Table 1.

The role of the vulva in sexuality.

The vulva is rich with sensitive fibres 26

The clitoris, along with the associated corpora cavernosa, 32 is the most innervated part of the vulva 9 and the main organ devoted to female genital arousal, pleasure, and orgasm 33

The vestibular bulbs (counterpart of the corpora cavernosa of the penis) are thought to work closely with the corpora cavernosa and the clitoral tissues and nerves. During sexual arousal, the vestibular bulbs fill with blood. The resulting congestion exerts pressure on the corpus cavernosum of the clitoris and the glans of the clitoris. This pressure on the clitoral nerves and tissues is thought to induce a pleasant sensation during sexual arousal 34 Following menopause, the width of the vestibular bulbs reduces. 35 The corpora cavernosa undergo a progressive, age-dependent reduction from age 20 onwards. 36 In parallel, an age-related reduction of sexual hormones (including testosterone and DHEA) is observed,9,37 with DHEA values in people in their eighties and nineties sometimes as low as 10% to 20% of the original values encountered in young individuals38,39

The vulvar vestibule and surrounding tissues become very congested during physiological sexual arousal, contributing to genital congestion and the formation of the so-called ‘orgasmic platform’ 9

The controversial G-spot, now considered a component of the CUV complex, is hypothesized to mediate and contribute to the vaginally-activated orgasm, the climax obtained during vaginal penetration9,32,33,40

The labia majora and minora engorge with blood and appear oedematous during sexual arousal 7

Bartholin’s glands secrete a mucus-like substance to lubricate the internal part of the labia minora and the vestibular region during sexual intercourse; this is essential for preventing painful coitus and making penetration enjoyable7,9

Skene’s glands release urethral secretions during sexual arousal 9

The mons pubis provides cushioning during sexual intercourse and secretes pheromones to induce sexual attraction. 7 Resident physiological microbiota activate pheromonal substances produced by vulvar apocrine glands, 41 and pubic hair facilitates evaporation of pheromones 42

Beneath the visible vulva, the muscular tissues (the three superficial trigonus muscles and the powerful levator ani) are key partners of pleasure (in addition to their roles in pelvic organ support and voluntary urinary and faecal continence) as they contract during the motor component of the orgasmic reflex. 9 A healthy and tonic pelvic floor is significantly associated with better arousal and orgasm. Hypoactivity of the muscles (low tone), relatively common after vaginal delivery, can lead to poor sexual function and lack of pleasure during coitus and orgasm, while hyperactivity (high tone) may be pathophysiologically linked to sexual pain disorders such as dyspareunia and vaginismus 9

Adjacent to the vulva, effective maintenance of perineal hygiene could reduce the risk of UTIs and Candida albicans infection (thrush), as well as maintain the physiological microbiome,19 –21,23,43 all of which contribute to a healthy vulvar and vaginal microenvironment, an underappreciated contributor to pleasurable intercourse

CUV: clitourethrovaginal; DHEA: dehydroepiandrosterone; UTI: urinary tract infection.