Surgical treatment of disabling conditions caused by anogenital lichen sclerosus in women: An account of surgical procedures and results, including patient satisfaction, benefits, and improvements in health-related quality of life

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Summary

Background

Anogenital lichen sclerosus (LS), a chronic dermatitis that causes scarring and introital stenosis, may prevent sexual intercourse and reduce health-related quality of life (QoL). Surgery can restore the anatomy, allowing patients to resume their sexual lives. This study investigates outcomes in women treated with local skin flaps.

Methods

Thirty-eight consecutive LS-verified patients, surgically treated for debilitating conditions between 1990 and 2013, were retrospectively evaluated. A survey measured patient satisfaction, benefits, and health-related QoL, and the patients were also evaluated by a long-term clinical follow-up.

Results

In total, 33 patients (87%) experienced dyspareunia, 24 of whom could not perform coitus. At mean short-term follow-up (10.0 months), only five patients (15%) reported dyspareunia; for seven patients, the outcome was unknown. The survey response rate was 87%, and the mean time from treatment to response was 7.6 years. Twenty of 24 patients reported dyspareunia. Seventy-five percent of patients with preoperative dyspareunia reported a surgical benefit, 74% were satisfied/very satisfied with the cosmetic and overall results, respectively, and 58% reported that surgery had improved their sexual lives. The mean long-term clinical follow-up was 8.4 years. The follow-up rate was 78%. The main reason for recurrent dyspareunia was minor LS relapse (50%); these patients were still able to have coitus, and dyspareunia was reported as considerably minor compared to before surgery; 38% had more severe LS relapse, resulting in apareunia.

Conclusions

Surgery for LS sequelae provides acceptable short-term functional results, enabling patients to resume coitus, with high patient satisfaction reported. However, the chronic relapsing nature of LS consequently provides varying and often short-term coital improvements following surgery.

Introduction

Lichen sclerosus (LS), a chronic inflammatory skin disease, can cause debilitating itching, pain, and discomfort. LS usually affects the anogenital region (only 15–20% cases are extragenital) and occurs in both sexes across all ages but is most commonly observed in prepubertal children and peri- or postmenopausal women.1 LS tends to relapse over time.2 An estimated 1:60 (1.7%) women presenting to a general gynecology practice exhibit vulvar LS.3 The condition is associated with an approximately 5% increase in the risk of developing vulvar squamous cell carcinoma.4 The etiology is unknown but it appears to be mostly associated with autoimmune disorders, particularly thyroid disease.5, 6, 7 In later stages and in spite of topical treatment, LS can develop into widespread scarring and superficial ulcers.8 Scarring may result in labial fusion, narrowing of the vaginal opening, clitoral hood adhesion, and clitoral burying, thereby impairing or destroying sexual function. Urination may also become problematic and painful,8, 9 and certain patients experience discomfort during defecation.10 In addition to being a debilitating physical condition, LS can have detrimental consequences on affected women's psychosexual and psychosocial life.10 There is no cure for LS, but treatment has three aims: relieve symptoms and discomfort, prevent the further progression of scarring that affects the anatomy of the region, and avoid malignant transformation.2, 11 The gold standard treatment for LS is potent topical corticosteroids. Surgical treatment is reserved for patients with malignancy and to correct secondary scarring leading to functional impairment.4, 8, 12

To date, no studies have assessed the long-term (a mean follow-up of 8.4 years) clinical results of surgical treatment in a manner that incorporates patient satisfaction, benefits, and improvements in aspects of patients' health-related quality of life (QoL).

The objectives of this study included the assessment of:

  • 1)

    Surgical procedures for the treatment of disabling conditions of the female perineum and external genitalia caused by LS, short- and long-term postoperative results, complications, and length of hospital stay.

  • 2)

    Patients' subjective satisfaction, the benefits achieved with surgical treatment, and health-related QoL following surgery.

Typically, less severe cases of LS involving labia minora fusion can be treated with simple perineotomy. However, more severe scarring, leading to introital stenosis or vulnerable skin, may require the excision of affected areas and subsequent reconstructive procedures. We used local skin flaps with different designs to restore the anatomy and function of the affected area. The indications for surgery were impaired functions such as dyspareunia, narrowing of the introitus preventing sexual intercourse, problems with urination or defecation, and pain when sitting or bicycling.

The present study consisted of three elements:

  • Case series: short-term results.

  • Survey: patient satisfaction, benefits, and improvement in health-related QoL.

  • Long-term clinical follow-up: long-term results.

Section snippets

Case series

The medical charts of 38 women referred to our department between 1990 and 2013 who underwent surgery performed by the same surgeon (the senior author) to treat debilitating conditions following anogenital LS were reviewed retrospectively. The patients' median age was 52 years (range, 16–77 years), and the mean LS duration was 9.0 years (range, 1.5–22.0 years). All patients had received topical treatment by a dermatologist or gynecologist before referral. LS had to be clinically inactive prior

Case series

Several of the 38 patients included in the study were subjected to more than one surgery; as a result, there were total 69 surgeries.

The median number of surgeries per patient was two, ranging from one to five. Twenty-one patients (55%) underwent more than one surgery. The patients subjected to only one surgery did not differ considerably from those subjected to more than one, with regard to age or prior treatment. In patients who underwent more than one surgery, the reason for the 31 total

Case series

When evaluating the benefits of surgical treatment, it should be kept in mind that anogenital LS is an incurable chronic disease with a tendency to relapse2 and that surgical treatment is reserved for patients with malignancy and to correct late scarring impairing normal function.4, 8, 12

In the present study, the most frequently reported functional impairment before surgery was introital dyspareunia (87%) and apareunia (73%). This finding was consistent with the results of another study9 where

Conclusion

In conclusion, our study showed that surgical treatment of LS sequelae provided acceptable short-term functional results (lasting several years for some patients) for sexual dysfunction by enabling patients to resume coitus from a previous state of apareunia. However, the survey and long-term clinical follow-up showed that as time passed, there was a high risk of LS relapse, leading to new debilitating changes and dyspareunia. Nevertheless, in most patients, the relapse was minor in nature, and

Funding

None.

Conflict of interest statement

None.

Authorship

All authors meet all the four criteria of authorship defined by the ICMJE guidelines.

Acknowledgments

We gratefully acknowledge photographers Kirstine Saad and Tina Rasmussen for kindly providing us the clinical photographs.

References (14)

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Meeting details: Conference, Department of Gynaecology and Obstetrics, Holbaek Hospital, Denmark, 18th June 2014.

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