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Skene's gland revisited: Function, dysfunction and the G spot

Article  in  International Urogynecology Journal · September 2011

DOI: 10.1007/s00192-011-1558-1 · Source: PubMed

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Int Urogynecol J (2012) 23:135–137
DOI 10.1007/s00192-011-1558-1
EDITORIAL
Skene’s gland revisited: function, dysfunction and the G spot
Peter L. Dwyer
Published online: 8 September 2011
# The International Urogynecological Association 2011
Despite Skene’s gland being described over 300 years ago,
and the frequent performance of surgery on and around
these glands, it is remarkable how little we know about
what they do and potential problems associated with them.
Infection in these glands was described with gonorrhoeal
infection in 1672 by Regnier de Graaf (1641–1693), which
was long before Skene [1] described them in 1880.
Controversy exists on the function of Skene’s glands, their
role in sexual function, female orgasm and ejaculation, and
even their anatomy. What is their role in the causation of
urogynecological symptoms such as urethral pain and
sexual dysfunction? Urogynaecological surgery in this area
is commonplace for the treatment of urethral or paraurethral
pathology, urinary incontinence or vaginal prolapse. What
effect can this have on their function and sexual function
more generally?
In a histopathological study Wernert et al. [2] described
Skene’s gland as a group of glands arranged in long
ductal structures situated in the caudal two thirds of the
urethra “mainly in the dorsal and lateral mucosal stroma but
extending in some cases to the smooth musculature of the
septum urethrovaginale”. These glands are not always
present and were found in only two thirds of the 33 women
they studied. They are “tubuloaveolar formations on long
ductal structures” and resemble male prostate glands prior
to puberty and androgenic stimulation. They contain
prostate-specific antigen (PSA) and prostatic acid phospha-
Related articles can be found at doi:10.1007/s00192-011-1461-9 and
doi:10.1007/s00192-011-1488-y.
P. L. Dwyer (*)
Department of Urogynaecology,
Mercy Hospital for Women and Melbourne University,
Melbourne, Australia
e-mail: pdwyer@connexus.net.auc
tase (PAP) on immunostaining [2]. A more recent study [3]
has confirmed the presence of prostate-specific antigen
reactivity in the paraurethral tissues and in the “superficial
layer of the female secretory (luminal) cells of the female
prostatic glands and membranes of secretory and basal cells
and membranes of cells of pseudostratified columnar
epithelium of the ducts”. These ductal structures run
longitudinally around the distal urethra located on the
anterior vaginal wall. The literature is unclear on whether
the glands open through a single or multiple orifices either
into the distal urethra (similar to the male prostate) or a
single duct orifice onto the left and right sides of the
external urethral orifice. However it is my experience in
asymptomatic women (Fig. 1) or where there is infection
and abscess formation (Fig. 2), there is a single duct
external to the urethral meatus.
The distal urethra and vagina have an intimate relation-
ship with the clitoris, both anatomically and functionally.
The clitoris consists of an exterior glans, a midline densely
neural nonerectile structure that is continuous with the
erectile tissue of the paired bulbs and crura, which surround
the distal urethra and vagina. The distal urethra, vagina and
clitoris have a shared vasculature and nerve supply (the
dorsal nerve to the clitoris) and form a tissue cluster
described by O’Connell et al. [4] as the “locus of female
sexual function and orgasm”. These tissues around the
distal urethra become engorged with sexual arousal, but
there is debate whether secretions are produced during
coitus by Skene’s gland, or if ejaculation with orgasm
occurs, similar to the male prostate. Heath [5] proposed
that a large amount of lubricating fluid can be secreted
from this gland similar to a “female ejaculation" when
stimulated from inside the vagina and to such an extent
that it can be mistaken for urine and coital urinary
incontinence. If this does occur, it is an uncommon cause
136
Fig. 1 Normal appearance of the external urethral meatus in an
asymptomatic woman. The orifice of Skene’s gland can be seen at 5
o’clock
as most coital incontinence is caused by weakness of the
urethral sphincter mechanism and successfully treated by
conventional stress incontinence surgery as shown by De
Souza et al. [6] in this issue.
In 1950 Ernest Gräfenberg described an area a few
centimetres up on the anterior vaginal wall that produces an
orgasm different from one produced by clitoral stimulation
[7]. The significance of this area, later called the G spot in
his honour, is debated. A recent review by Hines [8]
concerning evidence for the G spot concluded: “anecdotal
observations and case studies are not supported by
subsequent anatomic and biochemical studies”, and “no
different or special innervation has been found in the
lower anterior vaginal wall”. However the existence of
the G spot is accepted by many women; an anonymous
questionnaire was distributed to 2,350 professional
women in the US and Canada [9], found that 84% of
the women “believed that a highly sensitive area exists in
the vagina”. Of these respondents, 40% reported having a
fluid release (ejaculation) at the moment of orgasm.
Further, 82% of the women who reported the sensitive
area (Grafenberg spot) also reported ejaculation with their
orgasms.
Some practitioners are injecting collagen in this area to
enhance sexual enjoyment. I remember one patient of mine
refusing prolapse surgery because I could not guarantee that
my surgery would not interfere with her G spot
Fig. 2 Skene’s gland abscess with purulent discharge from ductal
orifice
Int Urogynecol J (2012) 23:135–137
