Professional Documents
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REVIEW
DOI: 10.1111/jsm.12166
ABSTRACT
Introduction. Women may expel various kinds of fluids during sexual arousal and at orgasm. Their origins, quantity,
compositions, and expulsion mechanisms depend on anatomical and pathophysiological dispositions and the degree
of sexual arousal. These are natural sexual responses but may also represent symptoms of urinary incontinence.
Aim. The study aims to clarify the etiology of fluid leakage at orgasm, distinguish between associated physiological
sexual responses, and differentiate these phenomena from symptoms of illness.
Methods. A systematic literature review was performed. EMBASE (OvidSP) and Web of Science databases were
searched for the articles on various phenomena of fluid expulsions in women during sexual arousal and at orgasm.
Main Outcome Measures. Articles included focused on female ejaculation and its variations, coital incontinence
(CI), and vaginal lubrication.
Results. Female ejaculation orgasm manifests as either a female ejaculation (FE) of a smaller quantity of whitish
secretions from the female prostate or a squirting of a larger amount of diluted and changed urine. Both phenomena
may occur simultaneously. The prevalence of FE is 10–54%. CI is divided into penetration and orgasmic forms. The
prevalence of CI is 0.2–66%. Penetration incontinence occurs more frequently and is usually caused by stress urinary
incontinence (SUI). Urodynamic diagnoses of detrusor overactivity (DOA) and SUI are observed in orgasmic
incontinence.
Conclusions. Fluid expulsions are not typically a part of female orgasm. FE and squirting are two different physi-
ological components of female sexuality. FE was objectively evidenced only in tens of cases but its reported high
prevalence is based mostly on subjective questionnaire research. Pathophysiology of squirting is rarely documented.
CI is a pathological sign caused by urethral disorder, DOA, or a combination of both, and requires treatment. An
in-depth appreciation of these similar but pathophysiologically distinct phenomena is essential for distinguishing
normal, physiological sexual responses from signs of illness. Pastor Z. Female ejaculation orgasm vs. coital
incontinence: A systematic review. J Sex Med 2013;10:1682–1691.
Key Words. Female Ejaculation; Squirting; Orgasmic Incontinence; Coital Incontinence; Female Prostate; Urinary
Incontinence
same phenomenon. The term female ejacula- or describing types of CI, including the charac-
tion (FE) was coined because of the similarities of teristics, quantity, and composition of the fluid
FE with male orgasm. However, FE encompasses and mechanisms of leakage. Furthermore, papers
various phenomena with different pathophysi- reporting urodynamic studies and therapies for CI
ologic mechanisms [8,10]. Physiological signs of were included. Studies examining the quality of
female arousal are sometimes mistaken for coital sexual life of incontinent women or other medi-
incontinence (CI). Furthermore, while expulsion of cal conditions but without any mention of fluid
fluid during sexual intercourse may signify a high leakage during sexual activities were excluded.
level of arousal, it can also be a sign of urinary Terminology used was based on the patho-
incontinence (UI). The fluid may originate from physiological mechanisms of expulsed fluids, and
the vagina, urinary bladder, female prostate, or these expulsions were classified according to their
from a combination of these sources. The develop- origins. Because of the heterogeneity of data, a
ment of more precise research methodologies qualitative assessment was performed. In the final
focusing on the urogenital area, such as magnetic analysis, a total 46 studies were evaluated, includ-
resonance imaging (MRI), ultrasonography, endo- ing four reviews [1,3,16,17]. Five books were also
scopy, urodynamic studies, and biochemical tests, included [5,18–21].
has enabled us to understand such phenomena
based on anatomical and pathophysiological corre-
lations [8,12–15]. Results
Orgasmic fluid expulsions may constitute varying
Aims types of physiological sexual response or UI. The
fluids may have different origins, volumes, and
The objectives of this systematic review are to mechanisms. They may also be a combination of
provide a chronological summary of opinions and fluids (Figure 1).
