Acta Radiologica

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Chapter 1: Anatomy of the Vulva

To cite this article: (1961) Chapter 1: Anatomy of the Vulva, Acta Radiologica, 55:sup208, 16-23,
DOI: 10.3109/00016926109176094

To link to this article: https://doi.org/10.3109/00016926109176094

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 CHAPTER 1

Anatomy of the Vulva

The vulva, mons veneris, and vestibule make up the external female genitalia
(pudendum muliebre).
The mons veneris is bounded superiorly by a transverse fold of skin and
laterally by the inguinal and genitofemoral grooves. Inferiorly, there is no separation
between the mons and labia. The mons is covered with the pubic hairing, its
subcutaneous tissue is well-developed and often contains large quantities of fatty
tissue. It has an ample vascular supply and a dense net of lymphatics.
The pudendal cleft is delimited on both sides by the labia majora, two folds
of skin whose subcutaneous tissue is of the same type and joins that of the mons
veneris. The connective tissue is particularly rich in collagen as well as elastic
fibres. Hairing extends from the mons down the lateral surfaces of the labia
majora, but the medial surfaces are not haired. The anterior and posterior
junctions of the labia majora are called the anterior and posterior commissures.
Parting the labia majora brings to view two labia minora which may be of
a very different degree of development. Anteriorly they are split by the clitoris
forming the prepuce and the frenulum of the clitoris. Posteriorly, the labia minora
evenly taper off.
In nulliparae there is a transverse fold in front of the posterior commissure,
called the frenulum labiorum, and within there is a small recess, the fossa
navicularis.
The clitoris is formed by the fusion of the two crura clitoridis, attached
superiorly to the rami of the pubis and ischium. Peripherally, there is the
glans clitoridis, the homologue of the glans penis in the male. The clitoris
is made up of spongy tissue of the same type as in the corpus cavernosum of
the penis, so-called erectile tissue. It is surrounded by the fascia clitoridis,
attached by the ligamentum suspensorium clitoridis to the under aspect of the
symphysis. By a longitudinal septum, the corpus clitoridis is separated into
two parts, corresponding to the crura. Apart from its small size, the clitoris
differs from the penis in not being traversed by the urethra.
The vestibule o f the vagina is framed laterally by the labia minora and
posteriorly by a small fold which connects them. It is separated from the vagina
by the hymen or the carunculae hymenales. The urethral orifice is situated
 17

anteriorly in the vestibule. The duct from Bartholin’s gland which courses, after
having penetrated the fascia of the inferior urogenital triangle, lateral to the
vaginal wall, opens into the vestibule close to the edge of the hymen, somewhat
behind the middle of the vaginal introitus. Close to the urethral orifice there
are two or generally three small openings of Skene’s glands, ductuli paraurethrales.
(Huffmann1948).

GLANDS OF EXTERNAL GENITALIA

Bartholin’s glands, the homologues of the bulbourethral gland in the male, are
situated on a level with the posterior limit of the vaginal introitus on both sides,
between the two layers of the fascia of the urogenital diaphragm and superficial
to the m. transversus perinei profundus. Bartholin’s glands are tubuloacinous
and give off a mucous secretion. Their ducts are lined with columnar squamous
epithelium, changing towards the surface into stratified epithelium.
In the haired portion of the external genitalia there are sebaceous glands,
consisting of one or more saccular elements with excretory ducts formed by a
continuation of the external root sheath of the hair. These glands are holocrine
(Gr. holos = whole) meaning that the entire content of the cell forms the secretion,
the nucleus perishes, and the cell ceases to exist.
Sebaceous glands are also present on unhaired areas of skin in several sites,
int. al. the prepuce and glans and, especially, on the labia minora. In such
cases, the excretory duct is direct to the surface. On the internal surface of the
labia minora there is, inwardly, an area which grossly resembles mucous mem-
brane, but is outwardly more like skin. The line of separation is named Hart’s
line. On the labia minora sebaceous glands are situated peripheral to Hart’s
line (Rubin & Novak 1956).
Sweat glands, purely tubular, are present in the form of small eccrine and
larger aprocrine types (Stohr & Mollendorff 1940). The eccrine glands are
present all over the skin, except on the internal surface of the prepuce and
glans, and secrete sweat.
The apocrine type may be found in the mons veneris, labia majora, and
perineum, and particularly in the groove between the labium majus and minus.
The secretion from these glands is of a characteristic smell.

VASCULAR SUPPLY

The vascular supply will be briefly mentioned. The arterial blood is supplied
mainly by the internal pudendal artery which divides, at the posterior edge of
the urogenital diaphragm into its end branches supplying the surrounding muscles
and the lower parts of the rectum and perineum. Moreover, the labia and clitoris
18

as well as the vaginal vestibule and urethra are supplied partly by the dorsal
artery of the clitoris which runs all the way to the glans, and partly by a
branch in the depth of each corpus cavernosum. Thus, the arterial blood supply is
very ample.
The venous side is made up in the main by venous plexuses which empty
into the internal pudendal vein. However, the dorsal vein of the clitoris com-
municates in the depth behind the symphysis with the hypogastric plexus.

