A Qualitative Study on Experiences After Vulvar Surgery in Women With Lichen Sclerosus and Sexual Pain

EuroGuiderm guideline on lichen sclerosus-Treatment of lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness; it may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are usually a whitening of the genital skin, sometimes preceded by redness and oedema; fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS (part 1), highlight important aspects in the care of LS patients, generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

Women's sexual activity and experiences following female genital fistula surgery

BACKGROUND

Surgical repair has a transformative impact on the lives of women affected by female genital fistula; however, various physical, social, and economic challenges may persist postrepair and prevent complete reengagement in relationships and communities. Nuanced investigation of these experiences is needed to inform programming that aligns with women's reintegration needs.

AIM

We investigated the sexual activity resumption, experiences, and concerns of women in Uganda during the year following genital fistula repair surgery.

METHODS

Women were recruited from Mulago Hospital between December 2014 and June 2015. We collected data at baseline and 4 times postsurgery about sociodemographic characteristics and physical/psychosocial status; we also assessed sexual interest and satisfaction twice. We performed in-depth interviews with a subset of participants. We analyzed quantitative findings via univariate analyses, and qualitative findings were coded and analyzed thematically.

OUTCOMES

We assessed sexual readiness, fears, and challenges following surgical repair of female genital fistula using quantitative and qualitative measures of sexual activity, pain with sex, sexual interest/disinterest, and sexual satisfaction/dissatisfaction.

RESULTS

Among the 60 participants, 18% were sexually active at baseline, which decreased to 7% postsurgery and increased to 55% at 1 year after repair. Dyspareunia was reported by 27% at baseline and 10% at 1 year; few described leakage during sex or vaginal dryness. Qualitative findings showed wide variance of sexual experiences. Some reported sexual readiness quickly after surgery, and some were not ready after 1 year. For all, fears included fistula recurrence and unwanted pregnancy.

CONCLUSION

These findings suggest that postrepair sexual experiences vary widely and intersect meaningfully with marital and social roles following fistula and repair. In addition to physical repair, ongoing psychosocial support is needed for comprehensive reintegration and the restoration of desired sexuality.

HIGHLIGHTS

Living with vulval lichen sclerosus: a qualitative interview study

BACKGROUND

Vulval lichen sclerosus (VLS) is a chronic inflammatory condition predominantly affecting the anogenital skin. Symptoms can be distressing and affect quality of life and everyday activities. Very little research has been undertaken to explore the experience of living with VLS from the perspective of people with the condition.

OBJECTIVES

To understand individuals' experiences of VLS and its impact on their lives.

PARTICIPANTS AND METHODS

Semi-structured remote (telephone or video) interviews were conducted with a purposive sample of 20 women living in the UK with VLS recruited via online support groups and social media. Data collection and analysis was informed by social constructionist grounded theory, using a constant comparison method.

RESULTS

We developed three themes to interpret the experience of living with VLS: missed opportunities (participants experienced delayed diagnosis, lack of information and disempowering encounters with healthcare professionals); learning to live with a long-term condition (the amount of work involved in learning how to self-manage the disease and the impact on everyday life); a secret life (experiences of the condition were often shrouded in secrecy, and there was stigma associated with a vulval skin condition resulting in them feeling isolated and lonely).

CONCLUSIONS

Patients attending healthcare appointments with vulval complaints should be examined and LS should be considered as a diagnosis. Healthcare professionals' awareness and knowledge of VLS needs to be improved and they should avoid language which is blaming or minimizing of patients' experiences. VLS is a chronic condition and patients need to be supported in self-management. Support groups may be a source of support and information but can also be challenging when hearing others' difficult experiences. Wider public health educational activities are needed to change societal attitudes towards female genitals and tackle the stigma around vulval conditions. What is already known about this topic? Vulval lichen sclerosus (VLS) can have a profound impact on quality of life and self-identity but is relatively underexplored from the perspective of those living with the condition. What does this study add? In-depth findings about the experiences of living with VLS including ongoing issues with timely diagnosis, learning to live with a long-term condition and the secrecy and stigma about the condition. The needs of women with symptoms of and diagnoses of VLS are not being met sufficiently by the healthcare system. What are the clinical implications of this work? Healthcare professionals should consider addressing knowledge gaps in vulval conditions including VLS to prevent delayed diagnosis and avoid the use of certain terminology which can minimize patients' experiences. Patients with vulval complaints should be examined and LS should be considered as a diagnosis. Regular follow-up would reflect its chronic nature and could provide patients with reassurance and confidence in self-management. Wider public health activities are needed to change societal attitudes and tackle stigma around vulval conditions.

Lichen Sclerosus and Sexual Dysfunction: A Systematic Review and Meta-Analysis

BACKGROUND

Lichen sclerosus (LS) is a common autoimmune dermatological condition that is often under-diagnosed in women and has been documented to affect quality of life and sexual function.

