1526

ORIGINAL RESEARCH—ANATOMY/PHYSIOLOGY

The Pars Intermedia: An Anatomic Basis for a Coordinated

Vascular Response to Female Genital Arousal jsm_2996 1526..1530

Cheryl Shih, MD,* Christopher J. Cold, MD,† and Claire C. Yang, MD*
*Department of Urology, University of Washington School of Medicine, Seattle, WA, USA; †Department of Pathology,
Marshfield Clinic, Marshfield, WI, USA

DOI: 10.1111/j.1743-6109.2012.02996.x

ABSTRACT

Introduction. The pars intermedia is an area of the vulva that has been inconsistently described in the literature.
Aim. We conducted anatomic studies to better describe the tissues and vascular structures of the pars intermedia and
proposed a functional rationale of the pars intermedia in the female sexual response.
Methods. Nine cadaveric vulvectomy specimens were used. Each was serially sectioned and stained with hematoxylin
and eosin and Masson’s trichrome.
Main Outcome Measures. Histologic ultrastructural description of the pars intermedia.
Results. The pars intermedia contains veins traveling longitudinally in the angle of the clitoris, supported by
collagen-rich stromal tissues. These veins drain the different vascular compartments of the vulva, including the
clitoris, the bulbs, and labia minora; also, the interconnecting veins link the different vascular compartments. The
pars intermedia is not composed of erectile tissue, distinguishing it from the erectile tissues of the corpora cavernosa
of the clitoris as well as the corpus spongiosum of the clitoral (vestibular) bulbs.
Conclusions. The venous communications of the pars intermedia, linking the erectile tissues with the other vascular
compartments of the vulva, appear to provide the anatomic basis for a coordinated vascular response during female
sexual arousal. Shih C, Cold CJ, and Yang CC. The pars intermedia: An anatomic basis for a coordinated
vascular response to female genital arousal. J Sex Med 2013;10:1526–1530.
Key Words. Female Genital Anatomy; Vulva; Pars Intermedia; Clitoris; Corpus Cavernosum

Introduction and connects the clitoral bulbs and corpora caver-

nosa [2]. In either case, it is unclear what role the

I n previous dissections of the female external

genitalia, we encountered the entity known as
the pars intermedia. This is an area immediately
beneath the midline vulvar skin, between the cli-
toral body and the commissure of the clitoral (ves-
tibular) bulbs. Some authors refer to the pars
intermedia as the continuation of the erectile
tissue of the corpus spongiosum in the midline,
above the vestibule of the vagina, joining the bilat-
eral clitoral bulbs [1]. Others do not identify the
pars intermedia as erectile tissue but as the venous
plexus of Kobelt that lies in the angle of the clitoris
pars intermedia might play in the female sexual
response given its proximity to the sexually
responsive tissues of the vulva. We therefore con-
ducted more detailed studies of the pars interme-
dia so that the anatomical findings could better
inform our understanding of the role of this struc-
ture in the female sexual response.
Materials and Methods
Nine cadaveric female vulvectomy specimens were
available for this study. The study was deemed

