Anatomy of the prepuce of the clitoris: Introducing the collar of the clitoris, a novel anatomical subdivision of the clitoral prepuce

Matthew J Zdilla

doi:10.1016/j.jpra.2026.01.016

. 2026 Jan 23;48:846–856. doi: 10.1016/j.jpra.2026.01.016

Anatomy of the prepuce of the clitoris: Introducing the collar of the clitoris, a novel anatomical subdivision of the clitoral prepuce^✰

Matthew J Zdilla ¹

PMCID: PMC12914519 PMID: 41716332

Abstract

The anatomy of the clitoral prepuce is surgically important, especially as female genital mutilation remains common and genital plastic, reconstructive, and aesthetic surgeries are performed with increasing frequency. Despite its surgical importance, basic anatomical study of the clitoral prepuce has been limited, and confusion exists regarding the fundamental gross anatomical structure of the prepuce. This study identifies novel anatomical structures of the clitoral prepuce including a distinct band of preputial tissue located around the neck of the clitoris, a structure which has not yet been described in the literature. The aforementioned structure, referred to here as the collar of the clitoris, was assessed through a review of digital images taken of 141 donor bodies. The presence of the collar was confidently identified in images of 130:141 bodies (80:83 unembalmed donor bodies; 50:58 embalmed donor bodies); the absence of the collar was confidently identified in 0:141; and the presence/absence of the collar was unclear in 11:141 (3:83 unembalmed donor bodies; 8:58 embalmed donor bodies). Thus, the collar of the clitoris was present in ≥92.2% of donor bodies and absent in ≤7.8%. This report posits that the typical clitoral prepuce consists of two main components: a superficial clitoral hood and an underlying clitoral collar. Further, this report presents a method for characterization of preputial anatomical variation by means of considering the clitoral collar as a fundamental anatomical structure. This study improves the understanding of the clitoral prepuce and has important implications for genital plastic, reconstructive, and aesthetic surgeries.

Keywords: Clitoris, Gynecology, Plastic surgery, Prepuce, Vulva

Introduction

A thorough understanding of the prepuce of the clitoris is surgically important, especially as female genital mutilation remains common and genital plastic, reconstructive, and aesthetic procedures are performed with increasing frequency.1, 2, 3, 4 The clitoral prepuce is involved in genital reconstruction,⁵^,⁶ reduction clitoroplasty,⁷ labiaplasty,⁸^,⁹ labiaplasty revision,¹⁰ and clitoral hood reduction procedures including clitoral hoodplasty and clitoral hoodectomy.⁹ The clitoral prepuce is also subject to pathologies that may require surgical intervention including lichen sclerosis, glandopreputial adhesions, infections, and varied tumors— benign, premalignant, and malignant.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 Thus, understanding preputial anatomy is important in differentiating typical anatomy from anatomical variation, deformity, and pathology.

Despite the surgical importance of the clitoral prepuce, there is confusion regarding its most basic anatomy. For example, some sources consider the prepuce as a subcomponent or extension of the labia minora whereas others suggest that it is an independent anatomical structure.27, 28, 29, 30, 31, 32, 33 Some consider the clitoral prepuce and clitoral hood to be the same structure, whereas others explicitly differentiate the prepuce from the hood.³¹^,³²^,³⁴^,³⁵ Likewise, some consider the prepuce or hood as the skin overlying the body of the clitoris whereas others do not.³¹^,³²^,³⁴^,³⁵

The lack of consensus regarding basic preputial anatomy may partly explain why there is discrepancy among reports regarding preputial size.⁶ The variation in reported size may also be attributable to variation in basic prepuce shape which has been described by subjective terminology such as “horseshoe, trumpet, coffee bean, and tent.”²⁹^,³⁶ Thus, as the idiom goes, we may be comparing apples to oranges or, in the case of the clitoris, we may be comparing trumpets to coffee beans with regard to measuring different types of prepuces. Non-metric morphological differences may be impacting anatomical measurements. Likewise, the term “hypertrophy,” often used to describe the clitoral prepuce in the context of aesthetics³; is ill defined in the literature and remains relatively subjective in its application.

