L. Kathleen Posey, MD FACOG In Office surgery and use of platelet rich plasma for treatment of vulvar lichen sclerosus to alleviate painful sexual intercourse L. Kathleen Posey, MD FACOG Charles Runels, MD

Research Objectives To evaluate patients’ symptoms and signs of vulvar lichen sclerosus and the ability to have pain free sexual intercourse after in office surgery to remove adhesions, followed by injection with platelet-rich plasma (PRP).

Surgical Treatment Surgical Lysis of Adhesions and Complicated Lichen Sclerosus Complicated LS - adhesions and scarring causing functional limitation Dyspareunia – pain during sexual intercourse, adhesions of posterior fourchette Urinary dysfunction – results from disfigurement and stenosis of the introitus Sexual dysfunction – decreased clitoral sensitivity Rectal dysfunction – anal pain and tears with defecation These complications are responsible for the highest morbidity in LS patients Clitoral Phimosis Release - Surgery to lyse adhesions of the clitoral prepuce Clitoral phimosis – surgical lysis of adhesions completely covering the clitoral prepuce that bury the glans clitoris creating the phimosis. Surgical lysis of the adhesions overlying the prepuce should resolve this complication of clitoral phimosis Pseudocyst – buildup of smegma beneath fused prepuce that can be very painful and totally prevent glans stimulation (secondary anorgasmia)

Patients Study was Comprised of: Every Patient in the Study Had: 14 patients seen in a gynecology clinic between August 2014 & December 2016 All patients were diagnosed with Lichen sclerosus confirmed by biopsy. Informed consent was obtained from all patients participating in this study Every Patient in the Study Had: Previously been treated with clobetasol with minimal improvement Significant degree of adhesion formation over the clitoral prepuce with distortion and stenosis of the vaginal introitus along with distortion of the labia minora and adhesions of the posterior fourchette Lichen sclerosus lesions severe enough to warrant surgical intervention Complained of pain, bleeding, and tearing during sexual intercourse All surgeries as well as PRP injections were preformed by me

Surgical Methods PRP Extraction from Whole Blood Anesthesia Regens Lab Centrifuge – yields 10mL PRP from 20mL of a patient’s whole blood Anesthesia Topical Anesthetic cream BLT 20%/8%/8%– applied 20 mins prior to procedure Lidocaine 2% Injection – 0.3cc into the dorsal nerve of the clitoris using a 30 gauge needle immediately prior to surgical dissection Several patients were sedated with hydrocodone 7.5mg and diazepam 10mg Surgical Dissection Blunt Probe Dissection – Insert a 5mm cervical dilator to lyse adhesions and create pocket between the clitoris and the prepuce as well as a hemostat to release adhesions Further Dissection - Iris scissors and blunt probe dissection of remaining adhesions involving the perineal body with a No. 15 blade scalpel Sharp Knife Dissection – Insert hemostat into pocket, clamp and use to guide a 5mm horizontal incision of the dorsal prepuce using iris scissors Hemostasis – Apply direct pressure and ferric subsulfate

Postoperative Methods Postoperative site PRP injections Bilateral injections into incised tissue – PRP injected into dissected areas of lichen sclerosus DATA COLLECTION METHOD Data collection - telephone administered 6-part questionnaire Post-procedural timeframe – contacted 10 weeks after last intervention

results Would you recommend procedure? Percentage Patients YES 100% 14 NO 0% Overall satisfaction with outcome of procedure?   Very pleased with outcome 93% 13 Somewhat pleased by outcome Not pleased by outcome 7% 1 Pain with sexual intercourse postoperatively? Normal (no dyspareunia) 67% 6 Improved but not normal 33% 3 No partner --- 5 Resolution of severe vulvar pruritus? Complete symptom resolution? 50%  7 Improvement but not completely asymptomatic? 43% No symptom improvement? Bleeding with sexual intercourse post operatively? Less bleeding 30% Nn bleeding 70% No Partner Experienced complications?

Discussion & Conclusion The primary conclusion that should be drawn from this study is that PRP contains endogenous factors that can improve the clinical and histological pathology by regeneration of healthy tissue at site of injury. Utilizing available surgical techniques in conjunction with the regenerative effects of PRP has been shown to provide relief from dyspareunia in most patients that participated in this study. Similar findings can be found in studies of the efficacy of PRP as a treatment for LS. Finally, as physicians, it is important to use our years of experience to recognize the importance of clinical experience not just statistical significance in patient care