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

FEMALE SEXUAL FUNCTION

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

Roman Chmel, MD, PhD,1 Marta Novácková, MD, PhD,1 Tomás Fait, MD, PhD,1 Libor Zámecník, MD, PhD,2 Lucie Krejcová, MSc,3 and Zlatko Pastor, MD, PhD1,3

ABSTRACT

Background: Surgery is the optimal treatment for a severe form of clitoral phimosis (CP) that is initiated by lichen sclerosus (LS) and causes female sexual dysfunction. Aim: We aimed to determine the etiology of clitoral phimosis, its influence on sexual function, and outcomes after surgical treatment. Methods: 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 (20e45 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 Measures: Sexual function was evaluated using the Female Sexual Distress ScaleeRevised 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. Results: 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 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 ScaleeRevised 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 Implications: The results of this study will help clinicians to centralize treatment methods and advise patients on the management of clitoral phimosis. Strengths & Limitations: This 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. Conclusion: Surgical 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 Novácková, Fait T, et al. Clitoral Phimosis: Effects on Female Sexual Function and Surgical Treatment Outcomes. J Sex Med 2019;16:257e266. Copyright 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. Key Words: Clitoral Phimosis; Lichen Sclerosus; Stenosis of the Vaginal Introitus; Clitoral Circumcision; Perineoplasty; Female Sexual Dysfunction

Received July 29, 2018. Accepted December 21, 2018. 3Institute of Sexology, 1st Medical Faculty, Charles University, Ke Karlovu 1Department of Obstetrics and Gynecology, 2nd Faculty of Medicine, Charles 460/11, Prague 2, Czech Republic University and Motol University Hospital, V Úvalu 84, Prague 5, Czech Copyright ª 2019, International Society for Sexual Medicine. Published by Republic; Elsevier Inc. All rights reserved. 2Department of Urology, 1st Faculty of Medicine, Charles University, Ke https://doi.org/10.1016/j.jsxm.2018.12.012 Karlovu 6, Prague 2, Czech Republic;

