Introduction Clitoral phimosis occurs when the prepuce adheres to the glans clitoris. Similarly, penile phimosis occurs when the prepuce adheres to the glans penis. Symptoms of clitoral phimosis can include pain, difficulty with arousal, and muted or absent orgasm. While previous studies on the prevalence of clitoral phimosis in a group of 589 college students in a health clinic was 33%, and in a population of 614 patients with sexual dysfunction, it was 23%. There are no diagnosis codes (ICD codes) or procedure codes (CPT codes) for clitoral phimosis or the lysis procedure for clitoral phimosis. Proper codes ensure that patients receive adequate treatment and are charged appropriately for medical services. Objective To determine the efficacy and patient satisfaction of the office-based lysis of clitoral phimosis procedure and to demonstrate that clitoral phimosis should have its own diagnosis and procedure codes. Methods To evaluate the efficacy and patient satisfaction of the lysis procedure, survey responses from 41 females who underwent the lysis procedure for clitoral phimosis from one sexual medicine practice were analyzed. The survey was sent to 61 patients and 41 responded (67% response rate). Results Among participants who reported pain as a symptom of phimosis (n=25), 76% saw an improvement in pain, with 44%, 28%, and 4% reporting significantly, moderately, or slightly reduced pain. Among those who reported difficulty with arousal before the procedure (n=40), 62.5% saw improvement, with 25%, 25%, and 12.5% considering it to be significantly, moderately, or slightly easier to become aroused. Among those who reported difficulty achieving orgasm before the procedure (n=39), 64% saw improvement, with 25.6%, 17.9%, and 20.5% reporting that they found it significantly, moderately, or slightly easier to achieve orgasm. All women who reported the ability to orgasm from external clitoral stimulation maintained this ability after the procedure (n=24). Of the women that could not orgasm before the procedure (n=16), 6 were able to afterward. 92.7% would recommend the procedure to a friend who had phimosis. Conclusions These findings show that most patients reported improvement in their pain and sexual function, and no patient reported a loss of functioning or worsening of symptoms. The lysis procedure should be recognized as a treatment for pain and sexual dysfunction associated with clitoral phimosis. The routine management of clitoral phimosis in clinical practice should be reflected in diagnosis and procedure codes, which currently do not exist. The lack of proper codes creates a barrier to diagnosis and treatment of clitoral phimosis. If doctors use the ICD code for phimosis, it is rejected by insurance - the codes for “phimosis” and “balanitis” are only designated for male patients. Proper codes support the importance and medical necessity for performing the lysis procedure, and would help communicate a patient's health to other healthcare providers, specialists, insurance payers, and data registries. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout, Absorption Pharmaceuticals

Introduction Clitoral adhesions (CA) occur when the prepuce adheres to the glans clitoris. CA can be classified as mild, moderate, or severe, based on if more than 75%, 25% to 75%, or less than 25% of the glans clitoris is exposed. Symptoms of CA include pain, difficulty with arousal, and muted or absent orgasm. There is a paucity of information on how hormone levels may contribute to the formation of CA. We hypothesize that patients with lower levels of free and total testosterone, and higher levels of the blood transport protein sex hormone binding globulin (SHBG) could have more severe adhesions. Higher free and total testosterone can yield more oily skin, which may break up or prevent adhesions. Additionally, with higher SHBG, there is less free testosterone available to be used by tissues in the body. Objective To determine if patients with lower free and total testosterone, and higher SHBG have more severe adhesions. Methods Charts of females with CA who underwent the non-surgical lysis procedure at one sexual medicine practice were considered for this study. 24 charts contained information on the severity of phimosis before lysis, total and free testosterone levels, as well as SHBG levels around the time of lysis. The study group consisted of patients with mild (n=9), moderate (n=8), or severe (n=7) CA. Results The average calculated free testosterone among patients with mild, moderate, and severe CA was 0.23ng/dL, 0.35ng/dL, and 0.14ng/dL. The average total testosterone among patients with mild, moderate, and severe CA was 24.79ng/dL, 27.81ng/dL, and 20.26ng/dL. The average SHBG among patients with mild, moderate, and severe CA was 98.69nmol/L, 95.76nmol/L, and 109.40nmol/L. Conclusions We predicted that patients with more severe adhesions would have lower levels of free and total testosterone, as well as higher levels of SHBG, yet this trend did not appear overall in this data among patients with mild, moderate, or severe adhesions. Additional studies with larger sample sizes are needed to explore the potential impact of free and total testosterone, as well as SHBG levels on the development and severity of CA. Studies could also compare levels of these hormones in patients with and without adhesions, or consider patients with recurrence of adhesions. Insight into a hormonal etiology could be important to patients with altered levels of these hormones - for example, patients with medical conditions such as PCOS, patients taking medications such as oral contraceptive pills, and menopausal women on oral estrogen (as increased estrogen raises levels of SHBG) could be at an increased risk for developing CA. Further studies could also consider if the clitoides of transgender males on gender-affirming hormone therapy with testosterone have lower incidences of CA. