(027) HIGH PREVALENCE OF SYMPTOMATIC CLITORAL ADHESIONS IN PATIENTS WITH NEUROPROLIFERATIVE VESTIBULODYNIA UNDERGOING VESTIBULECTOMY
Authors: Farrahi A , Goldstein S W , Wexler T , Yee A M , Goldstein I 
Published: June 2024

Abstract

Introduction
Clitoral adhesions occur when the epithelial skin surfaces of the prepuce and glans clitoris become adherent. The severity of clitoral adhesions is best documented during full prepucial retraction using vulvoscopy with photography; mild, moderate, and severe clitoral adhesions occur when there is &gt;75%, 25-75%, and &lt;25% visualization of the glans clitoris, respectively. Clitoral adhesions are associated with a closed compartment with inadequate clearance of keratinaceous sloughed material from the epithelial surfaces of the prepuce and glans clitoris. This trapped material may form keratin pearls resulting in local inflammation and glans hypersensitivity/pain. In one study of 614 evaluable individuals with vulvas who presented to a sexual medicine clinic for various sexual dysfunctions, 23% demonstrated clitoral adhesions based on vulvoscopy with photography (mild 44%, moderate 34%, and severe 22%) of which 14% complained of clitoral hypersensitivity/pain. We observe symptomatic and asymptomatic clitoral adhesions occurring in women presenting with entry dyspareunia, severe allodynia and hyperalgesia, who are clinical suspected and pathologically conformed to have neuroproliferative vestibulodynia (NPV). Surgical management of the NPV involves complete vestibulectomy with vaginal advancement flap. For those patients who also have clitoral adhesions, lysis of clitoral adhesions may be performed at the time of vestibulectomy.

Objective
To examine 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 October 31, 2023 was performed. History, physical examination, pre-op vulvoscopy with photographs, operative records and patient outcome data were collected.

Results
Sixty-three patients with NPV, (mean age 29, range 19 – 64 years), underwent vestibulectomy surgery. A total of 34 (54%) of these patients underwent concomitant lysis of (mild (38%), moderate (50%), or severe (12%) clitoral adhesions. Multiple keratin pearls were removed in 91% of cases. More than half (53%) of these patients with NPV and clitoral adhesions complained of glans hypersensitivity/pain during pre-op vulvoscopy. The majority (88%) of this cohort reported “somewhat better” or “very much better” on PGI-I after lysis of adhesions. No negative side effects following the lysis of clitoral adhesions were noted.

Conclusions
There is a high prevalence of symptomatic clitoral adhesions in patients with NPV (53%) compared to women who presented to a sexual medicine clinic for other sexual concerns (14%). While clitoral adhesions are not always symptomatic, we hypothesize the high prevalence in patients with NPV may be due any 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) the patient is already scheduled for surgery under anesthesia so the patient conveniently agrees to also undergo lysis of adhesions. Clinicians should be aware of this high association.

Disclosure
No.