Clitoral Phimosis Research Articles

Efficacy of in-office lysis of clitoral adhesions with excision of keratin pearls on clitoral pain and sexual function: a pre-post interventional study.

Keratin pearls are foci of central keratinization within concentric layers of squamous cells that can form under the clitoral prepuce and cause pain (clitorodynia); in-office removal of keratin pearls may reduce clitoral pain and improve sexual function. This study aims to investigate clitoral pain and sexual function in women with partial clitoral phimosis and keratin pearls before and after in-office lysis of clitoral adhesions with keratin pearl excision (LCA-KPE). A pre-post interventional study evaluated patients who underwent LCA-KPE between January 2017 and February 2023 in 2 metropolitan gynecology clinics specializing in vulvar pain. Patients presenting with keratin pearls and partial clitoral phimosis identified through retrospective chart review were asked to complete postprocedure questionnaires and provide subjective responses on clitoral discomfort, sexual function, sexual distress, and their experience with in-office LCA-KPE. Bivariate analyses with paired t tests were conducted to determine the effect of LCA-KPE. Qualitative data were analyzed with thematic coding. An 11-point pain visual analog scale was utilized to determine pre- and postprocedure clitoral discomfort and difficulty with orgasm. Female sexual dysfunction was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised. A total of 32 of 74 patients who met inclusion criteria completed postprocedure surveys (43% response rate). Mean clitoral pain for respondents was 6.91 at baseline and 2.50 after LCA-KPE (P < .001). Mean difficulty with orgasm was significantly decreased from 5.45 at baseline to 3.13 after LCA-KPE (P < .001). Participants had a mean FSFI total score of 17.68 after treatment compared with a mean total baseline FSFI of 12.12 (P = .017). The mean FSFI score for pain was 2.43 at follow-up compared with 1.37 at baseline (P = .049). There was no significant difference in the mean Female Sexual Distress Scale-Revised score before vs after the procedure (P = .27). Qualitative themes described the procedure as painful but worthwhile, with 77% of participants reporting the overall experience as positive. Recurrence rate overall was 28%, with a median of 2 repeat procedures. Recognizing keratin pearls as a structural cause of clitoral pain and offering in-office treatment is an important tool in addressing clitorodynia and improving sexual function. This is the largest study to date documenting the occurrence, identifying associated pain conditions, and evaluating procedural outcomes for clitoral keratin pearls. This study was limited by a relatively small sample size. In-office LCA-KPE significantly reduced clitoral discomfort and difficulty with orgasm.

(271) Patient with Severe Clitoral Phimosis and Smegmatic Cyst: A Case Report and Review of the Literature

Abstract Introduction Clitoral phimosis describes an attachment of the clitoral prepuce to the glans. This severe form of clitoral adhesions prevents the mobility and retraction of the clitoris and can be accompanied with clitorodynia, persistent arousal, and/or muted or absent orgasm. It often presents with a buildup of smegma and keratin pearls. Previous research suggests that these adhesions are found in up to 22% of women seeking evaluation for sexual dysfunction. Objective To describe a patient with a unique and severe presentation of untreated clitoral adhesions resulting in complete clitoral phimosis and a large pseudocyst, and to share an innovative and minimally invasive procedure option which preserved sexual function. Methods A 60-year old female presented with as a clitoral mass to a urology and sexual medicine practice for consultation regarding surgical excision of the mass with hopes to preserve clitoral sensation. Following an abdominal hysterectomy and bilateral salphingoophrectomy in 2010, the patient of interest presented to her gynecologist for an enlarging clitoris which progressed to form a mass over the course of several years. In 2022 she established care with a new gynecologist who referred her to a gyn-oncologist for concern of the now large mass. She underwent an MRI of the pelvis in September 2022 which revealed a 1.7 x 3.5 x 1.9 cm cystic lesion projecting from the prepuce. This was felt to be an epidermoid cyst or proteinaceous or hemorrhagic cyst arising from the vagina. After speaking to many specialists the plan was to undergo surgical excision, though preservation of sensation could not be guaranteed. The patient canceled surgery to obtain more information as preservation of clitoral sensation was a priority, at which point she presented to our clinic in April of 2023. Results On exam, there were normal labia majora and resorbed labia minora fusing with the clitoral mass. On further examination, complete phimosis with a pinpoint and closed phimotic ring visible and a large smegmatic pseudocyst that was not adherent to the clitoris was appreciated. Clitoral phimosis was discussed at length and as an innovative, yet relatively straightforward solution, our urological surgeon proposed a dorsal slit (in the operating room) procedure for removal of smegma and small excision of excess surrounding tissue. This approach would have little to no known effect on the clitoral nerves as they course dorsally and terminal at the clitoral glans and would allow full retraction of the clitoral prepuce. The procedure was performed in May 2023 under IV sedation. Copious amounts of smegma were irrigated from the cyst and no adhesions were appreciated. After the removal of the smegmatic pseudocyst, our patient reported improved sensation and orgasm without pain or cystic reaccumulation. She was instructed to dilate the opening to avoid re-adherence. Conclusions There is no standardized treatment for clitoral adhesions. This procedure improved our patient’s sexual function and orgasm ability and was spared from a major surgery with significant risks. Equipping physicians with fundamental knowledge about clitoral adhesions would likely result in earlier and more frequent intervention, preventing large and atypical masses like the one observed in this case. Disclosure No.

