1

Clitoral Size and Location in Relation to Sexual Function Using

Pelvic MRI

Susan H. Oakley, MD,* Christine M. Vaccaro, DO,*† Catrina C. Crisp, MD,* M. Victoria Estanol, MD,*
Angela N. Fellner, PhD,‡ Steven D. Kleeman, MD,* and Rachel N. Pauls, MD*
*Division of Urogynecology and Pelvic Reconstructive Surgery, Good Samaritan Hospital, Cincinnati, OH, USA;
†
Division of Urogynecology and Pelvic Reconstructive Surgery, Madigan Army Medical Center, Tacoma, WA, USA;
‡
Hatton Institute for Research and Education, Good Samaritan Hospital, Cincinnati, OH, USA

DOI: 10.1111/jsm.12450

ABSTRACT

Introduction. The female sexual response is dynamic; anatomic mechanisms may ease or enhance the intensity of
orgasm.
Aim. The aim of this study is to evaluate the clitoral size and location with regard to female sexual function.
Methods. This cross-sectional TriHealth Institutional Board Review approved study compared 10 sexually active
women with anorgasmia to 20 orgasmic women matched by age and body mass index (BMI). Data included
demographics, sexual history, serum hormone levels, Prolapse/Incontinence Sexual Questionnaire-12 (PISQ-12),
Female Sexual Function Index (FSFI), Body Exposure during Sexual Activity Questionnaire (BESAQ), and Short
Form Health Survey-12. All subjects underwent pelvic magnetic resonance imaging (MRI) without contrast;
measurements of the clitoris were calculated.
Main Outcome Measures. Our primary outcomes were clitoral size and location as measured by noncontrast MRI
imaging in sagittal, coronal, and axial planes.
Results. Thirty premenopausal women completed the study. The mean age was 32 years (standard deviation [SD] 7),
mean BMI 25 (SD 4). The majority was white (90%) and married (61%). Total PISQ-12 (P < 0.001) and total FSFI
(P < 0.001) were higher for orgasmic subjects, indicating better sexual function. On MRI, the area of the clitoral
glans in coronal view was significantly smaller for the anorgasmic group (P = 0.005). A larger distance from the
clitoral glans (51 vs. 45 mm, P = 0.049) and body (29 vs. 21 mm, P = 0.008) to the vaginal lumen was found in the
anorgasmic subjects. For the entire sample, larger distance between the clitoris and the vagina correlated with poorer
scores on the PISQ-12 (r = −0.44, P = 0.02), FSFI (r = −0.43, P = 0.02), and BESAQ (r = −0.37, P = 0.04).
Conclusion. Women with anorgasmia possessed a smaller clitoral glans and clitoral components farther from the
vaginal lumen than women with normal orgasmic function. Oakley SH, Vaccaro CM, Crisp CC, Estanol MV,
Fellner AN, Kleeman SD, and Pauls RN. Clitoral size and location in relation to sexual function using pelvic
MRI. J Sex Med **;**:**–**.
Key Words. Clitoris; Female Sexual Dysfunction; Orgasmic Disorder; Pelvic MRI

Introduction
This research was presented at the Society of Gynecologic
Surgeons’ 39th Annual Scientific Meeting, April 2013,
Charleston, South Carolina.
Condensation:
T he female sexual response is a dynamic
process, involving aspects of desire, arousal,
and orgasm. Difficulty or deficiency in achieving
Women with self reported anorgasmia had a significantly
smaller clitoral glans and greater distance from the clitoral orgasm (female orgasmic disorder) is common;
complex to the vaginal lumen on pelvic MRI. reported rates are between 18% and 34% in