AIM

To determine the prevalence of sexual dysfunction among women with vulvar lichen sclerosus.

METHODS

The authors conducted a systematic review and meta-analysis of the existing research on LS and sexual function in database including PubMed using search terms: lichen sclerosus OR vulvar lichen sclerosus OR vulvar lichen sclerosus et atrophicus OR kraurosis vulvae) AND (sexual function OR sexual functions OR sexual disorder OR sexual disorders OR sexual activity OR sexual activities OR sexual dysfunction OR sexual dysfunctions OR dyspareunia OR vaginismus).

OUTCOMES

Nearly 60% of women with lichen sclerosus suffer from sexual dysfunction.

RESULTS

Two hundred and ten studies were initially identified. Twenty-six articles met inclusion criteria and 3 were excluded as they did not relate to sexual function, were regarding a surgical or medical intervention and sexual dysfunction and one was a review article. Therefore, 23 studies were included in the final analysis resulting in a cumulative 486 participants with LS with 208 patients experiencing any kind of sexual dysfunction. Meta-analysis presented prevalence of sexual dysfunction among LS patients as 59% (95% CI: 48 - 70%). Dyspareunia or generalized pain with intercourse was the most commonly reported type of dysfunction.

CLINICAL IMPLICATIONS

Discussing sexual concerns with women with LS could empower them to seek treatment.

STRENGTHS AND LIMITATIONS

Few articles met criteria for inclusion.

CONCLUSION

A large proportion of women with LS experience sexual dysfunction. More research is needed, especially that which includes biopsy-proven LS and validated tools on sexual function.

Factors influencing the clinical efficacy of high-intensity focused ultrasound in the treatment of non-neoplastic epithelial disorders of the vulva: a retrospective observational study

BACKGROUND

High-intensity focused ultrasound (HIFU) is an important method for treating non-neoplastic epithelial disorders of the vulva (NNEDV), but the factors affecting the efficacy of HIFU for NNEDV treatment remain unclear.

OBJECTIVE

To determine the factors influencing the clinical efficacy of HIFU in the treatment of NNEDV.

METHODS

A retrospective observational study of 186 NNEDV patients treated with HIFU was performed to evaluate the therapeutic effect, and the relationship between treatment efficacy and clinicopathological factors was analyzed.

RESULTS

NNEDV signs and symptoms were effectively improved and relieved after HIFU treatment. The total effective and recurrent rates were 95.16% and 4.52%, respectively. Younger patients with shorter disease courses, mild itching, or peri-vulvar lesions had better therapeutic effects, and patients with anxiety and/or depression had worse treatment outcomes.

CONCLUSION

The therapeutic effect of HIFU on NNEDV is not only related to the itching degree, age, or disease course but is also closely related to lesion location as well as anxiety and depression in patients.

Quality of Life in Vulvar Lichen Sclerosus Patients Treated With Long-Term Topical Corticosteroids

OBJECTIVE

The aim of the study was to investigate the quality of life in vulvar lichen sclerosus (VLS) patients treated with long-term, individualized topical corticosteroids.

METHODS

A prospective cross-sectional study comparing new pretreatment and long-term treated VLS patients attending a dermatogynecology practice in Sydney, Australia. Participants were invited to complete the Vulvar Quality of Life Index (VQLI). The VQLI scores were compared between the 2 groups.

RESULTS

A total of 204 biopsy-proven VLS patients-68 new pretreatment and 136 treated patients on topical corticosteroids for 2 years or longer. Treated participants scored lower in all VQLI components, including total score (median = 2.0 [interquartile range {IQR} = 0.0-6.0] vs 13.5 [IQR = 7.5-22.0]; p < .001), symptoms (median = 0.5 [IQR = 0.0-0.5] vs 1.3 [IQR = 0.8-2.0]; p < .001), anxiety (median = 0.0 [IQR = 0.0-0.3] vs 0.8 [IQR = 1.1-2.0]; p < .001), activities of daily living (median = 0.2 [IQR = 0.0-0.3] vs 0.5 [IQR = 0.2-1.1]; p < .001), and sexuality (median = 0.0 [IQR = 0.0-0.7] vs 1.0 [IQR = 0.0-2.0]; p < .001). A higher proportion of treated patients achieved total scores of 0-5, representing nil to minimal impact of VLS on quality of life (98 [72.1%] vs 8 [11.8%]; p < .001). Mild and reversible adverse effects were developed in 11 patients (8.1%). Partially compliant patients were 12 times as likely to develop scarring progression than fully compliant patients (7 [22.6%] vs 2 [1.9%]; p < .001).

CONCLUSIONS

Long-term, individualized topical corticosteroid treatment is safe and effective in maintaining disease remission and improves the quality of life of VLS patients. Fully compliant patients demonstrate better treatment outcomes than partially compliant patients.

