Synonyms
Clitoral phimosis
Clitoral adherence
Clitorodynia closed compartment syndrome
Subdivisions
General Discussion
The clitoris is a crucial structure for female sexual pleasure and response. Sized at approximately 9-11 cm long, it is composed of an internal corpora or body, paired crura and vestibular bulbs, as well as the external glans (head of the clitoris) and prepuce (hood) (1). The glans of the clitoris is homologous to the head of the penis, and the prepuce to the foreskin. The prepuce should move freely over the surface of the glans and be easily retracted. When this ability is lost or partially restricted and the prepuce becomes stuck to the glans in one or more spots, this is known as a clitoral adhesion (2). Underneath the adhesion may be the presence of smegma (a collection of dead skin cells and oils) or keratin pearls which occur when skin cells stick together in concentric layers and form small, millimeter-sized masses which resemble tiny pearls (2).
Signs & Symptoms
People with clitoral adhesions may notice certain signs or symptoms, but it is important to note that not all adhesions cause symptoms, and they may only be discovered incidentally during an in-depth clitoral exam.
Symptoms may include:
Pain or discomfort
Foreign body sensation (like sand in your eye)
Difficulty wearing tight clothing
Increased or decreased sensitivity of the clitoris
Difficulty with arousal
Muted or absent orgasm
Pain with sex, masturbation or other clitoral stimulation
Persistent, distressing genital arousal not associated with sexual interest or thoughts (2,3)
Causes
The exact cause of clitoral adhesions in each patient is not often identifiable and more research must be done. In penis-owners, it is established that penile phimosis or inability of the foreskin to pull back from the glans, can be associated with poor hygiene. When smegma builds up and is not properly washed away, it can become trapped between the foreskin and glans, causing restriction of the foreskin and infection (4). It is unknown at this time if those with a clitoris should be performing similar hygiene techniques and removing smegma to prevent adhesions.
There is an association between clitoral adhesions and lichen sclerosus. Lichen sclerosus is a chronic, inflammatory skin disease that can cause changes to the vulvar skin. Without treatment, lichen sclerosus leads to progressive scarring which can include scarring of the clitoral prepuce and formation of keratin pearls (5).
Affected Populations
Clitoral adhesions can affect anyone who has a clitoris. At present, it is estimated that 23-33% of vulvar owners have clitoral adhesions (3). One study showed that of 61 patients with adhesions, 17% were menopausal, 73% had a history of hormonal birth control use, 59% had a history of UTI, 56% had a history of yeast infections and 12% had a diagnosis of lichen sclerosus (3). It is not known at this time if these conditions are a cause of adhesions or merely correlated. More research is needed to determine who is most at risk.
Diagnosis
Clitoral adhesions are diagnosed by a thorough clitoral exam. Unfortunately, most medical providers, even gynecologists, don’t know how to examine a clitoris, so it is important that you find an ISSWSH provider. On exam, your clinician will notice that they are unable to visualize the corona once the clitoral prepuce is retracted. They will instead see some parts of the hood stuck to the glans. They may also notice keratin pearls underneath or along the junction of the glans and prepuce. Magnification can be very helpful in examining the clitoris (2).
Standard Therapies
A Lysis of Adhesions is the standard treatment. This is an office-based procedure that involves no cutting or sewing. A strong, topical numbing agent is applied to the clitoris. Once sufficiently numb, a tool called fine Jacobsen mosquito forceps and/or a lacrimal duct probe are used to gently separate the prepuce from the glans. If smegma or keratin pearls are noted to be present, they are simply wiped away. Swelling may be present for a few days to a week. Any residual pain during recovery is effectively managed with tub soaks, ice and ibuprofen or acetaminophen. It is important to pull the clitoral hood back daily to prevent re-adherence and apply vaseline to keep the area lubricated and mobile (3).
Efficacy of this procedure was studied and the results were very encouraging. Of the patients who underwent the lysis of clitoral adhesion procedure, 76% had a reduction in pain, 71% noted improved satisfaction, 63% noticed an increase in sexual arousal, 64% improved their ability to achieve orgasm (26% reported significant improvement) and no one experienced worsening of their ability to achieve orgasm. Sixteen participants were unable to achieve orgasm from external clitoral stimulation prior to the procedure and 6 of those patients then gained that ability after the procedure. 93% of respondents stated that they would recommend the procedure to a friend who also had clitoral adhesions (3).
In some instances, like in the case of severe lichen sclerosus, a more invasive solution might be warranted such as the dorsal slit procedure. A lacrimal duct probe is used to separate the clitoral hood from the glans and then a 5 mm cut is made along the prepuce to allow access to further release tissues that have become stuck together (6).
In the mid 1970’s a technique called hoodoplasty was used which involved separating the prepuce from the glans and then trimming the prepuce. However, this procedure can cause damage to clitoral nerves and resulting numbness and is no longer recommended (3).
Investigational Therapies
Support Available
The International Society for the Study of Women’s Sexual Health (ISSWSH) The Sex Med Advocate (sexmedadvocate.com)
Sexual Medicine Society of North America (SMSNA)
References
- Pauls, RN. Anatomy of the clitoris and the female sexual response. Clin. Anat. 2015;28(3): 376-384.doi.org/10.1002/ca.22524.
- 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. Sex Med. 2018;6(2): 115-122. doi: 10.1016/j.esxm.2018.01.003.
- Myers, MC, Romanello JP, Nico E, Marantidis J, Rowen, TS, Sussman RD, Rubin, RS. A Retrospective Case Series on Patient Satisfaction and Efficacy of Non-Surgical Lysis of Clitoral Adhesions. J Sex Med. 2022; 19(9):,1412-1420. doi.org/10.1016/j.jsxm.2022.06.011.
- Shahid SK. Phimosis in children. Isrn urology. 2012;2012:1-6. doi:10.5402/2012/707329 5. Krapf JM, Mitchell L, Holton MA, Goldstein AT. Vulvar Lichen Sclerosus: Current Perspectives. Int J Womens Health. 2020;12:11-20. doi:10.2147/IJWH.S191200 6. Goldstein AT, Burrows LJ. Surgical treatment of clitoral phimosis caused by lichen sclerosus. American Journal of Obstetrics and Gynecology. 2007;196(2):126.e1-126.e4. doi:10.1016/j.ajog.2006.08.023