Knowledge of the clitoral prepuce is important for genital plastic, reconstructive, and aesthetic surgeries. Yet, there are few, and otherwise conflicting, resources detailing preputial anatomy. Therefore, study of the basic non-metric anatomy of the clitoral prepuce, preputial structural variation, and the anatomical relationships between the clitoral prepuce and surrounding structures is necessary to accurately detail and appropriately define the fundamental structure of the clitoral prepuce. This study provides a detailed assessment of the gross anatomy of the clitoral prepuce and its anatomical relationships to surrounding structures of the vulva.

Materials and methods

The study was approved by the West Virginia Anatomical Board. A total of 174 female donor bodies, accessed through the West Virginia Human Gift Registry between the years of 2022 and 2025 were sampled for this study.

Non-embalmed donor bodies were assessed within 48 h after death. To assess the non-embalmed donors, the prepuce of the clitoris was identified and then retracted. Debris, such as hair and smegma, were removed from the glandopreputial (balanopreputial) sulcus. When tissues of the prepuce of the clitoris were adherent to the glans, adhesions were broken to the extent that all surface anatomy including the entirety of both the prepuce, corona of the glans clitoris, and glandopreputial sulcus could be fully visualized.

Embalmed donors were hard-fixed, embalmed with Carolina’s Perfect Solution® Concentrate with Phenol (Carolina Biological Supply Company, 2700 York Road, Burlington, NC 27215). Among the embalmed donors, the anatomy of the mons and prepuce were noted. Then, to assess the anatomy of the glandopreputial sulcus, the prepuce was bisected distally to proximally to the deepest aspect of the glandopreputial sulcus. The mons pubis was also bisected to access the underlying anatomy as needed. Debris present within the glandopreputial sulcus was removed in order to adequately visualize underlying anatomy.

Digital photography was performed with a high-resolution camera (Canon PowerShot SX50 HS, 12.1 Megapixel) from varied angles prior to preputial retraction/bisection and after preputial retraction/bisection. Approximately 8000 digital photographs were then screened for variation in preputial anatomy. Donors were excluded from study in the event that the anatomy of the prepuce and glandopreputial sulcus could not be clearly assessed from digital images.

Results

Sample demographics

A total of 141 bodies (83 non-embalmed bodies and 58 embalmed bodies) qualified for anatomical assessment of the prepuce and anatomy of the glandopreputial sulcus based on clear visualization of anatomy. The average age-at-death of the included population sample was 79.1 ± 11.8 years (Mean ± SD) ranging from 44 to 103 years age-at-death. Of the included donor body sample, 78 were not embalmed (age-at-death ranging from 44 to 103; average age 78.5 ± 12.3 years) and 57 were embalmed (age-at-death ranging from 50 to 102; average age 79.9 ± 10.8 years).

Observations of preputial morphology

The prepuce of the clitoris was usually found to have two distinct parts: a deep part, which will henceforth be referred to as the “collar” due to its consistent appearance around the neck of the clitoris, and a superficial part, which, for the purpose of this study, will henceforth be referred to as the “hood” (Figure 1).

Figure 1 dummy alt text — Dorsolateral (**A-C; A** without retraction of the prepuce, B and C with retraction of the prepuce) and anterior (**D-F; D** without retraction of the prepuce, E and F with retraction of the prepuce) views of the anatomical substructures of the clitoral prepuce including the superficial preputial part, otherwise referred to as the hood of the clitoris, and the deep preputial part otherwise referred to as the collar of the clitoris. The collar curves around the lateral and dorsal aspects of the neck of the clitoris and abuts the clitoral glans. The outward convexity of the collar produces a primary sulcus between it and the neck/glans of the clitoris and a secondary sulcus between it and the hood of the clitoris. As demonstrated by this figure, the collar is often distinguished from surrounding structures by its hue, which is generally lighter than surrounding tissues. (**1 sulc**: primary or collar-neck sulcus located between the collar and the neck/glans of the clitoris; **2 sulc**: secondary or collar-hood sulcus located between the collar and the overlying hood; **COLLAR**: the deep-most prepuce of the clitoris which exists intermediate to the superficial prepuce (hood) and the neck/glans; **CORONA**: the corona of the glans clitoris; **C sulc**: coronal sulcus; **dotted line**: margin of the deep reflection of the glandopreputial/balanopreputial sulcus which marks the proximal most aspect of the clitoral hood and distinguishes the hood from the skin of the body of the clitoris; **GLANS**: the glans clitoris or “head” of the clitoris; **HOOD**: the preputial skin overlying the collar; HOOD*: the superficial prepuce retracted, exposing inner mucosa; **star**: skin of the body of the clitoris— the tegmentum corporis of the clitoris).

