Insights from a joint pediatric dermatology-gynecology vulvar clinic: A retrospective study.

BACKGROUND/OBJECTIVES: Pediatric vulvar disease has not been widely explored in the medical literature. Few studies focus on vulvar disease in skin of color. The vulvar disease can be distressing for young patients given the sensitive location, and providers may lack experience in diagnosing and managing vulvar dermatoses. We sought to characterize the conditions seen, diagnostic challenges encountered, and the racial and ethnic factors associated with vulvar diseases in our multidisciplinary pediatric dermatology-gynecology vulvar clinic at Children's National. METHODS: Medical records of 220 patients who presented to our multidisciplinary pediatric dermatology-gynecology clinic were reviewed retrospectively. RESULTS: Lichen sclerosus (LS) (36%, n = 80), inflammatory vulvitis (11%, n = 23), and vitiligo (9%, n = 19) were the three most frequent conditions observed. These conditions were often misdiagnosed as one another. There was a mean delay in diagnosis after symptom onset in LS patients of 16.43 months. CONCLUSIONS: LS, inflammatory vulvitis, and vitiligo are common vulvar diseases among pediatric patients. Accurate diagnosis is important because LS must be treated aggressively to prevent sequelae. Further studies are warranted to help differentiate LS and vitiligo with consideration of skin tone.

Symptoms in plasma cell vulvitis: first observational cohort study on type, frequency and severity.

BACKGROUND: Studies assessing symptoms of plasma cell vulvitis (PCV) are lacking. OBJECTIVES: To assess the prevalence and severity of PCV-related symptoms and identify possible associations between patient characteristics, clinical features of PCV and treatments administered before a definitive diagnosis. METHODS: Thirty-six patients affected with PCV were included. Data were collected by direct interview and clinical examination. RESULTS: Thirty patients (83.3%) complained of symptoms: burning was the most frequent (80.6%) while dyspareunia was the severest. Of the symptomatic patients, 73.3% experienced severe symptoms. Severity of symptoms was not associated with age at onset and duration of PCV. Almost 70% of the patients had previously undergone treatments. CONCLUSIONS: Symptoms in PCV are frequent and more than often severe. Neither age at onset nor duration of the disease nor the extent of vulvar involvement were associated with symptom severity. Both the delay in diagnosis and the inappropriate previous treatments seem to indicate frequent misdiagnosis.

Vulvovaginal-gingival syndrome.

Vulvovaginal-gingival syndrome is a distinct variant of classic lichen planus frequently associated with mucocutaneous scarring and vaginal stricture formation, therefore early diagnosis and treatment through a multidisciplinary approach is essential. Management is challenging and is characterised by wide variation in treatments and lack of evidence-based therapeutic approaches. Literature review with particular regard to therapeutic approaches is performed with a view towards a cooperative treatment study.

Female Genital Itch.

Vulvar pruritus is a common complaint among young girls and women presenting to primary care physicians, gynecologists, and dermatologists. Female genital itch is especially disruptive because of its interference with sexual function and intimacy. Causes of vulvar itch are vast and may be inflammatory, environmental, neoplastic, or infectious, often with several causes coexisting simultaneously. Diagnosis may be difficult because of the unique anatomy and inherent properties of genital and perianal skin. Treatment is aimed at eliminating outside irritants, restoring epidermal barrier function, and suppressing inflammation.

Vulvar vestibulitis syndrome: an important factor in the evaluation of lifelong vaginismus?

The aim of the study was to investigate the prevalence of vulvar vestibulitis syndrome (VVS) in a sample of women suffering from lifelong vaginismus (N=91). Lifelong vaginismus is defined as "having a history of never having been able to experience penile entry of the vagina". The results with respect to VVS are compared with the results of women who are suffering from pain during intercourse (superficial dyspareunia) (N=84). Both patients groups were recruited from two treatment outcome studies. Using a standard physical examination, erythema was found in 77%, pain "on touch" in 69% and erythema and pain on the same location was seen in 56% of the patients with lifelong vaginismus. Furthermore, it was found that erythema (94%), pain (98%) and erythema and pain on the same location (92%) were more frequently found in patients with dyspareunia compared to women with lifelong vaginismus. It is concluded that pain is an integral part of the experiences in the majority of women with lifelong vaginismus.

Vestibulodynia (former vulvar vestibulitis): personality in affected women.

AIM: There are very few studies regarding the personality in women suffering from vestibulodynia. Our former results showed increased levels of depression and state anxiety in these women (and their partners). In order to optimize treatment of these patients we wanted to assess personality and its association with depression and anxiety. METHODS: Thirty women attending the vulva clinic for the first time were included at the time of diagnosis (vestibulodynia). The Temperament and Character Inventory (TCI) was administered to assess personality, Beck's Depression Inventory (BDI) to assess depression, State Anxiety Inventory (STAI-S) to assess anxiety, and a questionnaire to assess clinical results. RESULTS: Results showed that women with vestibulodynia have a personality profile with specific temperament and character traits. The results on the TCI temperament dimension characterized them as cautious, careful, insecure, and pessimistic. Results on the TCI character dimension indicated them to experience their own behavior and choices influenced out of their control or against their own will. The interaction of these factors may form a personality profile, resulting in an increased vulnerability in intimate relations and it could also be an important factor for state of depression and anxiety. CONCLUSIONS: The present results indicate the importance of identifying psychological factors in order to optimize the care of vestibulodynia patients and to relieve their symptoms and improve their situation. We therefore want to emphasize that vestibulodynia patients should always, in addition to medical examination and treatment, also be psychologically examined.

