Desquamative Inflammatory Vaginitis and Plasma Cell Vulvitis Represent a Spectrum of Hemorrhagic Vestibulovaginitis.

OBJECTIVE: The aim of the study was to identify whether desquamative inflammatory vaginitis (DIV) and plasma cell vulvitis (PCV) are distinct clinicopathologic entities. MATERIALS AND METHODS: The pathology database identified biopsies described as "vaginitis" or "vulvitis" occurring in nonkeratinized epithelium or mucocutaneous junction. Exclusions were age less than 18 years, unavailable slides or records, concurrent neoplasia, or histopathology consistent with other entities. Clinical data included demographics, symptoms, examination, microbiology, treatment, and response. Histopathologic review documented site, epithelial thickness and characteristics, infiltrate, and vascular abnormalities. Cases were analyzed according to histopathologic impression of DIV or PCV based on previous pathologic descriptions. RESULTS: There were 36 specimens classified as DIV and 18 as PCV from 51 women with mean age of 51 years; 3 (6%) had concurrent biopsies with both. Pain was more common in PCV, but rates of discharge, itch, and bleeding were comparable. Rates of petechiae or erythema were similar and vaginal examination was abnormal in 72% of PCV cases. All DIV and 33% of PCV occurred in squamous mucosa; the remaining PCV cases were from mucocutaneous junction. Mean epithelial thickness, rete ridge appearance, exocytosis, and spongiosis were similar in DIV and PCV. Epithelial erosion, wide-diameter lesions, plasma cells, and stromal hemosiderin occurred in both but were more common in PCV. Lymphocyte-obscured basal layer, narrow-diameter lesions, hemorrhage, and vascular congestion were seen in both, but more common and marked in DIV. CONCLUSIONS: Desquamative inflammatory vaginitis and PCV have overlapping symptoms, signs, and histopathologic features. They may represent a single condition of hemorrhagic vestibulovaginitis with varying manifestations according to location and severity.

Clinicopathologic Diagnosis of Differentiated Vulvar Intraepithelial Neoplasia and Vulvar Aberrant Maturation.

OBJECTIVE: The aim of the study was to describe the demographic, clinical, and histopathologic features of differentiated vulvar intraepithelial neoplasia (dVIN) and vulvar aberrant maturation (VAM). METHODS: Specimens from 2010 to 2020 reported as dVIN or VAM were reviewed. Clinical data included age, rurality, symptoms, and evidence of lichen sclerosus (LS). Histopathologic data included epithelial thickness, keratinization, architectural and dyskeratotic features, stroma, p16, and p53. Differentiated vulvar intraepithelial neoplasia and VAM were distinguished by assessment of basal nuclear chromatin, enlargement, pleomorphism, and mitoses. RESULTS: One hundred twenty women with a median age of 71 years had 179 examples of dVIN and VAM. Squamous cell carcinoma was concurrent in 66% and associated with rurality. Ten percent were asymptomatic, and all but 3 had evidence of LS. Differentiated vulvar intraepithelial neoplasia showed a range of thickness, architecture, and dyskeratosis; its unifying !feature was basal atypia. Differentiated vulvar intraepithelial neoplasia displayed hyperchromasia in 83% and easily observed mitoses in 70%. Nonkeratinizing morphology, subcategorized into basaloid and intermediate, occurred in 24% of women with dVIN. Traditional dVIN represented 62% of keratinizing cases; the remainder were atrophic (13%), hypertrophic (13%), acantholytic (8%), or subtle (5%). Vulvar aberrant maturation had abnormal stratum corneum, acanthosis, premature maturation, and enlarged vesicular nuclei. Null p53 helped distinguish dVIN from VAM and dermatoses. CONCLUSIONS: The morphology of dVIN encompasses nonkeratinizing and keratinizing types, the latter subdivided into traditional, acantholytic, atrophic, hypertrophic, and subtle. Diagnosis relies on basal atypia with supportive p16 and p53. Atypia exists on a biologic spectrum with mild abnormalities of VAM and reactive change. Identification of dVIN and VAM requires collaboration between clinicians and pathologists experienced in vulvar disorders.

Vestibulovaginal Sclerosis Versus Lichen Sclerosus.

