Topical corticosteroids are the gold standard treatment; read about it here and here. While steroids are effective in reducing inflammation, slowing the progression of the condition, getting patients into remission, and reducing the likelihood of developing vulvar cancer, they cannot reverse existing vulvar fusing/scarring. Fusing and scarring, however, can affect the functioning of your vulva. If your fusing and scarring are causing functional issues, you *may* be a candidate for surgery.
In this post, I will review the surgery for clitoral fusing and recurrent tearing. Further, I will share important information you should know before booking surgery.
*This post is evidence-based. I draw on the medical literature to share what you need to know about surgery and lichen sclerosus. Importantly, what I share is my interpretation of the science and data.
Surgery for Clitoral Fusing
If you read my post on architectural changes, you are familiar with the term clitoral fusing or clitoral phimosis. Briefly, clitoral fusing is when the hood of the clitoris fuses to and scars over the glans clitoris. Sometimes but not always fusing is caused by a reduction of sensation.
It is important to note that not all folks with clitoral fusing experience loss of sensation or difficulty reaching orgasm. I have spoken with several folks who say they have severe fusing, but it does not negatively impact their lichen sclerosus. Everyone is different.
However, if your clitoral fusing does impact your sexual function, you *may* be a candidate for and *may* benefit from surgery.
Additionally, clitoral fusing can lead to keratin pearls (medically known as smegmatic pseudocysts). As someone who has had many of these in the past, I can tell you they are very painful and stressful. Not only are they painful, but they increase the risk of infection. Therefore, recurrent keratin pearls may be another reason to consider surgery.
Lysis of Adhesions for Clitoral Fusing
A lysis of adhesions can be performed to separate the clitoral hood from the glans. This procedure is performed in the operating room under anesthesia. Once the patient is asleep, the doctor will insert a duct probe between the hood of the clitoris and the glans to separate the two parts of the clitoris. Then, a 5-mm incision is made in the hood of the clitoris using medical scissors, and any remaining scar tissue is removed with the duct probe. (Goldstein and Burrows, 2007).
Post-operative care involves the use of Clobetasol 0.05% ointment applied daily to the surgical site to help the wound heal open. Using Clobetasol to heal open reduces the likelihood of re-fusing. Once the surgical site is healed, patients will use Clobetasol on a maintenance protocol.
Still trying to figure out what a maintenance protocol is? Check out this video where I explain steroid dosing schedules.
Surgery for Recurrent Tearing
Believe it or not, the lysis of adhesions can also help with recurrent tearing. Some folks experience tearing during sex, and, for some, this tearing can keep reoccurring in the same area (often around the vaginal opening and fourchette).
I discuss the process of recurrent tearing and how this may lead to a narrowing of the vaginal opening in his video (timestamp 26:28).
If your doctor assesses you and determines the recurrent tearing is due to extensive scaring, they can perform a lysis of adhesions on the area to help prevent future tearing.
Recurrent tearing can be corrected surgically if you have recurrent tearing and/or narrowing of the vaginal opening.
The surgery involves the surgeon using a scalpel to cut through and remove some of the scar tissue. A solution called ferric subsulfate is then applied to stop the bleeding (Flynn et al., 2015).
Post-operative care is the same as described above for the clitoral lysis of adhesions. Additionally, patients are instructed to retract their labia several times a day, again, to help prevent any re-fusing.
How Successful are These Surgeries for Lichen Sclerosus?
We know surgery is not a treatment, but it is a procedure that may be necessary in cases of severe fusing – but is the surgery worth it? What is the success rate for surgeries? Let us see what the medical literature says.
Flynn et al. (2015) conducted a study looking at patients' satisfaction post-surgery to address either clitoral fusing or recurrent tearing. 20 patients were involved in the study. Each patient completed an eight-question form after surgery to assess their satisfaction with the procedure.
The results from the study showed that the majority of the patients were happy with the procedure.
Specifically, 44% of patients were very satisfied, and 40% were satisfied. For the patients who initially reported decreased clitoral sensation, 75% of that group said they experienced increased sensation post-surgery. Finally, of the patients who initially reported painful sex, 33% reported having pain-free sex post-surgery, and 58% reported improvement. However, they still were not entirely able to have pain-free sex.
No complications or worsening of symptoms were reported. The authors concluded that surgery could be a good low-risk option for corrected clitoral phimosis and vulvar adhesions that cause recurrent tearing (ibid).
Goldstein and Burrows (2007) conducted a study with 8 people with biopsy-confirmed vulvar lichen sclerosus to assess how successful the surgery was for clitoral phimosis. All 8 patients had the surgery and they all filled out a follow-up questionnaire between 12-36 months post-op to determine their levels of satisfaction with the surgery. Overall, patients reported being either very satisfied (88%) or satisfied (12%).
Always Vet Potential Surgeons
I cannot stress enough how important it is to vet your surgeons. Surgery is an invasive procedure and one that comes with risks (especially if you are having surgery performed on the clitoris). You want to make sure they are an experienced surgeon. How can you know if they are an experienced surgeon? Vet them ahead of time and ask them the following questions:
- Have you performed the surgery before?
- If so, how many surgeries have you performed?
- Do you have many patients with LS?
- Do you feel comfortable operating on someone with LS?
- What is your success rate for this surgery?
- What are the risks of the surgery?
- What measures do you put in place to ensure I do not re-fuse?
You can email these questions to your doctor ahead of time to make sure you go with a skilled surgeon who has experience with LS and has performed many of these surgeries.
But Wait…Are There Any Non-Surgical Options
Glad you asked! We have a ton of content on this.
Here is a video on 3 evidence-based ways to unfuse your clitoris:
The Bottom Line with Surgery and Lichen Sclerosus
In sum, if your lichen sclerosus has caused severe scarring that impacts your bodily function, surgery may be an option for you. It is essential to ensure you do not just go to any surgeon. Make sure to vet your surgeon and make sure they have done this procedure before and specialize in lichen sclerosus. Finally, surgery is not a cure for LS. Surgery is performed to restore function. All patients are to continue with their steroids after they have recovered.
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Sources Cited & Consulted
Burrows LJ, Creasey A, Goldstein AT. The treatment of vulvar lichen sclerosus and female sexual dysfunction. J Sex Med 2011;8:219–22.
Goldstein A.T. and Burrows L.J. “Surgical treatment of clitoral phimosis caused by lichen sclerosus.” Am J Obstet Gynecol. 2007; 196: 126
Flynn AN, King M, Rieff M, Krapf J, and Goldstein AT. Patient satisfaction of surgical treatment of clitoral phimosis and labial adhesions caused by lichen sclerosus. Sex Med 2015;3:251–255.
Krapf JM, Mitchell L, Holton MA, Goldstein AT. Vulvar Lichen Sclerosus: Current Perspectives. Int J Women's Health. 2020 Jan 15;12:11-20. doi: 10.2147/IJWH.S191200. PMID: 32021489; PMCID: PMC6970240.
Rouzier R, Haddad B, Deyrolle C, Pelisse M, Moyal-Barracco M, Paniel BJ. Perineoplasty for the treatment of introital stenosis related to vulvar lichen sclerosus. Am J Obstet Gynecol 2002;186:49–52.