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INTRODUCTION examined postoperative complications and the incidence of recurrent illness in the external genitalia. Clitoral phimosis (CP) is a congenital or acquired, acute or chronic condition in which retraction of the clitoral hood is fully or partially disabled. CP may be mild, moderate, or severe based MATERIALS AND METHODS 1 fi on its stage. CP may be asymptomatic or it can cause signi cant Patients physical issues. Severe CP is most often caused by lichen scle- In this prospective cohort study, we observed the occurrences rosus (LS), but it may also occur secondary to untreated of CP and related vulvar changes in a group of 3,650 hetero- inflammation, trauma, or obstetric delivery. LS leads to sexual women with a mean age of 34.8 ± 14.9 (20e45) years emotional and physical problems, including female sexual from September 2014eSeptember 2016. A total of 1,820 dysfunction (FSD) and reduced frequency of intercourse.2 The women with no sexual problems from a urogynecologic clinic prevalence of LS in women is between 1 of 70 and 1 of 1,000, and 1,830 patients with various types of FSD or other sexual and it affects more women than men at a ratio of 10 to 1.3,4 The problems (for instance, relationship discord) from a sexologic etiology of LS is unclear and most likely multifactorial, with e clinic were examined. The study included fertile women, with no genetic and autoimmune factors playing significant roles.5 7 signs of estrogen deficiency, having penile-vaginal intercourse Early-stage LS does not necessarily present with specific skin with a current partner, and who were not pregnant at the time of abnormalities, but it may present with nonspecific itching or the study but who had at least 1 delivery. Women with severe or burning sensations, dysuria, or superficial dyspareunia. The malignant disease were excluded. manifestations of late-stage LS include chronic inflammatory conditions such as hypopigmentation, skin atrophy, erythema, and purpura. The loss of foreskin elasticity may cause balanitis, Ethical Considerations because of closed compartment syndrome, adhesions, or smeg- This study was approved by our local institutional ethical e matic pseudocysts.1,8 10 LS may cause discomfort in the clitoral board. All of the patients provided written informed consent. region, with tenderness, irritation, pain, pruritus, voiding dysfunction, and loss of clitoral sensitivity.1,9 Scarring of the Clinical Evaluations genitalia, stenosis of the vaginal introitus, labial resorption, and Every woman underwent a gynecologic examination (exami- recurrent tearing during intercourse (vulvar granuloma fissur- nation of the vagina using a speculum). We focused primarily on e atum) may occur in advanced stages of LS.10 13 LS is considered evaluating the external genitalia (the labia majora and minora, precancerous and could develop into vulvar carcinoma in 3-5% labial adhesions, clitoris, preputium, urinary meatus, and peri- of patients.11,14 The data on the prevalence of CP are inconsis- neum). The condition and appearance of the skin and mucous tent. Munarriz et al8 identified CP in 1 of every 5 patients (22%) membranes, evidence of estrogenized tissues, vaginal discharge, in a cohort of 250 female patients treated for FSD.8 Wiesmeier strictures, scarring, and signs of stenosis of the vaginal introitus et al15 stated that various stages of CP occur in almost one-third were assessed. If CP was identified, the patients were subse- of symptom-free women (n ¼ 589). The potential psychosexual quently examined by 2 gynecologists who determined the extent problems in women with CP include apareunia, dyspareunia, of CP. The length of the vagina in women was measured from anorgasmia, low sexual desire, low coital frequency, anxiety, the introitus (approximately at the level of the hymenal ring) to guilty feelings, or altered body image.9,16 The first-line treatment the posterior vaginal fornix. Vaginal spaciousness was estimated option for women with CP or SVI caused by LS, ideally initiated based on the possibility of insertion of a plastic phantom of 1e2 before scarring occurs, is localized therapy with ultrapotent cm size. The condition of the clitoris was considered abnormal corticosteroids.10,17 Topical calcineurin inhibitors, retinoids, when cranial traction resulted in varying degrees of incomplete sedating agents, topical laser therapy (photodynamic therapy), foreskin retraction and limited the exposure of the glans clito- ultraviolet phototherapy, cryotherapy, and laser vaporization are ridis. The degree of the adherence of the clitoral hood was used as second-line therapies.10,18,19 Smegmatic pseudocysts, determined based on whether we could visualize the glans and vulvar granuloma fissurata, or severe CP causing complications sulcus of the clitoris. We classified mild (<50% coverage of the are indications for surgical treatment.3,10,11 Although severe glans clitoridis), moderate (<75% coverage of the glans clito- forms of CP due to LS may cause FSD 10, only a few studies have ridis), and severe (100% coverage of the glans clitoridis) CP in evaluated patient satisfaction after surgical treatment in large each patient. The spaciousness of the vaginal introitus was patient cohorts.3,10,19,20 The aim of our research was to deter- evaluated according to the patients’ subjective feelings about mine the etiology of CP, the underlying extent of clitoral vaginal-penile disproportion during coitus, by the number of involvement and stenosis of the vaginal introitus, and the effect fingers that could be inserted during a vaginal examination, and of CP on FSD, sexual distress, and the perception of one’s own by tissue elasticity. The degree of vaginal introitus dilatation was genitalia. We aimed to identify any changes in sexual function determined precisely using a set of plastic phantoms with di- and sexual distress after surgical treatment. Furthermore, we also ameters ranging from 1e6 cm.

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Figure 1. Management of treatment of women with severe CP or SVI not responding to non-surgical treatment. CP ¼ clitoral phimosis; SVI ¼ stenosis of the vaginal introitus.