Modified vulvar vestibulectomy: simple and effective surgery for the treatment of vulvar vestibulitis.

OBJECTIVE: To evaluate the success of a simple modified vestibulectomy in treating vulvar vestibulitis. STUDY DESIGN: Fifty-nine patients with vulvar vestibulitis refractory to nonsurgical treatment underwent modified vestibulectomy. Response was defined as return to normal coitus and was graded as complete, partial or non-responsive. RESULTS: The postoperative follow-up period was 6 months-10 years. Thirty-nine (73.6%) patients reported complete response, 7 (13.2%) had partial response, and 7 (13.2%) were non-responsive to surgery. CONCLUSION: Surgery is an effective treatment for vulvar vestibulitis refractory to conservative treatment. Simple modified vestibulectomy is considerably less invasive, technically simpler and probably less time consuming. Postoperative results employing this surgical procedure are found to be in line with postoperative results reported by others who employ surgical methods that are more extensive.

Vulvar vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria.

OBJECTIVE: To assess the reliability of the diagnosis of vulvar vestibulitis as defined by Friedrich and to evaluate the usefulness of Friedrich's criteria in the diagnostic process. METHODS: In a university hospital, 146 women with dyspareunia had two sets of gynecologic examinations involving vulvar pain ratings, took part in structured interviews, and completed the McGill-Melzack Pain Questionnaire. RESULTS: Kappa values for the vulvar vestibulitis diagnosis ranged from 0.66 to 0.68 for inter-rater agreement and from 0.49 to 0.54 for test-retest reliability. Mean vestibular pain ratings ranged from 2.45 at the 12 o'clock site to 7.58 at the 9-12 o'clock site; ratings for all sites correlated significantly between gynecologists. Pain in the labia majora and labia minora was minimal for both sets of examinations, with mean participant pain ratings ranging from 0 to 1.49. Gynecologists' erythema ratings did not correlate significantly with respect to either inter-rater agreement or test-retest reliability. Of Friedrich's three diagnostic criteria, only tenderness to pressure within the vulvar vestibule differentiated dyspareunia patients with and without vulvar vestibulitis. In reference to their coital pain, 88.1% of women with vulvar vestibulitis chose adjectives from the McGill-Melzack Pain Questionnaire describing a thermal quality, and 86.6% chose adjectives describing an incisive pressure sensation. CONCLUSION: Vulvar vestibulitis can be reliably diagnosed in women with dyspareunia. Pain is limited to the vulvar vestibule and can be rated and described in a consistent fashion by these women. Erythema does not appear to be a useful diagnostic criterion.

Vulvar vestibulitis--subgroup with Bartholin gland duct inflammation.

Some women with vulvar vestibulitis have tenderness at the Bartholin gland duct opening and associated dyspareunia. Forty-four patients with severe incapacitating dyspareunia of up to 5 years' duration were studied. Microscopic examination revealed a chronic inflammation located near the Bartholin gland duct opening. No etiologic agent was evident. Of 30 women treated initially with laser vaporization of inflamed areas, 13 (43%) showed significant improvement. Sixteen patients were treated with perineoplasty and all improved significantly; all became functional sexually although eight had previously failed laser therapy. Women with vulvar vestibulitis can be identified easily with a simple Q-tip touch technique directed at the duct opening. This diagnosis should be considered in the evaluation of women with obscure etiologies of dyspareunia.

Vulvar vestibulitis: significant clinical variables and treatment outcome.

The subject of vulvar vestibulitis was reviewed in regard to clinical variables that may be associated with this problem as well as the success of available treatment modalities. Questionnaires were returned by 71 patients diagnosed as having vulvar vestibulitis. Identical information was obtained from a comparison group of individuals with no clinical or physical findings suggesting this diagnosis. A history of recurrent candidiasis and previous condyloma acuminatum were the only variables noted more frequently in patients with vestibulitis. Among the patients treated by perineoplasty, 66% reported complete or significant alleviation of vulvar pain; 78% of the women noted a significant decrease in dyspareunia. Of the patients treated with intralesional interferon, six (50%) reported significant improvement in dyspareunia. Vulvar vestibulitis is a puzzling clinical entity whose etiology is not well understood. Perineoplasty still appears to be the treatment of choice in properly selected individuals.

Vulvar vestibulitis syndrome: an exploratory case-control study.