The collar of the clitoris

The presence of the collar, a distinctive band of preputial tissue seen wrapping around the neck of the clitoris and abutting the glans clitoris, was confidently identified in 130:141 of individuals (80:83 unembalmed donor bodies; 50:58 embalmed donor bodies); the absence of the collar was confidently identified in 0:141; and the presence/absence of the collar was unclear in 11:141 (3:83 unembalmed donor bodies; 8:58 embalmed donor bodies). Thus, accounting for unclear ascertainment of presence/absence, the collar of the clitoris was present in ≥92.2% of donor bodies and absent in ≤7.8%.

The collar was occasionally evident without preputial retraction or bisection among both the embalmed and non-embalmed bodies. The collar and the neck of the clitoris were separated by a primary sulcus (collar-neck sulcus) (Figure 1). A distinctive secondary sulcus was identified between the collar and the hood (collar-hood sulcus) (Figure 1). Upon retraction of the hood, a band of tissue was occasionally found joining the collar to the hood in the midline. The primary sulcus was often indistinguishable from the coronal sulcus (retroglandular sulcus), forming a collar-corona sulcus. Regarding hue, the collar was typically lighter in color than the overlying hood, which further distinguished it from the hood (Figure 1, Figure 2). The hue of the collar was often different than that of the glans clitoris, as well (Figure 1, Figure 2).

Figure 2 dummy alt text — Images demonstrating the distinctive color differentiation that is common between the collar of the clitoris (C) and surrounding structures such as the hood of the clitoris (H) and the glans of the clitoris (G). A: The clitoral collar of a 72-year-old black female demonstrates a color which, unlike the brown-colored hood of the clitoris, resembles the pink hue of the vestibule (V). B: The hood and glans of a 75-year-old white female demonstrate a color difference between a relatively pale collar and surrounding structures. C: Prepuce and glans of a 100-year-old white female demonstrating a color difference between a relatively pale collar and surrounding structures.

The collar was adjoined to the clitoral neck, coronal sulcus, and frenulum. Often, the bands of tissues from the coronal sulcus and frenulum were distinct and separated by a sulcus (Figure 3). Thus, commonly, the anatomy of the collar was able to be differentiated into a distinct coronal part and a frenular part (Figure 3). In the presence of a dorsally located coronopreputial frenulum (an anatomical structure only recently described),²⁴^,³⁷ the coronal part of the collar often appeared absent or less prominent, and the collar-neck sulcus was especially distinct from the coronal sulcus. Frequently, the tissues of the collar appeared as twisting bands, and, quite often, the bands of tissues forming the collar would interweave across the midline.

Figure 3 dummy alt text — The anatomy of the collar of the clitoris (C) can often be differentiated into a coronal part (CP) which emerges from the coronal sulcus, just proximal to the corona of the clitoris (**Cor**) and a frenular part (FP) which emerges from the frenulum (F). Together, the coronal and frenular parts make up the collar. The collar and the hood (H) collectively form the prepuce (P) of the clitoris. A and B: Left lateral and right dorsolateral views of a 76-year-old white female. C: Dorsal view of an 89-year-old white female. D: Right dorsolateral view of a 72-year-old white female.

Variations of preputial morphotypes

The hood was often continuous with the crests of the labia minora. Otherwise, the hood would join with the lateral aspects of the labia minora, or tissues distinctly separate from the labia minora. The hood typically covered the collar and glans and was continuous with the skin of the body of the clitoris (Figure 1). Occasionally, the collar itself, especially the frenular part, would be continuous with the skin overlying the body of the clitoris, thus forming a pseudo-hood (Figure 4A). In such a case, a typical hood would not be completely formed across the midline. Rather its halves would be represented by labia which flanked the body of the clitoris. These hemipreputial labia or “hemihood” labia joined nearby tissues the same way each half of a hood would do otherwise (Figure 4A). Sometimes, the frenular part of the collar would be joined with the contralateral hood across the midline, forming a hemi-collar/hemi-hood; in which case, there would be a unilateral hemipreputial labium on the hemi-collar side. Asymmetry was frequently observed across the midline.