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Nonsurgical Treatment Table 1. Presence of CP in a group of patients from urogynecologic We used topical corticosteroids (TCS) as the first-line treat- practice and a group of patients from sexologic practice ment to achieve remission of LS. The initial TCS treatment took Patients from Patients from 6 weeks in our study and was dependent on the severity of hy- urogynecologic sexologic Total perkeratosis as follows: for mild LS, a mid-potency TCS practice practice number (methylprednisolone aceponate ointment, 0.1%) was applied Number of 1,820 1,830 3,650 once daily; for moderate LS, a superpotent TCS (betamethasone patients dipropionate ointment, 0.05%) was prescribed once daily; and Women with CP 3 (6.5%) 43 (93.5%) 46 (100%) for severe LS, ultrapotent TCS (clobetasol propionate ointment, Mild 2 (4.3%) 29 (63%) 31 (67.4%) 0.05%) was applied once or twice daily. If the symptoms and Moderate 1 (2.2%) 5 (10.9%) 6 (13%) skin color and texture were not normalized, we continued with Severe 0 (0%) 9 (19.6%) 9 (19.6%) the same TCS application for an additional 3e6 months. If we SVI 0 2 0 observed that the treatment had no effect, we proposed a surgical CP ¼ clitoral phimosis; SVI ¼ stenosis of the vaginal introitus. solution to those patients with the severe form of CP. 1 month before the planned surgery, TCS treatment was discontinued. Distress Scale-Revised (FSDS-R), the Female Sexual Function Index (FSFI), and the patient’s genital self-image was evaluated Surgical Procedures using the Female Genital Self-Image Scale (FGSIS).21,22 The The extent of the surgical procedure (adhesiolysis, dissection patients filled in the questionnaires 1 month before surgery and and circumcision of the preputial hood, or perineoplasty) 12 months after surgery. The cutoff score used for the 13-item depended on the severity of the abnormality in the tissues FSDS-Rwas11,withlowervaluesindicatinglessdistress.21,22 affected by LS. A biopsy of the underlying tissue was performed A previously reported cutoff of 26.55 was used for the total ’ before surgery to diagnose the patient s condition histopatho- FSFI score,23 with lower values representing possible sexual logically. Circumcision of the clitoris was performed with a CO2 dysfunction. The 7-item FGSIS was used to evaluate the 2 laser (CO2 Laser SmartXide Deka M.E.L.A. srl, Italy) under women’s feelings about their genitalia, with a total score general anesthesia. We used the pulse mode on the CO2 laser at ranging from 7e28.Higherscoresindicatedamorepositive 10 watts with 200 millijoules per pulse. image of the genitalia. After disinfecting the surgical area, the surgeon made an incision in the midline of the obliterated preputial pouch, Statistical Analyses protecting glans clitoridis from laser damage using glass rods. The statistical analysis was performed using SPSS software The glans clitoridis was visualized. Then, the right and left version 23.0 (SPSS Inc, Chicago, IL, USA). P values <.05 were lateral parts of the preputium were resected, and the glans considered statistically significant. All statistical tests were clitoridis was released. After the laser dissection, the periclitoral 2-tailed. Variables that were not normally distributed (Shapiro- e skin was oversewn using 6 8 stitches placed in a manner Wilk test, P < .05) were analyzed using the Wilcoxon Mann- similar to the classical technique for clitoral circumcision. In Whitney rank sum test. The differences between the patients’ patients with stenosis of the vaginal introitus, the affected preoperative and postoperative conditions in terms of psycho- perineal skin and an adjacent part of the posterior vaginal wall sexual variables were evaluated using t-tests. were excised. Then, the vaginal flap was drawn down and sutured to the skin margin to cover the defect. Vaseline gauze was applied to the surgical wound area, and an ice pack was placed RESULTS atthesitetoreduceswelling.Topicalcorticosteroidswere Characteristics of the Patient Cohorts and the administered after the sutured scar was healed to prevent Prevalence, Forms, and Manifestations of CP postoperative re-agglutination. The patients were recom- All forms of CP were observed in 46 of 3,650 women (1.3%) mended to manually rehabilitate the area of the preputial hood (Table 1). Severe clitoral phimosis was caused by LS in most and, in case of SVI, to use mechanical vaginal dilators cases (8/9) in our study. In 2 of the 9 patients, phimosis was (Figure 1). The patients were observed at intervals based on complicated by stenosis of the vaginal introitus, with a maximum their clinical conditions, their sexual function, and their distress diameter of a 2.5 cm. Only in 1 case was phimosis the result of fi level. Self-assessments of the genitalia were nally evaluated at postpartum inflammation. The average age of these 9 women 12 months after surgery. with severe CP was 36.2 ± 4.4 years (range 32e41). They had 1.6 ± 0.5 children (range 1e2), and their mean body mass index ± Questionnaires was 26.3 4.6. The general characteristics of the women and The following standardized questionnaires were used to information on the presence of CP are presented in Table 2. assess the mutual links between sexual function, sexual distress, All women with the severe form of CP (n ¼ 9) had FSD (low and self-perception about genital self-image: the Female Sexual desire, low arousal, poor lubrication, pain, anorgasmia, or