enhancement. Lubrication is important for satisfactory
vaginal coitus and female orgasm dramatically increases
this lubrication. The presence of Skene’s glands in this
area designated as the G spot has been suggested by
some to be important confirmation of its relevance [5],
but their role in coital lubrication, orgasm and sexual
satisfaction requires further clarification. The highly
variable nature of orgasms during intercourse in women
is also said to be consistent with the finding of absent
Skene’s glands in a third of females [2].
Transvaginal repair of anterior vaginal wall prolapse,
excision of infected Skene’s cysts, urethral diverticulum or
even placement of mid-urethral synthetic slings have the
potential to disrupt the normal anatomy and function of
Skene’s gland, the clitoris and their neurovascular supply,
and cause sexual dysfunction. This has not been reported
but also has not been extensively investigated. Overzealous
excision of urethral mucosa can result in urethral stenosis
and voiding dysfunction. As surgery and excision of the
gland usually involve only the distal urethra, the effect on
urinary control is usually minimal. De Souza et al. [6] in
this issue prospectively evaluated sexual function following
the retropubic TVT and transobturator Monarc slings, and
found no deletious effect on sexual or orgasmic function;
overall sexual satisfaction was improved following surgery
because of the lower incidence of coital incontinence.
Asymptomatic cysts of the duct or gland are uncommon
and when infection occurs can cause pain, dysuria, vaginal
discharge and dyspareunia. On examination a palpable
painful mass is present next to the distal urethra and
purulent material can be expressed from the ductal orifice
(Fig. 2). Skene’s abscesses can be distinguished from
urethral diverticulum, which is usually more proximal and
communicates with the urethra through a diverticular
orifice. When doubt exists, imaging with positive pressure
urography using a Trattner’s catheter, ultrasound or mag-
netic resonance imaging (MRI) can be helpful. Gittes et al.
[10] and Shah et al. [11] in this issue have suggested that
infection in Skene’s gland (skenitis) is more common than
previously appreciated and may be a cause of chronic
urethral pain in women and recurrent urinary tract infection.
Both are common and difficult problems to treat in
urogynecological practice. The diagnosis can be confirmed
by the clinical finding of urethral tenderness and expression
of pus from Skene’s duct. If confirmed, antibiotic treatment
is warranted, and consideration of surgical incision is
recommended by Shah et al. [11] in this issue.
The exact function of Skene’s gland and the lower anterior
vaginal wall in sexual function needs further clarification. Is
this a vestigial developmental remnant or does it have an
important function? Moalem and Reidenberg [12] recently
suggested that gland secretions may have antimicrobial
qualities and protect from urinary tract infections. Certainly
Int Urogynecol J (2012) 23:135–137
infection in Skene’s gland will present to clinicians; the role
of infection as discussed in the Shah et al. manuscript [11] in
causation of chronic urethral pain and recurrent UTI also
needs clarification. However we should all include careful
examination of this area routinely to detect urethral
tenderness, enlargement, or abscess formation or expression
of ductal pus (Fig. 2) in women with urethral syndrome and
recurrent UTI.
This area of female sexual function is very difficult
to investigate. While there is much public interest in
sexual well-being and normal physiological processes,
lack of good basic science allows supposition and
ignorance to blossom. There is an obvious need for
the next Kinsey to illuminate this important area of
human health.
Conflicts of interest None.
References
1. Skene A (1880) The anatomy and pathology of two important glands
of the female urethra. Am J Obs Dis Women Child 13:265–270
2. Wernert N, Albrech M, Sesterhenn I, Goebbels R, Bonkhoff H,
Seitz G, Inniger R, Remberger K (1992) The 'female prostate':
location, morphology, immunohistochemical characteristics and
significance. Eur Urol 22(1):64–69
View publication stats
137
3. Zaviacic M, Ablin RJ (2000) The female prostate and
prostate-specific antigen. Immunohistochemical localization,
implications for this prostate marker in women, and reasons
for using the term “prostate” in the human female. Histol
Histopathol 15(1):31–42
4. O’Connell HE, Hutson JM, Anderson CR, Plenter RJ (1998)
Anatomical relationship between urethra and clitoris. J Urol
159:1892
5. Heath D (1984) An investigation into the origins of a copious
vaginal discharge during intercourse: "Enough to wet the bed"—
that "is not urine". J Sex Res 20(2):194–215
6. DeSouza A, Schierlitz L., Dwyer PL, Rosamilia A., Murray
C., Thomas E., Hiscock R., Lim Y. Sexual function following
retropubic TVT and transobturator Monarc sling in women
with intrinsic sphincter deficiency: a multicentre prospective
study. Int Urogynecol J Pelvic Floor Dysfunct.; 2011
doi:10.1007/s00192-011-1461-9
7. Grafenberg E (1950) The role of the urethra in female orgasm. Int
J Sexology 3:145–148
8. Hines T (2001) The G-spot: A modern gynecologic myth. Am J
Obstet Gynecol 185:359–362
9. Davidson JK, Darling CA, Conway-Welch C (1990) Female
ejaculation: perceived origins, the Grafenberg spot/area, and
sexual responsiveness. Arch Sex Behav 19(1):29–47
10. Gittes RF, Nakamura RM (1996) Female urethral syndrome. A
female prostatitis? Western Journal of Medicine 164(5):435–
438
11. Shah SR, Biggs GY, Rosenblum N, Nitti VW. Surgical
management of Skene's gland abscess/infection: a contemporary
series. Int Urogynecol J Pelvic Floor Dysfunct. 2011
doi:10.1007/s00192-011-1488-y
12. Moalem S, Reidenberg JS (2009) Does female ejaculation serve
an antimicrobial purpose? Med Hypotheses 73(6):1069–1071,
Epub 2009 Sep 18