(023) PREVALENCE OF CLITORAL ADHESIONS AMONG PATIENTS UNDERGOING VESTIBULECTOMY FOR NEUROPROLIFERATIVE VESTIBULODYNIA
Authors: Goldstein SW , Goldstein I 
Published: December 2024

Abstract

Introduction
Previously we have reported that 23% of individuals with vulvas presenting to our sexual medicine clinic for various sexual dysfunctions demonstrated clitoral adhesions based on vulvoscopy with photography. Clitoral adhesions occur when the epithelial skin surfaces of the prepuce and glans clitoris become adherent, such that the corona is not fully visualized during full prepucial retraction. The severity of clitoral adhesions is best documented using vulvoscopy with photography and rated as mild, moderate or severe clitoral adhesions when &gt;75%, 25-75%, and &lt; 25% of the glans clitoris is visualized, respectively. (Figure 1) Clitoral adhesions are often associated with inadequate clearance of keratinaceous sloughed material from the epithelial surfaces of the prepuce and glans clitoris. This trapped material can form keratin pearls that result in local inflammation and glans hypersensitivity or pain. In the previous study, patients had mild (44%), moderate (34%), and severe (22%) clitoral adhesions. We observed clitoral adhesions in individuals who presented with entry dyspareunia, severe allodynia, and hyperalgesia and underwent complete vestibulectomy for clinically suspected neuroproliferative vestibulodynia (NPV). Patients could opt to have lysis of clitoral adhesions performed at the time of vestibulectomy.

Objective
We examined the association between clitoral adhesions and NPV.

Methods
A retrospective chart review of patients with NPV who underwent vestibulectomy and lysis of clitoral adhesions concomitantly between January 1, 2021 and May 31, 2024 was performed. History, physical examination, pre-op vulvoscopy with photographs, operative records and patient outcome data were collected.

Results
Eighty-eight patients with NPV, (mean age 29, range 19– 64 years), underwent vestibulectomy surgery. A total of 53 (60%) of these patients underwent concomitant lysis of mild (38%), moderate (49%), or severe (13%) clitoral adhesions. In 89% of cases, multiple keratin pearls were removed.

Conclusions
There is a high prevalence of clitoral adhesions in patients with NPV (60%) compared to the total population of individuals with vulvas who presented to our sexual medicine clinic for sexual concerns (23%). While clitoral adhesions are not always symptomatic, we hypothesize that the high prevalence in patients with NPV may be due one or more of the following: i) pain/stress resulting in peripheral nerves releasing neurotransmitters that stimulate proliferation/differentiation of prepucial sebaceous glands and upregulate prepucial sebaceous cell lipid synthesis, ii) infrequency of clitoral tissue engorgement from sexual activity, iii) limitation or aversion to touching or retracting clitoral prepucial tissue, iv) increased frequency of wearing menstrual pads rather than tampons, v) severe genital pain perceived as co-existing in both vestibule and clitoris and vi) surgery already scheduled for NPV so performing lysis of clitoral adhesions while under anesthesia was convenient. Clinicians should be aware of this high association.

Disclosure
No.