European Journal of Obstetrics & Gynecology and Reproductive Biology
The surgical management of complications of vulval lichen sclerosus
Introduction
Lichen sclerosus is a chronic inflammatory disorder which commonly affects the ano-genital skin. The most common symptoms are pruritus and pain with frequent relapses and remissions. The lifetime risk of squamous cell carcinoma of the vulva is low, in the order of 5% [1], [2]. Conventionally, ultra-potent topical corticosteroid cream or ointment is the recommended treatment of choice: high response rates have been reported from large case series of women diagnosed with lichen sclerosus, with either complete or partial resolution of symptoms in 54–96% of women [3], [4], [5], [6]. The recommended second-line treatment is topical tacrolimus under the supervision of a specialist clinician [7]. Remission is usually maintained with topical potent steroids [8]. There is a limited role for surgery in vulval lichen sclerosus where urinary or sexual dysfunction is compromised by adhesions or fusion of the vulva [7], [9]. Histological examination is ideal if there are atypical features or diagnostic uncertainty and is mandatory if there is any suspicion of neoplastic change [10].
A number of different surgical procedures with tissue conservation have been reported including cryosurgery [11], laser surgery [12], Fenton's procedure and other procedures to divide adhesions and strictures. There are, however, no studies describing current surgical practice or the clinical outcomes of different surgical modalities for vulval lichen sclerosus. One paper by Avoort et al. [13] looked into the management of vulval lichen sclerosus by dermatologists and gyanecologists. Women had either medical or surgical treatment and 21 women had surgery. The surgical procedures included were local excision, vulvectomy and laser vaporisation, but most had either extensive excision or vulvectomy, which does not reflect current recommended practice [13].
Our study looked into the outcomes following various surgical procedures performed for women with structural (architectural) complications of vulval lichen sclerosus.
Section snippets
Materials and methods
A retrospective review was conducted of women who had surgery for ano-genital lichen sclerosus at a tertiary referral centre at Aberdeen over a ten-year period from January 1999 till December 2009. Cases were collected from the gynaecology theatre register. Information was collected on the surgical procedures. Cases with co-existent VIN or invasive disease were excluded. Data were collect on age, duration of symptoms, treatment before surgery, type of surgical procedure, patient-reported
Results
In the ten-year period, 5458 women were seen at the vulval disorders clinic but only 25 (0.45%) women had surgery for lichen sclerosus. The mean age of women having a surgical procedure was 53 years (range 32–76 years) and twenty (80%) were over 40 years old. More than 80% of the women had symptoms of vulval itch and pain, with two women experiencing sexual discomfort. A number of different procedures were performed (Table 1) but the most common were Fenton's procedure (44%) and laser division
Comments
We found that surgery for ano-genital lichen sclerosus was an uncommon practice in our centre which provides a specialist vulval service for a geographically defined population in the north-east of Scotland. A dedicated vulval clinic service in Aberdeen was established in 1992. The number of surgical procedures in our study was small, indicating that the majority of women with vulval lichen sclerosus can be managed effectively with medical management alone. If surgery is indicated, most women
Acknowledgements
None.
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Cited by (25)
NASPAG Clinical Opinion: Diagnosis and Management of Lichen Sclerosis in Pediatric and Adolescent Patients
2022, Journal of Pediatric and Adolescent GynecologyOutcome of perineoplasty and de-adhesion in patients with vulvar Lichen sclerosus and sexual disorders
2021, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :Previous and this study showed that perineoplasty and de-adhesion can improve sexual satisfaction in these patients [16–20,22]. In earlier studies, the success rate regarding reduction of dyspareunia was very high, which was probably due to using other outcome parameters and performing surgery only in highly selected patients [16,18]. However, more recent studies reported that surgery improved the sexual life in the majority of patients, but most patients were still experiencing pain during intercourse [19,22–24].
Treatment of Vulvar Lichen Sclerosus et Atrophicus With Fractional Carbon Dioxide Laser Therapy: A Report of 4 Cases
2021, Actas Dermo-SifiliograficasGenital lichen sclerosus
2018, PielAnogenital lichen sclerosus: Change of tissue position as pathogenetic factor
2017, Gynecologic Oncology ReportsCitation Excerpt :In one study, out of 5458 women who presented to a specialized vulvar disorder clinic only 25 were treated surgically for LS (Gurumurthy et al., 2012). Operative procedures to release contracture bands such as Fenton's procedure (median perineotomy) or a V-Y plasty were the most common ones performed in this patient cohort (Gurumurthy et al., 2012). More extensive surgical treatment such as vulvectomy are generally performed only in women with LS who develop vulvar cancer, although cases of vulvectomy and subsequent anatomical reconstruction for the treatment of LS have been reported (Abramov et al., 1996; Rojavin et al., 2008).