Review of Atlas of Pelvic Anatomy and Gynecologic Surgery, Fourth Edition
This textbook is 1408 pages long. It was published in 2015.
1. The distal course of the dorsal nerves are not shown or described.
The course of nerves in the clitoris are omitted. This is the extent to which the nerves and vasculature of the clitoris and labia minora are covered:
Note how they show them stopping prior to the clitoris. They actually cover vulvar anatomy in two chapters in this book. In both, they fail to cover adequate anatomy. Here is an illustration from the other chapter:
2. The length of the body of the clitoris is minimized.
I haven’t talked about this previously, as there is very little data on clitoral body lengths and poor research methodology has led to it’s minimization, but this seems to be chronic in medical literature. This seems to arise due to a societal fear of how much the external portion of the clitoris resembles a miniature external penis.
According to Lepidi and Di Marino, who have done the most in depth study of the clitoris to date, the length of the descending body plus the glans, collectively, is 3.75 cm on average. According to them, on average, 2.94 of this length is external. Consider this length relative to the average distance from the top of the clitoral hood to the perineum, reported to be 9.3 cm on average by Lloyd et al. Also consider that the length of the external portion of the descending segment of the clitoral body plus the glans is equal to or greater than the distance from the top of the clitoral hood to the tip of the glans. The descending segment of the body in the above illustration should be at least 50% longer.
In this illustration, the clitoris resembles that of someone who has undergone FGM, as the length of the descending segment is very short, and the body does not appear to extend beyond the mons. There is no protruding body, covered by a clitoral hood, as there should be.
3. The shape of the clitoris is illustrated incorrectly
Both the above illustration and the next omit the ascending segment of the clitoral body.
The clitoris is illustrated incorrectly throughout this book. Here is another example:
4. Incorrect nerve mapping
The branches of the pudendal nerve innervate the entire length of the clitoral body and the clitoral hood. In this illustration, the clitoral hood and body extend 100% more anteriorly (up, in the illustration) beyond the border of the blue section. In the accompanying description, these authors describe the purple section as being the mons and upper labia majora, but they clearly have purple covering most of the clitoral hood.
5. Incorrect description of the clitoris
The authors say, “The clitoral body is deep to the glans.” As can be seen in Kobelt, MRIs, looking at real vulvas, etc, the clitoral body is not exactly “deep” to the glans, as the angle between the tangent plane of the clitoral body, beyond the elbow, and the tangent plane of the body in general, as the pelvis curves, is never more than 45 degrees. from the It is more aptly described as proximal and anterior/cephalad to the glans. Describing it as “deep” fails to recognize the fact that this anatomy is external under the hood for most of it’s length.
6. No discussion of sexual function of the labia minora
The labia minora are sensitive tissue that engorge with arousal and mechanically facilitate indirect stimulation of the clitoris during sex. Why do textbooks consistently fail to acknowledge their role in sexual function?
They do at least acknowledge a functional role, which is more than can be said for most OB/GYN textbooks.
“These labia keep the vestibular skin moist and prevent external detritus from entering the lower vagina and vestibule.”
7. Dangerous labiaplasty practices endorsed
This textbook’s chapter on labiaplasty technique demonstrates that some women do have a medical need for labiaplasty. As long as some women need these surgeries, professional organizations cannot categorically oppose them. And as long as they are approved, they will be done for cosmetic reasons, especially considering the significant financial incentive. What is most important is that surgeons do these procedures safely.
However, the illustration of a technique clearly shows an excessive amount of tissue being removed. There are no notes on how to perform this surgery safely so as to avoid complete amputation, which, according to experts, happens frequently by accident because “most doctors don’t know what they are doing” (Gary Alter).
Though the authors say, “complete amputation is rarely, if ever, indicated,” they show before and after photos where the labia minora of a woman with extreme hypertrophy, who actually needs surgery for medical reasons, are completely amputated. Though the illustrations of the technique show only removal of the labia minora, it is clear, based on the photos, that the clitoral hood was also reduced in this procedure. I am sorry for posting these photos, but this is basically medical malpractice getting published in a textbook. The level of ignorance required to think this is acceptable is tremendous.
8. False information about labia minora
No matter how large the labia minora are, they should not cause “hygienic probems,” yet these authors say:
“Occasionally, the labial configuration is greatly exaggerated so as to create hygienic problems.”
It is notable that in one sample of women seeking surgery, many of the women had labia minora smaller than average, most of the women were in their teens and 20s, most were virgins, and many cited hygiene issues as the reason for seeking surgery. It is important to not endorse such invalid reasons.
9. Iatrogenic causes of female sexual dysfunction is not discussed
This may not be a huge deal, as this books seems to focus primarily on surgical techniques, but it is worth mentioning. Techniques for both radical and simple vulvectomy are described without discussion of detailed surgical anatomy, how to preserve function, or how to reconstruct anatomy (in the event of clitoral glans and distal body removal, the proximal body could be externalized — this is not considered).