J Sex Med 2013;10:1526–1530 © 2012 International Society for Sexual Medicine

Pars Intermedia
Figure 1 (A) Gross sagittal section
through the midline urethral meatus (UM)
and vaginal introitus (V). Top of the
picture is anterior, right of the picture is
the perineal surface. The erectile tissue
of the clitoris and clitoral bulbs appear
dark red-brown and spongy. The asterisk
(*) marks the region of the pars interme-
dia. Marker in centimeters. (B) Clay
model (not to scale) of the clitoris
(yellow), clitoral bulbs (red), urethra
(blue), and pars intermedia (green) in the
context of the pelvic bones. The plane
indicates a midline sagittal section.
exempt from institutional review board over-
sight. The ages of the cadavers were unknown,
although they appeared to be from postmeno-
pausal women. Tissue samples were embalmed in
40% ethanol and 20% glycerin. They were trans-
ferred after sectioning to neutral buffered formalin
for processing (formalin-fixed paraffin-embedded
tissue blocks).
All vulvectomy specimens were serially sec-
tioned and submitted in separate cassette blocks.
Sections were taken from the clitoral glans and
corpora cavernosa, the anterior vestibule and cli-
toral bulbs, the labia minora, and the labia majora.
Serial sections were then stained with hematoxylin
and eosin to examine general histologic features.
Selected blocks were stained with Masson’s
trichrome.
Results
Vascular Compartments of the External
Female Genitalia
We have previously described the vascular com-
partments of the external female genitalia, which
include the erectile tissue of the corpora cavernosa
of the clitoris and the clitoral bulbs as well as the
nonerectile specialized genital vascular tissue of
the labia minora and vestibule of the vagina [3].
For the purpose of anatomic orientation and to
frame the subsequent description of the pars inter-
media, we briefly summarize the vascular compart-
ments here.
The clitoris is a wishbone-shaped structure
located beneath the vulvar skin, superficial to the
inferior pubic rami. The clitoral body is composed
of the erectile tissue of the paired corpora cavern-
osa. Immediately inferior to the convergence of
the paired corpora cavernosa lies the commissure
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of the clitoral bulbs. The clitoral bulbs are two
globular, teardrop-shaped structures connected by
a commissure and draped over the urethra similar
to a saddlebag. The bulbs are composed of the
erectile tissue of the corpus spongiosum. Histo-
logically, erectile tissue is characterized by promi-
nent vascular spaces interspersed by trabeculae of
smooth muscle and collagen-rich fibrous tissue.
In addition to erectile tissue, there are nonerec-
tile specialized genital vascular tissues, character-
ized by the abundance of vessels interspersed
within fibrous stroma that lacks smooth muscle
fibers. These include the tissues of the labia
minora, periurethra, vestibule/vagina, and glans
clitoris.
Pars Intermedia
In the intervening region between the corpora
cavernosa and the corpora spongiosum of the cli-
toral bulbs lies the pars intermedia (Figure 1).
Grossly, the pars intermedia is composed of tissue
with large vascular spaces filled with blood. In at
least one cadaveric specimen, the gross appearance
of the pars intermedia was indistinguishable from
the spongy tissue of the corpora cavernosa and
clitoral bulbs. However, in most of the cadavers,
the vascular spaces of the pars intermedia appeared
larger and more vacuous compared with that of the
erectile tissues (Figure 2). The area does not have
clear anatomic boundaries.
Histologically, the pars intermedia is very dif-
ferent from the erectile tissues of the clitoris and
the clitoral bulbs. Instead of prominent vascular
spaces interspersed by thin fibromuscular trabecu-
lae as seen in erectile tissue, the pars intermedia is
composed of predominantly collagen-rich stroma
supporting the veins of Kobelt’s plexus, which cor-
respond to the large vascular spaces noted on gross
examination (Figure 3). Veins from Kobelt’s
J Sex Med 2013;10:1526–1530
1528 Shih et al.

Figure 3 Photomicrograph of the pars intermedia adjacent

to the corpora cavernosa of the clitoris (CC). A thick fibrous
septum (S) separates the corporal bodies. The dense
stroma of the pars intermedia (arrow) contains collagen
(blue), interspersed with smooth muscle bundles (red). The
smooth muscle fibers in the pars intermedia are adjacent to
the vascular spaces and embedded in the stroma, not within
the trabeculae, as they are in erectile tissue. The veins (*) of
Kobelt’s plexus traverse through this stroma and can be
seen to penetrate the tunica albuginea of the corpora cav-
Figure 2 Gross axial section through the fused corpora ernosa. Masson’s trichrome, 20¥.
cavernosa of the clitoral body (CC), the anterior vestibule
(solid arrow), and the pars intermedia (rectangle), which
corresponds to the area depicted by the green clay in the
model in Figure 1. The gross appearance of the erectile
tissues of the corpora cavernosa (CC) is distinct from the
more vacuous tissues of the pars intermedia. The urethra is
not visible on this section because the meatus is deeper in
the perineum. Marker in centimeters.