J Sex Med 2019;16:257e266 e e 2019;16:257 Med Sex J Outcomes Treatment Surgical Phimosis: Clitoral

e The general characteristics of women treated surgically for CP (eventually with SVI) 266 Table 2. Patient 1 2 3 4 5 6 7 8 9

Diagnosis CP CP CP CP CP CP CP CP, SVI CP, SVI Etiology LS PPA LS LS LS LS LS LS LS Length of time suffering 434269665 from severe CP (mean ± SD, y) 5.0 ± 2.1 Age (mean ± SD) 33 32 40 36 30 41 33 40 41 36.2 ± 4.4 BMI (mean ± SD) 20 30 28 19 32 24 25 29 30 26.3 ± 4.6 Parity (mean ± SD) 12221122 1 1.6 ± 0.5 LCSP (mean ± SD) 4 6 3 10 5 15 8 17 16 9.3 ± 5.4 TSP (mean ± SD) 3454374 75 4.7 ± 1.5 Operation Circumcision Circumcision Circumcision Circumcision Circumcision Circumcision Circumcision Circumcision, Circumcision, perineoplasty perineoplasty Postop complications 0 0 0 0 0 0 0 0 0 Recurrence (months after 0 0 Mild CP, 8 0 Moderate 0 0 0 SVI, 10 months surgery) months CP, 9 after surgery after surgery months after surgery Solutions for recurrence Lysis of the Lysis of the Reoperation SVI adhesions adhesions 12-month follow-up NF NF NF NF NF NF NF NF NF

BMI ¼ body mass index; CP ¼ clitoral phimosis; LCSP ¼ length of current sexual partnership (years); NF ¼ normal ﬁnding; PPA ¼ postpartum postinﬂammatory agglutination; SVI ¼ stenosis of the vaginal introitus; TSP ¼ total number of sexual partners. 261 262 Chmel et al