(115) Prevalence of Clitoral Adhesions in Patients who have Undergone Breast Cancer Care

Abstract Introduction The incidence of female sexual dysfunction (FSD) in patients who have undergone breast cancer care is approximately 66-83% 1,2. Clitoral phimosis is a congenital or acquired condition in which the clitoral hood cannot be fully retracted and can be associated with sexual pain and impaired orgasmic capability. A paper by Aerts et al. in 2018 demonstrated a prevalence of clitoral adhesions/phimosis in patients presenting to their sexual medicine practice to be 22%3. Our sexual health clinic has observed that a large majority of patients who are diagnosed with FSD after treatment for breast cancer also have clitoral phimosis. This may remain underdiagnosed and undertreated since examination of the clitoris and clitoral hood is still not considered a routine portion of the gynecologic examination. Objective There is an increased prevalence of clitoral adhesions in patients who underwent breast cancer care. Methods This was a retrospective observational study. Data was collected from our IRB approved Sexual Health Clinic registry from August 2021 to November 2022. All female patients presenting to our clinic over the age of 18 with a diagnosis of breast cancer who underwent a pelvic exam were included. Patients who did not undergo treatment with an estrogen modulator for their breast cancer were excluded. Results A total of 25 patients presented to the clinic during this time period with a diagnosis of breast cancer. 24 patients underwent a pelvic exam. 23 patients previously underwent treatment with an estrogen modulator. Of these 23 patients, 15 patients (65%) had findings of clitoral adhesions, whereas 8 patients (35%) did not have evidence of clitoral adhesions. Table 1 presents severity of adhesions and associated diagnoses in patients with findings of clitoral adhesions. Conclusions This study serves as preliminary data from our clinic that would indicate that those with a diagnosis of breast cancer that were treated with an estrogen modulator have a higher incidence of clitoral adhesions than the general population. It is therefore our recommendation that all women who have a diagnosis of breast cancer should have a comprehensive vulvar exam including an inspection of the clitoral glans and prepuce. If the prepuce cannot be easily retracted, a diagnosis of clitoral adhesions should be considered. A pilot grant application has been submitted to further investigate prevalence, associated symptoms, severity and treatment efficacy over a longer period. Disclosure No

(125) Sexual Pain Symptoms in 910 Premenopausal Women with Vulvar Lichen Sclerosus

Abstract Introduction Lichen sclerosus (LS) is an autoimmune inflammatory skin condition primarily affecting the vulva and perianal areas and leading to scarring that can affect sexual function. Most research on symptomatology of LS to date includes predominantly postmenopausal populations and focuses on pruritis, not sexual pain symptoms. Objective This study aims to characterize sexual pain symptoms associated vulvar LS among premenopausal women. Methods A cross-sectional web-based study was conducted in premenopausal women with clinical and/or biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating demographics, characteristics of symptoms, timing and accuracy of diagnosis, and concomitant autoimmune conditions. Numerical data were expressed as mean +/- standard deviation. Bivariate Pearson correlation was used to determine the relationship between age of symptom onset and time interval to diagnosis. Results Of the 956 responses received, 910 met inclusion criteria. Self-reported ethnicity of the study population was 87% White, 4% Latina or Hispanic, 3% Asian, and 1% Black. The mean age of the population was 36.5 years, ranging from 18-50 years. There was a 4.3-year mean delay in diagnosis, with average age of symptom onset of 27.7 years and average age of diagnosis of 33.2 years. There was an inverse correlation between the age at which symptoms began and the time interval to diagnosis with a Pearson correlation coefficient of -0.509 (t(805)=16.752, p&amp;lt;0.0001). Most prevalent symptoms were vulvar fissures (68%), dyspareunia (68%), tearing with intercourse or vaginal insertion (63%), and labial resorption (61%), with vulvar fissures (49%) and dyspareunia (46%). These symptoms were more common than introital stenosis (34%). Vulvar fissures (41%) and dyspareunia (35%) most often prompted medical attention. Thirty-six percent reported clitoral phimosis and 34% reported decreased clitoral sensation. Only 4% of respondents reported that decreased clitoral sensation prompted medical attention. Over 75% of respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (54%) or bacterial vaginosis (22%). Most common concomitant autoimmune condition reported was hypothyroidism (10%); which was significantly greater than the general population prevalence (2%) (p&amp;lt;0.0001). Post-hoc analysis indicated no statistical difference between biopsy-confirmed and clinically-diagnosed LS across all demographics and responses. Conclusions Vulvar LS affects sexual function in premenopausal women. LS symptoms in premenopausal women include vulvar fissures, dyspareunia, tearing with intercourse or vaginal insertion, and decreased clitoral sensation. Dyspareunia is present is over two-thirds of premenopausal women with vulvar LS, with vulvar fissures and tearing much more common and bothersome than introital stenosis. Patients are less likely to be affected by or seek medical attention for clitoral phimosis, even though it is present in over one-third of those with LS. Vulvar LS should be considered and evaluated in women of all ages presenting with vulvar symptoms. Sexual health and function should be a core outcome measure in LS research and addressed in the evaluation and treatment of this condition. Disclosure No

