Is Vulvodynia Associated With an Altered Vaginal Microbiota?: A Systematic Review.

INTRODUCTION: Vulvodynia is defined as vulvar pain of at least 3 months' duration, without clear identifiable cause, which may have potential associated factors. It can have a significant impact on women's quality of life due to a combination of physical pain, emotional distress, and limited treatment options. Despite affecting a considerable number of women worldwide, the causes and underlying mechanisms of vulvodynia remain poorly understood. Given the recognized association of the vaginal microbiota with various gynecologic disorders, there has been growing interest in exploring the potential role of the vaginal microbiota in the etiology of vulvodynia. This systematic review aims to evaluate the current literature on the association between the vaginal microbiota and vulvodynia. MATERIAL AND METHODS: A systematic search of multiple databases, including PubMed, Scopus, Web of Science, Cochrane Library, and Ovid MEDLINE, was conducted to identify relevant peer-reviewed studies up to May 12, 2023. The following search terms were used across these databases: "vulvodynia," "vestibulodynia," "vulvar vestibulitis," "microbiome," "microbiota," and "flora." RESULTS: A total of 8 case-control studies were included, the quality of which was assessed using the Newcastle-Ottawa Scale. Data extraction and synthesis were performed using a standardized protocol. In most studies, no major differences were found between the vaginal bacterial composition of women with vulvodynia and that of controls. No specific bacterial taxa were consistently associated with vulvodynia. The relationship between vaginal microbiota diversity and vulvodynia remains to be fully understood. CONCLUSIONS: The role of vaginal microbiota in vulvodynia, if any, remains unclear. Because of the cross-sectional nature of the included studies, it is not possible to make any causal inferences. Further research, using larger and more diverse study populations and advanced sequencing techniques, is necessary to gain a better understanding of the potential relationship between the vaginal microbiota and vulvodynia.

Impact of the Sampling Site in the Result of Wet Mount Microscopy.

OBJECTIVES: Wet mount microscopy (WMM) is an ancillary test in the diagnosis of vulvovaginitis. However, there are little data about the impact of the sampling site. Our main objective was to determine the agreement between samples collected from different vaginal sites. MATERIALS AND METHODS: Five vaginal samples (one from each of the fornices and one from the lower third) were collected from 50 consecutive women and evaluated using phase-contrast WMM, including the following: lactobacillary grade, presence of other bacteria, clue cells, inflammation, and atrophy. Global percentage of agreement, κ index [poor (<0), slight (0.01-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), and almost perfect (0.81-1)], sensitivity and negative predictive value were calculated. RESULTS: Global percentage of agreement was high for all individual parameters (>75%), but low for the final diagnosis (57%). Agreement rate was substantial or almost perfect for the evaluation of normal versus abnormal flora, substantial for the presence of absence of bacteria other than lactobacilli and for the presence of clue cells, and moderate to almost perfect for the presence of dysbiosis and cytolysis. Agreement rates were worse for inflammation, atrophy, and the presence of Candida. The lower third of the vagina had the highest sensitivity for Candida (0.6, 95% CI = 0.41-0.86) and bacterial vaginosis (0.92, 95% CI = 0.73-1.00), whereas the anterior fornix performed better for cytolytic vaginosis (0.75, 95% CI = 0.43-0.93). CONCLUSIONS: There is some variation in the results according to the sampling site, which may be overcome by collecting 2 samples (anterior fornix and lower third of the vagina).

What differentiates symptomatic from asymptomatic women with lichen sclerosus?

AIMS: To investigate the differences between symptomatic and asymptomatic women with vulvar lichen sclerosus (LS). METHODS: Data on file concerning 228 LS patients was retrospectively reviewed. RESULTS: Most patients were symptomatic (193/228; 85%). Worsening of symptoms related to specific food intake was experienced by 26% (48/182) and pork was the most frequently cited (25/48; 52%); worsening at night was reported by 47% (87/185). Being over 50 years at the time of diagnosis or being menopausal were associated with being symptomatic (RR = 2.47, 95% CI: 1.15-5.29 and 6.55, 2.05-20.91, respectively). The same was true for urinary incontinence (UI) (5.23, 1.78-15.42), the use of absorbents (without UI) (3.59, 1.05-12.34) and dyspareunia (5.28, 1.64-17.0). All patients with a family history of LS were symptomatic. There was no association with hormonal factors or specific vulvar anatomical changes. CONCLUSIONS: Pork consumption may be involved in the worsening of symptoms. UI and the use of absorbents are more commonly present in symptomatic LS patients. Dietary changes and correction of UI might be useful in the control of LS symptoms. © 2015 S. Karger AG, Basel.

