Resection of a Clitoral Epidermal Inclusion Cyst with Sensory Nerve Mapping

Objectives: The objectives of this video are to discuss the presentation, evaluation, surgical management of a patient with a clitoral epidermal inclusion cyst utilizing a sensory nerve mapping technique.

Methods: We present the case of 19-year-old female with a large 3 cm clitoral cyst. The patient reported presence of the cyst for a year and a half. Initially, the cyst was not bothersome but gradually increased in size and was causing decreased sensation with intercourse. On examination, the patient had a large 3 x 2 cm cyst of the prepuce over the clitoris with scarring of the prepuce to the glans. She had absent labia minora with fusion anteriorly and mild generalized erythema of the vestibule. After counseling on the risks, benefits, and alternatives, the patient desired surgical management.

She underwent excision of the clitoral cyst utilizing a sensory mapping technique. Prior to administration of anesthesia, a sensory exam with a cotton tipped swab was performed to outline the dorsal clitoral nerve distribution to avoid incision in the sensual zone. The patient underwent excision of the clitoral cyst and a right vulvar biopsy. On post operative day 1, the patient presented to the clinic with a 4 x 4 cm clitoral hematoma with left labium majus swelling. The patient’s hematoma was managed conservatively and resolved by her 2 week post operative visit. The patient reported increased sensation in her clitoris and was satisfied with her results. The final pathology was consistent with an epidermal inclusion cyst and the right vulvar biopsy was consistent with early lichen sclerosus.

Clinical Relevance: Sensory nerve mapping previously described by Wu et al. is a useful technique when operating in the region of the clitoris. In patient with clitoral epidermal inclusion cysts, a vulvar biopsy should be considered if architectural changes are present as they may have underlying lichen sclerosus. Lastly, conservative management of a clitoral hematoma should be considered if the hematoma is not expanding and the patient can tolerate symptoms.