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1388

The Female Prostate Revisited: Perineal Ultrasound and


Biochemical Studies of Female Ejaculate

Florian Wimpissinger, MD, FEBU,* Karl Stifter, PhD,† Wolfgang Grin, MD,‡ and Walter Stackl, MD*
*Department of Urology, Rudolfstiftung Hospital—Urology, Vienna, Austria; †Institute for Perineometry and Sextherapy,
Vienna, Austria; ‡Rudolfstiftung Hospital—Obstetrics and Gynecology, Vienna, Austria

DOI: 10.1111/j.1743-6109.2007.00542.x

ABSTRACT

Introduction. Many speculations have been made on the possible existence of a “female prostate gland” and “female
ejaculation.” Despite several reports on the subject, controversy still exists around the “female prostate” and whether
such a gland might be the source of fluid emitted during orgasm (ejaculation).
Aim. To investigate the ultrasonographic, biochemical, and endoscopic features in two women who reported actual
ejaculations during orgasm.
Main Outcome Measures. Perineal ultrasound studies, as well as biochemical characteristics of ejaculate and
urethroscopy, have been performed in two women.
Methods. Two premenopausal women—44 and 45 years of age—who actually reported fluid expulsion (ejaculation)
during orgasm have been investigated. Ultrasound imaging, biochemical studies of the ejaculated fluid, and endo-
scopy of the urethra have been used to identify a prostate in the female. Ejaculated fluid parameters have been
compared to voided urine samples.
Results. On high-definition perineal ultrasound images, a structure was identified consistent with the gland tissue
surrounding the entire length of the female urethra. On urethroscopy, one midline opening (duct) was seen just
inside the external meatus in the six-o’clock position. Biochemically, the fluid emitted during orgasm showed all the
parameters found in prostate plasma in contrast to the values measured in voided urine.
Conclusions. Data of the two women presented further underline the concept of the female prostate both as an organ
itself and as the source of female ejaculation. Wimpissinger F, Stifter K, Grin W, and Stackl W. The female
prostate revisited: Perineal ultrasound and biochemical studies of female ejaculate. J Sex Med 2007;4:1388–
1393.
Key Words. Female Prostate; Ultrasound; Female Orgasm; Female Ejaculation

Introduction more deeply into the subject when two women


who reported fluid expulsion during orgasm

T he debate around female ejaculation and the


existence of a female prostate dates back to
300 BC when the Greek anatomist Herophilos
agreed to undergo further investigation.

Aims
first wrote about the “female prostate” [1]. The
term “female prostate” itself was first introduced To investigate the ultrasonographic, biochemical,
by the Dutch physiologist Reijnier De Graaf in and endoscopic features in two women who
1672 [1]. reported ejaculation during orgasm.
Even though most physiological and organic
functions of the female arousal cycle—and orgasm
Methods
in particular—have been clarified, the existence of
the female prostate and female ejaculation still In the two women who experienced ejaculation
remains a matter of debate [2–4]. With a year-long during orgasm, pelvic anatomy has been studied
experience on the topic [5], we wanted to look using high-definition perineal ultrasound (5 MHz)

J Sex Med 2007;4:1388–1393 © 2007 International Society for Sexual Medicine


The Female Prostate 1389

Table 1 Comparison of different biochemical parameters in female ejaculate and voided urine compared to male ejaculate
W1: female ejaculate W1: voided urine W2: female ejaculate W2: voided urine Male ejaculate
PSA (ng/mL) 213.49 0.80 105.00 0.16 110–2,211 [27]
PAP (U/L) 329 42 — <1 —
PSAP (U/L) 271 37 860.0 178 —
Glucose (mg/dL) 127 30 100 31 0.4–29.5 [28]
Creatinine (mg/dL) 33.0 178.0 30.0 225.0 —
BUN 1,474 — 363 —
K (mMol/L) 8.6 37.3 — 31 5.0–24.8 [28]
Na (mMol/L) 46 203 — 129 23.6–51.2 [28]
Cl (mMol/L) 37 148 — 144 43

W1 = woman 1; W2 = woman 2; PSA = prostate specific antigen; PAP = prostatic acidic phosphatase; PSAP = prostate specific acid phosphatase; BUN = blood
urea nitrogen; K = potassium; Na = sodium; Cl = chloride; — = no parameters available.

