Differential diagnostics of female “sexual” fluids: a narrative review

Abstract

Introduction and hypothesis

Women expel various kinds of fluids during sexual activities. These are manifestations of sexual arousal and orgasm or coital incontinence. This study is aimed at suggesting a diagnostic scheme to differentiate among these phenomena.

Methods

Web of Science and Ovid (MEDLINE) databases were systematically searched from 1950 to 2017 for articles on various fluid expulsion phenomena in women during sexual activities, which contain relevant information on sources and composition of the expelled fluids.

Results

An ultra-filtrate of blood plasma of variable quantity, which is composed of transvaginal transudate at sexual stimulation, enables vaginal lubrication. Female ejaculation (FE) is the secretion of a few milliliters of thick, milky fluid by the female prostate (Skene’s glands) during orgasm, which contains prostate-specific antigen. Squirting (SQ) is defined as the orgasmic transurethral expulsion of tenths of milliliters of a form of urine containing various concentrations of urea, creatinine, and uric acid. FE and SQ are two phenomena with different mechanisms. Coital incontinence (CI) could be classified into penetration and orgasm forms, which could be associated with stress urinary incontinence or detrusor hyperactivity.

Conclusion

Squirting, FE, and CI are different phenomena with various mechanisms and could be differentiated according to source, quantity, expulsion mechanism, and subjective feelings during sexual activities.

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References

  1. 1.

    Kratochvíl S. Orgasmic expulsions in women. Cesk Psychiatr. 1994;90:71–7.

    PubMed  Google Scholar 

  2. 2.

    Perry JD, Whipple B. Pelvic muscle strength of female ejaculators: evidence in support of a new theory of orgasm. J Sex Res. 1981;17:22–39.

    Article  Google Scholar 

  3. 3.

    Zaviačič M. The human female prostate. Bratislava: Slovak Academic Press; 1999.

    Google Scholar 

  4. 4.

    Darling CA, Davidson JK, Conwaywelch C. Female ejaculation: perceived origins, the Grafenberg spot area, and sexual responsiveness. Arch Sex Behav. 1990;19:29–47.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Bullough B, David M, Whipple B, Dixon J, Allgeier ER, Drury KC. Subjective reports of female orgasmic expulsion of fluid. Nurse Pract. 1984;9:55–9.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Goldberg DC, Whipple B, Fishkin RE, Waxman H, Fink PJ, Weisberg M. The Grafenberg spot and female ejaculation: a review of initial hypotheses. J Sex Marital Ther. 1983;9:27–37.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Schubach G. Urethral expulsions during sensual arousal and bladder catheterization in seven human females. E J Hum Sex. 2001;4. http://www.ejhs.org/volume4/Schubach/abstract.html. Accessed 26 July 2012.

  8. 8.

    Zaviačič M, Zaviačičová A, Holomán IK, Molčan J. Female urethral expulsions evoked by local digital stimulation of the G-spot: differences in the response pattern. J Sex Res. 1988;24:311–8.

    Article  PubMed  Google Scholar 

  9. 9.

    Wimpissinger F, Springer C, Stackl W. International online survey: female ejaculation has a positive impact on women’s and their partners’ sexual lives. BJU Int. 2013;112:177–85.

    Article  Google Scholar 

  10. 10.

    Rubio-Casillas A, Jannini EA. New insights from one case of female ejaculation. J Sex Med. 2011;8:3500–4.

    Article  PubMed  Google Scholar 

  11. 11.

    Korda JB, Goldstein SW, Sommer F. The history of female ejaculation. J Sex Med. 2010;7:1965–75.

    Article  PubMed  Google Scholar 

  12. 12.

    Sevely JL, Bennett JW. Concerning female ejaculation and the female prostate. J Sex Res. 1978;14:1–20.

    Article  Google Scholar 

  13. 13.

    Addiego F, Belzer EG, Commoli J, Moger W, Perry JD, Whipple B. Female ejaculation. A case study. J Sex Res. 1981;17:13–21.

    Article  Google Scholar 

  14. 14.

    Salama S, Boitrelle F, Gauquelin A, Malagrida L, Thiounn N, Desvaux P. Nature and origin of “squirting” in female sexuality. J Sex Med. 2015;12:661–6.

    Article  PubMed  Google Scholar 

  15. 15.

    Pastor Z. Female ejaculation orgasm vs. coital incontinence: a systematic review. J Sex Med. 2013;10:1682–91.

    Article  PubMed  Google Scholar 

  16. 16.

    Grafenberg E. The role of the urethra in female orgasm. Int J Sex. 1950;3:145–8.

    Google Scholar 

  17. 17.

    Heath D. Female ejaculation: its relationship to disturbances of erotic function. Med Hypotheses. 1987;24:103–6.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Heath D. An investigation into the origins of a copious vaginal discharge during intercourse: “enough to wet the bed”—that “is not urine”. J Sex Res. 1984;20:194–215.

    Article  Google Scholar 

  19. 19.