Figure 2. Circumcision of a clitoris phimosis using a CO2 laser. (Panel a) Before treatment. (Panel b) 3 weeks after laser dissection of the clitoris. (Panel c) 12 months after treatment. Figure 2 is available in color online at www.jsm.jsexmed.org. dyspareunia). Their mean FSFI was 17.9 ± 0.9. The disease surgery, all patients experienced healing without phimosis, the manifestations included skin irregularities (atrophy, hypo- vaginal introitus was freely penetrated, and the women could pigmentation, or erythema) that caused pruritus, discomfort, have sexual intercourse. burning, itching, and pain. Women with the severe form (n ¼ 9) underwent surgical interventions (dissection of the CP and Comparison of Sexual Function, Distress, and Self- circumcision, if necessary, with perineoplasty), after which their Evaluation of the Genitalia Before and 12 Months fi sexual function signi cantly improved. The patients with mod- After Surgery erate CP (n ¼ 6) anamnesis had delivery injuries in the clitoral All 9 patients with the severe form of CP complained of low area with complicated healing. In the case of the 31 women with sexual desire and dyspareunia before surgery, 7 (77.8%) could not mild CP, CP existed without chronic inflammation or atrophic achieve orgasm, and 4 (44.4%) complained of intermittent lack of tissue, was asymptomatic, did not require therapy, and was not lubrication. Their mean coital frequency was 1.5 ± 1.0 times per the cause of sexual pain problems. These were patients from the month (range 1e4). 12 months after surgery, the libido of all the sexological practice who did not have only female sexual surgically treated women had improved, 3 women were better able dysfunction but faced other issues, such as relationship discord to achieve orgasm, and only 1 patient complained of dyspareunia. and were seeking a solution. The characteristics and degree of lubrication did not change. The patients’ coital frequency increased after surgery to an average of 4 Surgical Treatment of CP ± 1.7 times (range 2e7) per month. Results and Complications Sexual function, as indicated by the total FSFI score, showed a fi Nine patients aged 36.2 ± 6.1 years (range 32e41) suffering clear, signi cant improvement from preoperatively to from severe CP for 5.0 ± 2.1 years (range 2e9) underwent surgical treatment using the CO2 laser (Figure 2). A preoperative biopsy verified that eight of these women (88.9%) had LS (Figure 3). Two patients with LS and stenosis of the vaginal introitus underwent perineoplasty to correct narrowing of the vaginal introitus so that insertion of a 5-cm in diameter phantom (Figure 4) would be possible. Early postoperative complications were not seen (Table 2). Recurrence of illness was identified in three patients (33.3%). In 2 patients, at 8 and 9 months after surgery, a thin filmy adhesion between the glans clitoridis and preputium appeared and re-agglutination of the preputial hood occurred, resulting in 30e50% coverage of the glans clitoridis. With the patients under general anesthesia, the adhesions were lysed bluntly using a small surgical probe and a partially sharp- ened scalpel. In a third patient, 10 months after surgery for CP and a perineoplasty due to repeated episodes of SVI that nar- Figure 3. A histopathologic image of lichen sclerosus in the rowed the introitus to a diameter of 3 cm, the dissection had a clitoral area. An acanthotic, squamous epithelium with hyperkera- good effect on the CP. Therefore, we reoperated on the stenosis, tosis and a fibrotic stroma with chronic, lymphocytic inflammatory which was again expanded so that the vagina could be freely cellularization are seen. Figure 3 is available in color online at www. dilated to a diameter of 5 cm. 12 months after the primary jsm.jsexmed.org.