OBJECTIVE: To assess the prevalence of genital bacterial infection among women with vulvar vestibulitis syndrome and to evaluate the association of several potential risk factors with the occurrence of the syndrome. METHODS: Fifty-seven women referred for dyspareunia who satisfied Friedrich's criteria and had symptoms for at least 6 months were recruited as cases. Controls included 173 patients without dyspareunia seen at a private clinic. Cases and controls were aged 18-35 years and were not pregnant. RESULTS: Among cases, the prevalences were low for genital infection with gonorrhea (0%), Chlamydia (0%), Trichomonas (0%), Mycoplasma (0%), Gardnerella (14%), and Candida (8.8%). Ureaplasma was detected in the Bartholin glands of ten affected women (17.5%). Human papillomavirus DNA was detected in only three cases (5.3%) based on polymerase chain reaction assays on vestibular biopsies. The relative risk (RR) of the syndrome was related to some aspects of sexual and reproductive history. In particular, the RR in women who had used oral contraceptives (OCs) early (before age 17) reached 11.0 (95% confidence interval [CI] 1.3-97.1) relative to those who had never used OCs. Women who had first intercourse at age 15 or earlier had a 3.3-fold increase in RR (95% CI 1.4-8.0) compared to those who had first intercourse at age 16 or later. CONCLUSION: Our data provide little support for the idea that infection causes the vulvar vestibulitis syndrome. Hormonal factors such as early OC use may be involved in the etiology of this condition.

Predicting the outcome of surgical treatment of vulvar vestibulitis.

OBJECTIVE: To identify predictive factors for success or failure of perineoplasty for severe vulvar vestibulitis. METHODS: Seventy-nine women with severe vulvar vestibulitis underwent perineoplasty by a single surgeon during 1992-1994. Sixty (76%) who experienced a complete response were compared with 19 (24%) who had an incomplete response. Using univariate and then multivariate (logistic regression) analysis, the two groups were compared with regard to preoperative demographic, social, and medical variables, as well as physical findings in the vestibule. RESULTS: The complete- and incomplete-response groups were similar in all comparisons except for constant vulvar pain of vestibular origin (in addition to dyspareunia) and the presence of symptoms since first coitus. On multiple logistic regression, these characteristics had odds ratios (and 95% confidence intervals) of 4.97 (1.49, 16.63) and 5.83 (1.74, 19.55), respectively. CONCLUSION: An incomplete response to perineoplasty may be anticipated in women with vulvar vestibulitis associated with dyspareunia since their first episode of intercourse and in those with associated persistent vulvar pain. Treatment approaches other than surgery should be considered for such patients.

Amniotic membranes in the treatment of necrotizing fasciitis complicating vulvar herpes virus infection.

Necrotizing fasciitis of the vulva developed in an immunocompromised patient with chronic myelogenous leukemia, apparently from secondarily infected herpes simplex lesions. In addition to surgical debridements and broad-spectrum intravenous antibiotic therapy, the wound was treated using specially prepared amniotic membranes as a wound dressing. The patient died on hospital day 65 because of complications of her immunocompromised state, with autopsy findings of disseminated cytomegalovirus. However, use of amniotic membranes as a wound dressing appeared to be beneficial.

Overnight 5% lidocaine ointment for treatment of vulvar vestibulitis.

OBJECTIVE: To assess the effectiveness of nightly application of 5% lidocaine ointment for treatment of vulvar vestibulitis. METHODS: Over 17 months, we assessed women presenting to our pain clinic for evaluation of introital pain; 61 women met the criteria for vulvar vestibulitis and participated in a treatment trial. We measured daily pain and intercourse-related pain using a 100-mm visual analog scale. We compared ability to have intercourse and pain ratings before and after treatment, and investigated whether prior treatment or gynecologic comorbidities predicted response to treatment. RESULTS: After a mean of 7 weeks of nightly treatment, 76% of women reported ability to have intercourse, compared with 36% before treatment (P =.002). Intercourse-related pain score was 39.11 (95% confidence interval [CI] 30.39, 47.83) points lower after treatment (P <.001), with a decrease of 10.37 (95% CI 3.53, 17.21) points in daily pain score (P =.004). We found no association between response to prior episodic use of lidocaine and response to nightly therapy with lidocaine ointment. Few patient characteristics predicted response to treatment; however, women with interstitial cystitis and other vulvar conditions were least likely to benefit. CONCLUSION: Long-term, nightly application of 5% lidocaine ointment shows promise as a treatment for management of vulvar vestibulitis; a randomized, double-blind, clinical trial is warranted.

Interferon therapy for condylomatous vulvitis.

During a 3-year period, 30 patients were referred for symptoms of vulvar pain characteristic of the vulvar vestibulitis syndrome. Colposcopic examination with a blue filter and pathologic biopsy revealed evidence of papillomavirus in 17 patients. Interferon alpha-2b recombinant was injected intradermally into the vestibule in a specific pattern three times weekly for 4 weeks. Fifteen women responded favorably with total absence of vulvar pain. Five women reported flu-like symptoms as a result of the injections. Patients without evidence of papillomavirus failed to respond to interferon therapy. Women with evidence of vulvar papillomavirus failed to respond to placebo but did respond to retreatment with interferon; vulvar biopsy specimens after therapy were negative. Interferon alpha-2b recombinant appears to offer an inexpensive, safe alternative to the more traumatic therapies currently recommended in the specific subset of vulvar vestibulitis patients in whom papillomavirus can be confirmed.