    Wimpissinger F, Stifter K, Grin W, Stackl W. The female prostate revisited: perineal ultrasound and biochemical studies of female ejaculate. J Sex Med. 2007;4:1388–93.

    Article  PubMed  Google Scholar 

  20. 20.

    Belzer EG. Orgasmic expulsions of women: a review and heuristic inquiry. J Sex Res. 1981;17:1–12.

    Article  Google Scholar 

  21. 21.

    Zaviačič M, Doležalová S, Holomán IK, Zaviačičová A, Mikulecký M. Concentrations of fructose in female ejaculate and urine: a comparative biochemical study. J Sex Res. 1988;24:319–25.

    Article  PubMed  Google Scholar 

  22. 22.

    Kinsey AC, Pomeroy WB, Martin CE. Sexual behaviour in the human female. Oxford: Saunders; 1953.

    Google Scholar 

  23. 23.

    Belzer EG Jr. A review of female ejaculation and the Grafenberg spot. Women Health. 1984;9:5–16.

    Article  PubMed  Google Scholar 

  24. 24.

    Levin RJ, Wagner G. Human vaginal fluid-ionic composition and modification by sexual arousal. J Physiol. 1977;266:62P–3P.

    CAS  PubMed  Google Scholar 

  25. 25.

    Levin RJ, Both S, Georgiadis J, Kukkonen T, Park K, Yang CC. The physiology of female sexual function and the pathophysiology of female sexual dysfunction (committee 13A). J Sex Med. 2016;13:733–59.

    Article  PubMed  Google Scholar 

  26. 26.

    Preti G, Huggins GR, Silverberg GD. Alterations in the organic compounds of vaginal secretions caused by sexual arousal. Fertil Steril. 1979;32:47–54.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Moller BR, Kaspersen P. The acidity of the vagina. In: Horowitz BJ, Mardh PA, editors. Vaginitis and vaginosis. New York: Wiley-Liss; 1991. p. 63–7.

    Google Scholar 

  28. 28.

    Wagner G, Levin RJ. Vaginal fluid. In: Hafez ESE, Evans TN, editors. The human vagina. Amsterdam: North Holland Publishing Co; 1978. p. 121–38.

    Google Scholar 

  29. 29.

    Wagner G, Levin RJ. Electrolytes in vaginal fluid during the menstrual cycle of coitally active and inactive women. J Reprod Fertil. 1980;60:17–27.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Godley MJ. Quantitation of vaginal discharge in healthy volunteers. BJOG. 1985;92:739–42.

    CAS  Article  Google Scholar 

  31. 31.

    Dawson SJ, Sawatsky ML, Lalumiere ML. Assessment of introital lubrication. Arch Sex Behav. 2015;44:1527–35.

    Article  PubMed  Google Scholar 

  32. 32.

    Owen DH, Katz DF. A vaginal fluid simulant. Contraception. 1999;59:91–5.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Zaviačič M, Zajičková M, Blažeková J, et al. Weight, size, macroanatomy, and histology of the normal prostate in the adult human female: a minireview. J Histotechnol. 2000;23:61–9.

    Article  Google Scholar 

  34. 34.

    Cartwright R, Elvy S, Cardozo L. Do women with female ejaculation have detrusor overactivity? J Sex Med. 2007;4:1655–8.

    Article  PubMed  Google Scholar 

  35. 35.

    Levin RJ, Wylie K. Vaginal vasomotion: its appearance, measurement, and usefulness in assessing the mechanisms of vasodilatation. J Sex Med. 2008;5:377–86.

    Article  PubMed  Google Scholar 

  36. 36.

    Levin RJ. Actions of spermicidal and virucidal agents on electrogenic ion transfer across human vaginal epithelium in vitro. Pharmacol Toxicol. 1997;81:219–25.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Belzer EG Jr, Whipple B, Moger W. On female ejaculation. J Sex Res. 1984;20(4):403–6.

    Article  Google Scholar 

  38. 38.

    Skene AJC. The anatomy and pathology of two important glands of the female urethra. Am J Obstet Dis Women Child. 1880;13:265–70.

    Google Scholar 

  39. 39.

    Huffman JW. The detailed anatomy of paraurethral ducts in the adult human female. Am J Obstet Gynecol. 1948;55:86–101.

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Dwyer PL. Skene’s gland revisited: function, dysfunction and the G spot. Int Urogynecol J. 2012;23:135–7.

    Article  PubMed  Google Scholar 

  41. 41.

    Dietrich W, Susani M, Stifter L, Haitel A. The human female prostate-immunohistochemical study with prostate-specific antigen, prostate-specific alkaline phosphatase, and androgen receptor and 3-D remodeling. J Sex Med. 2011;8:2816–21.

    Article  PubMed  Google Scholar 

  42. 42.

    Wimpissinger F, Tscherney R, Stackl W. Magnetic resonance imaging of female prostate pathology. J Sex Med. 2009;6:1704–11.

