Vulva

In mammals, the vulva comprises mostly external, visible structures of the female genitalia leading into the interior of the female reproductive tract. For humans, it includes the mons pubis, labia majora, labia minora, clitoris, vestibule, urinary meatus, vaginal introitus, hymen, and openings of the vestibular glands. The folds of the outer and inner labia provide a double layer of protection for the vagina. While the vagina is a separate part of the anatomy, colloquially the term has often been used synonymously with vulva. Pelvic floor muscles support the structures of the vulva. Other muscles of the urogenital triangle also give support.
Blood supply to the vulva comes from the three pudendal arteries. The internal pudendal veins give drainage. Afferent lymph vessels carry lymph away from the vulva to the inguinal lymph nodes. The nerves that supply the vulva are the pudendal nerve, perineal nerve, ilioinguinal nerve and their branches. Blood and nerve supply to the vulva contribute to the stages of sexual arousal that are helpful in the reproduction process.
Following the development of the vulva, changes take place at birth, childhood, puberty, menopause and post-menopause. There is a great deal of variation in the appearance of the vulva, particularly in relation to the labia minora. The vulva can be affected by many disorders, which may often result in irritation. Vulvovaginal health measures can prevent many of these. Other disorders include a number of infections and cancers. There are several vulval restorative surgeries known as genitoplasties, and some of these are also used as cosmetic surgery procedures.
Different cultures have held different views of the vulva. Some ancient religions and societies have worshipped the vulva and revered the female as a goddess. Major traditions in Hinduism continue this. In Western societies, there has been a largely negative attitude, typified by the Latinate medical terminology pudenda membra, meaning 'parts to be ashamed of'. There has been an artistic reaction to this in various attempts to bring about a more positive and natural outlook.

Structure

The human vulva is made up of the following:

Mons pubis

The mons pubis is a soft mound of fatty tissue in the pubic region covering the pubic bone. Mons pubis is Latin for "pubic mound" and is present in both sexes to act as a cushion during sexual intercourse, and is more pronounced in the female. The variant term mons veneris is used specifically for females.

Labia

The large outer pair of folds are the labia majora, which contain and protect the labia minora and other structures of the vulva. The labia majora meet at the front of the mons pubis, and meet posteriorly at the urogenital triangle below the anus. The labia minora are the small inner pair of skin folds that protect the openings. The labia minora are often pink or brownish black, relevant to the person's skin color.
The grooves between the labia majora and minora are called the interlabial sulci, or interlabial folds. The labia minora meet posteriorly as the frenulum.

Clitoris

Located at the anterior junction of the labia minora is the clitoris, a highly erogenous sexual organ. The visible portions of the clitoris are the glans and frenulum. Typically, the glans is roughly the size and shape of a pea, and can vary in size from about 6 mm to 25 mm. The size can also vary when the clitoris is erect, which happens when two regions of erectile tissue known as the corpora cavernosa fill with blood, making the shaft engorged. The glans contains many nerve endings, which makes it highly sensitive. The only known function of the clitoris is to focus on sexual feelings. The clitoral hood is a protective fold of skin and it may partially or completely cover the shaft and glans. The hood may be partially or completely hidden within the pudendal cleft.

Vestibule

The area between the labia minora where the vaginal introitus and the urinary meatus are located is the vestibule. The meatus is below the clitoris and atop the introitus. The introitus is sometimes partly covered by a membrane called the hymen. The hymen will usually rupture during the first episode of vigorous sex, and the blood produced by this rupture has been seen to signify virginity. However, the hymen may also rupture spontaneously during exercise or be stretched by normal activities such as the use of tampons and menstrual cups, or be so minor as to be unnoticeable, or be absent. In some rare cases, the hymen may completely cover the introitus, requiring a surgical procedure called a hymenotomy. Two greater vestibular glands known as Bartholin's glands open into either side of the introitus and secrete a mucous vaginal lubricant. The openings of the lesser vestibular glands, known as Skene's glands, are found on either side of the urethral meatus.

Muscles

help to support the vulvar structures. The voluntary, pubococcygeus muscle, part of the levator ani muscle partially constricts the vaginal opening. Other muscles of the urogenital triangle support the vulvar area and they include the transverse perineal muscles, the bulbospongiosus, and the ischiocavernosus muscles. The bulbospongiosus muscle decreases the vaginal opening. They play a role in the vaginal contractions of orgasm by causing the vestibular bulbs to contract.