© 2014 International Society for Sexual Medicine J Sex Med **;**:**–**

2 Oakley et al.

population-based analyses [1–5]. Further studies testing was provided at no cost to the patient
have confirmed that only 39–47% of married through a grant by the Medical Education Research
women achieve orgasm with every sexual encoun- Fund at TriHealth Good Samaritan Hospital
ter, and only 12–16% are multiorgasmic [6]. In in Cincinnati, OH, USA. The study received
theory, anatomic and physiologic mechanisms may TriHealth Institutional Board Review approval and
ease the ability or enhance the intensity of female was registered with the U.S. National Institutes of
orgasm. Health Clinical Trials Registry (NCT-01195701).
The clitoral complex, although variable in size Subjects were screened for eligibility by com-
[7], seems to play a central role in genital sensation pleting two validated indices of sexual function.
and orgasm, regardless of route of stimulation [8,9]. These included the Prolapse/Incontinence Sexual
Previous magnetic resonance imaging (MRI) and Questionnaire-12 (PISQ-12) [17] and the Female
anatomic studies have revealed the components of Sexual Function Index (FSFI) [18]. A response of
the clitoris, including the glans, body, crura, bulb, “rarely able” or “never able” to achieve orgasm
and root [10,11]. While the external component of on question #2 of the PISQ-12 and/or a total
the clitoral complex is the glans, the clitoral ure- unadjusted score of ≤6 on the orgasm domain
thral complex (CUC) is formed by the clitoris, of the FSFI was necessary to be categorized as
distal vagina, and urethra [10,12]. Deeper struc- anorgasmic. Normal orgasmic function was
tures including the body, bulbs, and crura are com- defined as the ability to achieve climax in “most”
posed of erectile tissues which may also be of great or “all” sexual encounters, as evaluated by ques-
importance to sexual function [10]. Prior studies tion #2 on the PISQ-12 and/or a total unadjusted
have attempted to detail this relationship by mea- score of ≥12 on the orgasm domain of the FSFI.
suring the urethrovaginal and clitoral–urethral dis- Both of these validated questionnaires inquire
tances and have suggested associations between the about orgasm during sexual activity, which could
position of this organ and ease of vaginal orgasm include caressing, foreplay, masturbation, and
[13,14]. However, very little has focused on the vaginal intercourse.
clitoral–vaginal distance or size of the organ rela- Our study population consisted of 10 sexually
tive to the female response. The available data were active, premenopausal women with anorgasmia.
biased by small sample sizes [15], retrospective Twenty orgasmic women, matched by age and body
evaluation [15], or nongeneralizable populations mass index (BMI), were enrolled as a comparison
undergoing surgery [16] and bear conflicting group (2:1 ratio). Inclusion criteria were as follows:
results. As such, a clear understanding of how these age over 18 years and currently sexually active—
facets of clitoral anatomy impact orgasm is lacking. defined as at least one sexual encounter (i.e.,
vaginal, anal, oral, or manual stimulation) with a
partner in the past 4 weeks. Exclusion criteria were
Aims
sexually inactive, postmenopausal (either natural or
Thus, the purpose of this cross-sectional study surgical—defined as no menses >1 year or climac-
was to determine if the size of the clitoris and its teric symptoms suggestive of menopause), stage >2
location relative to the vagina impact sexual pelvic organ prolapse (vaginal bulge noted beyond
stimulation and subsequent orgasmic function. hymen on physical exam), urinary incontinence
We hypothesized that women with normal orgas- with coitus limiting sexual activity (defined by a
mic function may possess a larger clitoral area or score of ≥3 on items #6 and #7 on the PISQ-12),
a CUC which is closer to the anterior vaginal pregnancy, currently taking selective serotonin
wall compared with women with anorgasmia. reuptake inhibitor, current use of testosterone
supplementation, a history of sexual abuse, any
abnormality in pelvic anatomy, and claustrophobia
Methods
or inability to undergo MRI because of presence of
This was a cross-sectional study at TriHealth Good metallic implants. Sexual dysfunction in the
Samaritan Hospital in Cincinnati, OH, USA. Sub- domain of pain was also an exclusion criteria; this
jects were recruited through their primary gyne- was defined by a score of ≥3 on item #5 of the
cologist’s office or study announcements posted in PISQ-12 and/or a total unadjusted score of ≤6 out
the hospital. All participants provided written of 15 on the pain domain of the FSFI.
informed consent to undergo a pelvic MRI and Following enrollment, subjects completed a
serum laboratory evaluation, and complete several detailed demographic and sexual history, validated
questionnaires. The pelvic MRI and laboratory sexual function and general health questionnaires,