plexus were observed to penetrate the thick tunica

albuginea of the clitoral corpora cavernosa. These
veins can be seen traveling in the angle of the
clitoris between the glans clitoris and the corporal
bodies, between the erectile tissues of the corpora
cavernosa and the clitoral bulbs, connecting to the
lamina propria of the anterior vestibule (Figure 2),
and into the sexually responsive, nonerectile, spe-
cialized vascular tissues of the labia minora
(Figure 4). Together, the veins of Kobelt’s plexus
and their surrounding stroma make up the pars
intermedia.

Discussion
In this anatomic study of the pars intermedia, we
found that it contains veins traveling longitudi-
nally in the angle of the clitoris, supported by
collagen-rich stromal tissues, and linking the erec-
tile tissues to the other vascular compartments of
the female external genitalia. The pars intermedia
Figure 4 Photomicrograph of the anterior vestibule. The
veins of Kobelt’s plexus (*) can be seen in the lamina
propria, connecting the labia minora inferiorly with the other
vascular compartments of the female external genitalia. The
vaginal vestibule is lined by nonkeratinized stratified squa-
mous epithelium. Masson’s trichrome, 10¥.

J Sex Med 2013;10:1526–1530

Pars Intermedia
is not composed of erectile tissue, thus distinguish-
ing it from the erectile tissues of the corpora cav-
ernosa of the clitoral body as well as the corpus
spongiosum of the clitoral bulbs.
In the 1800s, Kobelt provided the first detailed
account of the pars intermedia [4]. Kobelt’s plexus
of veins make up the pars intermedia, “which on
both sides lies under the corpus clitoridis and is in
direct contact with the upper end of the bulbus
vestibule” [4]. He goes on to describe venous
tributaries from the clitoris, the corpus spongio-
sum, the frenulum, and the labia minora that feed
into the plexus. “[The veins] are to be equated with
the venae communicantes between the corpus
spongiosum urethrae and the corpus spongiosum
penis” in the male [4].
Recent studies have also described the pars
intermedia but not to the degree of detail as we
have in our investigation. Foldes and Buisson [5,6]
were able to visualize the pars intermedia on sono-
graphic images as a distinct part of the clitoral
complex. O’Connell et al. [7,8] referred to “a
double row of veins surrounding the distal urethra
adjacent to the bulbs” and implied that the pres-
ence of the pars intermedia is controversial and the
anatomical region is not readily identifiable; while
van Turnhout et al. [1] used both surgical and
cadaveric specimens to conclude that the pars
intermedia is a part of the corpus spongiosum and
a continuation of the bilateral clitoral bulbs.
However, there is a clear distinction between the
pars intermedia and the corpus spongiosum. While
on gross examination in fixed cadaveric tissue, the
pars intermedia appears spongy and bloodstained
similar to the neighboring corpus spongiosum of
the clitoral bulbs; on histologic examination, it is
clear that these tissues are distinct.
These vascular channels of the pars intermedia,
as Kobelt depicted in his illustration [2], were
observed to penetrate the erectile tissues and
receive tributaries from the various vascular com-
partments of the female external genitalia. Clinical
and magnetic resonance imaging studies have
shown that the clitoris, clitoral bulbs, and labia
minora simultaneously engorge during arousal
[3,9]. The confluence of the veins between the
vascular compartments within the pars intermedia
leads us to speculate that this arrangement pro-
vides the anatomic basis for a coordinated vascular
response during female sexual arousal. In order to
accommodate the higher rates of blood flow
during arousal and maintain simultaneous
engorgement between the vascular tissues, the vas-
cular drainage needs to be interconnected, or else
1529
differential drainage may occur. The veins of the
pars intermedia appear to be the mechanism by
which coordinated drainage occurs. Although the
findings of this study are not new, we are now able
to bring forth a coordinated view of the anatomy
of the female genitalia, in the context of genital
