Background: There is sparse normative data on clitoral-vestibular bulb anatomy and how it changes with aging, despite growing evidence of the latter playing a notable role in female sexual function and other pelvic symptoms.Objective: To identify age differences in clitoral-vestibular bulb anatomy (dimensions, position, shape) among women across the adult lifespan.Study Design: This was a retrospective study of pelvic magnetic resonance images of women (≥18 years) without pelvic floor disorder/dysfunction symptom indications (pelvic organ prolapse, urinary incontinence/pain, fecal incontinence/pain, dyspareunia) and with normal pelvic anatomy (radiographically normal reproductive, genitourinary, or gastrointestinal systems). Participants were categorized into the following age groups: Young Adult (18-34 years), Early Midlife (35-49 years), and Older Adult (≥50 years). Axial images of participants in the supine position at rest were acquired for medical indications. The clitoral-vestibular bulb complex, vagina, and urethra were manually segmented to construct 3-dimensional anatomical models. Computational methods quantified clitoral-vestibular bulb dimensions, position, vaginal-urethral distances, and shape (given by principal component scores obtained from a statistical shape model). Age differences in clitoral-vestibular bulb measures were evaluated using Bonferroni-corrected one-way multivariate and univariate analyses of covariance, with adjustments for body mass index and parity. Age-related correlations were assessed using Spearman's rank correlation.Results: A total of 134 women were analyzed (median [range] age, 39 [19-80] years): 47 Young Adult, 46 Early Midlife, and 41 Older Adult women. All Young Adult and Early Midlife women were premenopausal, whereas 27 (71%) of Older Adult women were postmenopausal. Older Adult women had a shorter clitoral body length than Early Midlife women (24.1 mm vs 27.9 mm; P=.006). Overall, smaller vestibular bulb volume was associated with increasing age (P=.04). Older Adult women had a more inferiorly positioned clitoral-vestibular bulb complex (lower in the pelvis) than Early Midlife women (-21.0 mm vs -17.6 mm; P<.001) and Young Adult women (-21.0 mm vs -17.9 mm; P<.001). Across the entire cohort, increasing age correlated with a shorter clitoral body length (ρ=-0.21; P=.01) and vestibular bulb volume (ρ=-0.20; P=.02), and a more posteriorly (ρ=-0.22; P=.01) and inferiorly (ρ=-0.43; P<.001) positioned clitoral-vestibular bulb complex, whereas clitoral volume remained unchanged (ρ=-0.03; P=.73). The shape analysis revealed that age predominantly affected the vestibular bulbs, which became more medially positioned (closer together) (ρ=-0.28; P=.001) and proportionally smaller relative to the clitoris (ρ=-0.28; P=.001) with advancing age.Conclusions: Older age was associated with reduced size and posterior-inferior descent of the clitoral-vestibular bulb complex, with aging primarily affecting the vestibular bulbs compared to the clitoris. Findings demonstrate age-related atrophy and descent of clitoral-vestibular bulb anatomy, which may contribute to sexual function and other pelvic symptoms.

Objective: To identify postoperative vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery. Design: Secondary analysis of MRIs of the Defining Mechanisms of Anterior Vaginal Wall Descent cross-sectional study. Setting: Eight clinical sites in the US Pelvic Floor Disorders Network. Population: Women who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for symptomatic uterovaginal prolapse between April 2013 and February 2015. Methods: MRIs (rest, strain) obtained 30-42 months after surgery, or earlier for participants with recurrence who desired reoperation prior to 30 months, were analyzed. Prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create 3D models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position between groups. Main Outcome Measures: Vaginal angulation (upper, lower, and upper-lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume), and position (apex, mid-vagina) at rest. Results: Of the 82 women analyzed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, recurrences had a more laterally deviated upper vagina (p=0.02) at rest than successes. After hysterectomy, recurrences had a more inferiorly (lower) positioned vaginal apex (p=0.01) and mid-vagina (p=0.01) at rest than successes. Conclusions: Vaginal angulation and position were associated with prolapse recurrence and indicative of vaginal support mechanisms related to surgical technique and unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors. Funding: Eunice Kennedy Shriver National Institute of Child Health and Human Development-sponsored Pelvic Floor Disorders Network (Grant/Award Number: U10 HD054214, U10 HD041267, U10 HD041261, U10 HD069013, U10 HD069025, U10 HD069010, U10 HD069006, U10 HD054215, U01 HD069031); National Institutes of Health Office of Research on Women’s Health; Boston Scientific Corporation; National Academies of Sciences, Engineering, and Medicine’s Ford Foundation Predoctoral Fellowship Program