Quality of life of women with untreated vulval lichen sclerosus assessed with vulval quality of life index (VQLI)

BACKGROUND/OBJECTIVE

The diagnosis of vulval lichen sclerosus (VLS) is often delayed, and little is known about quality of life (QoL) of women with it prior to receiving diagnosis and treatment. This study aimed to investigate the impact on QoL on patients with previously untreated VLS using the Vulval Quality of Life Index (VQLI).

METHODS

A prospective cross-sectional survey of patients attending a dermato-gynaecology practice in Sydney, Australia from March 2018 to November 2019. Patients with a new biopsy-proven diagnosis of VLS not previously commenced on topical corticosteroid treatment were invited to complete the VQLI.

RESULTS

A total of 68 participants with median age of 58 (interquartile range, IQR 48-67) years. Median symptom duration was 24 (IQR 11-60) months. Scarring was present in 53% of participants. The median total score was 13.5 (IQR 7.5-22.0), global score 1.0 (IQR 1.0-2.0). Twelve per cent had nil to minimal effect on QoL, 38% had a mild effect on QoL, 28% had a moderate effect on QoL, 22% had a severe effect on QoL, and none had a very severe effect on QoL. The highest-scoring domains were symptoms, followed by sexuality, anxiety and activities of daily living.

CONCLUSION

There was significant impairment in all QoL areas of women with untreated VLS. Most experienced moderate-to-severe impairment as a result of the disease and approximately half had already developed scarring at the time of diagnosis. The findings emphasise the importance of improved awareness, early diagnosis and early commencement of treatment in VLS.

Outcome of perineoplasty and de-adhesion in patients with vulvar Lichen sclerosus and sexual disorders

OBJECTIVE

Vulvar Lichen sclerosus (LS) is a chronic inflammatory disease in which architectural changes and symptoms like itching, soreness, pain and dyspareunia can affect quality of life and sexual activity. Perineoplasty has been shown to be effective as a supportive surgical treatment in women with refractory dyspareunia in addition to the standard topical immunosuppressive treatment. The aim of this study was to evaluate retrospectively general complaints, patient satisfaction concerning sexual activity, reduction of dyspareunia/apareunia, orgasm ability and recurrence of LS after perineoplasty.

STUDY DESIGN

This study is a retrospective monocentric observational study, in which patients with vulvar LS who had undergone perineoplasty were invited to fill out a standardized questionnaire during the follow-up time. The main outcome measure is the overall patient satisfaction after surgical therapy of vulvar LS.

RESULTS

Forty-one of the 70 invited patients with a median age at surgery of 58 years (18-74 years) and a median 60 years (19-76 years) at the last follow-up were evaluated. The median follow-up time was 2.3 years (1-5 years). There was a significant (p < 0.001) reduction in general complaints after surgery. Twenty-two patients were very satisfied, 15 were satisfied and 3 were not satisfied with the outcome of the surgery. Only 2 patients would not recommend the surgery. Although, there was a significant (p = 0.02) reduction in dyspareunia after surgery, 10 patients still felt pain during sexual intercourse.

CONCLUSION

This is one of the largest studies reporting on long-term results of perineoplasty. It showed that perineoplasty is a safe surgical treatment option with a high satisfaction rate in patients with dyspareunia due to LS and a desire to regain sexual activity. Perineoplasty can improve sexual activity and achieve overall satisfaction in selected patients even though the recurrence rate of LS in sexually active patients remains high.

Discussing sexuality in the field of plastic and reconstructive surgery: a national survey of current practice in the Netherlands

Background

Patient-reported outcomes have become increasingly important to assess the value of surgical procedures. Sexual function is a proven important constituent of quality of life, but is often overlooked by health care professionals. We aim to investigate to what extent plastic surgeons address or discuss issues concerning sexuality with their patients, and if there is a need for improvement.

Methods

We developed a survey to assess whether topics pertaining to sexual function were discussed during plastic surgical consultations. In 2016, all 385 members of the Dutch Association for Plastic Surgery were invited via post mail to participate.

Results

We received 106 completed surveys (27.5%). The median age of the respondents was 45 (29–66) years. Most participants (78.3%) indicated that they rarely to never discuss sexuality with their patients. Surgeons in the subspecialization gender and genital surgery discussed sexual function most frequently. Two thirds of all respondents indicated that their current knowledge on this topic was insufficient, yet there was generally no interest expressed in receiving additional training (78.6%). However, there was a need for proper patient brochures (43.4%) and an organized referral network (36.5%) regarding sexuality.

Conclusions

In plastic surgery practice, sexuality appears to be a rarely discussed subject, with the gender and genital surgery subspecialties as the exception. Although professionals and patients emphasize the importance of sexuality, plastic surgeons express limited urge to be trained and prefer written patient information and referring patients to other healthcare professionals. The authors stimulate more education on sexuality during (continued) plastic surgery training.

Level of Evidence: Not ratable