(271) Patient with Severe Clitoral Phimosis and Smegmatic Cyst: A Case Report and Review of the Literature
Authors: Wardrop F , Negris O , Milazzo M , Rubin R 
Published: February 2024

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.