I N N E R VAT I 0 N

The innervation is also ample, and this accounts for the great sensibility
of the vulva. The greater part is derived from the pudendal nerve which innervates
the perineum, vestibule of the vagina, labia, and clitoris with sensory fibres
and supplies also motor fibres to the levator ani, the external and internal
sphincter ani, the external sphincter urethralis, and the bulbocavernosus and
ischiocavernosus muscles. From the femoral nerve, moreover, fibres course to
the perineum and the lateral parts of the labia majora.
The genitofernoral nerve also sends fibres to the labia majora. The ilioinguinal
nerve supplies the mons and the upper parts of the labia majora.
Autonomic innervation is made up partly by a delicate network forming
the plexus cavernosus of the clitoris, communicating with the uterovaginal plexus
and centrally with the hypogastric plexus, and partly by fibres following the
course of arteries and veins.
The parasympathetic fibres are derived from the second, third, and fourth
sacral nerves and the-usually four-sacral ganglia. These fibres have a
collective name: nervus erigens, and they end in Frankenhauser’s ganglion situated
close to the posterior aspect of the cervix uteri. The sympathetic fibres issue from
the sympathetic trunk and the inferior mesenteric ganglion.

L Y M P H A T I C SYSTEM O F T H E VULVA

The study of the lymphatics in the vulva is of fundamental importance to the

surgical treatment of vulvar carcinoma. In 1912 (a) Basset described a method
for radical surgery, a method which has formed the basis of subsequent modi-
fications. According to Basset, there are two presuppositions for surgical treat-
ment, viz. removal of the carcinoma with a sufficient margin of healthy tissue
and, whenever it is possible, systematic dissection of the entire lymphatic
system which drains the region of the tumour including at least the lymph nodes
which form the first stop of this lymphatic system.
The study of the lymphatics may be on two fronts so to speak, being partly
anatomical and partly by analysis of the localization of the metastases. The
 19

two will supplement each other, anatomical study affording data regarding the
abundance of the lymphatics, their anastomoses, and possible paths of drainage,
whereas the clinical studies also permit the introduction of a time factor.
McKelvey (1947) pointed out the important fact that lymphatic metastases in
the groins remain there for a considerable length of time.
The vulva has an extraordinarily ample lymphatic system, the channels
forming a fine network. Rentschler (1929) distinguishes the anterior third of the
vulva, whence collecting trunks run directly to the mons, from the posterior
two-thirds, whence collecting trunks proceed directly to the terminal lymph nodes.
The fine network gives occasion to ample anastomosing, in part between
the two sides of the vulva by way of the commissures (cf. Fig. 1) and in part
by the ample lymphatic network in the mons pubis.
Another important factor is the distinct separation, by the hymen, of the
lymphatics from the vagina and from the vulva (Poirier 1890 and Rentschler 1929).
The inguinal lymph nodes form the first barrier to the lymphatic drainage
from the vulva. These nodes are arranged in two layers in relation to the
cribriform fascia which is traversed by blood vessels and lymphatics.
The superficial layer contains between 10 and 20 lymph nodes divisible
into two main groups, one including the crural lymph nodes or inferior super-
ficial lymph nodes which accompany the great saphenous vein in the last part
of its course before it penetrates the cribriform fascia. The other group, subinguinal
nodes or superior superficial inguinal lymph nodes are parallel and distal to
the inguinal ligament and are situated between the anterior superior iliac spine
and the pubic tubercle. All these superficial lymph nodes are situated deep
in the subcutaneous fat and connective tissue.
The deep inguinal lymph nodes are situated deep to the cribriform fascia in
relation to the femoral vessels, often medial to the femoral vein, but separated
from the vessels by the vascular sheath which forms a continuation of the
transversalis fascia and the femoral septum of Cloquet formed by this fascia.
The uppermost one is situated on the femoral septum proper and is called the
node of Rosenmiillerl) in German and the node of Cloquet2) in French literature.
It was present in all 54 cases of Bruhns’ (1898) series.
Drainage from the deep lymph nodes is through perforations of the femoral
septum of Cloquet to the external iliac lymph nodes. Of these, the medial ones
are situated along the obturator nerve.
Drainuge of the superficial inguinal lymph nodes is through the cribriform
fascia to the deep inguinal lymph nodes or through direct channels to the
external iliac lymph nodes.

’) Johann Christian Rosenniiiller, born in Leipzig 1771. Professor of anatomy to the University of
Leipzig and author of many anatomical papers, particularly on the obturator nerve.
*) Jules Germain Cloquet, born in Paris 1790. Professor of clinical surgery to the University of Pans.
Described int. al. hernial operations.
20
From the external iliac lymph nodes, it proceeds to the common iliac lymph
nodes and to the lymph nodes along the aorta.
Lastly, it may be mentioned that the drainage from the hypogastric lymph
nodes is also to the common iliac lymph nodes. Frequently, there is a close
relation between the sacral plexus and the hypogastric lymph nodes.
According to this survey on the lymphatics, the drainage from the vulva may
be explained as follows (Basset 1912, Srein 1916, Miiller 1917, Rentschler 1929,
Tuussig 1938, Berven 1941, Daseler 1948, Way 1948, Baranofsky 1948):

. Aortic lymph ncdar.