(135) Keratin Pearl Excision for Clitorodynia and Female Sexual Dysfunction

Abstract Introduction Clitoral adhesions occur when the clitoral prepuce adheres to the glans clitoris. This can cause accumulation of desquamated epithelial cells under the prepuce, resulting in the formation of smegmatic pseudocysts and keratin pearls. A keratin pearl is a focus of central keratinization within concentric layers of squamous cells. Presence of these firm, millimeter-sized masses can lead to clitoral irritation and hypersensitivity (similar to a grain of sand in the eye). Although keratin pearls have been described in the literature, there is little known about their clinical presentation or association with female sexual dysfunction (FSD). Objective Investigate the effectiveness of keratin pearl excision as a treatment for clitoral pain and female sexual dysfunction. Methods A retrospective chart review was conducted in two metropolitan gynecology clinics specializing in vulvar pain between January 2017 and December 2021. Patients presenting with clitoral pain (clitorodynia) were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed via review of the clinical notes. Adult patients with documented clitoral pain as well as clitoral adhesions (clitoral phimosis) and keratin pearls noted on exam were included in the study. Female Sexual Dysfunction (FSD) was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Prospective data was collected via an electronic follow-up survey. Data were presented in means and percentages. Results Fifty-eight patients met inclusion criteria. Average age at presentation was 35 years (range 19-73 years). Self-reported ethnicity of the study population was 81% White, 7% Hispanic, 5% Asian, 2% Black, with no response from 5% of participants. Preliminary results show that patients reported a 66% decrease in mean clitoral discomfort (p &amp;lt; 0.0001) and a 52% reduction in mean difficulty with orgasm (p = 0.019) after excision of keratin pearls. Patients who completed the follow-up questionnaire (n = 18) had a mean FSFI total score of 18.3 compared to mean total baseline FSFI of 13.11 (p = 0.03). The mean FSFI score for pain was 2.85 at follow up compared to 1.52 at baseline (p = 0.01). The mean FSFI score for orgasm was 3.36 at follow up compared to 2.16 at baseline (p = 0.03). Although not statistically significant, most likely because of a small sample size, the mean FSFI score was higher at follow-up than at baseline for lubrication (45%), arousal (42%), satisfaction (19%), and desire (17%). Patients had no change in mean FSD-R score from baseline to follow up. Conclusions Clitorodynia associated with clitoral adhesions and keratin pearls occurs in women of all ages. Excising keratin pearls may reduce female sexual dysfunction. These preliminary results suggest that excising keratin pearls may improve clitoral discomfort and reduce difficulty with orgasm. Excising keratin pearls may also lead to an improvement in overall female sexual function. Disclosure No

(191) A Systematic Review of Sexual Health Consequences among Women with Vulvar Lichen Sclerosus

Abstract Introduction Lichen Sclerosus (LS) is a chronic, inflammatory skin condition that predominantly affects the vulva. This condition often leads to scarring involving the clitoris, labia minora, vaginal introitus, and perineum, leading to clitoral phimosis and introital stenosis. Women with LS are less likely to be sexually active than those without the condition. Studies have shown a high rate of sexual dysfunction in vulvar LS; however, the sexual effects of the condition are still poorly acknowledged. Objective To identify sexual health consequences of vulvar lichen sclerosus among women with vulvar lichen sclerosus through systematic review of available literature. Methods A systematic review of the literature was conducted on sexual health consequences of lichen sclerosus among women with lichen sclerosus. PubMed, MEDLINE, and Scopus were queried and results were screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies are observational studies evaluating women of premenopausal or postmenopausal status with clinical or biopsy confirmed lichen sclerosus and sexual health, or randomized controlled trials or comparative studies utilizing a validated sexual function measure to evaluate sexual health prior to intervention among the same population. Manuscripts included must have been written in English from January 1991 to April 2022. Selection of studies was done by three independent reviewers and conflicts were resolved by discussion. Systemic reviews and committee guidelines were identified for references review. Results The search produced 683 references for title and abstract screening. Of these, 32 articles met criteria for full-text review. After full-text review, 20 studies met inclusion criteria and were evaluated. Three systematic reviews and three committee guidelines were identified and all references had been identified in the initial search. Eight publications yielded qualitative data regarding sexual health consequences of LS. A negative impact of sexual dysfunction was reported in 16-60% of affected women, and dyspareunia reported by 22-56.7%. LS is also associated with decreased sexual frequency and satisfaction, a negative impact on romantic relationships, and feelings of inadequacy as a sexual partner. Eight publications evaluated the Female Sexual Function Index (FSFI), and all demonstrated a central tendency less than 26.55 among those with LS. Four publications evaluated the Female Sexual Distress Scale (FSDS), and all demonstrated a score greater than 12 among women with LS. Two publications evaluated Female Genital Self-Image Scale (FGSIS) scores in women with LS, and both found decreased FGSIS scores compared to controls. Four publications evaluated the Dermatology Quality of Life Index (DQLI), with LS causing a small to very large impact on quality of life. The subcategory with the greatest impact of quality of life is sexual difficulties. One publication evaluated the Vulval Quality of Life Index (VQLI) in women LS, and found sexuality to be the second highest scoring subgroup. Conclusions The sexual health consequences of LS include sexual pain symptoms, all facets of female sexual function, sexual distress, negative genital self-image, and negative impact on romantic relationships. Women with LS experience a significant impact on quality of life, particularly in relation to sexual functioning. Disclosure No