To determine if vestibulovaginal sclerosis and lichen sclerosus (LS) are 2 distinct entities. Biopsies obtained from the vagina or vulvar vestibule that contained abnormal subepithelial collagen were reviewed. Cases were categorized either as LS or vestibulovaginal sclerosis based on presence or absence of basal layer degeneration and lymphocytic infiltrate. Clinical data collected included examination findings, biopsy site and indication, previous vulvovaginal surgery, medications at time of biopsy, vulvar LS, treatment, and response. There were 15 cases with a mean age of 62 yr (range: 32-86 yr); 12 (80%) specimens were from vestibule and 3 from vagina. Nine cases were categorized as LS because of lymphocytic infiltrate in combination with basal layer degeneration, of these 8 had LS elsewhere on vulvar skin. Six cases were classified as vestibulovaginal sclerosis and had an absent or sparse lymphocytic infiltrate and essentially normal epithelium; none of these had vulvar LS. While vestibulovaginal sclerosis and lichen sclerosus are distinguishable clinically and histopathologically, further studies are needed to determine if vestibulovaginal sclerosis is a subset of LS or a different condition.

Interpretation of Nondiagnostic Vulvar Biopsies.

OBJECTIVE: The aim of the study was to assess clinical and histopathologic characteristics of symptomatic women who underwent a nondiagnostic biopsy of the inner vulva. MATERIALS AND METHODS: Consecutive nondiagnostic biopsies from medial labia minora, posterior fourchette, and vestibule obtained from symptomatic women between 2011 and 2015 were reviewed for this retrospective histopathologic case series. Histopathologic assessment included site, basal layer appearance, lymphocytic infiltrate, and presence of fibrosis or sclerosis. Examination findings, treatment, initial impression, and final clinical diagnosis were recorded. Descriptive statistics were performed; clinical and histopathologic characteristics were compared with Fisher exact test. RESULTS: There were 85 cases; mean age was 53 years. Most women presented with painful erythema and underwent biopsy to confirm (30, 35%) or exclude (43, 51%) lichen planus. After clinical follow-up and histopathologic review, most cases had persistent diagnostic discordance. Final clinical diagnoses were available in 70 women: lichen planus in 27 (38%), vulvodynia in 15 (21%), and the other 28 (40%) had LS (8), plasma cell vulvitis (5), psoriasis (4), dermatitis (4), candidosis (3), estrogen deficiency (3), and aphthosis (1). Histopathologic review highlighted the difficulty in distinguishing mucosa-associated lymphoid tissue from an inflammatory infiltrate in 23 (27%) of cases. Compared with other sites, biopsies from the mucocutaneous junction were more likely to be associated with a positive culture for Candida albicans. CONCLUSIONS: Nondiagnostic biopsies from the inner vulva should prompt thoughtful multidisciplinary review, but more research is required to resolve the problem of clinicopathologic discordance through better understanding of vulvar histology and pathophysiology.

Can Routine Histopathology Distinguish Between Vulvar Cutaneous Candidosis and Dermatophytosis?

OBJECTIVES: This study aimed to determine if vulvar cutaneous candidosis and dermatophytosis can be distinguished by routine histopathology. MATERIALS AND METHODS: Twenty-four cases of periodic acid-Schiff-stained vulvar biopsies with a diagnosis of cutaneous mycosis were reviewed and histopathological characteristics on both periodic acid-Schiff and hematoxylin and eosin were recorded. Data were collected on age, clinical impression, microbiological results, and treatment, and all specimens underwent multiplex polymerase chain reaction analysis. RESULTS: The mean age was 60 years, and all but 3 women had at least 1 risk factor for mycosis including 15 (62.5%) with lichen sclerosus and/or planus managed with topical corticosteroids. A clinical suspicion of tinea or candidosis was documented in 12 (50%) of the cases. Vulvovaginal swabs showed Candida species in 9 women; one skin scraping was positive for Trichophyton rubrum. Microbiology was not obtained in 8 patients, 5 had a negative swab, and 1 had negative skin scrapings. No histopathological or morphological features distinguished Candida species from dermatophytes. Organisms appeared as basophilic structures in the stratum corneum in 15 (62.5%) hematoxylin and eosin-stained slides. Polymerase chain reaction results were positive for Candida species in 5 (21%) and for dermatophytes in 3 (13%), negative in 13, and unassessable in 3 cases. CONCLUSIONS: Vulvar cutaneous candidosis and dermatophytosis cannot be reliably distinguished by routine histopathology or specific polymerase chain reaction. A high index of suspicion combined with adequate microbiological testing remains the best approach to differentiating between the 2, which impacts on counseling, treatment, and prognosis.