Figure 4 dummy alt text — Examples of preputial diversity including a pseudohood (A) and a secondary hood (B and C). A: Lateral view of a clitoris presenting a pseudo-hood, a clitoral collar that is continuous with the skin of the body of the clitoris. This morphology often presents with hemipreputial labia, which likely represent independent sides of the clitoral hood that have not joined across the midline with their contralateral counterparts. B: A secondary hood with connections to the right labium majus and left labium minus is shown partially covering a primary hood. C: Upon retraction of the secondary hood and primary hood shown in panel B, the collar of the clitoris is identified. (**1 HOOD:** primary hood; 1 HOOD*: primary hood retracted; **2 HOOD**: secondary hood; 2 HOOD*: secondary hood retracted: **1 sulc**: primary sulcus (collar-neck sulcus) located between the collar and the neck/glans of the clitoris; **2 sulc**: secondary sulcus (collar-hood sulcus) located between the collar and typically, the overlying hood; however, in this case, the secondary sulcus is found between the collar or pseudo-hood and a hemipreputial labium; **3 sulc**: tertiary sulcus (hood-hood sulcus) located between the primary hood and secondary hood. **COLLAR**: the deep-most prepuce of the clitoris, in this case, presenting as bands of tissue overlapping in the midline; **COLLAR (PSEUDOHOOD)**: a clitoral collar with no overlying superficial prepuce or “hood” presenting as pseudo-hood; **CORONA**: the corona of the glans clitoris; **CPF**: coronopreputial frenulum; **C sulc**: coronal sulcus; F: frenulum; **GLANS**: the glans clitoris or “head” of the clitoris; **HPL**: Hemipreputial labium which likely represents one side of a clitoral hood which has not joined across the midline with its counterpart; **L maj**: labium majus; **L min**: labium minus; **MONS**: mons pubis; **star**: skin of the body of the clitoris, otherwise designated as the tegmentum corporis of the clitoris).

Some individuals were found to have a secondary hood comprised of tissues in closer proximity to (or adjoining) the tissues of the labia majora and mons pubis than those of the primary hood (Figure 4B and C). The secondary hood was either joined with the crests of the labia minora, the lateral aspects of the labia minora, or tissues lateral to the labia minora. For example, the lateral aspect of the secondary hood could connect with the labium majus (Figure 4B and C). In the presence of a secondary hood, the primary hood could appear like a pseudo-collar (and, upon retraction, the true collar would be identified). Occasionally, the primary hood would be continuous with the skin of the body of the clitoris and would be flanked by hemipreputial labia (representing two halves of a complete secondary hood that were not joined across the midline). In such a case, there would be a primary sulcus, secondary sulcus, and a tertiary sulcus found intermediate to the primary and secondary hood (Figure 4).

Thus, several morphotypes were identified by first identifying the collar of the clitoris, the most consistently present preputial structure; then, when present, the hood; and, occasionally, a secondary hood. Hemipreputial labia were present when a hood or secondary hood were partly formed but not fully joined across the midline, producing a midline preputial cleft. Bilateral hemipreputial labia would, however, often contact one another in the midline and contribute to the structure of the pudendal cleft which often, when viewed from the anterior, would not present as one sulcus (between the labia majora) or two sulci (between the clitoris and flanking labia majora) but rather three sulci (two between the labia majora and hemipreputial labia, and one in the midline, between the hemipreputial labia).

Incidental findings

Several pathological findings were incidentally identified during this study. Clitoral pearls (otherwise known as clitoral keratin pearls), known to occur typically in the substance of the glans,¹⁹^,²³^,²⁴^,²⁶^,³⁸ were found on the surface of the collar (Supplement 1). Clitoral pearls found in the collar of the clitoris were present in 5.0% (4:80) of the non-embalmed donors. Also, the pearls were observed to abut erythematous areas and surface deformations of the glans clitoris (Supplement 1). When present, the pearls were always located at the lateral/ventral-lateral aspect of the collar near the ala of the glans clitoris (Supplement 1).