Clitoral Phimosis Should Have its own Diagnostic and Procedural Codes

ABSTRACT Introduction Clitoral phimosis occurs when the prepuce adheres to the glans clitoris. Similarly, penile phimosis occurs when the prepuce adheres to the glans penis. Symptoms of clitoral phimosis can include pain, difficulty with arousal, and muted or absent orgasm. While previous studies on the prevalence of clitoral phimosis in a group of 589 college students in a health clinic was 33%, and in a population of 614 patients with sexual dysfunction, it was 23%. There are no diagnosis codes (ICD codes) or procedure codes (CPT codes) for clitoral phimosis or the lysis procedure for clitoral phimosis. Proper codes ensure that patients receive adequate treatment and are charged appropriately for medical services. Objective To determine the efficacy and patient satisfaction of the office-based lysis of clitoral phimosis procedure and to demonstrate that clitoral phimosis should have its own diagnosis and procedure codes. Methods To evaluate the efficacy and patient satisfaction of the lysis procedure, survey responses from 41 females who underwent the lysis procedure for clitoral phimosis from one sexual medicine practice were analyzed. The survey was sent to 61 patients and 41 responded (67% response rate). Results Among participants who reported pain as a symptom of phimosis (n=25), 76% saw an improvement in pain, with 44%, 28%, and 4% reporting significantly, moderately, or slightly reduced pain. Among those who reported difficulty with arousal before the procedure (n=40), 62.5% saw improvement, with 25%, 25%, and 12.5% considering it to be significantly, moderately, or slightly easier to become aroused. Among those who reported difficulty achieving orgasm before the procedure (n=39), 64% saw improvement, with 25.6%, 17.9%, and 20.5% reporting that they found it significantly, moderately, or slightly easier to achieve orgasm. All women who reported the ability to orgasm from external clitoral stimulation maintained this ability after the procedure (n=24). Of the women that could not orgasm before the procedure (n=16), 6 were able to afterward. 92.7% would recommend the procedure to a friend who had phimosis. Conclusions These findings show that most patients reported improvement in their pain and sexual function, and no patient reported a loss of functioning or worsening of symptoms. The lysis procedure should be recognized as a treatment for pain and sexual dysfunction associated with clitoral phimosis. The routine management of clitoral phimosis in clinical practice should be reflected in diagnosis and procedure codes, which currently do not exist. The lack of proper codes creates a barrier to diagnosis and treatment of clitoral phimosis. If doctors use the ICD code for phimosis, it is rejected by insurance - the codes for “phimosis” and “balanitis” are only designated for male patients. Proper codes support the importance and medical necessity for performing the lysis procedure, and would help communicate a patient's health to other healthcare providers, specialists, insurance payers, and data registries. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout, Absorption Pharmaceuticals

Lysis of Clitoral Adhesions Should be in the Scope of a Urologist's Care

ABSTRACT Introduction Clitoral phimosis occurs when the prepuce adheres to the glans clitoris. Similarly, penile phimosis occurs when the prepuce adheres to the glans penis. Symptoms of clitoral phimosis can include pain, difficulty with arousal, and muted or absent orgasm. While previous studies on the prevalence of clitoral phimosis in a group of 589 college students in a health clinic was 33%, and in a population of 614 patients with sexual dysfunction, it was 23%. While the treatment of penile phimosis is widely practiced by urologists, training on the diagnosis and treatment of clitoral phimosis is lacking. Lysis of clitoral phimosis is a minimally invasive, office-based procedure to stretch the preputial tissue. Lysis of clitoral phimosis can be performed with a topical anesthetic or nerve block of the dorsal nerve of the clitoris. A fine Jacobsen mosquito forceps can then be used to separate the plane between the prepuce and the glans clitoris. Following the procedure, patients are instructed to pull back the prepuce at least once daily to prevent re-adherence. Objective To determine the efficacy and patient satisfaction of the office-based lysis of clitoral phimosis procedure and to demonstrate that diagnosing and treating clitoral phimosis should be in the scope of a urologist's practice. Methods Survey responses from 41 females who underwent the lysis procedure for clitoral phimosis from one sexual medicine practice. The survey was sent to 61 patients and 41 responded (67% response rate). Results Among participants who reported pain as a symptom of phimosis (n=25), 76% saw an improvement in pain, with 44%, 28%, and 4% reporting significantly, moderately, or slightly improved pain. Among those who reported difficulty with arousal before the procedure (n=40), 62.5% saw improvement, with 25%, 25%, and 12.5% considering it to be significantly, moderately, or slightly easier to become aroused. Among those who reported difficulty achieving orgasm before the procedure (n=39), 64% saw improvement, with 25.6%, 17.9%, and 20.5% reporting that they found it significantly, moderately, or slightly easier to achieve orgasm. Of the women that could not orgasm before the procedure (n=16), 6 were able to afterward. All women who reported the ability to orgasm from external clitoral stimulation maintained this ability after the procedure (n=24). 92.7% (n=41) would recommend the procedure to a friend who had phimosis. Conclusions These findings show that most patients reported improvement in their pain and sexual function, and no patient reported loss of functioning or worsening of symptoms. The lysis procedure should be recognized as a treatment for pain and sexual dysfunction associated with clitoral phimosis. Since urologists are trained in procedural management of male preputial disorders, urologists are uniquely positioned to also routinely manage clitoral phimosis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Clinical Presentation of Clitorodynia associated with Clitoral Adhesions and Keratin Pearls