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Introduction Clitoral phimosis occurs when the prepuce adheres to the glans clitoris. Similarly, penile phimosis occurs when the prepuce adheres to the glans penis. Symptoms of clitoral phimosis can include pain, difficulty with arousal, and muted or absent orgasm. While previous studies on the prevalence of clitoral phimosis in a group of 589 college students in a health clinic was 33%, and in a population of 614 patients with sexual dysfunction, it was 23%. While the treatment of penile phimosis is widely practiced by urologists, training on the diagnosis and treatment of clitoral phimosis is lacking. Lysis of clitoral phimosis is a minimally invasive, office-based procedure to stretch the preputial tissue. Lysis of clitoral phimosis can be performed with a topical anesthetic or nerve block of the dorsal nerve of the clitoris. A fine Jacobsen mosquito forceps can then be used to separate the plane between the prepuce and the glans clitoris. Following the procedure, patients are instructed to pull back the prepuce at least once daily to prevent re-adherence. Objective To determine the efficacy and patient satisfaction of the office-based lysis of clitoral phimosis procedure and to demonstrate that diagnosing and treating clitoral phimosis should be in the scope of a urologist's practice. Methods Survey responses from 41 females who underwent the lysis procedure for clitoral phimosis from one sexual medicine practice. The survey was sent to 61 patients and 41 responded (67% response rate). Results Among participants who reported pain as a symptom of phimosis (n=25), 76% saw an improvement in pain, with 44%, 28%, and 4% reporting significantly, moderately, or slightly improved pain. Among those who reported difficulty with arousal before the procedure (n=40), 62.5% saw improvement, with 25%, 25%, and 12.5% considering it to be significantly, moderately, or slightly easier to become aroused. Among those who reported difficulty achieving orgasm before the procedure (n=39), 64% saw improvement, with 25.6%, 17.9%, and 20.5% reporting that they found it significantly, moderately, or slightly easier to achieve orgasm. Of the women that could not orgasm before the procedure (n=16), 6 were able to afterward. All women who reported the ability to orgasm from external clitoral stimulation maintained this ability after the procedure (n=24). 92.7% (n=41) would recommend the procedure to a friend who had phimosis. Conclusions These findings show that most patients reported improvement in their pain and sexual function, and no patient reported loss of functioning or worsening of symptoms. The lysis procedure should be recognized as a treatment for pain and sexual dysfunction associated with clitoral phimosis. Since urologists are trained in procedural management of male preputial disorders, urologists are uniquely positioned to also routinely manage clitoral phimosis. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Introduction Storytelling mediums (ie: podcasts, blogs, essays) have highlighted patients who report their pain being dismissed and normalized when seeking diagnosis for chronic pelvic, vulvar, and/or vaginal pain (CPVVP) conditions. Among these stories, there are patients who, for example, were told statements from their doctors to manage pain during intercourse by having a glass of wine beforehand or that their pain is just part of being a woman. Objective This study aims to identify the extent to which these statements will also appear in a sample of patients with diagnoses for certain CPVVP conditions.An additional aim is to identify the extent to which a sample of patients recruited for this study felt their pain was dismissed or normalized while seeking diagnosis and treatment for CPVVP conditions. Additionally, in storytelling mediums, some patients who perceived their pain was dismissed or normalized by doctors, also experienced poor psychological health outcomes ("primary crises") and compromised wellness in different life domains - i.e., strains on relationships and finances ("secondary crises"). Medical Trauma describes how interactions between patients and medical professionals can have lasting and harmful psychological effects on patients, from the development of mental health issues to affecting the health of a patient's relationships, sense of self, work, or leisure. This study aims to identify the extent to which patients who perceive they had their pain dismissed or normalized by doctors also experience primary and