and endosopically with a 4F cystoscope. The ejacu- Sexual Medicine Clinic because of frequent, signifi-
lated fluid collected during orgasm with masturba- cant fluid expulsions during orgasm have been
tion at the sexual medicine office has been evaluated subjected to further studies following informed
biochemically at the hospital laboratory. The consent. Both women are in stable, heterosexual
results were compared to the parameters of urine relationships; one of them (44 years) gave birth to a
voided prior to sexual activity, as well as to the daughter at 20 years of age.
parameters usually found in normal male ejaculate. Biochemically, parameters of the examination
of the fluid emitted were clearly different than
Main Outcome Measures urine voided prior to sexual activity. Biochemical
parameters—with special reference to prostate
The focus of the present study was to further
specific antigen (PSA)—are shown in Table 1. The
clarify the anatomic features of paraurethral
values show that the source of fluid expulsion
anatomy in women reporting “ejaculation” during
during orgasm is not urine, but is rather similar to
orgasm, with new imaging techniques, especially
male ejaculate.
high-definition perineal ultrasound. To define the
Perineal ultrasound imaging showed a hyperin-
emitted fluid as “ejaculate,” biochemical param-
tense structure surrounding the entire length of
eters have been evaluated, mainly to rule out stress
the urethra with the anterior wall of the vagina
incontinence as the source of fluid emission.
adjacent dorsally (Figure 1). This picture closely
resembles that of the male prostate.
Results
On urethroscopy with a 4F endoscope, an open-
Two premenopausal, karyotypically normal women ing was identified in the distal part of the urethra in
—44 and 45 years of age—who reported to the the six-o’clock position. Passage into this opening

a b

Figure 1 Perineal ultrasound of the female prostate. (a) median aspect (b) sagittal aspect. B = bladder; U = urethra;
P = prostate; V = vagina.

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1390 Wimpissinger et al.

Figure 2 Huffman’s wax model, longi-


tudinal aspect.

was possible; however, the duct ended blindly after male prostate (and that had been described by De
2 cm. Endoscopically, no diverticulum or other Graaf in the first place). Later on, J.W. Huffman
pathologies of the urethra have been found. was the first to disagree with several conclusions
drawn by Skene. Ultrastructural and immunohis-
tochemical work in the 1980s—with special refer-
Discussion
ence two PSA staining—further strengthened the
Orgasm Intensity concept of the existence of the female prostate.
It seems that female orgasm with fluid emission Taking anatomical data of Huffman’s revolu-
is more intense than an orgasm without tionary wax models [11] into account (Figures 2
ejaculation—in women who do experience such and 3), M. Zaviacic found different types of female
phenomena [6]. This finding has been confirmed prostates according to his pathoanatomic cross-
by both women reported in this study. Is female sectional studies: anterior (meatal) type, posterior
ejaculation the cause or the effect of more intense type, the prostate distributed over the hole length
orgasms—a similar question just raised in a study of the female urethra, the rudimentary female
on lubrication difficulties [7]? With female orgasm prostate, and rare middle and dumbbell configu-
and arousal difficulties being highly prevalent [8], a rations [10,12].
possible link to ejaculations would be an interest- J.W. Huffman’s description of a female pro-
ing field of future studies. state with ductal tissue predominating has been
strengthened by later observations [13,14]. This
Anatomy
Perineal ultrasound has been used to study para-
urethral anatomy without artefacts that occur in
any form of endoluminal ultrasound investigation
(distortion and compression). From an anatomic
point of view, we found glandlike structures sur-
rounding the female urethra of the two female
subjects who had frequent ejaculations during
orgasm. Comparing these findings with previous
data from the literature, we agree with De Graaf’s
description of a gland similar to the male prostate
rather than with Skene’s concept of pure female
paraurethral glands [9]. In this respect, some
authors even believe that Skene’s work hindered
further studies of a female prostate for many years
[10].
Historically, Reinjer de Graaf was the first to
study the female prostate as early as 1672 [1]. Alex-
ander Skene reported on “paraurethral glands” in
1880, leading to the terminology “Skene’s glands”
of a female organ that seems to be the same as the Figure 3 Huffman’s wax model, anterior aspect.