studies about fluid expulsions occurring during
sexual activity and distinguish between the origins,
Vaginal Lubrication Fluid
mechanisms, and biochemical compositions of
expelled fluids. By appreciating that fluid leakage As the most common and important “sexual fluid,”
may occur not only at FE but also at squirting vaginal lubrication is a plasma transudate which
or CI, inaccurate diagnoses can be avoided. A uro- diffuses across the vaginal wall due to the activities
dynamic diagnosis for penetration or orgasmic of vasoactive intestinal peptide and neuropeptide
incontinence is also clarified. Y [22]. The composition and quantity of lubrica-
tion fluid change according to the intensity and
length of sexual arousal. Insufficient lubrication is
Methods reported in 3–43% women and occurs most com-
The electronic databases OvidSP (EMBASE) and monly after menopause [23]. In contrast, increased
Web of Science were searched according to the lubrication does not cause any problems and is
fluid expulsion type, such as FE, squirting, vaginal considered a discharge rather than a gush, espe-
lubrication, and CI. The key words for the titles and cially when a penis is inserted. Kinsey et al. sug-
abstracts were as follows: “female ejaculation” gested that vaginal fluid may be forced out by
AND “orgasm”; “female ejaculation” AND “fluid”; the contractions of perivaginal muscles and thus
“female ejaculation” AND “female prostate”; resemble FE [19]. In addition, Perry and Whipple
“vaginal lubrication” AND “orgasm”; “squirting” reported that women with FE have significantly
AND “female ejaculation”, “coital incontinence”; stronger contractions of pubococcygeus muscles
and “coital incontinence” AND “orgasm.” The and reach uterine orgasmic contractions more
electronic database search yielded 413 articles from frequently [4].
1948 through 2012. Only papers in English were
used. The search was further refined to “human” Ejaculation Orgasm
and “female” studies. Ejaculation orgasm is defined as a physiological
response occurring as expulsion of various quanti-
ties of fluids at orgasm that originate from the
Main Outcome Measures
urinary bladder (squirting), the female prostate
The review focused on articles evaluating fluid (female ejaculation), or a combination of both, and
expulsions occurring during female sexual activity may occur at the height of sexual arousal [8,10]. In
Figure 1 Summary of fluids released during sexual activities based on origins and mechanisms
some cases, it may resemble orgasmic inconti- in the female prostate [28]. The ducts are not
nence, which is a symptom of UI and requires visible on urethroscopy, and the fluid expulsions
treatment. have not been demonstrated to be associated with
urethroceles [13]. The presence of prostate-
FE and Female Prostate specific antigen (PSA), prostatic specific acid phos-
FE is an orgasmic expulsion of a smaller quantity phatase, fructose, and glucose are characteristic for
of whitish fluid produced by the female prostate secretions from the female prostate [33]. Its glan-
[8]. Opinions regarding the quantity of expelled dular cells contain moderate to strong expression
fluid vary from 1 mL to 30–50 mL [7–9,11,24,25]. of androgenic receptors, which are not present
Following the work of E. Gräfenberg regarding in cytoplasm [30]. The role and function of the
the role of the urethra at sexual arousal [26], female prostate remain unclear. Some studies
Addiego et al. hypothesized that this fluid may suggest an antimicrobial protective effect of pros-
come from the female prostate, previously called tate secretions against urinary tract infections
Skene’s paraurethral glands, given the presence of [34]. The female prostate can produce very scanty,
prostatic acid phosphatase in female ejaculate [27]. milky fluid similar to the male semen during
The female prostate is an exocrine organ of vari- vaginal or clitoral stimulation [8]. Most studies
able size and location [28]. Studies suggest that consider orgasmic expulsions as FE and the fluid as
one half to two thirds of women have a female female prostate secretions [8,11,13,24,27,33,35],
prostate [29,30]. In MRI studies, Wimpissinger leaking urine [9], or a combination of both [8,10].
et al. found anatomical structures suggestive of the Two studies also demostrated that in case of squirt-
female prostate in 6 of 7 women [14]. The average ing, this fluid could be changed diluted urine
weight of the female adult prostate is 2.6–5.2 g with a lower content of uric acid, urea, and crea-
[31]. Its location is typically lateral in the distal half tinine when compared with voided urine and with
of the urethra, producing secretions to the urethral lower PSA than in female prostate secretion
meatus [30]. Zaviacic et al. distinguished five types (Tables 1 and 2) [8,10]. Only eight studies objec-
of female prostate according to location: meatal, tively confirmed FE in a total of 52 respondents
posterior, rudimentary, whole length, and other (Table 1). Studies reporting a higher prevalence of
[31]. This tubulalveolar formation resembles the FE in hundreds of cases were based on question-
male prostate prior to puberty and androgenic naire studies [6,7,18,37] or anecdotal evidence
stimulation [32] and is composed of glands, ducts, [21].