    Article  PubMed  Google Scholar 

  43. 43.

    WHO laboratory manual for the examination and processing of human semen. 2010. WHO web. http://apps.who.int/iris/bitstream/10665/44261/1/9789241547789_eng.pdf. Accessed 20 July 2017.

  44. 44.

    Owen DH, Katz DF. A review of the physical and chemical properties of human semen and the formulation of a semen simulant. J Androl. 2005;26:459–69.

    CAS  Article  PubMed  Google Scholar 

  45. 45.

    Cooper TG, Noonan E, von Eckardstein, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update. 2010;16:231–45.

    Article  PubMed  Google Scholar 

  46. 46.

    Coffey D. What is the prostate and what is its function? In: Robaire B, Pryor JL, Trasler JM, editors. Handbook of andrology. Lawrence: Allen Press Inc.; 1995.

    Google Scholar 

  47. 47.

    Biancardi MF, dos Santos FCA, de Carvalho HF, Sanches BDA, Taboga SR. Female prostate: historical, developmental, and morphological perspectives. Cell Biol Int. 2017;41:1174–83.

    Article  PubMed  Google Scholar 

  48. 48.

    Lilja H. A kallikrein-like serine protease in prostatic fluid cleaves the predominant seminal vesicle protein. J Clin Invest. 1985;76:1899–903.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Moalem S, Reidenberg JS. Does female ejaculation serve an antimicrobial purpose? Med Hypotheses. 2009;73:1069–71.

    Article  PubMed  Google Scholar 

  50. 50.

    Haylen B, De Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol. 2010;21:5–26.

    Article  Google Scholar 

  51. 51.

    Serati M, Salvatore S, Uccella S, et al. Urinary incontinence at orgasm: relation to detrusor overactivity and treatment efficacy. Eur Urol. 2008;54:911–7.

    Article  PubMed  Google Scholar 

  52. 52.

    Serati M, Salvatore S, Uccella S, Nappi RE, Bolis P. Female urinary incontinence during intercourse: a review on an understudied problem for women’s sexuality. J Sex Med. 2009;6:40–8.

    Article  PubMed  Google Scholar 

  53. 53.

    Lau H-H, Huang W-C, Su T-H. Urinary leakage during sexual intercourse among women with incontinence: incidence and risk factors. PLoS One. 2017;12:e0177075.

    Article  PubMed  PubMed Central  Google Scholar 

  54. 54.

    Jha S, Strelley K, Radley S. Incontinence during intercourse: myths unravelled. Int Urogynecol J. 2012;23:633–7.

    Article  PubMed  Google Scholar 

  55. 55.

    El-Azab AS, Yousef HA, Seifeldein GS. Coital incontinence: relation to detrusor over-activity and stress incontinence. Neurourol Urodyn. 2011;30:520–4.

    Article  PubMed  Google Scholar 

  56. 56.

    Hilton P. Urinary incontinence during sexual intercourse: a common, but rarely volunteered, symptom. Br J Obstet Gynaecol. 1988;95:377–81.

    CAS  Article  PubMed  Google Scholar 

  57. 57.

    Khan Z, Bhola A, Starer P. Urinary incontinence during orgasm. Urology. 1988;31:279–82.

    CAS  Article  PubMed  Google Scholar 

  58. 58.

    Vierhout ME, Gianotten WL. Mechanisms of urine loss during sexual activity. Eur J Obstet Gynecol Reprod Biol. 1993;52:45–7.

    CAS  Article  PubMed  Google Scholar 

  59. 59.

    Moran PA, Dwyer PL, Ziccone SP. Urinary leakage during coitus in women. J Obstet Gynecol. 1999;19:286–8.

    CAS  Article  Google Scholar 

  60. 60.

    Nilsson M, Lalos O, Lindkvist H, Lalos A. How do urinary incontinence and urgency affect women’s sexual life? Acta Obstet Gynecol Scand. 2011;90:621–8.

    Article  PubMed  Google Scholar 

  61. 61.

    Madhu C, Hashim H, Enki D, Yaasin M, Drake M. Coital incontinence: what can we learn from urodynamic assessment? Urology. 2015;85:1034–8.

    Article  PubMed  Google Scholar 

  62. 62.

    Gilliland AL. Women’s experiences of female ejaculation. Sex Cult. 2009;13(3):121–34.

    Article  Google Scholar 

  63. 63.

    Leiblum SR, Hayes RD, Wanser RA, Nelson JS. Vaginal dryness: a comparison of prevalence and interventions in 11 countries. J Sex Med. 2009;6:2425–33.

    Article  PubMed  Google Scholar 

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Correspondence to Zlatko Pastor.

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Pastor, Z., Chmel, R. Differential diagnostics of female “sexual” fluids: a narrative review. Int Urogynecol J 29, 621–629 (2018). https://doi.org/10.1007/s00192-017-3527-9

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Keywords

  • Female ejaculation
  • Squirting
  • Coital incontinence
  • Female prostate
  • Vaginal lubrication