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Figure 4. Dissection of a clitoris phimosis and perineoplasty to correct narrowing of the introitus. (Panel a) Before treatment. (Panel b) 3 weeks after circumcision and perineoplasty. (Panel c) 12 months after treatment. Figure 4 is available in color online at www.jsm.jsexmed.org. postoperatively (17.9 ± 0.9 vs 26.6 ± 0.5; P < .001). This Clitoral Phimosis improvement was also reflected in higher postoperative scores in Occurrence and Influence on FSD the individual domains, except for the lubrication category, in FSD caused by CP and LS affecting the surrounding tissues which there was no change. The FGSIS assessment score for occurs because of disturbances to the morphologic structure, genital perception was significantly higher in women after function, and sensitivity of the genitalia, as well as the patient’s circumcision than it was before (20 ± 3.0 vs 12.3 ± 3.3; P < negative perception of her genitalia (vulvar scarring, labial .001). The operation clearly improved the patients’ feelings of resorption, atrophy). Psychogenic factors and the patient’s self- satisfaction with the appearance of their genitalia. The FSDS-R evaluation of her genital esthetics, as well as organic reasons, score was significantly lower after surgery than it was before can cause anxiety, distress, depression, and decreased sexual (21.3 ± 6.2 vs 33.8 ± 6.9; P < .001), indicating that women appetite. There are inconsistent data on the prevalence of CP. In felt significantly less sexual discomfort and distress after un- our group of 3,650 patients, clitoral complications were seen in dergoing surgery for CP than they did before surgery, although 1.3% (n ¼ 46). This statement roughly corresponds to the LS these values were not over the cutoff (11) for the FSDS-R prevalence of 1 of 60 3 or 1 of 30 among the older female (Table 3). Based on the total FSFI score, 6 women were population.24 Even though Wiesmeier et al15 found a prevalence moved (after surgery) from the dysfunctional to the normal of 30% of women with CP in their retrospective study, only 4% sexual function category, including 2 patients with combined had the severe form of clitoral phimosis. According to the CP and SVI. Sexual function in the remaining 3 women Centers for Vulvovaginal Diseases, LS occurs in 7e26% of improved as well but was not evidenced by significant differ- women.3 The severe form of CP almost always causes FSD, and ences in the FSFI. milder forms without LS are not reported by women to be a disorder, because these forms do not cause any problems. When Comparison of Sexual Function to the Level of comparing the group of women with severe and other forms of Sexual Distress in Women With CP, and CPþSVI CP, we did not find significant differences among their parity, Before and After Surgery age, and body mass index. Sexual function (FSFI) in women with CP (n ¼ 7) compared þ ¼ fi with that in women with CP SVI (n 2) was not signi cantly Indications for the Surgical Treatment of CP different before and after surgery (before the surgery it was The more severe forms of CP that cause problems and do dysfunctional in both groups and after surgery it was in the not respond to conservative therapy are indicated for surgical physiological range). However, sexual distress levels (FSDS-R) treatment. Minor adhesions may occur in asymptomatic fi þ were signi cantly higher in women with CP SVI before and women, for whom treatment is not necessary.15 The surgical after surgery than in women with CP only (Table 4). method (laser vs the classic technique) and extent (full or partial circumcision), variants, and prevention of recurrence differ according to the experiences of various clinics. Surgical DISCUSSION correction of LS-related CP and the neighboring structures Our research confirmed that the severe form of CP is primarily of the external genitalia is not a complete solution because caused by LS and causes FSD in all cases. The asymptomatic we do not know the exact etiology of LS. However, it does mild and moderate forms of CP are reported most frequently, eliminate the symptoms. The chronic, inflammatory changes but these rarely cause FSD. In our study population, surgical caused by LS mostly lead to full obliteration of the preputial treatment of the severe form of CP caused by LS is successful and hood. Accumulation of smegma may initiate acute smeg- improves sexual function. However, up to 30% of patients suffer matic pseudocysts that can become infected and in turn from recurrent underlying clitoral and surrounding tissue develop into abscesses that require rapid solutions dysfunction and require reoperation. (“hoodectomy”).25

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Table 3. The FSFI, FSDS-R, and FGSIS scores of patients before and after surgery Patients (n ¼ 9) before Patients (n ¼ 9) after operation (mean ± SD) operation (mean ± SD) Differences P value FSFI Desire 1.5 ± 0.3 4.1 ± 0.2 t ¼15.6, df ¼ 16 .001* Arousal 2.1 ± 0.6 4.4 ± 0.4 t ¼7.7, df ¼ 16 .001* Lubrication 3.3 ± 0.5 3.3 ± 0.4 t ¼.164, df ¼ 16 .871 Orgasm 3.0 ± 0.5 4.8 ± 0.1 t ¼3.9, df ¼ 16 .001* Satisfaction 2.4 ± 0.9 5.2 ± 0.1 t ¼6.8, df ¼ 16 .001* Comfort 5.6 ± 0.2 4.8 ± 1.1 t ¼ 6.9, df ¼ 16 .001* Total score 17.9 ± 0.9 26.6 ± 0.5 t ¼23.6, df ¼ 16 .001* FSDS-R 33.8 ± 6.9 21.3 ± 6.2 t ¼ 3.9, df ¼ 16 .001* FGSIS 12.3 ± 3.3 20 ± 3.0 t ¼5.1, df ¼ 16 .001* df ¼ degrees of freedom; FSFI ¼ Female Sexual Function Index; FSDS-R ¼ Female Sexual Distress Scale-Revised; FGSIS ¼ Female Genital Self Image Scale. *Signiﬁcant difference from the control group, P < .05.