Although not related to pathology per se, in two of the non-embalmed donors the retraction of the hood and the lysis of glandopreputial adhesions between the collar and the corona of the glans clitoris resulted in an edematous and turgid clitoral collar (Supplement 2). The edema was isolated to the collar while the hood remained unremarkable (Supplement 2). Adhesions between the collar of the clitoris and glans clitoris were especially common; however, no adhesions were identified between the collar and the hood of the clitoris.

Discussion

This report details anatomical variation of the prepuce of the clitoris and identifies a novel anatomical structure and subdivision of the clitoral prepuce. The common prevalence of the clitoral collar suggests that it is a typical anatomical structure rather than an anatomical variant or pathological finding. However, coexisting pathological findings were occasionally found at the clitoral collar. Such findings included adhesions, clitoral pearls, and surface deformations which may warrant surgical intervention.

This report suggests that the collar of the clitoris is a fundamental part of the clitoral prepuce. Accordingly, the collar of the clitoris may be utilized as a reference structure from which to assess the anatomical diversity of preputial morphotypes and may help refine anatomical assessment, surgical procedures, and aesthetic outcomes.

The clitoral prepuce is not a subdivision of the labia minora

Numerous anatomical texts including Terminologia Anatomica, the international standard of anatomical terminology, describe the prepuce of the clitoris as a subcomponent of the labia minora rather than as an independent anatomical structure.³⁰ However, this report, considered alongside embryological and pediatric reports,²⁹^,³³^,³⁶ demonstrates that the clitoral prepuce may exist as a unique structure distinct from the labia minora across the life cycle.

Labium minus enlargement is often accompanied by native clitoral prepuce hypertrophy (the reason that clitoral preputial tissue is often resected during labiaplasty)³; however, the clitoral prepuce has been documented to be hypertrophic in the setting of concomitant bilateral labium minus agenesis.³⁹ Such difference between preputial enlargement alongside labium minus agenesis is further suggestive of some independence of growth and development between the prepuce and labia minora. Thus, anatomical resources should be revised to note that, while the clitoral hood may insert at the crest of the labium minus, it is not a subdivision of the labium minus as it often inserts lateral to the labium minus. Considering the clitoral prepuce as a subdivision, crus, or extension of the labium minus disregards preputial anatomical diversity. Likewise, understanding preputial diversity, including the differentiation of the collar from the hood and the variations in hood “insertion” sites, may help guide decisions with regard to genital plastic and reconstructive procedures.

Distinguishing between the clitoral prepuce, clitoral hood, and the skin covering the body of the clitoris

In addition to distinguishing the clitoral prepuce from the labia minora, this report suggests distinguishing the clitoral prepuce from the hood and skin overlying the body of the clitoris. While many use the terms prepuce and hood synonymously, some explicitly differentiate the prepuce from the hood.³¹^,³⁴ For example, Di Marino and Lepidi³⁴ identify the clitoral prepuce as the skin overlying both the body and glans of the clitoris and identify the clitoral hood as the loose end of the prepuce which overhangs the glans clitoris. Others do not differentiate the “loose end” of skin from that overlying the body of the clitoris and use prepuce and hood in a similar way. For example, Tappy and Corton³⁵ note that the clitoral body is covered dorsally and laterally by the prepuce and make no mention of a clitoral hood. Similarly, Kelling et al.³² identify the single layer of skin overlying the body of the clitoris as “clitoral hood skin” rather than, for example, the skin of the clitoral body. These descriptions may be likened to describing the skin which covers the body of the homologous penis as the prepuce of the penis, which would be considered an unconventional and inaccurate use of language.

The discrepancies in defining the anatomy of the clitoral prepuce may influence the anatomical study of the prepuce. A recent meta-analysis from Longhurst et al.⁶ documented preputial length to range from 5.00 to 40.00 mm. The wide-ranging data and discrepancy among reports of preputial size may be partly attributable to confusion regarding what anatomical boundaries actually define the clitoral prepuce or clitoral hood. As a hypothetical example to elaborate on the confusion that might occur due to alternative definitions, when defining a prepuce as the free tissue overlying the glans clitoris, the prepuce might measure 10 mm, whereas, in the same individual, when defining a prepuce as the tissue covering the body of the clitoris along with the free margin, the prepuce might measure 35 mm. When considering the prepuce and hood as distinct structures, one might measure the prepuce (overlying the body of the clitoris) as 25 mm and the hood as 10 mm. So, this hypothetical prepuce can measure 10 mm, 35 mm, and 25 mm in the same individual depending on the definition of “prepuce.”