and smooth muscle tissue. Compared with the
male prostate, there is a higher proportion of ducts Squirting and Urinary Bladder
and musculofibrous tissues than glands in the Squirting, or gushing, is the orgasmic transure-
female prostate [31]. It is not clear if the glands thral expulsion of a larger quantity of diluted
open into the distal urethra through single or chemically changed urine [8]. Goldberg et al. were
multiple orifices, which is similar to the male pros- the first to suggest that orgasmic expulsions may
tate, or whether they lead to the sides of urethral be an altered form of urine [9]. Zaviacic et al.
meatus [8,31]. Early studies found up to 20 ducts argued that female ejaculate is not urine, as it
Cabello No 24 (6 ejaculation Biochemical No data No data PSA detected in 75% of Female The female prostate is activated during
Santamaria samples, analysis postorgasmic urine samples prostate orgasm, emitting the fluid containing
[35] 18 urine (MEIA) PSA. Most women ejaculate, and
samples) there are variations in the quantity of
the fluid.
Schubach Yes 7 Biochemical Milky-white, Up to No data Female Ejaculate is characterized by low
[10] analysis mucous-like 2 mL prostate levels of urea and creatinine with no
emissions fructose.
50-900 mL Urea, creatinine levels in the Urinary Lowered levels of urea and creatinine
ejaculate lower than those bladder were observed in the changed
in urine, no prostatic diluted urine, with no prostatic
components components found.
Wimpissinger Yes 2 Ultrasonography, No data No data Biochemical values (PSA) of Female Ultrasonography and urethroscopy
et al. [13] biochemical examined fluid are similar prostate confirmed the existence of structures
analysis, to male ejaculate consistent with the female prostate.
urethral
endoscopy
Rubio-Casillas Yes 1 Biochemical Squirting-thin, watery 120 mL Lower amounts of PSA, uric Urinary Squirting is the expulsion of diluted
and Jannini analysis liquid, almost no acid, urea and creatinine bladder changed urine.
[8] color/smell
Biochemical Ejaculate scanty, 1 mL High concentration of PSA Female FE is the expulsion of whitish, thick
analysis thick and milky prostate fluid from the female prostate.
FE = female ejaculation; PAP = prostatic acid phosphatase; MEIA = microparticle enzyme immunoassay; PSA = prostate-specific antigen
Table 2 Comparison of the compositions of voided urine, incontinent women varies quite widely, ranging
squirting, and ejaculate from 0.2% to 66% [39,42–50]. There is much
Voided urine Squirting Ejaculate controversy regarding various research method-
PSA + +/+ + +++
ologies resulting in these inconsistent prevalence
PSAP + +/+ + +++ rates as well as the associations between types of
Uric acid +++ + – UI and CI [51–53]. Women with stress urinary
Urea +++ +/+ + –
Creatinine +++ +/+ + –
incontinence (SUI) have a significantly high preva-
Glucose – + +++ lence of CI at 89.4%, compared with 33.3% in
Fructose – + +++ women with detrusor overactivity (DOA) [50]. CI
Sodium +++ ++ +
Potassium +++ ++ +
is caused by various provocative moments, such as
Chlorine +++ ++ + increased intraabdominal pressure, penile inser-
Color Yellow Clear White tion, deep penetration, high arousal, orgasm, and
Volume + +/+ + + + +/+ + + +
clitoral stimulation [47]. Hilton suggested that
+ + +, large quantity; + +, moderate quantity; +, small quantity; –, no presence. penetration incontinence is mostly associated with
PSA = prostate-specific antigen; PSAP = prostatic specific acid phosphatase
SUI whereas orgasmic incontinence occurs more
commonly in women with DOA [44]. Studies
remain equivocal (Table 3) [39,43,44,47,49,50,
contains chemical components of female prostate 54–56]. Serati et al. described a causal relation
secretions [11,27,33]. However, he did concede between DOA and orgasmic incontinence, report-
that in some cases of stress incontinence, female ing that women with orgasmic incontinence have
ejaculate could be urine [38]. Cabello Santamaria significantly thicker urinary bladder walls and
found that in a group of 24 respondents, at lower resistance to the effects of antimuscarinics,
least 75% had traces of PSA in postorgasmic urine which are indicative of a severe form of DOA [56].
