Clitoral Dysesthesia Following Suprapubic Liposuction: A Case Report of Injury to the Nerves Adjacent to the Clitoris

Abstract

ABSTRACT Introduction Clitorodynia is a bothersome genito-pelvic dysesthesia characterized by atypical sensations such as burning, stinging, and/or sharp pain confined to the glans clitoris, common clitoral shaft and/or prepucial (hood) area that may be constant, intermittent or occurring only when provoked. Clitorodynia, like other genito-pelvic dysesthesia conditions, may result from a trigger in the end organ (clitoris), pelvic/perineum (pudendal/pelvic nerve neuropathy), cauda equina (Tarlov cyst, annular tear), spine, or brain. While the primary sensory nerve of the clitoris is the dorsal nerve, there are sensory nerves adjacent to the clitoris in the suprapubic area. A 55 year old woman who presented to our sexual medicine clinic for evaluation of clitoral dysesthesia following a suprapubic liposuction in May 2016. She described a 5 year history of unusual, unwanted, unrelenting sensations that felt weird, electrical, uncomfortable, and "nervy", were located to the left side of her clitoris/upper left inner labia, were present all the time at a minimum 5/10 intensity increasing to 7-8/10 that prevented her from focusing on tasks, including sexual activity. Objective We herein describe our evaluation and management of this patient with clitoral genito-pelvic dysesthesia. Methods The evaluation involved a detailed biopsychosocial assessment including: medical history; psychologic assessment; hormone assessment; vulvoscopy with cotton-tip swap testing; neurogenital testing for assessment of the integrity of the pudendal and sciatic nerves; and left clitoral/left inner labia anesthesia testing to assess for clinically significant symptom reduction. Results History was positive for diabetes mellitus, hypercholesterolemia, hypertension, abdominoplasty surgery (2007) and L5-S1 fusion (2010). Physical examination using vulvoscopy with cotton-tip swab testing revealed a focal region of dysesthesia (∼ 4 cm long, ∼2 cm wide) to the left of the clitoris and left upper inner labia associated with significant tenderness (7/10). Pudendal nerve integrity testing was normal. Sciatic nerve integrity testing was abnormal consistent with her previous spine surgery. Cotton-tip swab testing after focal anesthesia of the region of dysesthesia with benzocaine 20%, lidocaine 8% and tetracaine 6% revealed a clinically significant symptom reduction to pain free (0/10). Conclusions Clitoral dysesthesia can occur from injury to the nerves adjacent to the clitoris. This is a case of clitoral genito-pelvic dysesthesia in the end organ following a liposuction procedure to the suprapubic area. The most likely trigger was iatrogenic neuropathic injury of the left anterior labial branch of the genital branch of the genitofemoral nerve and/or left anterior labial branch of the ilioinguinal nerve. These latter nerves course in the suprapubic area and do not innervate the clitoris itself. Nerve testing of the clitoris, innervated by the dorsal nerve branch of the pudendal nerve, was unremarkable. Proposed management of the clitoral dysesthesia will focus on treating the iatrogenic peripheral neuropathy in the end organ and include perineural 5% dextrose injections, low intensity shockwave treatments, platelet rich plasma injections, and/or steroid injections. Disclosure No