma resembling an actual female prostate [15,16]. Critics of the concept of female ejaculation often postulate that urethral diverticula might be the source of uid emitted during female orgasms. In this respect, both ultrasound and endoscopic features in the two cases presented show that no diverticulum was present. It must be postulated, however, that the majority of the female prostate glands excretory ducts are not seen on conven- tional urethroscopy. Previous studies reported of more than 20 ducts [11,15]. Immunohistochemically, PSA is the major tissue-specic marker for male prostate tissue. Wernert et al. [13] performed PSA and prostate specic acid phosphatase immunohistochemical staining of female paraurethral glandular tissue with positivity found in 22 of 33 cases (66.7%). Other authors found female prostatic tissue in up to 80% of cases [14,17]. With increasing awareness of the existence of a female prostate, pathology of the female paraure- thral apparatus has been linked to adenocarcinoma similar to male prostate cancer [1820]. In this context, more common problems like lower urinary tract symptoms or recurrent urinary tract infection could possibly be attributed to dis- eases of the female prostate [21,22]. This could in turn pave the way for new treatment strategies and research on new immunohistochemical markers [23]. Female Ejaculation The description of female ejaculation dates back to the ancient Indian erotic text Ananga-Rang pub- lished in the 16th century AD [5]. In 20th century literature, Grfenberg was among the rst to describe the release of a milky opalescent uid via the urethra during orgasm [11,12]. The fact that the female ejaculate is not a form of orgasm-induced stress urinary incontinence or the result of increased vaginal lubrication is estab- lished among all authors involved in studying female sexual response [11,12,2427]. Because PSA is physiologically excreted by the prostate and appears in high levels in the male ejaculate to liquefy the ejaculated coagulum after its positioning at the female cervix, it seems obvious that measuring PSA levels in female ejacu- late could differentiate between actual prostatic excretion and possible other sources of the uid [28]. Biochemical parameters of the ejaculate in the women studied (high levels of PSA, prostatic acidic phosphatase [PAP], and PSAP) further strengthen the fact that the emitted uid comes from prostatic tissue and resembles that of male prostatic excre- tions with PSA levels in male seminal plasma ranging from 110 to 2,211 ng/mL (Table 1) [29,30]. Considering all studies published, rates of women who experience ejaculation during orgasm range from 10% to 69% [10,12,3133]. It has been shown previously that PSA is detect- able in female voided urine, and that the levels are higher following intercourse and orgasm [34]. Some specialists postulate that every woman ejacu- lates during orgasm, but most women experience retrograde ejaculation (into the bladder) [32,35]. To differentiate between urine and emitted uid during orgasm (ejaculate), voided urine was col- lected prior to sexual activity in this study, and could thus be clearly differentiated (Table 1). Fur- thermore, urinary incontinence has been com- monly associated with urinary incontinence [36]just the opposite of what ejaculating women do experience. Conclusions Female ejaculationrst described as love juice in ancient Indian textbooksseems to be more common than generally recognized. In the two women who ejaculated during orgasm, perineal ultrasound and urethroscopy revealed structures consistent with a (paraurethral) female prostate. The uid emitted during orgasm was biochemi- cally comparable to male prostatic plasma. Corresponding Author: Florian Wimpissinger; Rudolfstiftung HospitalUrology, Juchgasse 25 Vienna A1030, Austria. Tel: +431711654808; Fax: +431711654809; E-mail: orian.wimpissinger@gmx.at Conict of Interest: None declared. The Female Prostate 1391 J Sex Med 2007;4:13881393 References 1 De Graaf R. New treatise concerning the generative organs of women. First published 1672, reprint in J Reprod Fertil 1972;17(suppl):1037. 2 Masters WH, Johnson VE. 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Arch Androl 2005;51:33543. 36 Guiseppe PG, Pace G, Vicentini C. Sexual function in women with urinary incontinence treated by pelvic oor transvaginal electrical stimulation. J Sex Med 2007;4:7027. Commentary on Wimpissinger F, Stifter K, Grin W, Stackl W. The Female Prostate Revisited: Perineal Ultrasound and Biochemical Studies of Female Ejaculate In this paper, the authors demonstrate the bio- chemical differences between the uid emitted during female ejaculation and samples of urine taken prior to sexual activity. The paraurethral glands have been previously suggested as a female homolog of the male prostate, and histological evi- dence suggests that they might be the source of such ejaculatory uid. In support of this hypoth- esis, the authors draw a comparison between the PSA levels found in the female ejaculate samples, and that expected in male ejaculate. While the biochemical data provide convincing evidence that the ejaculatory uid collected was not urine, we are concerned that the authors have over-interpreted the ultrasound data to t with their hypothesis of a female prostate. The image reproduced in the paper is of poor quality. The area labeled U for urethra probably represents a stripe of artifact caused by scanning the urethra along its course. Furthermore, while paraurethral glandular tissue may extend along the length of the urethra, it is not noted to surround the proximal urethra. Thus the area labeled P for prostate most likely represents the striated urethral sphinc- ter, a structure which does surround the proximal urethra in this way. We would suggest that three- dimensional ultrasound or magnetic resonance imaging may be more appropriate modalities for imaging the periurethral structures. Dr. Rufus Cartwright and Professor Linda Cardozo Department of Urogynaecology Golden Jubilee Wing, Kings College Hospital, Denmark Hill, London E-mail: rufus.cartwright@gmail.com Author Response We appreciate the thoughtful comments regarding the interpretation of perineal ultrasound images in our examination of women reporting ejaculation during orgasm. Perineal ultrasound is a well- established tool in the workup of women with sus- pected prolapse as well as nullipara girls. In the hands of the experienced clinician, the female introitus, including urethra, bladder neck, and vagina, can easily be identied. The image printed in the manuscript is a static view of a very dynamic examinationa fact that applies to all ultrasound techniques. Therefore, denition of the urethra and surrounding tissue must be seen in the context with this dynamic process and the resulting three- dimensional image in the observers mind. However, we agree that the actual denition of paraurethral tissue as prostate P is rather hypo- thetic. Only biopsies could prove that this gross anatomic feature really relates to the female pros- tate. Hopefully, high resolution magnetic reso- nance images will help us solve this problem in future studies. The Female Prostate 1393 J Sex Med 2007;4:13881393