physiology.
The pars intermedia is a collection of veins sup-
ported by dense stroma, which is different from
the erectile tissues of the clitoris and clitoral bulbs.
It is a continuation of the clitoral bulbs only in the
sense that the veins penetrate the corpus spongio-
sum and link it to the other vascular compartments
of the female external genitalia. These veins, by
means of their number and size, appear to be the
primary venous drainage of the sexually responsive
tissues of the vulva. The dorsal veins of the clitoris,
which also provide venous drainage of the corpora
cavernosa, appear to be a secondary venous system
and restricted to the clitoris.
Although the different parts of the vulva have
been described for centuries, we have only recently
begun to consider these parts as a whole and to
study how they respond in a coordinated fashion
during sexual arousal. Here, we present the
anatomy of the pars intermedia and speculate on
its role in the coordinated vascular response of the
external female genitalia. This has implications for
surgical procedures that could potentially disrupt
the vascular communications of the pars interme-
dia, such as transvaginal incontinence procedures,
radical urethrectomy, vulvectomy and other
exenterative procedures for malignancy, and
plastic reconstructive procedures of the perineum.
This also has implications for our understanding
of female sexual dysfunction, which affects
approximately 40% of American women [10].
Despite its high prevalence, relatively little is
known about its physiology and pathophysiology.
A more complete understanding of female vulvar
anatomy and vascular physiology, including the
role of the pars intermedia, will be helpful in the
development of medical therapies for female
sexual dysfunction as well as surgical modifications
for female genital surgery.
Limitations of this study include the lack of
demographic and clinical information on our
cadaveric specimens, restricting our ability to draw
clinical conclusions from our neuroanatomical
findings. This is a common limitation of cadaveric
studies. Surgical pathology vulvectomy specimens
have associated clinical data but are usually altered
by malignancy and, therefore, also difficult to
interpret.
J Sex Med 2013;10:1526–1530
1530
Conclusion
The pars intermedia is composed of the veins of
Kobelt’s plexus, supported by dense fibromuscular
stroma, running in the region under the angle of
the clitoris, and linking the erectile tissues of the
corpora cavernosa and corpus spongiosum to the
other vascular compartments of the female exter-
nal genitalia. The venous communication of these
vascular compartments provides the anatomic
basis for a coordinated vascular response during
female sexual arousal.
Acknowledgment
The authors wish to thank Dr. John Harting, Dr. Ed
Schultz, and the University of Wisconsin, Madison
School of Medicine and Public Health for assistance
with cadaver dissections, the Marshfield Histology
Laboratory for assistance with histology and special
stains, and Dr. Van Ginger of the Polyclinic, Seattle,
WA, for her pilot work on this project. The authors
would also like to thank Marie Fleisner of the Marsh-
field Clinic Research Foundation, Marshfield, WI, for
editorial assistance.
Corresponding Author: Cheryl Shih, MD, Depart-
ment of Urology, University of Washington School of
Medicine, 1959 NE Pacific St, Box 356510, Seattle, WA
98195, USA. Tel: 206-543-3640; Fax: 206-543-3272;
E-mail: csshih@uw.edu
Conflict of Interest: None to report.
Statement of Authorship
Category 1
(a) Conception and Design
Claire C. Yang; Christopher J. Cold; Cheryl Shih
(b) Acquisition of Data
Christopher J. Cold; Cheryl Shih
J Sex Med 2013;10:1526–1530
Shih et al.
(c) Analysis and Interpretation of Data
Claire C. Yang; Christopher J. Cold; Cheryl Shih
Category 2
(a) Drafting the Article
Claire C. Yang; Cheryl Shih
(b) Revising It for Intellectual Content
Claire C. Yang; Christopher J. Cold; Cheryl Shih
Category 3
(a) Final Approval of the Completed Article
Claire C. Yang; Christopher J. Cold; Cheryl Shih
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