The Possibilities and Aims of the Surgical considered very important28; however, their early postoperative Treatment of CP use may increase the risk of dehiscence and postoperative The goal of surgery is to restore sexual function and the infection.17 The evaluation of phimosis recurrence and other LS appearance of the genitalia, eliminate symptoms, and visualize symptoms depends on the time elapsed since surgery. At 1 year the clitoris. Disposal of the underlying tissue usually does not after surgery in our study, none of the patients had serious solve the problem of LS permanently. Surgical CO2 laser or use problems. However, we had resolved 2 cases of relapse of the of bipolar radiofrequency wire cold cutting bipolar electrodes are mild and moderate forms of CP and 1 case of recurrent stenosis effective methods of treatment of CP. Both of these techniques of the vaginal introitus. allow the surgeon to cut tissue into very tiny slices and perform fi ne dissection with minimal bleeding, better retraction of the Results of the Surgical Treatment of CP in Terms of tissues, better hemostasis, less scarring, and without causing Improvement of Sexual Function damage to the clitoris.26,27 Most studies state that surgical treatment decreases a patient’s Corticosteroids were applied to prevent recurrence only after negative feelings and improves sexual function.3,10,20,29 Primar- the incisions were fully healed. The use of corticosteroids is ily, those patients reported improved clitoral sensation and achievement of orgasm, as well as decreased pain during coitus.13 Our study confirmed these facts. No patient had painful sexual Table 4. Comparison of sexual function and sexual distress rates intercourse, and 3 women were able to achieve orgasm. among women with CP and women with CPþSVI before and after Improved sexual function occurred because of renewal of the surgery anatomic structures, improved function and sensitivity, and the FSFI FSDS-R cosmetic effects of surgery. The restoration of self-confidence and (mean ± SD) (mean ± SD) a positive relationship with one’s own genitalia led to improve- ments in overall sexual satisfaction. Before surgery Women with CP 17.9 ± 0.9 31.4 ± 5.7 Women with CP 17.8 ± 1.3 42.0 ± 4.2 Changes in Sexual Function and Sexual Distress and SVI Among Women With CP and Women With CPþSVI ¼ ¼ ¼ ¼ Differences t .115, df 7t2.4. df 7 After Surgery P value 0.912 0.049* Although sexual function among women with CP and women After surgery with CPþSVI was dysfunctional before surgery but showed Women with CP 26.4 ± 0.4 18.9 ± 4.0 significant improvement after, the level of sexual distress Women with CP 27.1 ± 0.8 30.0 ± 4.2 and SVI (according FSDS-R) only changed among women with CP (even Differences t ¼1.6, df ¼ 7t¼3.4. df ¼ 7 though it was still considered dysfunctional). In women with þ fi P value 0.114 0.011* CP SVI, the level of distress did not show signi cant changes. Sexual function improved significantly after surgery in both CP ¼ clitoral phimosis; df ¼ degrees of freedom; FSFI ¼ Female Sexual Function Index; FSDS-R ¼ Female Sexual Distress Scale-Revised; SVI ¼ groups; however, sexual distress decreased only in the group of stenosis of the vaginal introitus. women with isolated CP. SVI associated with the impossibility of *Significant difference from the control group, P < .05. vaginal intercourse is likely more stressful than CP alone.

