Ejaculation Associated With Bladder Muscle Overactivity? - A Journal Article I Read

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Well, my friends, this is another installment of A Journal Article I Read - a segment in which I read a lady-gasm related peer-reviewed journal article and try my damndest to summarize the article here for you without taking away too much of the detail and subtlety, yet making it readable and not too long. I do my best to achieve those goals, and that's all I can say.

In these summaries, you can assume that anything I write is a genuine attempt to reflect what is said in the paper - even if it's shortened or summarized. My opinions, if I have any to add will either be inside brackets likes these [me:], or in a section headed in a way that clearly lets you know these are my opinions. All quotes are from this article unless specifically noted.

You can check out the list of all the past 'A Journal Article I Read' Summaries HERE.

Do women with female ejaculation have detrusor overactivity? Cartwright R1, Elvy S, Cardozo L. J Sex Med. 2007 Nov;4(6):1655-8.

My Quick Summary
In order to identify if bladder abnormalities (specifically problems with bladder control) tend to exist in women that claim to ejaculate during intercourse and/or orgasm, the researchers (who have a urogynecology practice) investigated 6 women that claimed to ejaculate and 6 women who claimed to have never ejaculated. They had them fill out a 3-day journal of their peeing situations, and they also did a test where they filled their bladder up and checked to see if they could hold it while doing things like coughing. What they found was that none of these 12 women had issues with bladder control. Although in their practice they have identified some women who they believe misidentified their bladder control problems during sexual activity with ejaculation, this study showed that not all women that claim ejaculation also have bladder problems. They conclude that if women have liquid release during orgasm or intercourse but do not also exhibit other symptoms of bladder control problems, then there need to be no more medical investigation, and these women should be assured that their release is not a problem.

I think this is a really simple, thoughtful, generally well-done study. Although it's quite small and specific, I believe it adds 1 tiny drop into the already quite small pool of knowledge that can be used to help piece together an understanding of sexual fluid expulsion. I also appreciate that this study does not seem to push any agendas and doesn't carelessly confuse ejaculation with orgasm - because they are not physiologically the same thing.

Introduction

• "Questionnaire surveys have suggested that 40% to 54% of women have at some time experienced an expulsion of fluid at orgasm [1,2]." There have also been references to female ejaculation throughout history and in more recent discussions by Dr. Graffenburd in the 50's and Beverly Whipple in the 80's who "reported that a minority of women passed small volumes of fluid during heightened sexual arousal or at orgasm."
• "Although it is anatomically and physiologically plausible that small volumes of fluid might be expelled from the para-urethral Skene's duct, some sources imply that it is a normal part of female sexuality to discharge large volumes of fluid at orgasm." [Me: "Skene's gland is said to be the female prostate since it is the embryological, yet less developed, equivalent to the male prostate. It wraps around the urethra and can sometimes be felt through the vaginal wall towards the front of the body in the area that is most commonly called the G-spot (although G-spot is also used as a catch-all phrase to describe an imaginary button that causes vaginal orgasms).]
• The authors go on to describe how now there 'ejaculation gurus' that try and teach women to ejaculate and porn that shows large volumes of fluid expulsion. "The most anatomically and physiologically plausible explanation is that such fluid is emitted from the bladder."
• Maybe partially because of those misleading depictions in porn and the like, it remains controversial what the liquid at ejaculation is - urine, prostate fluid, vaginal secretions, a mixture of the two?
• There are some past studies, but many of them have small sample sized and some are not peer reviewed.
• Some studies showed higher levels of prostate enzymes than would be expected in urine
• One study catheterized 7 women who claimed to regularly experience ejaculation. For all of the women, "large volumes of fluid were passed down the urethral catheter, with the timing of fluid expulsion corresponding with the peak of orgasm." [Me: So, in other words in this study there seemed to be liquid coming from the bladder during sexual arousal even though the bladder had been emptied beforehand].
• In the author's urogynocological practice, they often treat women with bladder control issues. A previous study has indicated that orgasm can cause a detrusor (muscle on wall of bladder) contraction that can cause leakage, and women who complain of leakage at orgasm have a high prevalence of detrusor overactivity. However, symptoms of detrusor overactivity do not only include leakage at orgasm or intercourse, but also other bothersome things like urinary urgency and frequency.
• The authors, as female ejaculation has become more commonly known, have treated women with a proven detrusor overactivity diagnosis who rationalized the leakage at orgasm as ejaculation. So from this anecdotal evidence, they wanted to see if they would find a connection between ejaculation and detrusor overactivity - and particularly wanted to see if women that self identified as ejaculating also showed this bladder condition. This was not meant to stigmatize but to help counsel women who presented leakage at orgasm and also to maybe better understand the physiology of ejaculation.