*

Fig. 1 .
Schematic representation of the lymphatic drainage from the vulva and cross section through
the triangle of Scarpa.
 21

From the anterior third of the vulva, the drainage is through the lymphatic
net in the mons pubis to the superficial sub-inguinal lymph nodes, whereas the
channels from the posterior two-thirds proceed directly lateral to the superficial
sub-inguinal and crural lymph nodes. Drainage from Bartholin's glands is only
to the inguinal lymph nodes (Bruhns).
Drainage from the clitoris is more complicated: From the prepuce the channels
proceed to the superficial inguinal lymph nodes (Rentschfer),while from the glans
clitoridis they may accompany the dorsal vein of the clitoris to the superficial
inguinal lymph nodes. There may be interrupting nodules at the anterior border of
the symphysis. There is direct drainage, however, also to the deep inguinal lymph
nodes, and lastly there may be small channels along the crura clitoridis and through
the inguinal canal to the external iliac lymph nodes (Cune'o & Marcille 1901,
Berven 1941).
Analogous to the drainage from the deep parts of the penis, there is also
drainage direct to the hypogastric lymph nodes by channels accompanying the
dorsal vein of the clitoris (or through a differentiated profound vein of the
clitoris, if any) in its anastomosis with the pudendal plexus and the internal
pudendal vein which opens into the hypogastric vein (Marcille 1902).
According to Tuussig (1938), the lymphatic drainage of the vulva on the
whole is to the inguinal lymph nodes.
Clinical observations based on the presence of metastases are somewhat
difficult to interpret, mainly because comparatively few extensive nodal dissections
have been followed up by accurate histological studies.
Berven ( 1 949) found 45 % with operable, clinically demonstrable metastases
and 12 % with inoperable metastases, but he does not mention the exact criteria
of inoperability.
Among 25 patients treated by extensive nodal dissection, Collins et a f . (1951)
found that the metastases had passed the inguinal lymph nodes in 50 % of the
patients with histologically demonstrable metastases. The numbers involved are
small, however (2 out of 4 cases). For extent of dissection in relation to lymphatic
system see pp. 116-120.
EMBRYOLOGY
Development of Vulva.
As stated by Parks (1945) the formation of the vulva in foetal life is very
similar to that of the mouth.
During the first weeks of foetal life, the foregut as well as the hindgut are
closed by membranes, the buccopharyngeal and cloaca1 membranes, formed by
a layer of entodermal cells interiorly and a layer of ectodermal cells exteriorly.
These membranes disappear in the course of the second foetal month. Prior
to that time, the cloaca has been divided, by the urogenital septum, into an
 22

anterior urogenital section and a posterior section, the rectum, so that the cloaca1
membrane has been divided into a urogenital septum anteriorly and an anal
septum posteriorly.
The first sign of the external genitalia is in the form of the genital eminence
which grows down from the anterior aspect, and the genital groove formed in
the anterior part of the anogenital fossa. In the third foetal month the sex
may be discerned. The urogenital septum which has now opened, is limited by
the genital folds-to become the labia minora-and the labio-scrota1 folds-to
become the labia majora. The genital papilla becomes the clitoris.
It is difficult to identify the site of the anal membrane and urogenital
membrane. Possibly, the valvulae anales represent remnants of this membrane,
whereas the hymen appears to belong developmentally to the vagina, so that
the limit is rather at the free border of the labia minora (Hamilton et al.
1952).
Bartholin’s glands develop from the entoderm. They are present in the third
month (Taussig 1923 a) and contain mucus in the 5th month of foetal life.

Development of the Skin.

In early foetal life the “skin” consists of the embryonal stratum germinativum
and a peridermal layer. The latter disappears at an early stage, whereas the
former persists, forming in the 3 r d 4 t h foetal month the pre-stages of eccrine

Lever’s diagram.

Embryonal
stratum germinativum

basal
cell squamous hair seba- apo- eccrine ?dendritic
layer epithelium ceous crine sweat gland cells
gland gland
1 L Y J

surface epidermis cutaneous appendages

 23

sweat glands (eccrine sweat gland germ), hair, sebaceous glands and apocrine
glands (primary epithelial germ). The embryonal stratum germinativum also forms
the basal cell layer whence the squamous epithelium, the outer hair sheath, and
the duct of the sebaceous gland are derived (Lever 1948). Lastly, the embryonal
stratum germinativum possibly also gives rise to the dendritic cells (which are,
however, perhaps of neural origin) and clear cells which have been related to the
origin of naevus (melanoblasts).