Emphysematous vaginitis.

BACKGROUND: Emphysematous vaginitis is a rare condition, characterized by the presence of multiple gas-filled cysts in the vaginal and/or exocervical mucosa. Although its etiology is not completely understood, it is self-limited, with a benign clinical course. Vaginal discharge, sometimes bloody, and pruritus are the most common symptoms. Chronic and acute inflammation can be found, and diseases that impair the immune system and pregnancy have been associated with this condition. CASE REPORT: A 48-year-old postmenopausal woman, with a history of hysterectomy with several comorbidities, presented with a 4-month history of bloody discharge and vulvar pruritus. Examination showed multiple cystic lesions, 1 to 5 mm, occupying the posterior and right lateral vaginal walls. Speculum examination produced crepitus. Vaginal wet mount was normal, except for diminished lactobacilli; results of Trichomonas vaginalis DNA test and vaginal cultures were negative. Lugol's iodine applied to the vagina was taken up by the intact lesions. Biopsy result showed typical features of emphysematous vaginitis. CONCLUSIONS: This is an unusual entity, presenting with common gynecological complaints, and both physicians and pathologists should be aware to prevent misdiagnosis and overtreatment.

Vaginal Leptothrix: An Innocent Bystander?

Leptothrix are long bacteria of rare occurrence; although these bacteria have been implicated in causing vaginal symptoms identical to candidiasis, studies on prevalence and effect on overall vaginal health are lacking. In this study, we evaluated data of women referred to a private clinic for treating vulvovaginal symptoms (n = 1847) and reassessed data of our previous and ongoing studies (n = 1773). The overall rate of leptothrix was 2.8% (102/3620), and the mean age of affected women was 38.8 ± 10.65 years (range 18-76). The majority of the women with leptothrix had normal vaginal flora (63.7% [65/102]). Leptothrix was associated with a higher risk of candidiasis (relative risk (RR) 1.90, 95% confidence interval (CI) 1.1600-3.1013; p = 0.010) and a lower risk of bacterial vaginosis (RR 0.55, 95% CI, 0.3221-0.9398; p = 0.029) and cytolytic vaginosis (RR 0.11, 95% CI, 0.0294-0.4643; p = 0.002). No cases of trichomoniasis were observed. Human immunodeficiency virus infection increased the risk of leptothrix (RR 3.0, 95% CI, 1.6335-5.7245; p = 0.000). Among the women evaluated for vulvovaginal symptoms, 2.4% (45/1847) had leptothrix, and in 26.7% (12/45), leptothrix was considered the causative entity. This study suggests that leptothrix occurrence is rare; it remains unresolved if it can be a cause of vulvar symptoms.

G-spot: Fact or Fiction?: A Systematic Review.

INTRODUCTION: The G-spot, a putative erogenous area in the anterior vaginal wall, is a widely accepted concept in the mainstream media, but controversial in medical literature. AIM: Review of the scientific data concerning the existence, location, and size of the G-spot. METHODS: Search on Pubmed, Pubmed Central, Cochrane, clinicaltrials.gov and Google Scholar from inception to November 2020 of studies on G-spot's existence, location and nature. Surveys, clinical, physiological, imaging, histological and anatomic studies were included. MAIN OUTCOME MEASURE: Existence, location, and nature of the G-spot. RESULTS: In total, 31 eligible studies were identified: 6 surveys, 5 clinical, 1 neurophysiological, 9 imaging, 8 histological/anatomical, and 2 combined clinical and histological. Most women (62.9%) reported having a G-spot and it was identified in most clinical studies (55.4% of women); in 2 studies it was not identified in any women. Imaging studies had contradictory results in terms of its existence and nature. Some showed a descending of the anterior vaginal wall, that led to the concept of clitourethrovaginal complex. In anatomic studies, one author could systematically identify the G-spot, while another group did not find it. Studies on innervation of the vaginal walls did not systematically identify an area with richer innervation. CONCLUSION: The different studies did systematically agree on the existence of the G-spot. Among the studies in which it was considered to exist, there was no agreement on its location, size, or nature. The existence of this structure remains unproved. Vieira-Baptista P, Lima-Silva J, Preti M, et al. G-spot: Fact or Fiction?: A Systematic Review. Sex Med 2021;9:100435.