Subjects and Method

• 6 participants that self-identified as having experienced female ejaculation and 6 that had not were recruited from the researcher's institution staff. They were between 27 and 41 and having given birth between 0 and 3 times.
• They were given a short survey asking about frequency and conditions of ejaculation. All 6 of the 'ejaculating' women said they ejaculated either "often" or "sometimes" and did so either during masturbation or intercourse.
• "Each women completed a 3-day bladder diary, documenting the volume and timing of urinary void."
• Each woman also completed 2 short validated bladder questionnaires; one asking about perception of desire to void and the other asking about bother associated with lower urinary tract symptoms.
• Each woman also underwent 'short provocative ambulatory urodynamics." This is basically a test for detrusor over-activity where a catheter is placed up the urethra and anus, and the bladder is fully filled for about 30 minutes while the participant is asked to do things like coughing and heel bouncing while holding their pee.
• Data was analyzed by a blind 3rd party. There was no difference between the groups and so no extra statistical analysis was performed.

Results

• There was no indication of detrusor over-activity in either group and the bladder-diaries showed no significant difference between groups.
• There was no significant difference between the scores on the validated bladder questionnaires about desire to void. "Almost all the women agreed with the statement, 'I am usually able to finish what I am doing before going to the toilet.'"
• The scores for the validated bladder questionnaires about bother associated with lower urinary tract symptoms were "marginally higher (more impairment) in the female ejaculation group." This was due to 2 women in that group who had given birth that "reported occasional bothersome stress incontinence."

Discussion

• "This study does not exclude the possibility that female ejaculate is coming from the bladder. It does however, demonstrate that women who report female ejaculation do not necessarily have the associated symptoms or pathophysiology of women who complain of coital incontinence."
• This research did not replicate the "symptoms" of an ejaculation. The women were not sexually aroused, so there is still a possibility that for the ejaculating women there is uninhibited detrusor (muscle of bladder wall) contractions at orgasm. A future study in this vein, but with women during sexual arousal and orgasm would be useful and informative.
• Like most female ejaculation studies, this sample size was small, and it is possible there was bias in that women who had incontinence issues may not have volunteered for the study.
• The researchers also wonder if there could be bias because the ejaculating women in this study did not necessarily experience it frequently. Other past studies have used women that were able to ejaculate at most episodes of intercourse or masturbation.

Conclusions
"Based on our findings, we would recommend that women who report female ejaculation, in the absence of other bothersome lower urinary tract symptoms, do not require further investigation. They should be assured that this is an uncommon, but physiological phenomenon."

Fluid Expulsion During Female Sexual Activiy - A Journal Article I Read

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J Sex Med.2013 Jul;10(7):1682-91. 2013 May 1.
Female ejaculation orgasm vs. coital incontinence: a systematic review. Pastor Z

So this is another installment of A Journal Article I Read. Let's get right down to it. This is a review article, which means it's not about a study the author did. The author simply looks at the articles that exist on a particular subject and discusses where there is agreement and where there is not, and then gives a conclusion, given the current scientific understanding, about the topic in question.

I very much like a review because it's kind of what science is all about. One study is one study - might be useful, might be a bit of an anomaly, might be bullshit. However, looking at many studies on a topic from all different directions, with different biases and methods and disciplines involved - now that is the way to get to the bottom of something.

This article does, in fact, try to get as close to the bottom of a thing as it can - which isn't really very far given the lack of high quality studies to go from, but in the right direction none the less. It's about liquid coming out of women during sexual activity - what the hell is it and why does it happen? It's a fair question. Not only are there women who report that something spurts out of them during certain sexual activity or orgasm, but there is also objective documentation of this in a lab situation. The problem is, it's hard to categorize it all as one thing because the timing of the expelling of liquid (during orgasm, arousal, penetration?) and the amount and make-up of the liquid seems to be quite variable. Currently there seems to be a few different ways that studies describe liquid expelling from women during the ol' sex and some are sexual releases or arousal related and some are due to Coital Incontinence (CI), otherwise known as some pee escaping during the sex. So, this article aims to see what the existing studies on liquid expulsion have shown so far.