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Impact of Clitoral Size and Location on Female Orgasm 3

laboratory evaluation, and a pelvic MRI. Demo-

graphic data obtained included age, weight,
height, parity, marital status, race, chronic medical
conditions, prior pelvic surgery, and medications
influencing sexual function. A detailed sexual
history was obtained which included the number
of sexual encounters in the past 4 weeks (i.e.,
vaginal, anal, oral, and/or manual stimulation), the
percentage of time to orgasm, and the ease of
orgasm with each type of sexual encounter. In
addition, the preferred sexual position (i.e., mis-
sionary, female dominant, etc.) to maximize likeli-
hood of climax was ranked in order from most
preferred (1) to least preferred (5). Validated
questionnaires were obtained: PISQ-12, which
Figure 1 MRI of the female pelvis in sagittal view demon-
evaluates sexual function in women with urinary
strating the “boomerang” appearance of the clitoris (the
incontinence and/or pelvic organ prolapse with length and width of each component was obtained).
higher score indicating better sexual function [17];
FSFI, a sexual function questionnaire to detect
female sexual dysfunction in which a total score
≤26.55 suggests sexual dysfunction and individual images from which the standardized measurements
domains of desire, arousal, lubrication, orgasm, were then obtained [15].
satisfaction, and pain may be analyzed (maximum All anatomic measurements were performed
adjusted score in each domain being 6) [18,19]; using the general electric picture archiving system/
Body Exposure during Sexual Activity Question- centricity system for radiology which has ruler
naire (BESAQ), a body image questionnaire mea- and angle measurement functions scaled to each
suring the extent to which one feels self-conscious specific image. Each subject underwent the same
during sex with the higher values suggesting measurements from all imaging angles. The
more self-consciousness regarding body exposure sagittal-dependent variables measured were glans
during sexual activity [20]; and Short Form Health width, glans length, calculated glans area, body
Survey-12 (SF-12), a general health questionnaire width, body length, calculated body area, distance
with higher scores indicating a higher physical and from inferior aspect of glans to the anterior vaginal
mental functioning [21]. wall, distance from the body to the anterior vaginal
Recent publications regarding clitoral anatomy wall, proximal vaginal length, distal vaginal length,
and the use of pelvic MRI were referenced to calculated total vaginal length (TVL), and distance
develop a consistent method of anatomic measure- between the midproximal urethra and midvagina.
ment [11,22,23]. The Siemens 1.5 Tesla Avanto All sagittal area measurements were calculated by
(Siemens Medical Solutions USA Inc., Malvern, approximating the glans and body structures to a
PA, USA) was used to image each subject with a rectangular geometry based on concepts intro-
protein density fat saturation sequence with an duced by Huffman [24]. Figure 1 illustrates the
average slice thickness of 4 mm in the axial, sagittal, sagittal view of clitoral components from which
and coronal planes. In addition, an axial Short TI measurements were taken.
Inversion Recovery sequence with slice thickness of The axial-dependent variables measured were
6 mm was used. Several test subjects were imaged body base, body height, calculated body area, crus
to ensure standardization of measurements. A base, crus height, calculated crus area, distance
pelvic coil, used to enhance clitoral imaging, was between the medial aspect of the anterior vaginal
placed low on the pelvis between the umbilicus and wall to the body, distance between the lateral
the upper thighs. Additionally, each subject was aspect of the anterior vaginal wall to the medial
positioned supine with ischial tuberosities flat on aspect of the crus, and the distance between the
the table, confirmed by scout imaging. This anterior body to the skin. Figure 2 illustrates a
approach ensured symmetry of clitoral measure- sample of the distances obtained. The axial area
ments. During imaging, individual pelvic MRIs measurements were calculated by approximating
were reviewed by the blinded investigators (S.O. the body and crus structures to a triangular geom-
and C.V.) for the optimal sagittal, coronal, and axial etry. The coronal-dependent variables measured

