(038) Surgical Lysis of Clitoral Adhesions in a 7-year-old Female–A Case Report

Abstract Introduction The clitoris is a homologous structure to the penis; the glans of the penis corresponds to the glans of the clitoris, and the penile foreskin corresponds to the clitoral hood (or prepuce). Like the foreskin, the clitoral prepuce should easily retract over the glans surface beyond the corona (Romanello et al 2023); however, when these tissues adhere, the space beneath the prepuce can accumulate squamous cells, leading to keratin pearls, pain, discomfort, irritation, erythema, or infection. In both male and female patients, this is called phimosis. While male pediatric patients are frequently seen by pediatric urologists and surgeons with foreskin concerns and retraction issues (Sutton et al 2023), there are no standardized measures for diagnosing and treating clitoral phimosis in pediatric female patients. This case report and accompanying video of a young child with complete clitoral phimosis will review her diagnosis and treatment via surgical lysis of clitoral adhesions. Objective To describe the patient’s diagnosis and treatment with aims of highlighting the need for improved clitoral examination in pediatric populations, bringing recognition to clitoral phimosis as a pediatric gynecologic condition, and presenting surgical lysis of adhesions as an avenue for resolving pediatric clitoral phimosis. Methods We present the case of a 7-year-old prepubertal female with four years of genital pain and persistent complaints of a hair “stuck” in her clitoris. On exam, she was found to have complete phimosis of the glans clitoris. There was at least one embedded keratin pearl visualized underneath the tissue. The patient was prescribed Clobetasol Propionate 0.05% and Estradiol 0.1 mg/gm cream daily. After two months of this regimen with incomplete resolution of the clitoral discomfort, the patient was scheduled for a lysis of clitoral adhesions. Given the patient’s age, the patient underwent a surgical lysis under general anesthesia. A fine Jacobsen hemostat along with gentle traction and counter traction was used to achieve lysis of the adhesions between the prepuce and the glans of the clitoris until the corona was visible around the entire glans. Multiple keratin pearls were excised from under the glans clitoris. The patient’s parents were informed to retract the clitoral hood and place vaseline on the area daily to prevent re-adhesion. Results Two weeks post-op, the patient’s parents report, “Her [clitoral] pain has completely disappeared! She is having flares of bladder discomfort and nausea that we don’t think are related but are checking with our family doctor next week.” Conclusions This case highlights a profound lack of information and knowledge surrounding clitoral examination in a young patient. While keratin pearls are known in the literature to cause clitoral discomfort, there is no standardized management for the diagnosis and treatment of clitoral adhesions in pediatric populations, despite multiple reports of similar findings (Bragiel et al. 2023) (Kciuk et al 2023) (King, Goldstein 2017) (Nelson et al 2016). This case calls to attention the need for further recognition of prepubertal clitoral adhesions, and highlights surgical lysis of clitoral adhesions as a promising option in such cases. Disclosure No.