This report suggests changes to the nomenclature regarding the clitoral prepuce. First, neither prepuce of the clitoris nor clitoral hood should be used to describe the single layer of skin which overlies the body of the clitoris, much like the term prepuce of the penis should not describe the single layer of skin which overlies the body of the penis. This report differentiates the single layer of skin covering the body of the clitoris as its tegmentum corporis, in order to differentiate it from the prepuce (Figure 1). This report describes the free double-layer of skin that overlies the glandopreputial sulcus together with the clitoral collar as the collective prepuce of the clitoris. The prepuce of the clitoris can be structurally subdivided into the collar of the clitoris, which surrounds the neck of the clitoris, and the hood of the clitoris, which typically overlies the collar (Figure 1).

By first identifying the clitoral collar, other aspects of the clitoral prepuce may then be categorized as hood structures. When hood structures are absent, the collar itself forms a pseudo-hood. Such a pseudo-hood, flanked by hemipreputial labia, may be likened to the “lateral hypertrophy” type of prepuce categorized by Liu et al.³ Concerning the use of “hypertrophy” categorization, it seems prudent to have accurate morphometric measurements upon which to objectively define hypertrophy (for example, a “hypertrophic” prepuce size outlier might be classified as greater than two standard deviations from the mean). However, in order to assess the size of the clitoral prepuce, standard structural categorization is a prerequisite. Also, due to the commonplace asymmetry, laterality should also be taken into consideration regarding the clitoral prepuce. Based on the observations of this report, the clitoral prepuce might best be considered as a complex of bilateral structures which are often joined or interdigitate across the midline.

Surgical implications

Differentiating between the tegmentum corporis (i.e., the skin overlying the body of the clitoris) and the prepuce of the clitoris is of surgical importance. Because the dorsal nerves of the clitoris travel just under the tegmentum and arborize as they approach the prepuce and glans of the clitoris,²^,³²^,⁴⁰ making incisions atop the body of the clitoris may place the large dorsal nerves that innervate the sensitive glans clitoris at risk of iatrogenic injury. Even for this reason alone, emphasizing the difference between the single layer of skin overlying the body of the clitoris and the reflected layer of skin overlying the glans of the clitoris (hood) through anatomical language, description, and depiction is important. Differences in dorsal nerve branching as it relates to the innervation of the hood and the collar remain unclear. Likewise, further investigation is warranted with regard to the innervation of the pseudocollar, hemipreputial labia, and secondary hood. Based upon location, the hemipreputial labia and secondary hood may be innervated by the genital branches of the genitofemoral nerves or anterior labial branches from the ilioinguinal nerves.

Also, considering the prepuce as a subdivided anatomical structure, comprised of a “hood” and “collar,” may be useful with regard to operative procedures. Concerning procedures such as hoodplasty, hoodectomy, and dorsal slit surgeries,⁹ it begs the question of whether or not these procedures have involved incisions of the clitoral “collar” in addition to the clitoral “hood.” In other words, have hoodectomies truly been “hoodectomies” or have they been “hood-collar-ectomies”? Likewise, was it the secondary hood, primary hood, and/or collar that was addressed in the operation?

Due to its location, the collar of the clitoris is implicated in glandopreputial adhesions (also referred to as preputial adhesions, clitoral adhesions, and clitoropreputial adhesions) and, accordingly, the development of clitoral pearl and clitoral cyst formation, tissue irritation, pain and discomfort, aberrant sensory function, difficulty with orgasm, and deformation of the clitoris.¹⁴^,18, 19, 20^,22, 23, 24^,²⁶ Thus, inability to visualize the full collar of the clitoris may indicate the presence of adhesions which may require lysis in order to prevent adverse sequelae. Such adhesions may be encountered during routine screenings as well as during preoperative and postoperative assessment. Regarding adhesion lysis, this report documents that the clitoral collar may become edematous upon lysis of glandopreputial adhesions postmortem. Further investigation of collar edema in vivo is warranted.