J Sex Med **;**:**–**

4 Oakley et al.

30 subjects. Our sample size calculation was per-

formed using n-Query Advisor 7.0 (Statistical
Solutions, Saugas, MA, USA).
Statistical analysis was performed using IBM
spss Statistics version 19.0 (SPSS Inc., an IBM
Company, Chicago, IL, USA). Descriptive statis-
tics were calculated for subject demographics and
dependent variables. Additional data were ana-
lyzed using Student’s t-test, Pearson’s correlation,
and univariate anova. The Mann–Whitney U and
Wilcoxon’s signed rank test were applied to non-
parametric data. The MRI technicians and statis-
tician were blinded regarding clitoral imaging and
data entry and analysis.
Figure 2 Sagittal MRI illustrating a sample of distance
measurements taken (solid line represents the distance Main Outcome Measures
from the clitoral glans to the vaginal lumen; dashed lines
represent the distance from the clitoral body to the vaginal Our primary outcomes were clitoral size and loca-
lumen; dotted lines represent the vaginal length). tion as measured by noncontrast MRI imaging in
sagittal, coronal, and axial planes. Secondary mea-
sures of sexual functioning and general quality of
were: glans width, glans length, and calculated life included serum hormones markers (total and
glans area, as illustrated by Figure 3. free testosterone, SHBG, and estradiol) and vali-
All measurements were straight line distances dated questionnaires including the FSFI, PISQ-
measured in millimeters and at right angles to the 12, BESAQ, and SF-12.
structures being measured, when possible. All axial
and coronal measurements were of the patient’s
Results
left side. However, for the purposes of analysis, the
measurements were not doubled. In addition, all Thirty-five women were screened for participa-
subjects were asked to refrain from any form of tion: four failed to return for testing, and one
genital stimulation for at least 24 hours prior to orgasmic subject was not able to be matched.
undergoing imaging. Thus, 30 women completed the study. The mean
Serum hormone levels (total and free testoster- age was 32 years (standard deviation [SD] 7), mean
one, sex hormone binding globulin (SHBG), and BMI 25 (SD 4). The majority was white (90%) and
estradiol) were drawn during the follicular phase married (61%). Mean number of vaginal deliveries
of each subject’s menstrual cycle, approximately
7–10 days after the first day of menstrual bleeding.
Free androgen index was calculated using the total
testosterone and SHBG as per the standard
formula [25,26]. As use of hormonal contraception
was not an exclusion criterion, each subject was
asked to stop their hormonal contraception 7 days
prior to their testing and imaging unless long-
acting reversible contraception was in place.
The initial validation paper for the FSFI docu-
mented a mean difference of 2.07 for the domain
of orgasm between normal and dysfunctional sub-
jects. Using a similar difference for our study, we
determined a sample size of 10 participants with
anorgasmia, and 10 normal subjects would be nec-
essary (90% power, alpha <0.05) [18]. However, to
improve upon the ability to detect a difference, a Figure 3 MRI coronal view illustrating measurements
2:1 ratio of orgasmic subjects to anorgasmic sub- taken of the clitoral glans (solid white lines indicating length
jects was selected, yielding an enrollment goal of and width).

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Impact of Clitoral Size and Location on Female Orgasm 5

Table 1 Characteristics of sample: general demographics

Total sample Anorgasmic group Orgasmic group
N = 30 N = 10 N = 20 P value
Age, mean (SD)* 31.6 (7.4) 31.7 (8.2) 31.6 (7.2) 0.973
BMI, mean (SD)* 24.8 (4.4) 25.3 (4.9) 24.6 (4.2) 0.685
Race† N = 30 N = 10 N = 20 0.299
Caucasian, n (%) 27 (90.0) 8 (80.0) 19 (95.0)
African American, n (%) 1 (3.3) 1 (10.0) 0 (0)
Asian, n (%) 2 (6.7) 1 (10.0) 1 (5.0)
Marital status† N = 28 N = 10 N = 18 0.108
Single, n (%) 2 (7.1) 0 (0) 2 (11.1)
Married, n (%) 17 (60.7) 9 (90.0) 8 (44.4)
Divorced, n (%) 4 (14.3) 0 (0) 4 (22.2)
Relationship, n (%) 5 (17.9) 1 (10.0) 4 (22.2)

