(Video Poster 22) Nonsurgical Lysis of Clitoral Adhesions

Objectives: Clitoral adhesions are common and can be found in up to 25% of patients presenting with sexual pain or decreased sensation. Common causes include lichen sclerosus, genitourinary syndrome of menopause and keratin pearls. The objective of this video is to highlight the non-surgical approach to lysis of clitoral adhesions using a case example. This procedure aims to restore the anatomy and function of the clitoris while preserving integrity and minimizing complications. This video provides stepwise guidance for clinicians and emphasizes proper techniques which will allow the procedure to be more widely performed.

Methods: This procedure can be done with topical anaesthetic alone, or with a dorsal clitoral nerve block. The procedure can be done in-office. For the nerve block, a spinal needle is advanced in front of the pubic bone to the level of the clitoral complex, through the clitoral fascia. Two to five millilitres are injected, ensuring to withdraw first due to the proximity of the superficial dorsal vein and the deep dorsal veins and arteries. The dorsal nerves of the clitoris are bathed in bupivicaine with epinephrine. Next, a copious amount of xylocaine jelly is applied with Q-tips to find the plane of fusion. At this time, it is helpful to have an assistant provide countertraction by retracting the labia.
Finally, a hemostat or occasionally a lacrimal duct probe can be used to bluntly dissect the adhesions. Any keratin pearls can be removed with fine surgical forceps. This continues until the entire corona of the clitoris can be restored. No incisions should be made in the clitoral hood skin nor the frenulum as this may cause surgical scarring, chronic pain, anatomic distortion and worsening sexual dysfunction

Clinical Relevance: Clitoral adhesions are a significant cause of sexual dysfunction and can cause pain and irritation. Non-surgical lysis is a minimally invasive alternative to surgery and can preserve clitoral anatomy with decreased risks of postoperative pain, scarring, and altered sensation. Although previously described in the literature, to our knowledge there is no instructional video available to walk clinicians through how to do this procedure safely. This approach provides an effective and safe option for patients with adhesions. This video serves as a resource for healthcare professionals to better refine their technique and help standardize a method for clitoral adhesion lysis. Pre-procedure consent and post-procedure care are described. With this video, we aim to enhance patient outcomes, access to care, improved quality of life and promotion of best practices in urogynecologic care.