Postoperative Sexual Concerns and Functioning in Patients Who Underwent Lysis of Vulvovaginal Adhesions

Outcomes After Lysis of Adhesions and Dilator Placement for Treatment of Vulvovaginal Agglutination Due to Lichen Planus

OBJECTIVE

The aim of the study is to determine intraoperative and postoperative surgical outcomes for the treatment of vulvovaginal agglutination secondary to lichen planus (LP) following a standard protocol using intraoperative dilator placement and postoperative intravaginal steroid use.

MATERIALS AND METHODS

This was a retrospective chart review of patients who underwent surgical management of vulvovaginal agglutination due to LP following a protocol that included surgical lysis of vulvovaginal adhesions, intraoperative dilator placement and removal 48 hours later, and high-potency intravaginal corticosteroid and regular dilator use thereafter. Demographic and clinical data were abstracted from the medical record and analyzed using descriptive statistics.

RESULTS

Thirty-four patients, with mean age 51.2 ± 11 years and body mass index 32.8 ± 8.5 kg/m 2 , underwent lysis of vulvovaginal adhesions between 1999 and 2021 with 8 different surgeons at a single institution. The mean preoperative, immediate postoperative, and 6-week postoperative vaginal lengths were 2.8 ± 1.8 cm ( n = 18), 8.0 ± 1.9 cm ( n = 21), and 7.9 ± 2.2 cm ( n = 16), respectively. The mean estimated blood loss intraoperatively was 16 ± 15 mL. No patients had a documented surgical site infection or reoperation within 30 days after surgery. Of patients who had it documented ( n = 26), 70% (18/26) reported postoperative sexual activity. Where documented, 100% (18/18) reported preoperative dyspareunia, while 17% (3/18) did postoperatively. Six percent (2/34) had recurrent severe agglutination and 3% (1/34) underwent reoperation.

CONCLUSIONS

Lysis of vulvovaginal adhesions, intraoperative dilator placement, and postoperative intravaginal corticosteroids with dilator use is a safe and effective treatment option to restore vaginal length for those with vulvovaginal LP.

Vulvar lichen planus–induced vulvovaginal stenosis: A case report and review of the literature

The authors report a case of vulvar lichen planus–induced vulvovaginal stenosis along with a review of the current literature. The authors outline a case of a patient with biopsy-proven vulvar lichen planus who subsequently developed a vulvovaginal stenosis. Treatment was initiated with clobetasol ointment, oral prednisone, later transitioned to oral methotrexate and clobetasol, and then switched to acitretin. Collaboration with the patient’s family physician and the hypertension clinic has been sought to remove medications associated with lichenoid reactions from the patient’s regimen. Review of literature was conducted through Ovid MEDLINE. Only six cases of vulvar lichen planus–induced vulvovaginal stenosis had been found, suggesting the relative rarity of this severe disease presentation. The patient has achieved control with her current regimen, as well as some clinical improvement of the resulting vaginal stenosis. Vulvovaginal stenosis can be induced by vulvar lichen planus, and its management requires a multimodal and multidisciplinary approach.

Diagnosis and Management of Vulvovaginal Lichen Planus

Importance

Genital lichen planus is a debilitating disorder that lacks definitive recommendations regarding diagnosis and treatment.

Objective

The aim of this study was to present best practices from available evidence for the diagnosis and treatment of genital lichen planus.

Evidence Acquisition

We conducted a narrative review of the literature on genital lichen planus by searching PubMed using the following search terms: "vulvar lichen planus" OR (vulvar diseases[mesh] OR vulva[mesh]) AND lichen planus[mesh] OR vulvar[ti] AND "lichen planus"[ti]. We included all languages and years in the search.

Results

The search resulted in 273 citations that we reviewed for relevancy and selected 60 as the foundation for this review that focuses on genital sites. Diagnosis can be made without biopsy, and when a biopsy is taken, the pathologic findings may be nonspecific. Topical ultrapotent corticosteroids are most commonly used as first-line treatment of genital lichen planus.

Conclusions and Relevance

When patients present with genital lichen planus, a complete review of systems and a thorough physical examination should be performed because of the prevalence of extragenital sites. Treatment of genital disease should start with a topical, ultrapotent steroid, and follow-up visits should occur to ensure improvement and to monitor for adverse drug reactions and malignancy.

A Qualitative Exploration of Women's Experiences of Living With Chronic Vulvar Dermatoses

BACKGROUND

Many vulvar dermatoses (VDs) are chronic and cannot be "cured," thus affected women must learn to live with the impact of the disease, and its treatment, on their quality of life.

AIM

To qualitatively investigate the impact of VDs on women's quality of life through firsthand accounts.

METHODS

12 women, 7 with lichen sclerosus and 5 with erosive vulvovaginal lichen planus recruited from a vulvar disease clinic participated in in-depth, exploratory interviews. Scripts were analyzed by applying a thematic network. The following steps were used: (1) coding the text, (2) development of descriptive themes, and (3) generation of thematic networks.

OUTCOMES

The main outcome explored was the narrative experiences of women living with VDs.