[35]. Schubach used a thin urethral catheter to El Azab et al. assumed that orgasmic incontinence
distinguish the origins of gushing fluid at orgasm, is always related to SUI symptoms and therefore
thus draining the urinary bladder while avoiding CI and DOA are associated, although their study
compression of the meatuses of the female prostate findings did not confirm this hypothesis [50,53].
ducts. In a study involving seven women, he col- They argued that orgasmic incontinence is not
lected 50–900 mL of fluid containing less urea and associated only with DOA, and that in these
creatinine and without the prostatic components women, an incompetent urethral sphincter or
of fructose and glucose during the massive orgas- vaginal prolapse may be the main cause of urine
mic expulsions. In three cases, Schubach noted the leakage at orgasm, explaining the decreased effects
simultaneous secretion of a small quantity of thick of anticholinergics in such cases [50]. These
whitish fluid in the area of urethral meatus, which studies suggest that the penetration form of CI
he considered to be a secretion of the female is largely associated with urodynamic findings of
prostate [10]. Rubio-Casillas and Jannini arrived at SUI. Orgasmic incontinence may be associated
the same conclusions in the case of one woman, with both SUI and DOA. Of nine studies, five
where they observed squirting and FE to be two found that DOA is more likely to be related to
distinct phenomena consisting of fluids of various orgasmic incontinence [44,50,54–56], whereas the
quantity and composition expelled by two differ- remaining four did not observe this association
ent organs [8]. Hence, fluids expelled at orgasm (Table 3) [39,43,47,49]. Urodynamic examination
can be divided into three types based on biochemi- may help differentiate orgasmic incontinence from
cal parameters (Table 2). FE or squirting. Continent women with ejacula-
tion orgasm do not show high detrusor activity or
any other abnormal urodynamic parameters [15].
Orgasmic Incontinence as a Type of CI In contrast, incontinent women with CI always
The prevalence of UI in the female population have pathological findings on urodynamic studies
is approximately 20–45% [39]. The International (Table 3). Biochemical analysis of leaked fluids at
Continence Society estimates the prevalence of orgasm is a very reliable method to determine the
overactive bladder at 33–41%, based on the fre- origin(s) [8,13]. Although ejaculation orgasm was
quency of urinary urgency [40,41]. CI is defined as historically considered a constant or at least inter-
the complaint of involuntary leakage of urine mittent symptom of UI [9,20,33], it is now obvious
during coitus and can be divided into penetration that these are two completely different phenomena
and orgasm types [40]. The prevalence of CI in [8,10,13,57].
Hilton [44] 79 21-67 SUI 37/53 (70%) SUI 11/26 (42%) Penetration incontinence is mostly associated with
DOA 2/53 (4%) DOA 9/26 (34%) SUI. Women with orgasmic incontinence have a
MUI 5/53 (9%) MUI 2/26 (8%) high incidence of DOA.
Khan et al. [54] 3 24–35 SUI 0 SUI 0 Orgasm caused involuntary detrusor contractions
DOA 0 DOA 3/3 (100%) combined with relaxation of urethral sphincter.
MUI 0 MUI 0
Vierhout and 57 47 Urodynamic diagnoses were Urodynamic diagnoses were Urine leakage during sexual activities occurs in all
Gianotten [47] not specified to CI type. not specified to CI type. urodynamic diagnoses.
Moran et al. [43] 228 48.2 SUI 100/158 (63.3%) SUI 34/45 (75.6%) SUI is the most frequent diagnosis in all forms of CI,
DOA 4/158 (2.5%) DOA 0 with detrusor instability incidence observed in only
MUI 26/158 (16.5%) MUI 8/45 (17.8%) a few cases.
Serati et al. [55] 132 22-70 SUI 40/83 (48.2%) SUI 5/49 (10.2%) Incontinence at orgasm is primarily related to DOA.
DOA 13/83 (15.7%) DOA 34/49 (69.4%)
Female Ejaculation Orgasm vs. Coital Incontinence
SUI = stress urinary incontinence; DOA = detrusor overactivity; MUI = mixed urinary incontinence; OAB = overactive bladder; CI = coital incontinence
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