*Student’s t-test
†Pearson Chi-Square

was 0.66 (range 0–4), whereas the mean number of Serum Hormone Levels
cesarean deliveries was 0.08 (range 0–1) (not For laboratory values, the SHBG was unexpectedly
shown). Demographics were not significantly dif- higher in the orgasmic group (102 vs. 69nmol/L,
ferent between groups (Table 1). All subjects P = 0.017). Despite this there were no significant
described themselves as heterosexual (Table 2). differences noted in other serum hormone levels of
estradiol, total testosterone, or calculated values of
Questionnaires the FAI (Table 4).
First, responses on the validated questionnaire
scores were evaluated. Total PISQ-12 (P < 0.001)
and total FSFI (P < 0.001) were higher for orgasmic MRI Measurements
subjects. A mean difference on question 11 of the Regarding MRI measurements for all subjects, the
FSFI orgasm domain was notably higher in the area of the clitoral glans was 111 mm2 (SD 61) in
orgasmic patients with a score of 4.6 vs. 1.6 coronal view and 115 mm2 (SD 44) in sagittal view.
(P < 0.001). Furthermore, overall FSFI domain Notably, the area of the glans in coronal view was
score of orgasm was significantly higher in these significantly smaller for the anorgasmic group
subjects (P < 0.001). However, there was no differ- (66.4 vs. 129.2 mm2, P = 0.005). Additionally, a
ence between groups for the SF-12 or BESAQ larger distance from the clitoral glans (51.3 vs.
scores (P = 0.075) (Table 3). 45.1 mm2, P = 0.049) and body (29.4 vs. 20.6 mm2,

Table 2 Characteristics of Sample—sexual history

Total sample Anorgasmic group Orgasmic group
N = 30 N = 10 N = 20 P value
‡
Number of months with current partner, median (IQR) 56.5 (12.8, 111.5) 7.0 (25.5, 165.0) 52.5 (6.2, 106.5) 0.245
N = 28 N = 10 N = 18
Number of sexual encounters per month, n (%)† N = 30 N = 10 N = 20 0.335
0–4, n (%) 9 (30.0) 2 (20.0) 7 (35.0)
5–8, n (%) 8 (26.7) 4 (40.0) 4 (20.0)
9–12, n (%) 6 (20.0) 3 (30.0) 3 (15.0)
>12, n (%) 7 (23.3) 1 (10.0) 6 (30.0)
Sexual position preferred most, n (%)† N = 29 N = 10 N = 19 0.020
Missionary, n (%) 11 (37.9) 6 (60.0) 5 (26.3)
Female dominant, n (%) 7 (24.1) 0 (0) 7 (36.8)
Female on all fours, n (%) 2 (6.9) 2 (20.0) 0 (0)
Manual, n (%) 5 (17.2) 2 (20.0) 3 (15.8)
Oral, n (%) 4 (13.8() 0 (0) 4 (21.1)

*Student’s t-test
†
Pearson Chi-Square
‡Mann-Whitney U test

IQR = interquartile range; SD = standard deviation

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6 Oakley et al.

Table 3 Responses to validated questionnaires between groups

Anorgasmic group Orgasmic group Mean
N = 10 N = 20 difference P value
PISQ-12 Total, mean (SD)* †
30.89 (4.6) 41.83 (2.2) 10.9 (4.8) <0.001
BESAQ, mean (SD)* 1.5 (0.9) 1.1 (0.5) 0.5 (1.0) 0.155
SF-12*
Total, mean (SD) 32.6 (2.4) 31.7 (1.0) 0.9 (2.7) 0.317
PCS, mean (SD) 56.1 (2.1) 56.6 (1.6) –0.5 (3.0) 0.629
MCS, mean (SD) 49.4 (6.7) 49.8 (6.9) –0.48 (12.3) 0.905
Female Sexual Function Index*
Desire, mean (SD) 2.6 (1.4) 4.8 (0.7) –2.2 (1.5) 0.001
Arousal, mean (SD) 3.2 (0.7) 5.4 (0.6) –2.2 (1.0) <0.001
Lubrication, mean (SD) 4.0 (1.3) 5.5 (0.5) –1.5 (1.4) 0.008
Orgasm, mean (SD) 1.9 (0.7) 5.6 (0.6) –3.7 (1.1) <0.001
Question #11, mean (SD) 1.6 (1.0) 4.6 (0.9) –3.0 (0.4) <0.001
Satisfaction, mean (SD) 3.6 (1.3) 4.8 (0.8) –1.2 (1.9) 0.078
Pain, mean (SD) 4.9 (1.1) 5.5 (0.6) –0.7 (1.2) 0.128
Total, mean (SD) 20.2 (4.4) 31.6 (2.7) –11.4 (6.0) <0.001

*Paired samples t-test

†Data missing for one case (N = 9)

