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Clitorodynia - pain localized to the clitoris - is one of the most undertreated conditions in women's sexual medicine. In part because it's rarely discussed. In part because most providers were never taught to examine the clitoris thoroughly, retract the hood, or look for the structural causes hiding underneath it. If your clitoral pain has been dismissed, normalized, or attributed to "sensitivity," you have not had a complete evaluation.
Research shows that approximately 23% of women have some degree of clitoral adhesions - the clitoral hood adhering to the glans and trapping shed skin cells underneath. This mechanical cause of clitoral pain is almost always missed because the exam required to find it is almost never performed.
The clitoral hood adheres to the glans, trapping keratin (shed skin cells) underneath. The trapped material creates mechanical pressure and pain. Found in ~23% of women to some degree. Highly treatable.
Both conditions can affect the clitoral hood and glans directly, causing inflammation, tissue fusion, and pain. Lichen sclerosus specifically causes progressive clitoral phimosis when undertreated.
The dorsal clitoral nerve can be injured by trauma, surgery, cycling, or chronic compression, causing neuropathic pain in the clitoris - burning, sharp, or electric-like sensations.
Estrogen and testosterone receptors are present in clitoral tissue. Hormonal deficiency causes the clitoral hood to thicken and adhere and the glans to become hypersensitive. Topical hormones are highly effective.
Spinal conditions including Tarlov cysts, disc disease, or pudendal nerve entrapment can cause referred pain and hypersensitivity in the clitoris.
The lysis data: A study by Dr. Rachel Rubin and colleagues found that non-surgical lysis of clitoral adhesions resulted in a 76% decrease in pain and a 64% improvement in orgasmic ability - with six women in the study achieving orgasm for the first time after the procedure. These are remarkable results for a condition that goes virtually undiagnosed in most clinical settings.
A proper evaluation of clitoral pain requires careful examination of the clitoral complex - including retraction of the clitoral hood to visualize the glans, assessment for adhesions and keratin accumulations, evaluation of the surrounding skin for lichen sclerosus or lichen planus, hormonal assessment, and if indicated, neurologic evaluation for pudendal or sacral nerve involvement.
This examination takes skill, attention, and a provider who understands clitoral anatomy. It is not a standard part of most pelvic exams - which is why clitorodynia is so widely missed.
Treatment is directed at the identified cause. For clitoral adhesions and keratin pearls, lysis of adhesions - releasing the hood from the glans and removing trapped material - can be performed non-surgically in the office using topical anesthetic and a blunt probe, or surgically under local anesthesia for more adherent cases. Topical hormones are applied to prevent re-adhesion. For neuropathic clitoral pain, low-dose tricyclic antidepressants, anticonvulsants, and topical lidocaine are used. Skin conditions are treated with targeted topical therapies.
Dr. Toubi's Beverly Hills practice includes detailed evaluation of clitoral anatomy as part of every vulvovaginal assessment. If clitoral pain has been dismissed or inadequately evaluated, a specialist appointment can change everything.
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