The author used a variety of terms were used to search through literature databases, and anything that focused on "evaluating fluid expulsion occurring during female sexual activity or describing types of CI, including characteristics, quantity, and composition of the fluid and mechanism of leakage" were used. In the end 46 studies were evaluated including 4 reviews - and 4 books were also used.

So types of fluid expulsion:

First off, we're not really talking about vaginal lubrication here. Vag lube is a fluid that is emitted from the walls of the vagina during arousal. Although, a lack of this fluid can be problematic for some women, increased lube doesn't cause a problem and is considered a discharge more than a gush. Apparently Alfred Kinsey and his crew suggested that lubrication could be forced out through contractions of the perivaginal muscles thus resembling Female Ejaculation (FE). However, there is no actual evidence of an "expulsion" of this kind happening. The authors here talk about vaginal lube very quickly at the beginning of the article in much the same way I do above, but the focus of this article is liquid that comes out of the urethral opening - or as I like to call it the ol' pee hole. I want to mention this because this can be confusing. A lot of people think women actually pee out of the vagina or ejaculate out of the vagina, but we don't. We have a pee hole down there for that, and if you didn't know that, don't worry, you are very much not alone. I used to (into my 20's really) think I peed out of my clit, but that's another story.

So anyway, here's just that basics - because to really give you all the nuances- and there are a lot, you would just need to read the article in its entirety - which I suggest you do if you have any further questions or are interested in this kind of thing. Anyway, the body of evidence so far seems to suggest that the quantity and composition are kinda good indicators of where the fluid is coming from and what it's all about.

Here's the kinda flow chart that was made for the different categories of fluid.

 Female ejaculation orgasm vs. coital incontinence: a systematic review. Pastor Z J Sex Med.2013 Jul;10(7):1682-91. 2013 May 1.

1. Female Ejaculation (FE) - A little bit of milky white fluid that contains some prostate enzymes and sugars also seen in male ejaculate. This likely originates from the female prostate (kinda similar to the male prostate before puberty) in response to clitoral or vaginal stimulation in some women or during orgasm. 
2. Squirting - A larger amount of fluid released that may be a chemically altered urine from the bladder. Some very small studies were done that emptied the bladder before orgasm and then checked the make-up of the fluid released during squirting. It did have a little bit of uric acid and urea, but it also had some sugars and prostate enzymes. It was not urine, but probably came from the bladder. The mechanism for how this happens - even after the bladder is drained, is not fully understood. It seems to be a clear liquid that doesn't smell like pee.
3. The other possible fluid release is basically urine. It can happen during arousal, stimulation, penetration and orgasm. There is some speculation in different studies about what types of problems (stress urinary incontinence or detruser over activity for instance) are most likely to cause urine leakage during which sexual activities, but there is little agreement. This type of fluid looks chemically like urine, though.

Here's the table showing the chemical make-up of the different categories of fluid.

Female ejaculation orgasm vs. coital incontinence: a systematic review. Pastor ZJ Sex Med.2013 Jul;10(7):1682-91. 2013 May 1.

Other things this article said were suggested from the studies so far:

• Women who squirt or ejaculate as described above don't generally have issues with incontinence, but women who have urine leakage do tend to. 
• I noticed from the article that the estimates of the percentage of women who complain of urine leakage during sexual activity varies wildly, but it seemed to me it's not insignificant...my point being that it seems to be a fair amount of women, so if this is you - you're not alone by any means.
• There are clearly some women who naturally have fluid release in relation to certain stimulation or orgasms, but it doesn't seem to be a very high number of women.
• A lot of the studies don't involve solid clinical evidence: "Only eight studies objectively confirmed FE in a total of 52 respondents. Studies reporting a higher prevalence of FE in hundreds of cases were based on questionnaire studies or anecdotal evidence" 
• "A consensus regarding terminology and classification may contribute to more precise diagnosis and provision of correct information to both healthcare professionals and the public." - I mean, right?
• There are better studies about this stuff that can and should be done. They may not be super easy, but good science never is...usually...I think.

So that's the very basics. I know some people can tend to get a little defensive and worried when it comes to defining fluid during sexual activity - given that ejaculation/squirting has and still is misunderstood. However, I hope everyone can recognize that gaining knowledge through good research on this topic is important, and that we can all figure out how to be tolerant and accepting no matter what things are learned as more research is done.