Clitoral pearls, associated with glandopreputial adhesions, may be found at the collar of the clitoris alongside abutting erythema at the glans. Such erythema may indicate inflammation due to mechanical irritation from the protruding collar pearl. Likewise, a recent study provided photographic examples of the clitoral collar being deformed by a “preputial crater” that might result from a clitoral pearl or clitoral cyst.²⁴ Clitoral pearls located in the substance of the glans clitoris may cause clitorodynia, and removal of the pearls may reduce clitoral pain and improve sexual function.²³^,²⁶ Although speculative, pearls found in the adjacent collar of the clitoris might also cause clitorodynia, and their removal might also potentially reduce clitoral pain and improve sexual function. Thus, postoperative screening and follow-up assessments should include screening for adhesions and accompanying clitoral pearls and clitoral cysts in order to prevent postoperative morbidity.

Conclusion

The results of this report demonstrate that preputial anatomy is more complex and variable than has been commonly represented. In addition to describing anatomical variation of the prepuce of the clitoris, this study identifies a novel anatomical structure and subdivision of the clitoral prepuce. Based upon the commonality of the clitoral collar, it should neither be considered an anatomical variation nor a pathological finding, though it may be subject to pathology including adhesions and clitoral pearls. Accordingly, assessment of the clitoral collar and surrounding structures should be a part of clitoral anatomy screening. In addition to identifying anatomical variations of the clitoral prepuce and detailing a previously undescribed anatomic structure, this study provides a new framework with which to describe varied anatomy of the vulva. The typical prepuce consists of a superficial hood and deep collar. This anatomical insight may help to refine anatomical language and distinguish a prepuce from a “hood.” The hood may join the crest of the labium minus, join at the lateral aspect of the labium minus, or not join at the labium minus at all. Thus, the prepuce should not be considered as a subdivision of the labium minus. Likewise, based upon its unique anatomy, the prepuce should be considered distinct from the tegmentum corporis of the clitoris. The results of this anatomical study have implications for plastic, reconstructive, and aesthetic surgery with respect to preoperative anatomical assessment, operative techniques, and postoperative care.

Funding

None.

Ethical approval

The study was approved by the West Virginia Anatomical Board.

Declaration of competing interest

The author declares no conflicts of interest.

Acknowledgements

The author would like to acknowledge the West Virginia Anatomical Board and the West Virginia University Human Gift Registry. Most importantly, the author would like to acknowledge the individuals who donated their bodies for the advancement of science and healthcare, without whom, this work would not have been possible.

Footnotes

^✰

Sources of Support: None.

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jpra.2026.01.016.

Appendix. Supplementary materials

Supplement 1: A series of images identifying “collar pearls” (black arrowheads), which resemble clitoral keratin pearls often found at the glans clitoris that are known to have clinical importance. The collar pearls are embedded in the tissue of the collar and protrude from the collar as rounded white accretions. Note that the abutting tissues of the glans clitoris may appear erythematous, which might indicate an inflammatory process at the glans due to aberrant mechanical insult from the presence of the collar pearl. Note also that the surface of the glans clitoris abutting the collar pearl may demonstrate surface deformation. A: Collar pearls located along the coronal part of the left-side of the collar in a 57-year-old white female. B: An isolated collar pearl is located at the distal/ventral most aspect of the right side of a collar in a 67-year-old white female. C: A sessile collar pearl is embedded in the left side of the frenular part of a collar in a 62-year-old white female. D: A collar pearl is embedded in the right side of the coronal part of a collar in a 93-year-old white female.

mmc1.jpg^{(1.1MB, jpg)}

Supplement 2: Upon retraction of the clitoral hood and after lysis of glandopreputial adhesions, occasionally the collar of the clitoris would become edematous and turgid. A and B are images taken before (A) and after (B) glandopreputial adhesion lysis in a 72-year-old black female. C and D are images taken before (C) and after (D) glandopreputial adhesion lysis in a 44-year-old white female.

mmc2.jpg^{(1.2MB, jpg)}

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