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However, because it was only a very small number of women, it STATEMENT OF AUTHORSHIP fi fi is dif cult to make any signi cant statistical conclusion. Category 1 (a) Conception and Design Other Aspects of Female Sexual Surgery in Relation Roman Chmel; Marta Novácková; Tomás Fait; Libor Zámecník; to Clinical Practice Zlatko Pastor The specialists who deal with FSD should be educated and (b) Acquisition of Data made aware that a thorough physical examination of the geni- Roman Chmel; Marta Novácková; Tomás Fait; Libor Zámecník; talia, including the clitoral region, should be performed in all Lucie Krejcová; Zlatko Pastor (c) Analysis and Interpretation of Data patients with genital and sexual complaints. If TCS or any other Roman Chmel; Marta Novácková; Libor Zámecník; Lucie treatment method (for instance, radiofrequency laser or dilation Krejcová; Zlatko Pastor in case of SVI) fails, a surgical solution should be considered. Although laser therapy is more expensive, according to our Category 2 experience, it has a lower rate of complications and results in (a) Drafting the Article better healing of the tissues than classic surgery. Prevention of Roman Chmel; Marta Novácková; Tomás Fait; Libor Zámecník; recurrence, postoperative therapy, and multidisciplinary cooper- Lucie Krejcová; Zlatko Pastor (b) Revising It for Intellectual Content ation within holistic, somatic, and psychosocial approaches are Roman Chmel; Marta Novácková; Tomás Fait; Libor Zámecník; important for successful treatment. Zlatko Pastor Category 3 Limitations of the Study Our study was limited by the small number of women who (a) Final Approval of the Completed Article Roman Chmel; Marta Novácková; Libor Zámecník; Lucie underwent surgery and were not compared with a control group Krejcová; Zlatko Pastor of healthy women. However, statistically reviewed data on preoperative and postoperative sexual function were included, using validated instruments to assess sexual function and evaluating the REFERENCES histologic diagnoses. The small number of patients limited our 1. Goldstein I. Dorsal slit surgery for clitoral phimosis. J Sex Med ability to compare the characteristics of severe phimosis caused 2008;5:2485-2488. by LS (especially with or without additional SVI) to the char- 2. Dalziel KL. Effect of lichen sclerosus on sexual function and acteristics of severe phimosis due to other causes (congenital, parturition. J Reprod Med 1995;40:351-354. postpartum, and posttraumatic). Other causes of CP could have 3. Goldstein AT, Marinoff SC, Christopher K, et al. Prevalence of varying effects on the manifestation and development of sexual vulvar lichen sclerosus in a general gynecology practice. dysfunction. This study should be complemented by long-term J Reprod Med 2005;50:477-480. follow-up studies. In the future, there is a need for studies 4. Wallace HJ. Lichen sclerosus et atrophicus. Trans St Johns including a larger number of patients and a longer postoperative Hosp Dermatol Soc 1971;57:9-30. follow-up period. 5. Jones RW, Scurry J, Neill S, et al. Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics. Am CONCLUSION J Obstet Gynecol 2008;198:496.e1-496.e3. The severe form of CP inflicted by LS causes sexual problems 6. Günthert AR, Faber M, Knappe G, et al. Early onset vulvar in most cases. Mild and moderate CP in most cases did not Lichen Sclerosus in premenopausal women and oral contra- correlate with FSD. In women with CP and FSD caused by LS, ceptives. Eur J Obstet Gynecol Reprod Biol 2008;137:56-60. in whom local corticosteroid therapy has failed, a surgical solu- 7. Pugliese JM, Morey AF, Peterson AC. Lichen sclerosus: review tion should be considered. In our study, the surgical procedure of the literature and current recommendations for manage- not only corrected the anatomic changes, but also reduced the ment. J Urol 2007;178:2268-2276. sexual complaints. Circumcision of the clitoris is currently the 8. Munarriz R, Talakoub L, Kuohung W, et al. The prevalence of most effective treatment for the severe form of CP caused by LS, phimosis of the clitoris in women presenting to the sexual even though recurrence may still occur in the future. dysfunction clinic: Lack of correlation to disorders of desire, Corresponding Author: Zlatko Pastor, MD, PhD, 2nd Faculty arousal and orgasm. J Sex Marit Ther 2002;28:181-185. of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, 9. Burrows LJ, Creasey A, Goldstein AT. The treatment of vulvar Czech Republic. Tel: 420-724-031-582; Fax: 420-224-433-692; lichen sclerosus and female sexual dysfunction. J Sex Med E-mail: [email protected] 2011;8:219-222. 10. Flynn AN, King M, Rieff M, et al. Patient satisfaction of sur- Conflict of Interest: The authors report no conflicts of interest. gical treatment of clitoral phimosis and labial adhesions Funding: None. caused by lichen sclerosus. Sex Med 2015;3:251-255.

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