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The Female Prostate 1391

lobulated appearance of the gland is similar to the The fact that the female ejaculate is not a form
prostate of the male before puberty [13]. Termina- of orgasm-induced stress urinary incontinence or
tion of hormonal stimuli in the female embryo, the result of increased vaginal lubrication is estab-
together with a different anatomic development of lished among all authors involved in studying
the urethra (and adjacent anterior vaginal wall), female sexual response [11,12,24–27].
stops the full development of the gland. Because PSA is physiologically excreted by the
According to ultrasonography, the subject stu- prostate and appears in high levels in the male
died exhibits a paraurethral gland that is “distrib- ejaculate to liquefy the ejaculated coagulum after
uted over the hole length of the female urethra” its positioning at the female cervix, it seems
(Figure 1). This type of distribution has been found obvious that measuring PSA levels in female ejacu-
in about 6% of Zaviacic’s autopsy material [11]. late could differentiate between actual prostatic
The ultrasonographic appearance of the struc- excretion and possible other sources of the fluid
ture surrounding the female urethra just like the [28].
male prostate is supported by numerous histologic Biochemical parameters of the ejaculate in the
and ultrastructural studies that found PSA-positive women studied (high levels of PSA, prostatic acidic
glands and stroma resembling an actual female phosphatase [PAP], and PSAP) further strengthen
prostate [15,16]. the fact that the emitted fluid comes from prostatic
Critics of the concept of female ejaculation tissue and resembles that of male prostatic excre-
often postulate that urethral diverticula might be tions with PSA levels in male seminal plasma
the source of fluid emitted during female orgasms. ranging from 110 to 2,211 ng/mL (Table 1)
In this respect, both ultrasound and endoscopic [29,30]. Considering all studies published, rates of
features in the two cases presented show that no women who experience ejaculation during orgasm
diverticulum was present. It must be postulated, range from 10% to 69% [10,12,31–33].
however, that the majority of the female prostate It has been shown previously that PSA is detect-
gland’s excretory ducts are not seen on conven- able in female voided urine, and that the levels are
tional urethroscopy. Previous studies reported of higher following intercourse and orgasm [34].
more than 20 ducts [11,15]. Some specialists postulate that every woman ejacu-
Immunohistochemically, PSA is the major lates during orgasm, but most women experience
tissue-specific marker for male prostate tissue. retrograde ejaculation (into the bladder) [32,35].
Wernert et al. [13] performed PSA and prostate To differentiate between urine and emitted fluid
specific acid phosphatase immunohistochemical during orgasm (ejaculate), voided urine was col-
staining of female paraurethral glandular tissue lected prior to sexual activity in this study, and
with positivity found in 22 of 33 cases (66.7%). could thus be clearly differentiated (Table 1). Fur-
Other authors found female prostatic tissue in up thermore, urinary incontinence has been com-
to 80% of cases [14,17]. monly associated with urinary incontinence
With increasing awareness of the existence of a [36]—just the opposite of what ejaculating women
female prostate, pathology of the female paraure- do experience.
thral apparatus has been linked to adenocarcinoma
similar to male prostate cancer [18–20].
In this context, more common problems like Conclusions
lower urinary tract symptoms or recurrent urinary Female ejaculation—first described as “love juice”
tract infection could possibly be attributed to dis- in ancient Indian textbooks—seems to be more
eases of the female prostate [21,22]. This could in common than generally recognized. In the two
turn pave the way for new treatment strategies and women who ejaculated during orgasm, perineal
research on new immunohistochemical markers ultrasound and urethroscopy revealed structures
[23]. consistent with a (paraurethral) female prostate.
The fluid emitted during orgasm was biochemi-
Female Ejaculation cally comparable to male prostatic plasma.
The description of female ejaculation dates back to
the ancient Indian erotic text Ananga-Rang pub- Corresponding Author: Florian Wimpissinger;
lished in the 16th century AD [5]. In 20th century Rudolfstiftung Hospital—Urology, Juchgasse 25
literature, Gräfenberg was among the first to Vienna A1030, Austria. Tel: +431711654808; Fax:
+431711654809; E-mail: florian.wimpissinger@gmx.at
describe the release of a milky opalescent fluid via
the urethra during orgasm [11,12]. Conflict of Interest: None declared.

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1392 Wimpissinger et al.

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Dr. Rufus Cartwright and
Professor Linda Cardozo
Commentary on Wimpissinger F, Stifter K, Department of Urogynaecology
Grin W, Stackl W. The Female Prostate Revisited: Golden Jubilee Wing, King’s College Hospital,
Perineal Ultrasound and Biochemical Studies of Denmark Hill, London
Female Ejaculate E-mail: rufus.cartwright@gmail.com
In this paper, the authors demonstrate the bio-
chemical differences between the fluid emitted
Author Response
during female ejaculation and samples of urine
taken prior to sexual activity. The paraurethral We appreciate the thoughtful comments regarding
glands have been previously suggested as a female the interpretation of perineal ultrasound images in
homolog of the male prostate, and histological evi- our examination of women reporting ejaculation
dence suggests that they might be the source of during orgasm. Perineal ultrasound is a well-
such ejaculatory fluid. In support of this hypoth- established tool in the workup of women with sus-
esis, the authors draw a comparison between the pected prolapse as well as nullipara girls. In the
PSA levels found in the female ejaculate samples, hands of the experienced clinician, the female
and that expected in male ejaculate. introitus, including urethra, bladder neck, and
While the biochemical data provide convincing vagina, can easily be identified. The image printed
evidence that the ejaculatory fluid collected was in the manuscript is a static view of a very dynamic
not urine, we are concerned that the authors have examination—a fact that applies to all ultrasound
over-interpreted the ultrasound data to fit with techniques. Therefore, definition of the urethra
their hypothesis of a female prostate. The image and surrounding tissue must be seen in the context
reproduced in the paper is of poor quality. The with this dynamic process and the resulting three-
area labeled “U” for urethra probably represents a dimensional image in the observer’s mind.
stripe of artifact caused by scanning the urethra However, we agree that the actual definition of
along its course. Furthermore, while paraurethral paraurethral tissue as prostate “P” is rather hypo-
glandular tissue may extend along the length of the thetic. Only biopsies could prove that this gross
urethra, it is not noted to surround the proximal anatomic feature really relates to the female pros-
urethra. Thus the area labeled “P” for prostate tate. Hopefully, high resolution magnetic reso-
most likely represents the striated urethral sphinc- nance images will help us solve this problem in
ter, a structure which does surround the proximal future studies.

J Sex Med 2007;4:1388–1393