secondary crises. Methods For this study, patient accounts from various storytelling mediums were reviewed for statements by doctors that made these patients feel their pain was not taken seriously while seeking diagnosis for the CPVVP conditions. These statements are compiled in the survey, and study participants are asked if they have been told these statements, and if so, by how many doctors. The survey also asks about the participants’ perceptions of if their symptoms were taken seriously overall while seeking care. Additionally, the survey asks participants if they have experienced different primary and secondary crises since first seeking care. Results The creation of the survey was informed by accounts of patient experiences from storytelling mediums. The survey will consider the extent to which experiences and perceptions of participants sampled for this study can reflect and recreate those established on storytelling mediums. IRB approval is pending, and survey results will be available by the time of the annual meeting. Conclusions We hope that knowledge gained from this study can benefit patients in the future. This study could allow physicians to better understand their role in contributing to or mitigating medical trauma. Words matter - statements that may make patients feel their pain is dismissed or normalized may cause long-lasting psychological harm as well as disruptions in different life domains. If physicians are able to better understand this, they can be better prepared to communicate with patients in ways that are validating and affirming. Additionally, we hope that this study could ultimately minimize the time from onset of symptoms to diagnosis of CPVVP conditions, by demonstrating the importance of validating patients' reports of their pain. Disclosure Yes, this is sponsored by industry/sponsor: I was chosen as a receipt of an ISSWSH Research Grant (2021) for this project. Previous title at the time of receiving the grant: “Words Matter: A Study of Medical Trauma in Patients with Chronic Pelvic Pain.” Clarification Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals

Introduction Clitoral stimulation is an essential component of the orgasm experience for many women during sexual intercourse. Stimulating the clitoris indirectly stimulates other parts of the genital area, including the vagina, and ultimately affects the ability to have an orgasm experience. In a 2017 study looking at women's experiences with genital touching, sexual pleasure, and orgasm by Herbenick et al, 36.6% of women noted clitoral stimulation was necessary for orgasm and another 36% of women indicated that even though clitoral stimulation was not required it did make orgasms feel better. Clitoral adhesions (CA) can be associated with the inability to reach orgasm with clitoral stimulation. CA occur when the prepuce adheres to the glans clitoris leading to discomfort, hypersensitivity/hyposensitivity, and chronic vulvodynia. Two lysis of CA treatment modalities exist - one surgical procedure and one non-surgical office-based procedure that stretches the preputial tissue open. There are no studies that explore the ability of the non-surgical lysis of CA procedure to improve a woman's ability to achieve orgasm with external clitoral stimulation. Objective The aim of this study is two-fold: 1) to evaluate the characteristics of women who were not able to orgasm with external clitoral stimulation prior to the non-surgical lysis of CA procedure and 2) to evaluate patient satisfaction and outcomes of the non-surgical lysis of CA procedure in these same women. Methods 61 women who have been treated for CA using the non-surgical lysis procedure at one sexual medicine practice from 2017-2021 were identified using an IRB-approved retrospective chart review. An online survey was sent to these patients to evaluate the efficacy of the procedure in improving pain and sexual functioning, as well as patient satisfaction with the procedure. Results 41 women participated in the study (67% response rate) and 16 (39%) of them could not achieve orgasm with external clitoral stimulation prior to the non-surgical lysis of CA procedure. Of those 16 women who could not achieve orgasm from external clitoral stimulation, 6 (38%) were able to do so after the non-surgical lysis of CA procedure. Of these 6 women prior to the procedure, 67% had a diagnosis of vulvodynia/vestibulodynia, 67% reported discomfort or pain during sexual activity that involves physical touch of the vulva, and 83% reported lack of clitoral sensation. Unfortunately, 50% of these women who were able to orgasm with clitoral stimulation after the procedure did lose this ability over time. Nonetheless, 83% were extremely satisfied with the procedure and 100% would recommend it to a friend who also had CA. Conclusions The non-surgical lysis of CA procedure may be a worthwhile option for women who are unable to achieve orgasm with external clitoral stimulation. Of note, many of these women with CA who were unable to orgasm with clitoral stimulation also had pain or discomfort with sexual intercourse which may exacerbate the problem. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Sprout (Raleigh, NC), Absorption Pharmaceuticals