Vulvodynia: A disease commonly hidden in plain sight.

•Vulvodynia affects at least 6% of women, and can be found at any age and in all ethnic groups.•The diagnosis is one of exclusion but is very often missed.•Women with vulvodynia are frequently misdiagnosed as having vaginismus.•Failure to make the diagnosis often leads to irrelevant or deleterious examinations and treatments.

Women without vulvodynia can have a positive 'Q-tip test': a cross sectional study.

BACKGROUND: Vulvodynia is a frequently missed pathology, often confused with vaginismus. The Q-tip test (QTT) is fundamental for the diagnosis; however, there is lack of data about its performance in asymptomatic women. OBJECTIVE: This study intended to evaluate the QTT for painful vestibular spots in asymptomatic women. METHODS: Q-tips were gently pressed at different areas of the vulvar vestibule to obtain a 0-10 score representing the pain felt. This was performed in 267 consecutive patients presenting to the gynecology outpatient clinic for reasons other than vulvovaginal complaints. A questionnaire was done to evaluate the possibility of unrecognized vulvodynia. RESULTS: Out of the 267 women, 18 (6.7%) fitted the diagnosis of vulvodynia and were excluded from the analysis. Of the remaining 249, 41 (16.5%) had a positive QTT. We could not find differences in the sexual activity rate between women with and without a positive QTT. No demographic differences could be found between the two groups. Only depression was more common in women with a positive QTT [31.7% (13/41) versus 10.8% (21/208), p=.001). CONCLUSIONS: Asymptomatic women can have painful vestibular spots in the absence of vulvodynia. A positive QTT cannot be considered equivalent to vulvodynia, highlighting the need for extensive workup of these women before that diagnosis can be assumed.

Survey on Aesthetic Vulvovaginal Procedures: What do Portuguese Doctors and Medical Students Think?

Objective To assess the medical doctors and medical students' opinion regarding the evidence and ethical background of the performance of vulvovaginal aesthetic procedures (VVAPs). Methods Cross-sectional online survey among 664 Portuguese medical doctors and students. Results Most participants considered that there is never or there rarely is a medical reason to perform: vulvar whitening (85.9% [502/584]); hymenoplasty (72.0% [437/607]); mons pubis liposuction (71.6% [426/595]); "G-spot" augmentation (71.0% [409/576]); labia majora augmentation (66.3% [390/588]); labia minora augmentation (58.3% [326/559]); or laser vaginal tightening (52.3% [313/599]). Gynecologists and specialists were more likely to consider that there are no medical reasons to perform VVAPs; the opposite was true for plastic surgeons and students/residents.Hymenoplasty raised ethical doubts in 51.1% (283/554) of the participants. Plastic surgeons and students/residents were less likely to raise ethical objections, while the opposite was true for gynecologists and specialists.Most considered that VVAPs could contribute to an improvement in self-esteem (92.3% [613/664]); sexual function (78.5% [521/664]); vaginal atrophy (69.9% [464/664]); quality of life (66.3% [440/664]); and sexual pain (61.4% [408/664]). Conclusions While medical doctors and students acknowledge the lack of evidence and scientific support for the performance of VVAPs, most do not raise ethical objections about them, especially if they are students or plastic surgeons, or if they have had or have considered having plastic surgery.