ABSTRACT Introduction Clitoral adhesions occur when the clitoral prepuce adheres to the glans clitoris. This can lead to accumulation of desquamated epithelial cells under the prepuce, resulting in the formation of smegmatic pseudocysts and keratin pearls. A keratin pearl is a focus of central keratinization within concentric layers of squamous cells. Presence of these firm, millimeter-sized masses can lead to clitoral pain (similar to a grain of sand in the eye). Although keratin pearls have been described in the literature, there is little known about their clinical presentation or association with female sexual dysfunction (FSD). Objective Explore the clinical presentation of clitoral pain associated with clitoral adhesions and keratin pearls related to concomitant genitopelvic pain conditions and sexual dysfunction. Methods A retrospective chart review was conducted in two metropolitan gynecology clinics specializing in vulvar pain between January 2018 and September 2021. Patients presenting with clitoral pain (clitorodynia) were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed by review of the clinical notes. Adult patients with documented clitoral pain as well as clitoral adhesions (clitoral phimosis) and keratin pearls noted on exam were included in the study. FSD was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Data was presented in means and percentages. Results Forty-one patients met inclusion criteria. Average age at presentation was 35 years (range 19-73 years). Self-reported ethnicity of the study population was 73% White, 5% Hispanic, 5% Asian, 2% Black, with no response from 15% of participants. Vulvar lichen sclerosus was noted in 17% (7/41) of patients, with an average age of 46 years (range 24-73 years). Seventy-six percent (31/41) of patients also had the diagnosis of overactive (hypertonic) pelvic floor muscle dysfunction (PFD), 25% (8/31) had pudendal neuralgia and 10% (3/31) had interstitial cystitis/painful bladder syndrome. Forty-six percent (19/41) of patients had provoked vestibulodynia (PVD) associated with a hormonal factor (hormonal contraceptive use, postpartum/breastfeeding, perimenopause, or menopause). Recurrent vulvar candidiasis or tinea cruris was noted in 5% of patients. Four patients (10%) presented with clitoral pain alone and were not found to have other identified genitopelvic pain conditions. Baseline FSFI and FSDS-R data were available in 35 patients. Mean FSFI score was 13.25, with 91% of patients meeting criteria for FSD (total FSFI score &amp;lt; 26.55). Mean scores for FSFI domains were: desire (2.4), arousal (2.1), lubrication (2.5), orgasm (2.0), satisfaction (2.5), and pain (1.6). Mean FSDS-R score was 29.42, with 89% of patients meeting criteria for FSD (FSDS-R score ³11). Conclusions Clitoral pain associated with clitoral adhesions and keratin pearls occurs in women of all ages. Clitoral adhesions are not confined to patients with vulvar lichen sclerosus. A vast majority of patients with clitoral adhesions and keratin pearls have additional chronic vulvar pain conditions, most commonly overactive PFD, pudendal neuralgia, or hormonally-associated PVD. Clitoral pain with clitoral adhesions and keratin pearls is associated with FSD and sexual distress. Clitorodynia and clitoral phimosis should be identified in the clinical evaluation of genitopelvic pain. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; part-time employee of Dare Bioscience. Received research funding from Dare Science, SST, Endoceutics, The Cellular Medicine Association, and Ipsen for other projects. He is a consultant for Ipsen, SST, and AMAG

Sexual Pain Symptoms in Premenopausal Women with Vulvar Lichen Sclerosus

ABSTRACT Introduction Lichen sclerosus (LS) is a chronic, inflammatory skin condition that primarily affects the anogenital epithelium in women. Vulvar LS has historically been regarded as a condition of premenarchal girls and postmenopausal women, overlooking women of reproductive age. Although vulvar LS characteristically presents with pruritis, specialists in LS have clinically observed that premenopausal women often present with dyspareunia related to introital tearing and vulvar skin changes. Objective This study aims to characterize the clinical presentation of vulvar LS among premenopausal women related to sexual pain. Methods A cross-sectional web-based study was conducted in premenopausal women with biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating characteristics of symptoms, as well as timing and accuracy of diagnosis. Numerical data were expressed as mean +/- standard deviation. Bivariate Pearson correlation was used to determine the relationship between age of symptom onset and time interval to diagnosis. Results Of the 956 responses received, 503 met inclusion criteria of biopsy confirmed LS and premenopausal status. Self-reported ethnicity of the study population was 87% White, 4% Latina or Hispanic, 2% Asian, and 1% Black. The mean age of the population was 37 years, ranging from 19-50 years. There was a 4-year delay in diagnosis, with an average age of symptom onset of 27 years and average age of diagnosis of 32 years. There was an inverse correlation between the age at which symptoms began and the time interval to diagnosis with a Pearson correlation coefficient of -0.487 (t(455)=14.184, p&amp;lt;.0001). Most prevalent symptoms were dyspareunia (68%), tearing with intercourse or vaginal insertion (63%), and decreased clitoral sensation (35%). Symptoms reported as most affecting the individual were dyspareunia (44%), tearing with intercourse or vaginal insertion (39%) and pruritis (25%), followed by decreased clitoral sensation (13%). Symptoms that most frequently prompted patients to seek medical attention were dyspareunia (35%), pruritus (31%), and tearing with intercourse or vaginal insertion (26%). Only 4% of respondents reported that decreased clitoral sensation prompted medical attention. Most prevalent skin changes included hypopigmentation (81%), vulvar fissures (72%), labial resorption (60%), clitoral phimosis (39%), and vaginal stenosis (37%), with vulvar fissures affecting the individual the most (48%) and prompting medical attention (39%). Sixty-six percent of respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (49%). Conclusions Vulvar LS affects premenopausal women and often causes skin changes related to sexual function. This condition is often misdiagnosed as vulvovaginal candidiasis, leading to a delay in diagnosis of 4 years, which is consistent with existing literature. LS symptoms in premenopausal women related to sexual function and pain include dyspareunia, tearing with intercourse or vaginal insertion, and decreased clitoral sensation. These symptoms may be more concerning to premenopausal women, who are more likely to be sexually active, than the classic symptoms of vulvar pruritis found predominantly in postmenopausal women. Vulvar LS should be considered and evaluated in women of all ages presenting with vulvar symptoms and sexual pain. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; Part-time employee of Dare Bioscience, has received research funding from Dare Science, SST, Endoceutics, The Cellular Medicine Association, and Ipsen for other projects, and is a consultant for Ipsen, SST, and AMAG