BESAQ = Body Exposure During Sexual Activity Questionnaire; MCS = Mental Component Score; PCS = Physical Component Score; PISQ = Pelvic Organ
Prolapse/Urinary Incontinence Sexual Function Questionnaire; SD = standard deviation; SF-12 = 12-Item Short-Form Health Survey

P = 0.008) to the vaginal lumen was found in the Correlations

anorgasmic subjects in the sagittal view. Finally, Pearson’s correlations were calculated to deter-
TVL was shorter for this group than for orgasmic mine associations among several important vari-
women (8.5 vs. 9.5 cm, P = 0.005) (Table 5). ables. All validated questionnaires were correlated

Table 4 Serum levels of hormones between groups

Anorgasmic group Orgasmic group
N = 10 N = 20 P value
Sex hormone binding globulin, median (IQR)* 69.0 (54.5, 98.0) 101.5 (68.9, 148.1) 0.017
Estradiol, mean (SD)† 74.1 (34.5) 62.2 (27.2) 0.469
Free testosterone, median (IQR)* 2.6 (1.9, 4.6) 2.5 (2.2, 3.7) 0.445
Total testosterone, median (IQR)* 26.5 (18.2, 53.2) 33.0 (28.6, 43.9) 0.440
Free androgen index, median (IQR)* 1.3 (0.9, 2.4) 1.2 (1.0, 1.8) 0.333

*Related-samples Wilcoxon signed rank test

†
Paired samples t-test
IQR = interquartile range; SD = standard deviation

Table 5 MRI measurements between groups

Anorgasmic group Orgasmic group
N = 10 N = 20 P value
†
Glans area, sagittal 51.8 (30.14, 94.5) 73.2 (59.6, 95.0) 0.093
Body area, sagittal* 131.3 (58.9) 106.4 (31.7) 0.243
Bulb area, sagittal* 134.7 (38.7) 119.0 (24.2) 0.246
Crura area, axial* 185.8 (68.8) 170.8 (26.4) 0.506
Body area, axial* 89.0 (26.0) 71.2 (12.9) 0.080
Glans area, coronal† 66.4 (40.2, 80.1) 129.2 (100.0, 154.2) 0.005
Glans distance, sagittal* 51.3 (7.6) 45.1 (5.7) 0.049
Body distance, sagittal* 29.4 (6.8) 20.6 (3.2) 0.008
Crura distance, medial axial* 24.2 (5.2) 28.3 (4.6) 0.086
Crura distance lateral axial* 15.6 (6.1) 23.8 (3.7) 0.002
Total vaginal length* 84.5 (11.1) 94.9 (6.5) 0.005
Clitoris to skin distance* 26.6 (11.4) 27.0 (6.2) 0.878
Midurethra-midvagina distance* 13.3 (2.5) 12.6 (1.0) 0.397

Area in mm2; distance in mm

*Mean (SD); Paired samples t-test
†Median (IQR); Related-samples Wilcoxon signed rank test

IQR = interquartile range; SD = standard deviation

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Impact of Clitoral Size and Location on Female Orgasm 7

