The surgical management of complications of vulval lichen sclerosus

https://doi.org/10.1016/j.ejogrb.2012.01.016Get rights and content

Abstract

Objective

To review the surgical procedures used to treat the complications of vulval lichen sclerosus at a single tertiary referral institution in north-east Scotland over a ten year period.

Study design

A retrospective case note review of women who had surgery for ano-genital lichen sclerosus at Aberdeen Royal Infirmary between January 1999 and December 2009.

Results

The total number of women was 25 and the two most common procedures were Fenton's procedure (median perineotomy) and laser division of adhesions. Initial surgery resulted in an improvement of symptoms for 80% of women.

Conclusions

When surgery for vulval lichen sclerosus is reserved for highly selected cases where there are complications secondary to adhesions, the proportion of women benefiting is high.

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.

References (22)

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