Could Hormone Levels Impact the Severity of Clitoral Phimosis?

ABSTRACT Introduction Clitoral adhesions (CA) occur when the prepuce adheres to the glans clitoris. CA can be classified as mild, moderate, or severe, based on if more than 75%, 25% to 75%, or less than 25% of the glans clitoris is exposed. Symptoms of CA include pain, difficulty with arousal, and muted or absent orgasm. There is a paucity of information on how hormone levels may contribute to the formation of CA. We hypothesize that patients with lower levels of free and total testosterone, and higher levels of the blood transport protein sex hormone binding globulin (SHBG) could have more severe adhesions. Higher free and total testosterone can yield more oily skin, which may break up or prevent adhesions. Additionally, with higher SHBG, there is less free testosterone available to be used by tissues in the body. Objective To determine if patients with lower free and total testosterone, and higher SHBG have more severe adhesions. Methods Charts of females with CA who underwent the non-surgical lysis procedure at one sexual medicine practice were considered for this study. 24 charts contained information on the severity of phimosis before lysis, total and free testosterone levels, as well as SHBG levels around the time of lysis. The study group consisted of patients with mild (n=9), moderate (n=8), or severe (n=7) CA. Results The average calculated free testosterone among patients with mild, moderate, and severe CA was 0.23ng/dL, 0.35ng/dL, and 0.14ng/dL. The average total testosterone among patients with mild, moderate, and severe CA was 24.79ng/dL, 27.81ng/dL, and 20.26ng/dL. The average SHBG among patients with mild, moderate, and severe CA was 98.69nmol/L, 95.76nmol/L, and 109.40nmol/L. Conclusions We predicted that patients with more severe adhesions would have lower levels of free and total testosterone, as well as higher levels of SHBG, yet this trend did not appear overall in this data among patients with mild, moderate, or severe adhesions. Additional studies with larger sample sizes are needed to explore the potential impact of free and total testosterone, as well as SHBG levels on the development and severity of CA. Studies could also compare levels of these hormones in patients with and without adhesions, or consider patients with recurrence of adhesions. Insight into a hormonal etiology could be important to patients with altered levels of these hormones - for example, patients with medical conditions such as PCOS, patients taking medications such as oral contraceptive pills, and menopausal women on oral estrogen (as increased estrogen raises levels of SHBG) could be at an increased risk for developing CA. Further studies could also consider if the clitoides of transgender males on gender-affirming hormone therapy with testosterone have lower incidences of CA. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Does compliance to topical corticosteroid therapy reduce the risk of development of permanent vulvar structural abnormalities in pediatric vulvar lichen sclerosus? Aretrospective cohort study.

Vulvar lichen sclerosus (VLS) is a chronic inflammatory dermatosis of the genital skin, with up to 20% of cases in the pediatric age group. Limited data exist concerning the prognosis of pediatric VLS, particularly the likelihood of permanent architectural change and whether this can be prevented by compliance with topical corticosteroid treatment (TCS). To evaluate the extent to which compliance to TCS treatment influences the risk of developing vulvar structural abnormalities, including clitoral phimosis and diminutive or fused labia minora. A retrospective chart review of case records of pediatric-age females with VLS between January 31, 2004 and January 31, 2021. One hundred eighteen cases of VLS were identified, with a mean age at diagnosis of 7.25years and a mean follow-up period of 42.7months. Thirty-four girls were "partially compliant," whereas 84 were "compliant." The risk ratio (RR) of developing any vulvar structural abnormality or clitoral phimosis was 5.76 (95% CI 2.96-11.3) and 21.2 (95%CI 5.23-85.9) times higher, respectively, in partially compliant compared with compliant subjects. The RR of a partially compliant female with pre-pubertal onset VLS having a vulvar structural abnormality persisting beyond menarche was increased 3.54-fold relative to compliant females (95% CI 1.75-7.17). The retrospective nature of our data, lack of a control group, wide variability in follow-up duration, and nonstandardized method of stratifying compliance. Vulvar structural abnormalities are common in prepubertal onset VLS. Compliance to TCS appears to be critical in the prognosis of pediatric VLS although attitudes underpinning noncompliance to TCS treatment require further elucidation.

Surgical treatment of clitoral phimosis

The clitoris has a crucial role in the feminine pleasure. Chronic inflammatory dermatosis along with post-menopausal atrophy of the vulva and obstetrical traumas can cause clitoral phimosis, thereby compromising its function. Medical treatments exist depending on the etiology, but when irreversible scarring occur, a surgical treatment can be necessary to regain its function. We present here our surgical technique that achieves excellent functional results with low morbidity and the outcome of our patients in order to improve this sexual dysfunction.