Blood, lymph and nerve supply

The tissues of the vulva are highly vascularised and blood supply is provided by the three pudendal arteries. Venous return is via the external and internal pudendal veins.
The organs and tissues of the vulva are drained by a chain of superficial inguinal lymph nodes located along the blood vessels.
The ilioinguinal nerve originates from the first lumbar nerve and gives branches that include the anterior labial nerves, which supply the skin of the mons pubis and the labia majora. The perineal nerve is one of the terminal branches of the pudendal nerve and this branches into the posterior labial nerves to supply the labia. The pudendal nerve branches include the dorsal nerve, which gives sensation to the clitoris. The clitoral glans is seen to be populated by a large number of small nerves, a number that decreases as the tissue changes towards the urethra. The density of nerves at the glans indicates that it is the center of heightened sensation. Cavernous nerves from the uterovaginal plexus supply the erectile tissue of the clitoris. These are joined underneath the pubic arch by the dorsal nerve of the clitoris.
The pudendal nerve enters the pelvis through the lesser sciatic foramen and continues medial to the internal pudendal artery. The point where the nerve circles the ischial spine is the location where a pudendal block of local anesthetic can be administered to inhibit sensation to the vulva. A number of smaller nerves split off from the pudendal nerve. The deep branch of the perineal nerve supplies the muscles of the perineum and a branch of this supplies the bulb of the vestibule.

Variations

There is a great deal of variation in the appearance of the vulva. Much of this variation lies in the significant differences in the size, shape, and color of the labia minora. Though called the smaller lips, they can often be of considerable size and may protrude outside the labia majora. This variation has also been evidenced in a large display of 400 vulval casts called the Great Wall of Vagina created by Jamie McCartney to fill the lack of information of what a normal vulva looks like. The casts taken from a large and varied group of women showed clearly that there is much variation. Other variations of the vulva include the appearance of Fordyce spots and clitoral phimosis.
Researchers from the Elizabeth Garret Anderson Hospital, London, measured multiple genital dimensions of 50 women between the ages of 18 and 50, with a mean age of 35.6:

	Measurements	Mean
Clitoral length	5.0–35.0	19.1
Clitoral glans width	3.0–10.0	5.5
Clitoris to urethra	16.0–45.0	28.5
Labia majora length	7.0–12.0	9.3
Labia minora length	20–100	60.6
Labia minora width	7.0–50.0	21.8
Perineum length	15.0–55.0	31.3
Vaginal length	6.5–12.5	9.6
Tanner stage	IV	4.0
Tanner stage	V	46
Color of the genital area compared to the surrounding skin	Same color	9
Color of the genital area compared to the surrounding skin	Darker color	41
Rugosity of the labia	Smooth	14
Rugosity of the labia	Moderately wrinkled	34
Rugosity of the labia	Markedly wrinkled	2

Development

Prenatal development

In week three of the development of the embryo, mesenchyme cells from the primitive streak migrate around the cloacal membrane. Early in the fifth week, the cells form two swellings called the cloacal folds. The cloacal folds meet in front of the cloacal membrane and form a raised area known as the genital tubercle. The urorectal septum fuses with the cloacal membrane to form the perineum. This division creates two areas one surrounded by the urethral folds and the other by the anal folds. These areas become the urogenital triangle and the anal triangle. The area between the vulva and the anus is known as the clinical perineum.
At the same time, a pair of swellings on either side of the urethral folds known as the genital swellings develop into the labioscrotal swellings. Sexual differentiation takes place, and at the end of week six in the female, hormones stimulate further development and the genital tubercle bends and forms the clitoris. The urogenital sinus persists as the vulval vestibule, vestibular glands and urethra. The urethral folds form the labia minora and the labioscrotal swellings form the labia majora.
The uterovaginal canal or genital canal, forms in the third month of the development of the urogenital system. The lower part of the canal is blocked off by a plate of tissue, the vaginal plate. This tissue develops and lengthens during the third to fifth months and the lower part of the vaginal canal is formed by a process of desquamation or cell shedding. The end of the vaginal canal is blocked off by an endodermal membrane, which separates the opening from the vestibule. In the fifth month, the membrane degenerates but leaves a remnant called the hymen.