GENERAL GYNECOLOGY Surgical treatment of …

1 Research www. GENERAL GYNECOLOGY . Surgical treatment of clitoral phimosis caused by lichen sclerosus Andrew T. Goldstein, MD; Lara J. Burrows, MD, MSc OBJECTIVE: The purpose of this study was to examine Surgical out- had decreased clitoral sensation before surgery regained clitoral sen- comes for the correction of clitoral phimosis caused by lichen sation and their ability to achieve orgasm. sclerosus. CONCLUSION: This study demonstrates that surgery for clitoral STUDY DESIGN: Eight women with lichen sclerosus underwent surgi- phimosis caused by lichen sclerosus can be performed to restore cal repair of clitoral phimosis . They were assessed 12-36 months post- clitoral sensation and vulvar anatomy. There were few com- operatively by an independent research assistant.

2 A questionnaire was plications and a high degree of patient satisfaction with the used to assess the patients' perception of Surgical success. procedure. RESULTS: Patients reported that they were either very satisfied (88%). or satisfied (12%) with the results of their surgery. All 4 women who Key words: clitoris, lichen sclerosus, phimosis , vulva Cite this article as: Goldstein AT, Burrows LJ. Surgical treatment of clitoral phimosis caused by lichen sclerosus. Am J Obstet Gynecol 2007;196 L ichen sclerosus is a lymphocyte-me- diated inflammatory dermatitis1. that most commonly occurs in the ano- phimosis of the clitoris is often prob- lematic because smegma can accumulate in the space between the clitoris and pre- tent topical corticosteroids reverse the underlying histopathologic changes of lichen By reversing the un- genital epithelium.

3 Although the exact puce that can cause a smegmatic pseudo- derlying chronic lichenoid inflamma- prevalence of lichen sclerosus is not cyst. These pseudocysts can become in- tion, further scarring of the vulva is pre- known, it has been reported that it affects flamed or In addition, clitoral vented. Therefore, by applying ultra- 1 in 660 British women and approxi- phimosis frequently causes loss of clito- potent topical corticosteroids after sur- mately 1 in 70 women in a GENERAL gyne- ral sensitivity, which may cause second- gery, Koebnerization theoretically could cology private practice in the United ary Lastly, women with cli- be prevented and surgery to correct scar- 4 The chronic inflammation as- toral phimosis often complain of ring from lichen sclerosus could now be psychologic trauma caused by the distor- successfully performed.

4 The purpose of sociated with this condition often leads tion of their vulvar architecture and a this study was to assess patient satisfac- to scarring and distortion of the vulvar perceived diminution of their sexuality tion with surgery to correct clitoral phi- architecture (Figure 1). Frequently, scar or femininity. mosis, as well as to determine potential tissue forms between the clitoral prepuce In the past, surgery for lichen sclerosus complications associated with this pro- and the glans clitoris leading to bury- was reserved for patients in whom there cedure. ing or phimosis of the clitoris (Fig- ure 2). was associated high-grade vulvar intra- epithelial neoplasia or Sur- M ATERIALS AND M ETHODS. gery to correct architectural changes Eight women with biopsy-proven lichen From the Division of Gynecologic such as narrowing of the introitus or cli- sclerosus had surgery to correct clitoral Specialties, Department of GYNECOLOGY and toral phimosis was contraindicated be- phimosis between November 2002 and Obstetrics, Johns Hopkins Medicine, cause of a process known as the Koebner March 2005.

5 Women were considered Baltimore, MD (Dr Goldstein); and the phenomenon. Koebnerization in lichen candidates for surgery if their lichen scle- Division of Obstetrics and GYNECOLOGY , The sclerosus is a pathologic process in which rosus was in complete remission as as- University of Connecticut School of normal skin becomes sclerotic after it is sessed by a gynecologist who specializes Medicine, Farmington, CT (Dr Burrows). injured or Thus, surgery in the treatment of vulvar diseases. Ob- Received May 9, 2006; revised June 12, can lead to even more vulvar scarring. jective and subjective criteria were to di- 2006; accepted Aug. 1, 2006. treatment with topical ultrapotent agnose remission: there had to be com- Reprints not available from the authors.

6 Topical corticosteroids such as clobetasol plete resolution of lichenification and 0002-9378/$ 2007 Mosby, Inc. All rights reserved. propionate has changed the manage- inflammation, and patients had to have doi: ment of lichen In addition to resolution of their pruritis and burning. effectively treating symptoms, ultrapo- Women underwent surgery for the fol- American Journal of Obstetrics & GYNECOLOGY FEBRUARY 2007. GENERAL GYNECOLOGY Research FIGURE 1 FIGURE 3 FIGURE 5. Scarring of the vulva from A lacrimal probe is used to Telephone questionnaire lichen sclerosus lyse adhesions between the 1. Overall, would you say that you are: very satisfied / satisfied / not satisfied with the results of your surgery? prepuce and the clitoris 2.

7 Knowing the discomforts of surgery and the results of your surgery, would you recommend this surgery to another woman with similar symptoms? Yes / No / Unsure 3. Did you have decreased clitoral sensation prior to surgery? Yes / No. If yes, are you: very satisfied / satisfied / not satisfied with your improvement in clitoral sensation from surgery. 4. Was your ability to achieve orgasm decreased prior to surgery? Yes / No. If yes, has your ability to achieve orgasm: returned to normal / improved but not normal / no improvement? 5. Were any symptoms made worse by the surgery? Yes / No. If yes, what were they? 6. Did you have any complications with the surgery? Yes/ No. If yes, what were they? 7. Have you had any recurrent scarring ( phimosis ) of your clitoris since surgery?

8 Sue was excised during the procedure. Postoperatively, the patients applied clo- betasol ointment daily to the sur- gical site to prevent Koebnerization. Af- ter the Surgical site healed, patients decreased the frequency of clobetasol ap- plication to twice weekly. The primary measure of success in this study was overall patient satisfaction with surgery. Additional outcome mea- surements included improvement in cli- toral sensation, improvement in ability to achieve orgasm, occurrence of post- lowing indications: recurrent pseudo- operative complications, and recurrence cyst (n 2), decreased clitoral sensation of clitoral phimosis after surgery. was used to bluntly lyse any adhesions (n 4), and emotional distress caused Patients were contacted between 12.

9 (Figure 3). A dorsal incision approxi- by the distortion of their vulvar architec- and 36 months after their surgery (me- mately 5 mm in length was then made in ture and a perceived a diminution of sex- dian 20 months). Patients were con- the prepuce with Iris scissors and any re- uality and femininity because of the cli- tacted by an independent research assis- maining adhesions were then lysed with toral phimosis (n 2). tant via telephone. An institutional the lacrimal duct probe (Figure 4). He- The procedure performed was as fol- review board approved the 7-item ques- mostasis was obtained by applying direct lows: a lacrimal duct probe was inserted tionnaire written by the authors for the pressure or with electrocautery.

10 No tis- purposes of this study (Figure 5) was ad- between the clitoris and the prepuce and ministered by the research assistant after FIGURE 2 FIGURE 4 obtaining informed consent. Partici- phimosis of the clitoris and The glans clitoris is now pants were assured that their responses resorption of the labia minora completely visible would be confidential, and that their surgeon would be blinded to individ- ual responses. In addition, each patient was examined by the gynecologic sur- geon ( ) at least 1 time between 12 and 36 months after their surgery to assess if there was recurrence of phi- mosis. A thorough chart review was performed after contacting individual patients to determine demographic data, operative indications, and post- operative complications.