to one another, to all MRI measurements, and to consciousness [BESAQ]), clitoral measurements
each serum hormone level; then, all MRI measure- differed significantly. In addition, we reported
ments were correlated with each serum hormone several significant differences in women with
level. The total PISQ scores had a positive corre- anorgasmia, in particular regarding clitoral prox-
lation with total BESAQ scores (r = 0.67, P < imity to the vaginal lumen. Such findings support
0.001) and a negative correlation with total FSFI that clitoral characteristics impact female sexual
scores (r = −0.88, P < 0.001), whereas the negative symptoms.
correlation with the SF-12 mental and physical The prior literature evaluating clitoral charac-
components was not significant. A larger distance teristics with respect to female sexual symptoms is
between the clitoral body and the vagina in sagittal limited. Recent research using cadaveric dissection
view correlated with poorer scores on the PISQ-12 and histologic examination has documented the
(r = −0.44, P = 0.02), FSFI (r = −0.43, P = 0.02), intricate neuroanatomy of the clitoris and strongly
and BESAQ (r = 0.37, P = 0.04). Although supported its central role in sexual eroticism and
PISQ-12 and FSFI scores did not significantly cor- climax [12]. A previous cohort study, performed at
relate with serum hormone levels, free testosterone our institution, suggested that women with normal
(r = 0.5, P = 0.007) and FAI (r = 0.5, P = 0.013) did orgasmic function had a smaller clitoral complex
correlate with a higher BESAQ score and total on MRI [15]. However, we believe the small
testosterone (r = −0.41, P = 0.025), and SHBG sample size, retrospective design, and the con-
(r = −0.45, P = 0.013) did correlate with a lower founding effect of the patient’s comorbidities ren-
score on the SF-12 physical component. MRI mea- dered these findings unreliable. Ultimately, the
surements of the clitoral glans area in the sagittal question of size influencing function or function
view correlated positively with free testosterone (usage) influencing size is controversial. In 2005,
(r = 0.466, P = 0.009), total testosterone (r = 0.535, Lloyd et al. concluded that clitoral dimensions,
P = 0.002), and FAI (r = 0.427, P = 0.019), suggest- although varying widely in a population of 50 pre-
ing a larger area in those with higher levels of menopausal women, were not significantly associ-
androgens. In axial view, a larger clitoral body was ated with age, parity, ethnicity, hormonal use, or a
noted with a higher estradiol level (r = 0.390, history of sexual activity [7]. However, a photo-
P = 0.037). All other relationships were not signifi- graphic method of measuring sizes and distances
cantly associated. was employed in contrast to our study design, pos-
sibly accounting for their lack of significant find-
Other Analyses ings. In a recent Lancet study, Foldès et al.
Anorgasmic women tended to prefer the mission- revealed that reconstructive surgery approximately
ary position (60%), whereas the female dominant 20 years after female genital mutilation procedures
position was favored in orgasmic subjects (37%, on African women resulted in reduced pain and
P = 0.02). The remaining choices of sexual activity restored sexual functioning [16]. Athough their
(rear entry vaginal, manual stimulation, oral study population is not generalizable and validated
stimulation, and anal intercourse) were favored indices were not used, it suggests that clitoral size
evenly within the groups with manual and oral could influence achievement of sexual pleasure
ranking lowest in both groups and anal not (usage). Nonetheless, sexual pleasure could also
ranking at all. After further analysis, no other rela- influence size, particularly during arousal and
tionships were found based on sexual history. engorgement. Ultrasound studies during coitus
have demonstrated engorgement of clitoral struc-
tures and a stretching effect of the penis in the
Conclusion
vagina such that there is consequently a close rela-
This cross-sectional study evaluated detailed clito- tionship between the clitoral root and anterior
ral measurements using noncontrast pelvic MRI in vagina wall [8]. Although this research included
order to assess potential differences in women with one couple and no evidence of orgasm, our study
anorgasmia from those with normal orgasmic similarly found that a shorter distance (even
function. Validated questionnaires and serum hor- without coitus) between the clitoris and vagina
monal profiles were utilized to document other correlates with improved sexual function.
relationships and confirm patient symptomatol- Concerning clitoral location, a previous case
ogy. Although important sexual function variables report illustrated that a closer proximity of the
were similar between subjects (i.e., mental and clitoris to the vaginal lumen was associated with
physical function [SF-12 MCS and PCS], and self- multiorgasmic sexual function for that subject [27].

