Lichen planus is a rare dermatological disorder that is often associated with painful and disfiguring vulvovaginal effects. At the University of Michigan Center for Vulvar Diseases, we see many women with vulvovaginal lichen planus each year, with marked scarring and vulvovaginal agglutination that precludes vaginal intercourse and causes difficulty with urination. Through our experience, we developed a protocol for the operative management and postoperative care for severe vulvovaginal agglutination. Our objective is to share this protocol with a wider audience so that providers who see patients with these devastating effects of lichen planus can benefit from our experience to better serve this patient population. The figure represents a case of erosive lichen planus with early vaginal agglutination. The video reviews the pathophysiology and presentation of lichen planus. We then present a case of scarring and agglutination in a young woman, including our surgical management and postoperative care recommendations.
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Problem
Lichen planus is a rare dermatological disorder, often associated with painful and disfiguring vulvovaginal effects. At the University of Michigan Center for Vulvar Diseases, we see many women with vulvovaginal lichen planus each year. They often have marked scarring and vulvovaginal agglutination, which precludes vaginal intercourse and causes difficulty in urination.
Our solution
Through our experience, we developed a protocol for the operative management and postoperative care for symptomatic vulvovaginal agglutination. The initial procedure is the surgical lysis of adhesions, followed by daily vaginal dilation and continued medical treatment to the vulva and vagina with topical steroids. This treatment protocol is utilized to reestablish and maintain vaginal patency in this patient population.
A 37 year old presented with a history of dyspareunia and vaginal pain and was unable to have vaginal intercourse. Examination revealed circumferential adhesions of the introitus (1 cm in diameter). The vagina was foreshortened, measuring 2.5 cm in length. The cervix was unable to be visualized with a small pediatric speculum. The vulvovaginal mucosa was intensely erythematous, with shallow-based erosions ( Figure ). Treatment with intravaginal hydrocortisone suppositories and vaginal dilation failed in the patient. She elected to proceed with operative management of the adhesions in the hope of regaining the ability to have vaginal intercourse.
This video demonstrates our approach to lysis of vaginal adhesions. In this case, as is common in patients with nonadvanced disease, some of the thinner adhesions were easily disrupted with the vaginal preparation using betadine-soaked sponge sticks, resulting in simple mechanical abrasion once the patient was anesthetized. Often, however, the scarring is so extensive that sharp dissection with blunt pressure is required from the beginning of the procedure. For the remaining adhesions, we combined blunt and sharp dissection while utilizing an end-to-end anastomosis sizer placed rectally to delineate the plane between the rectum and the vagina.
Once normal length and width were restored, a foam dilator covered with 2 sterile condoms was placed in the vagina and secured by suturing the labia majora together. Removal of the dilator was performed in clinic after 48 hours. After removal of the dilator, the patient was started on high-dose intravaginal steroids and daily dilator therapy. To maintain vaginal patency following the procedure, patients must continue with lifelong dilator therapy and intravaginal steroids (with gradual dose reduction; see Table ).
| Intervention | Dosing | Timing |
|---|---|---|
| Intravaginal corticosteroids | ||
| Hydrocortisone 100 mg/g in emollient cream base | 300 mg (3 g) per vagina QHS | First week postoperatively |
| 400 mg (4 g) per vagina QHS | Second week postoperatively | |
| 500 mg (5 g) per vagina QHS | Third week postoperatively | |
| 400 mg (4 g) per vagina QHS | Fourth week postoperatively | |
| 300 mg (3 g) per vagina QHS | Fifth week postoperatively | |
| 200 mg (2 g) per vagina QHS | Sixth week postoperatively | |
| 100 mg (1 g) per vagina QHS | Starting week 7, indefinitely a | |
| Dilators b | Largest size tolerated | QHS for 20–25 min for 6 mo (with silicone lubricant), then consider daily dilation with a water soluble lubricant in the shower (dilator placed into vagina and immediately removed to prevent adhesion formation) |
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