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Keratin pearls are intraepithelial accumulations of squamous cells and debris that can be an etiology of vulvovaginal irritation in pediatric patients and are often associated with clitoral adhesions. Historically, most cases have been managed with manual or operative lysis of adhesions. Two prepubertal girls presented to our clinic with chronic clitoral irritation and were found to have clitoral adhesions with keratin pearls. Both were managed with topical estrogen cream, which resulted in resolution of their symptoms. Keratin pearls can form when the overlying clitoral epithelium becomes blocked by clitoral adhesions. Hypoestrogenism is thought to be implicated in adhesion development; thus, topical estrogen cream is a reasonable option in initial management. Our results demonstrate a noninvasive alternative to the initial treatment of clitoral keratin pearls. [ABSTRACT FROM AUTHOR]

Introduction: The glans clitoris is covered by a prepuce that normally moves over the glans surface and can be retracted beyond the corona. Clitoral adhesions, ranging from mild to severe, occur when preputial skin adheres to the glans. Physical examination consistent with clitoral adhesions is based on the inability to visualize the entire glans corona. In this closed compartment, the space underneath the adherent prepuce and clitoris can become irritated, erythematous, or infected and can result in sexual dysfunction., Aim: To determine the prevalence of clitoral adhesions in a sexual medicine practice and assess risk factors associated with clitoral adhesions., Methods: This research involved retrospective examinations of vulvoscopy photographs taken from August 2007 to December 2015. Clitoral adhesions were considered absent when preputial retraction enabled full glans corona visualization. The study group consisted of women with mild, moderate, or severe clitoral adhesions based on more than 75%, 25% to 75%, or less than 25% glans clitoris exposure without full corona visualization, respectively. 2 independent reviewers evaluated photographs; a 3rd analyzed study group health record data., Main Outcome Measure: Prevalence of severity of clitoral adhesions., Results: Of the 1,261 vulvoscopy photographs, 767 (61%) were determined adequate for assessment and 614 photographs represented individual patients. The study group with clitoral adhesions consisted of 140 women (23%) of whom 44%, 34%, and 22% demonstrated mild, moderate, and severe clitoral adhesions, respectively. In the study group, 14% presented with clitorodynia. Risk factors included a history of sexual pain, yeast infection, urinary tract infection, blunt perineal or genital trauma, lichen sclerosus, low calculated free testosterone, and other sexual dysfunctions including persistent genital arousal disorder., Conclusion: Women with sexual dysfunction should routinely undergo clitoral physical examination. If the glans corona is not fully visualized, then clitoral adhesions should be suspected. Education, counseling, and/or referral for sexual pain management should be considered. Aerts L, Rubin RS, Randazzo M, et al. Retrospective Study of the Prevalence and Risk Factors of Clitoral Adhesions: Women's Health Providers Should Routinely Examine the Glans Clitoris. Sex Med 2018;6:115-122., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)