J Sex Med **;**:**–**

8 Oakley et al.

However, the report included only one female, and one levels in those with dysfunction; SHBG did
her anatomy was not typical. Other studies have not differ significantly [29,30]. Our study reveals
examined distances between the clitoris and similar findings with a lower total testosterone in
urethra, reporting that a shorter distance increased the anorgasmic group. Although the use of birth
a woman’s likelihood of experiencing orgasm in control was not an exclusion criteria, the presence
intercourse [13]. In 2010, Wallen and Lloyd used of exogenous hormones from birth control circu-
samples from two investigations in the 1920s and lating 7–10 days after discontinuing may have
1940s to conduct an analysis years later and admit- raised SHBG levels in both groups. It has been
tedly reported there were “significant differences documented by prior authors that women taking
between the two samples in both characteristics of hormone-based contraceptive methods may have
data and the extent of the relationship” between decreased circulating androgens, and this can con-
distance and orgasm. Nonetheless, their data sets tribute to diminished libido [31]. Although we did
both purported a significant association between not control for this factor in our methods, we did
clitoral–urethral distance and vaginal orgasm. An not note any difference among groups regarding
ultrasound-based subanalysis of 20 healthy women usage of birth control. Therefore, we are unable to
without sexual dysfunction correlated a “thicker” explain the elevated levels in our orgasmic group.
urethrovaginal space with likelihood of vaginal Finally, PISQ-12 and FSFI total scores were
orgasm [14]. The findings of our study confirm higher for orgasmic subjects, indicating a better
that the proximity of the clitoris to the vagina may quality of sexual health and specifically a lack of
be critical in enhancing sexual sensation although orgasmic dysfunction which concurs with the vali-
we did not distinguish between clitoral–urethral dation studies by Rogers [15] and Rosen [17],
and urethrovaginal spaces, as in the aforemen- respectively. Although the groups were screened
tioned studies. Although the actual distances were and deemed eligible based on the orgasm-specific
not large, they are likely clinically relevant as sig- portions of these questionnaires, the significant
nificant associations between these measures and difference in total scores gives credence to
lower scores on several validated questionnaires our findings and correlations. Still, previously
were noted. published reports on female sexual function, par-
Another imaging study from O’Connell and ticularly orgasm, contend that the topic is con-
DeLancey evaluated the clitoris by MRI and deter- troversial, and the “assumption that women may
mined that structures were best displayed using a experience only the clitoral, external orgasm is
fat saturation technique without contrast and sug- not based on” adequate scientific evidence [9].
gested that axial planes displayed the clearest Although both our study groups preferred vaginal
images [11]. Although our subjects were similarly penetration (missionary position or female domi-
premenopausal, their report was restricted to nul- nant position), the orgasmic group was more
liparous women without known sexual dysfunction successful in achieving climax. In both vaginal
and limited by including only a series of 10 as part intercourse approaches, direct contact with clitoral
of a larger study evaluating the effects of a first tissue is possible and could be impacted by location
birth. Thus, we believe it was reasonable to use all relative to the vagina. During female dominant
imaging planes in our study design as our popula- intercourse, an increased possibility of direct
tions were different. contact with the external components of the clitoris
Though not specific to orgasmic women, we exists. Still, a shorter distance between the clitoris
found a larger clitoral glans correlated with higher and vagina was also found in the orgasmic group
androgen and estradiol levels. This suggests that preferring a male dominant position positing that
clitoral tissue is responsive to serum hormones, vaginal displacement by the penis to allow the cli-
which is similar to other reports [28]. The signifi- toris to come into direct contact with the anterior
cant difference in SHBG levels noted between vaginal wall may affect pleasure.
groups has limited clinical importance, given the Strengths of this study include our stringent
FAI was the same in both groups. Recent studies inclusion and exclusion criteria. We used several
examining the serum androgen levels in healthy validated indices to quantify symptomatology as
premenopausal women illustrated a stepwise well as to ensure an appropriate diagnosis in those
decline in androgens with age, with an FAI that enrolled. An age- and BMI-matched comparison
mirrors this decline. Furthermore, an age- group, as well as subjects undergoing all testing
matched comparison between women with and in the follicular phase after refraining from genital
without sexual dysfunction noted lower testoster- sensation, limited confounders. Furthermore,

J Sex Med **;**:**–**

Impact of Clitoral Size and Location on Female Orgasm 9

serum lab testing provided additional information Financial Support: Funding provided by an educational
to clarify other related factors and comorbidities. grant from TriHealth Good Samaritan Hospital
Our MRI technicians, reviewers, and statistician Medical Education Research Fund, Cincinnati, Ohio.
were blinded regarding clitoral imaging and data Military Disclaimer: Christine Vaccaro, DO, MAJ, MC,
entry and analysis. Finally, significant differences USA is a military service member. This work was
were noted between our anorgasmic and orgasmic prepared as part of her official duties. The views
subjects on the validated questionnaires, confirm- expressed in this article are those of the authors and do
ing the robust difference between these groups and not necessarily reflect the official policy or position of
supporting that our sample size was sufficient. Nev- the Department of the Navy, Department of Defense,
ertheless, we recognize the potential for limita- nor the U.S. Government.
tions. We were restricted to recruitment based on
patient self- reported symptoms and were aware of References
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