The value of histology in predicting the effectiveness of vulvar vestibulectomy in provoked vestibulodynia.

OBJECTIVE: This study aimed to determine whether histology can predict response to vestibulectomy in the management of provoked vestibulodynia. MATERIALS AND METHODS: Inflammatory cell, mast cell, and nerve fiber counts were determined in prospectively collected vulvar vestibulectomy specimens from 30 women treated surgically for provoked vestibulodynia. RESULTS: Twenty-three subjects (77%) had a complete early response to surgery. At 3 years of follow-up, this had increased to 28 (93%), with a 29th showing some improvement. No subject had gotten worse after surgery or in the 3 years of follow-up. When comparing patients with an early complete response with those patients who still had symptoms, no difference in lymphocyte counts (27.6 vs. 37.8 per mm), mast cell counts (110.4 vs. 97.8 per mm), or stromal nerve fiber counts (16.4 vs. 16.4 per mm) was found. CONCLUSIONS: Vestibulectomy is a very effective treatment option in women with provoked vestibulodynia who have had failed conservative treatment. Histology is unable to predict which patients will respond to surgery.

Use of amitriptyline cream in the management of entry dyspareunia due to provoked vestibulodynia.

OBJECTIVE: This study aimed to evaluate the effectiveness of topical amitriptyline 2% in sorbolene (cetomacrogol aqueous) cream in the management of patients with entry dyspareunia caused by provoked vestibulodynia. MATERIALS AND METHODS: A prospective study of 150 patients presenting with entry dyspareunia to a private gynecologist (R.P.) was undertaken during a 12-month period. Provoked vestibulodynia was diagnosed by the presence of pinpoint tenderness confined to the vulvar vestibule. Most patients (102) had purely provoked vestibulodynia, whereas 48 had both provoked and unprovoked pain. There were 7 patients with grade 1 dyspareunia (intercourse always painful but only occasionally preventing penetration), 83 patients with grade 2 (intercourse always painful preventing penetration on most occasions), and 60 patients with grade 3 (apareunic). Questionnaires were evaluated before and 3 months after commencement of treatment. No control group using placebo was studied because of the private-practice setting. RESULTS: Duration of symptoms varied from 1 to 30 years, the mean being 4.7 years. There was no response in 66 patients (44%). Of these, 16 patients ceased treatment early because of local skin irritation and hence were regarded as treatment failures. The 84 patients (56%) that responded were divided into 3 groups as follows: (i) 25 with a slight but noticeable improvement; (ii) 44 with a moderate degree of improvement; and (iii) 15 with an excellent response, describing intercourse as comfortable and pain free (10% of the total study group). Most patients in all 3 groups elected to continue application of the cream after completion of the study. The response rate was similar (48%) in the subgroup that also had unprovoked vestibulodynia. There was no difference in the response rate according to parity. The response rate was also similar in patients who had previously taken oral amitriptyline unsuccessfully. In these 44 patients, the overall response rate was 59%. CONCLUSIONS: Topical amitriptyline cream should be considered for first-line treatment in the management of patients with provoked vestibulodynia causing entry dyspareunia. The response rate is reasonable (56%), and it eliminates the problems with systemic administration, namely, drowsiness and the difficulty patients have in accepting antidepressant medication for their condition.

Value of colposcopy in the diagnosis of candidiasis in patients with vulvodynia.

OBJECTIVE: To evaluate the value of colposcopy in the diagnosis of chronic vulvar candidiasis in patients presenting with vulvodynia. STUDY DESIGN: A prospective study of 460 patients presenting with vulvodynia over a 24-month period was undertaken. All patients underwent colposcopy of the vulva, which was regarded as positive if acetowhite lesions with central clearing with or without petechiae were present. Vulvar skin scrapings were taken for Candida culture on all patients. Those patients with positive colposcopic findings were treated with long-term oral antimycotic therapy irrespective of laboratory findings. RESULTS: Patients with positive colposcopic findings and positive cultures had a 93% rate of improvement in symptoms. Those with positive colposcopic findings and negative cultures also had a 60% rate of improvement. Thus, the overall improvement rate in patients with positive colposcopic findings (irrespective of culture results) was 76%. When colposcopy findings were negative, Candida cultures were also negative in 92% of patients. CONCLUSION: Colposcopy of the vulva can be a valuable triage tool in the assessment of patients with vulvodynia by detecting changes that are highly suspicious for the presence of chronic vulvar candidiasis.