Vulvar Lichen Sclerosus: Current Perspectives.

Vulvar lichen sclerosus (LS) is a chronic, inflammatory dermatosis that may lead to scarring of the vulva and sexual dysfunction. LS affects women of all ages and often goes unrecognized and underreported. Uncertainty continues to exist around its pathogenesis, histologic diagnosis, and treatment. However, there have been great advances in our understanding of autoimmunogenic targets in disease formation and progression. In addition, there has been recent investigation of potential non-steroid-based treatments, including platelet-rich plasma therapy and energy-based modalities such as the fractional CO2 laser, photodynamic therapy, and high intensity focused ultrasound. Refinement of surgical techniques for restoring vulvar anatomy and treating clitoral phimosis, introital stenosis, and vulvar granuloma fissuratum is leading to improved patient outcomes. This review summarizes current perspectives on the pathogenesis, symptomatology, diagnosis, and treatment for vulvar lichen sclerosus.

PS-03-003 Surgical treatment of clitoral phimosis and its effects on female sexual functions

We aimed to determine the etiology of clitoral phimosis, its influence on sexual function, and outcomes after surgical treatment. In this prospective cohort study, we observed the occurrence of clitoral phimosis and related changes in a group of 3,650 sexually active heterosexual women with a mean age of 34.8 ± 14.9 years (20–45 years) from September 2014 to September 2016. Ultimately, we compared the changes in sexual function and distress and satisfaction with postoperative genital appearance in nine patients with severe clitoral phimosis at 12 months after surgical treatment. Various forms of CP were found in 46 of 3,650 patients (1.3%). Severe forms of CP were found in 9 cases, but it was complicated by stenosis of vaginal introitus (SVI) in only two cases. These nine patients underwent circumcision and two of them underwent perineoplasty. FSD occurred mainly in those with LS and severe forms of phimosis. Sexual function, as indicated by the total FSFI score, was significantly improved at 12 months postoperatively (17.9 ± 0.9 vs. 26.6 ± 0.5; p<0.001). The FGSIS score assessing genital perception was significantly higher postoperatively than preoperatively in women who underwent clitoral circumcision (20 ± 3.0 vs. 12.3 ± 3.3; p<0.001). The FSDS-R score was significantly lower postoperatively than before (21.3 ± 6.2 vs. 33.8 ± 6.9 vs.; p<0.001). Sexual function in two women with CP and SVI improved postoperatively, but the sexual distress level did not decrease significantly.

Clitoral Phimosis: Effects on Female Sexual Function and Surgical Treatment Outcomes

BackgroundSurgery is the optimal treatment for a severe form of clitoral phimosis (CP) that is initiated by lichen sclerosus (LS) and causes female sexual dysfunction. AimWe aimed to determine the etiology of clitoral phimosis, its influence on sexual function, and outcomes after surgical treatment. MethodsIn this prospective cohort study, we observed the occurrence of clitoral phimosis and related changes in a group of 3,650 sexually active heterosexual women with a mean age of 34.8 ± 14.9 years (20–45 years) from September 2014 to September 2016. Ultimately, we compared the changes in sexual function and distress and satisfaction with postoperative genital appearance in 9 patients with severe clitoral phimosis at 12 months after surgical treatment. Main Outcome MeasuresSexual function was evaluated using the Female Sexual Distress Scale–Revised and the Female Sexual Function Index, and the patient’s genital self-image was evaluated using the Female Genital Self-Image Scale; gynecologic examinations were performed on all patients. ResultsVarious forms of CP were found in 46 of 3,650 patients (1.3%). Severe forms of CP were found in 9 cases, but it was complicated by stenosis of vaginal introitus in only 2 cases. These 9 patients underwent circumcision, and 2 of them underwent perineoplasty. Female sexual dysfunction occurred mainly in those with LS and severe forms of phimosis. Sexual function, as indicated by the total Female Sexual Function Index score, was significantly improved at 12 months after surgery (17.9 ± 0.9 vs 26.6 ± 0.5; P < .001). The Female Genital Self-Image Scale score assessing genital perception was significantly higher after surgery than before in women who underwent clitoral circumcision (20 ± 3.0 vs 12.3 ± 3.3; P < .001). The Female Sexual Distress Scale–Revised score was significantly lower after surgery than before (21.3 ± 6.2 vs 33.8 ± 6.9; P < .001). Sexual function in 2 women with CP and stenosis of vaginal introitus improved after surgery, but the sexual distress level did not decrease significantly. Clinical ImplicationsThe results of this study will help clinicians to centralize treatment methods and advise patients on the management of clitoral phimosis. Strengths & LimitationsThis is a study evaluating postoperative results of sexual function, distress, and satisfaction with genitalia in women with severe CP, using validated questionnaires. However, the small number of patients and the absence of an appropriate control group are limitations. ConclusionSurgical treatment of clitoral phimosis can improve sexual function, but because LS—a common underlying cause—is chronic in nature, patients may experience recurrence.Chmel R, M Nováčková, Fait T, et al. Clitoral Phimosis: Effects on Female Sexual Function and Surgical Treatment Outcomes. J Sex Med 2019;16:257–266.