RESULTS

A global theme of suffering emerged. Themes associated with this suffering were organized under the themes of isolation, interference, and grieving. Women felt isolated because they felt unable to talk about their suffering; experienced a lack of external validation and support; and felt different as individuals, women, and sexual beings. Most women expressed negative views of their genitalia. Women spoke of the VDs, and its management, as interfering with thoughts, activities, and sex life. Symptoms were described as all-encompassing. Women spoke about limiting and/or avoiding daily activities and, in particular, sexual activities. Women described diminished sexual pleasure and experienced loss in their intimate relationships. Women described an ongoing grieving process; anger and sadness over the loss of their former healthy self; the burden of ongoing treatment; and attempts to cope and accept their current condition.

CLINICAL IMPLICATIONS

The findings suggest that assessment of women with VDs should include a detailed history of the impact of the VDs on women's psychological and sexual health.

STRENGTHS AND LIMITATIONS

A strength of this study is that we openly explored the lived experiences of women who had been clinically diagnosed with vulvar lichen sclerosus and erosive vulvovaginal lichen planus. A limitation is that the findings may not represent the experience of women living with VDs who do not wish to discuss their VDs or who are undiagnosed, untreated, and/or treated by other health-care providers.

CONCLUSIONS

Women described profound impact of VDs on psychological and sexual health. Sadownik LA, Koert E, Maher C, et al. A Qualitative Exploration of Women's Experiences of Living With Chronic Vulvar Dermatoses. J Sex Med 2020;17:1740-1750.

Update on treatments for erosive vulvovaginal lichen planus

Vulvovaginal lichen planus (VVLP) is a debilitating disease that causes significant pain and psychological distress. Management is made difficult by the chronic course of the disease and its resistance to treatment. While topical steroids have been accepted as the first-line treatment, they fail to achieve symptomatic control in approximately 40% of patients. Second-line therapies include other topical treatments such as calcineurin inhibitors, systemic therapies including oral steroids, methotrexate, mycophenolate mofetil, biologics, and tacrolimus, and procedural options including surgery and dilation, photodynamic therapy, and ultrasound. This review provides an overview of the current treatments and explores the level of evidence supporting each of them.

2016 European guideline for the management of vulval conditions

Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners. Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).

Surgical management of vulvovaginal agglutination due to lichen planus

Lichen planus is a rare dermatological disorder that is often associated with painful and disfiguring vulvovaginal effects. At the University of Michigan Center for Vulvar Diseases, we see many women with vulvovaginal lichen planus each year, with marked scarring and vulvovaginal agglutination that precludes vaginal intercourse and causes difficulty with urination. Through our experience, we developed a protocol for the operative management and postoperative care for severe vulvovaginal agglutination. Our objective is to share this protocol with a wider audience so that providers who see patients with these devastating effects of lichen planus can benefit from our experience to better serve this patient population. The figure represents a case of erosive lichen planus with early vaginal agglutination. The video reviews the pathophysiology and presentation of lichen planus. We then present a case of scarring and agglutination in a young woman, including our surgical management and postoperative care recommendations.

Vulvar Dermatoses: A Primer for the Sexual Medicine Clinician

INTRODUCTION

Vulvar dermatoses are common dermatological conditions that affect the vulva, and can cause considerable pain, irritation, pruritus, and burning, and have an adverse impact on a woman's sexual function.

AIM

To provide an overview of the clinical features, etiology, and management options for the common vulvar dermatoses, including lichen sclerosus, lichen planus, lichen simplex, contact dermatitis, and vulvar psoriasis, and briefly describe the impact of vulvar dermatoses on sexual function.

METHODS

The key words "vulvar dermatoses," "lichen sclerosus," "lichen planus," "lichen simplex chronicus," "vulvar dermatitis," and "vulvar psoriasis," were utilized to search Medline and PubMed for articles, with special attention given to those published within the past 5 years.

MAIN OUTCOME MEASURE

Five hundred thirty-six results were generated from the literature search. Publications that were judged current and relevant to the pathophysiology, evaluation, and treatment of vulvar dermatoses were included in the review.

RESULTS

Fifty-seven articles were selected for inclusion in this review.

CONCLUSIONS

Vulvar dermatoses can cause chronic pain, itching, and dyspareunia, and can have a profound effect on a woman's sexual expression and comfort. Delay in diagnosis is often due to hesitancy to seek treatment on the part of the patient or delay in biopsy on the part of the provider. This can result in failed prescriptive and self-treatment measures, worsening symptoms, and frustration and sexual dysfunction for the patient, and potentially the development of squamous cell carcinoma. It is imperative for sexual medicine providers, who commonly treat women with vulvar concerns, to be familiar with the presentation, diagnosis, and treatment of common vulvar dermatoses and their effect on sexual function. Kellogg Spadt S and Kusturiss E. Vulvar dermatoses: A primer for the sexual medicine clinician. Sex Med Rev 2015;3:126-136.

Vulvar dermatosis

Vulvar dermatoses are inflammatory conditions responsible for chronic or recurrent itching and soreness. The lesions are either circumscribed to the vulva or associated with extragenital localizations which may help to assess the diagnosis. They should be differentiated from infectious or neoplastic diseases which may have clinical similarities. As opposed to the majority of all dermatoses that have a benign and regular course, lichen sclerosus or lichen planus could exceptionally foster the occurrence of an epithelial cancer precursor which may evolve to squamous cell carcinoma. Topical corticosteroids are the mainstay treatment of vulvar dermatosis. We do not know if the treatment of vulvar lichen sclerosus and vulvar lichen planus prevents squamous cell carcinoma.