Wardrop, F, Negris, O, Milazzo, M, Rubin, R

Clitoral adhesions, smegma, phimosis, dorsal slit, clitoris

 This video describes an innovative procedure used to treat a patient with a unique and severe presentation of untreated clitoral adhesions resulting in complete clitoral phimosis and a large pseudocyst. A 60-year old female presented to a urology and sexual medicine practice with a slowly enlarging clitoral mass seeking treatment with preservation of clitoral sensation. A previous pelvic MRI had revealed a large cystic lesion projecting from the prepuce thought to be an epidermoid, proteinaceous or hemorrhagic cyst arising from the vagina. The patient had previously been offered surgical excision of the mass, but without guaranteed preservation of sexual function. The patient presented to our clinic in April 2023 seeking management that prioritized preservation of sexual function. Our team proposed a dorsal slit procedure for removal of smegma and small excision of excess surrounding tissue. This approach has little to no known effect on the clitoral nerves as they course dorsally and terminal at the clitoral glans and allows full retraction of clitoral prepuce. A dorsal slit of the clitoris was made, and a 4 cm clitoral mass with sebaceous material forming a pseudocyst on top of the clitoris was removed. After the removal of the smegmatic pseudocyst, our patient reported improved sensation and orgasm without pain or cystic reaccumulation. Despite their prevalence, as demonstrated in previous research, 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.

References:

1. Aerts L, Rubin RS, Randazzo M, Goldstein SW, Goldstein I. Retrospective Study of the Prevalence and Risk Factors of Clitoral Adhesions: Women’s Health Providers Should Routinely Examine the Glans Clitoris. Sexual Medicine. 2018;6(2):115-122. doi:10.1016/j.esxm.2018.01.003

2. Munarriz, Ricardo, et al. “The Prevalence of Phimosis of the Clitoris in Women Presenting to the Sexual Dysfunction Clinic: Lack of Correlation to Disorders of Desire, Arousal and Orgasm.” Journal of Sex & Marital Therapy, vol. 28, no. sup1, Feb. 2002, pp. 181–85. DOI.org (Crossref), https://doi.org/10.1080/00926230252851302.

3. Cox S, Nasseri R, Rubin RS, Santiago-Lastra Y. Genitourinary Syndrome of Menopause. Medical Clinics of North America. 2023;107(2):357-369. doi:10.1016/j.mcna.2022.10.017

4. Munarriz R, Talakoub L, Kuohung W, et al. The Prevalence of Phimosis of the Clitoris in Women Presenting to the Sexual Dysfunction Clinic: Lack of Correlation to Disorders of Desire, Arousal and Orgasm. Journal of Sex & Marital Therapy. 2002;28(sup1):181-185. doi:10.1080/00926230252851302

5. Nico E, Romanello J, Myers M, Sussman R, Marantidis J, Rubin R. Improvement in the Ability to Orgasm after the Non-Surgical Lysis Procedure for Clitoral Adhesions. The Journal of Sexual Medicine. 2022;19(Supplement_3):S26-S27. doi:10.1016/j.jsxm.2022.05.104

6. Myers MC, Romanello JP, Nico E, et al. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. The Journal of Sexual Medicine. 2022;19(9):1412-1420. doi:10.1016/j.jsxm.2022.06.011

7. Myers MC, Romanello JP, Nico E, et al. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. The Journal of Sexual Medicine. 2022;19(9):1412-1420. doi:10.1016/j.jsxm.2022.06.011

8. Myers MC, Romanello JP, Nico E, et al. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. The Journal of Sexual Medicine. 2022;19(9):1412-1420. doi:10.1016/j.jsxm.2022.06.011

9. Bachmann G. Female Sexuality and Sexual Dysfunction: Are We Stuck on the Learning Curve? The Journal of Sexual Medicine. 2006;3(4):639-645. doi:10.1111/j.1743-6109.2006.00265.x

10. McPhee AS, Stormont G, McKay AC. Phimosis. StatPearls Publishing; 2023.