025 Lysis of Vulvar Adhesions for Lichen Sclerosus: A Series of 5 Patients

Lichen sclerosus (LS) is a common but often underdiagnosed and undertreated disease affecting approximately 1 in 70 women. The chronic inflammatory character of the disease leads to the classic symptoms of pruritis and burning. In addition, progressive scarring of the vulvar skin causes fissuring, loss of vulvar architecture, and vulvar adhesions of the labia and clitoral prepuce. These architectural changes can interfere with basic functions such as micturition, clitoral stimulation, and vaginal penetration. Five patients were diagnosed with biopsy-proven LS and treated with topical clobetasol with or without topical or systemic hormone supplementation. Adhesions involved varying combinations of clitoral phimosis, labial adhesions, and narrowing of the anterior and posterior introitus. After all areas of lichen sclerosus were in remission, the patients were taken to the operating room for lysis of vulvar adhesions. Lysis was performed firstly by opening tissue planes with minimal sharp dissection, and subsequently with liberal blunt separation both manually and using a lacrimal probe along the natural planes of the adherent tissues. Patients used daily postoperative application of topical clobetasol and were instructed to aggressively separation and/or retraction of previously adherent tissues several time daily. Topical estradiol/testosterone was also frequently used an adjuvant therapy to help improve tissue health.

Patient Satisfaction of Surgical Treatment of Clitoral Phimosis and Labial Adhesions Caused by Lichen Sclerosus

Obstet Gynecol Surv 2016;71(4):221–222 Anogenital lichen sclerosus (LS) is a chronic inflammatory dermatosis that can cause scarring of genitalia including narrowing of the introitus and clitoral phimosis.

Patient Satisfaction of Surgical Treatment of Clitoral Phimosis and Labial Adhesions Caused by Lichen Sclerosus.

IntroductionLichen sclerosus (LS) is a chronic inflammatory dermatosis, usually affecting the anogenital skin in women. This chronic inflammation can cause scarring of genitalia including narrowing of the introitus and phimosis of the clitoris. These architectural changes can lead to recurrent tearing during intercourse (vulvar granuloma fissuratum) and decreased clitoral sensation. Surgical correction of vulvar granuloma fissuratum (VGF) and clitoral phimosis can be performed, but there is little data on the patient satisfaction and complications following these surgical procedures.AimTo evaluate patient experience and outcomes in women undergoing surgical correction of scarring caused by anogenital LS.MethodsA retrospective chart review of patients at a vulvar disorders clinic was performed to identify women who had undergone surgical correction of clitoral phimosis or lysis of vulvar adhesions for VGF due to LS. Twenty‐eight women were contacted via telephone between 4 and 130 months postoperatively. An eight‐question survey was used to determine patient experience and outcomes.Main Outcome MeasuresAll participants completed an eight‐question survey to evaluate patient satisfaction with the surgery, effects on clitoral sensation, orgasm and pain with intercourse, postoperative symptoms or complications, and the presence of recurrent vulvar scarring.ResultsParticipants reported that they were either very satisfied (44%) or satisfied (40%) with the procedure. Of the women who experienced decreased clitoral sensation prior to surgery, 75% endorsed increased clitoral sensitivity postoperatively. Of the women who had dyspareunia prior to surgery, the majority of women reported having pain‐free sex (33%) or improved but not completely pain‐free sex (58%) after surgery. There were no complications or symptoms made worse by the surgical procedures.ConclusionsThis study shows high patient satisfaction and low complication risk associated with surgical correction of clitoral phimosis and lysis of vulvar adhesions for VGF caused by LS. Patients reported improvement in clitoral sensation and ability to achieve orgasm, as well as decreased dyspareunia. Surgical correction of vulvar scarring is a viable option to restore vulvar anatomy and sexual function in appropriate candidates with anogenital LS. Flynn AN, King M, Rieff M, Krapf J, and Goldstein AT. Patient satisfaction of surgical treatment of clitoral phimosis and labial adhesions caused by lichen sclerosus. Sex Med 2015;3:251–255.

The Use of Specific Myofascial Release Techniques by a Physical Therapist to Treat Clitoral Phimosis and Dyspareunia

Introduction: Clitoral phimosis is adherence of the clitoral prepuce to the glans and can result from inflammatory dermatoses, blunt trauma, chronic infection, and inadequate hygiene. Aim: The aim of this report was to demonstrate myofascial release (MFR) techniques utilized by a physical therapist to treat clitoral phimosis. Methods: The patient was a 41-year-old woman with low back pain, a bruised sensation of her pubic region, vulvar pain provoked by sexual arousal, decreased clitoral sensitivity, dyspareunia, and anorgasmia. The patient sustained a blunt trauma injury to the vulva. Examination revealed lumbosacral and pelvic dysfunction, pelvic floor muscle dysfunction, bone bruise of the pubic bone, and decreased retractability of the clitoral prepuce and scarring. Eleven physical therapy sessions over 16 weeks included stretching, joint mobilization, muscle energy techniques, transvaginal pelvic floor muscle massage, clitoral prepuce MFR techniques, biofeedback, Integrative Manual Therapy (IMT) techniques, nerve mobilization, and therapeutic and motor control exercises. The patient applied topical clobetasol 0.05% cream for 30 days. Results: The low back pain was reduced and full resolution of her vulvar pain, dyspareunia, and pubic bone bruised sensation resulted. Mobility of the clitoral prepuce was restored. Normal clitoral sensitivity and clitoral orgasm returned. Symptom resolution was confirmed upon telephone evaluation at 6 months. Conclusion: With proper training, physical therapists managing patients with dyspareunia can identify clitoral phimosis and use specific MFR as a conservative treatment approach. Physical therapy techniques can be performed alone or in concert with medical therapy.