Objetivos Avaliar a opinião de médicos e estudantes de medicina relativamente à evidência e contexto ético para a realização de procedimentos estéticos vulvovaginais (PEVVs). Métodos Estudo transversal, consistindo de inquérito online a 664 médicos e estudantes de medicina portugueses. Resultados A maioria dos participantes considerou que nunca ou raramente há uma razão médica para a realização de: branqueamento vulvar (85,9% [502/584]); himenoplastia (72,0% [437/607]); lipoaspiração do mons pubis (71,6% [426/595]); aumento do "ponto G" (71,0% [409/576]); aumento dos grandes lábios (66,3% [390/588]); aumento dos pequenos lábios (58,3% [326/559]) ou aperto vaginal com laser (52,3% [313/599]). Ser ginecologista e especialista associou-se a maior probabilidade de considerar não haver razões médicas para a realização de PEVV; o oposto foi verdade para os cirurgiões plásticos e estudantes/internos.A himenoplastia levantou dúvidas em termos éticos em 51,1% (283/554) dos participantes. Cirurgiões plásticos e estudantes/internos relataram menos dúvidas em termos éticos; o oposto foi verdade para os ginecologistas ou especialistas.A maioria considerou que os PEVVs podem contribuir para uma melhoria na autoestima (92,3% [613/664]); função sexual (78,5% [521/664]); atrofia vaginal (69,9% [464/664]); qualidade de vida (66,3% [440/664]); e dor sexual (61,4% [408/664]). Conclusões Ainda que os médicos e estudantes de medicina reconheçam a falta de evidência e bases científicas para a realização de PEVVs, a maioria não levanta objecções em termos éticos, especialmente se forem estudantes, cirurgiões plásticos, ou se eles próprios tiverem sido submetidos a cirurgia plástica ou considerem vir a sê-lo.

Lipschütz ulcers: should we rethink this? An analysis of 33 cases.

OBJECTIVES: To describe the presentation and characteristics of patients with Lipschütz ulcers (LU) and to evaluate the role of a standard protocol in the aetiological diagnosis. STUDY DESIGN: Retrospective analysis of all cases of diagnosis of LU at our Vulvar Clinic during a five-year period. RESULTS: Of 110 women with vulvar ulcers, 33 (30.0%) had a diagnosis of LU. The mean age was 29.1±15.14 years (10-79 years). Nine (27.3%) were 35 years old or more. The majority had had their sexual debut (28, 84.8%). Ten patients (30.3%) referred had at least one previous similar episode. Twenty-five (75.7%) had non-gynecological symptoms in the week before. The ulcers were located most frequently on the vestibule (19, 57.6%) and the labia minora (10, 30.3%). Isolated lesions on the left side were uncommon (3, 9.1%). Most had multiple (22, 66.7%) lesions. The mean time to full healing of the lesions was 15.6±6.20 days. A microbiological possible cause was identified in 9 (27.3%) patients: CMV (3 cases), Mycoplasma pneumoniae (3 cases), EBV (2 cases) and PVB19 (1 case). The protocol did not include systematic biopsies, blood count differentials, C-reactive protein and liver enzymes, which may have lead to some missed diagnosis. CONCLUSIONS: LU can be found in women of any age, most of them sexually active. In most cases the lesions are preceded by non-gynecological symptoms and recurrence is common. Most lesions occur on the vestibule and labia minora, being rarely found isolated on the left side. Viruses seem to be the most frequent associated agents but Mycoplasma pneumoniae serology should be considered. In one case there was a possible role for PVB19. A standard protocol can effectively exclude sexually transmitted diseases and lead to a diagnosis in up to a third of cases.

Prevalence of vulvodynia and risk factors for the condition in Portugal.

OBJECTIVE: To investigate the prevalence of vulvodynia in Portugal and factors associated with this condition. METHODS: In a cross-sectional study, an online survey was distributed by email and posted on a website and social networks. Women aged at least 18 years who were living in Portugal were eligible to complete the survey between June 1 and November 30, 2013. Participants had to have had symptoms for at least 6 months to be deemed to have vulvodynia. RESULTS: Overall, 1229 questionnaires were included in analyses. A total of 80 (6.5%) women had vulvodynia at the time of the survey, and 117 (9.5%) had had it previously; lifetime prevalence was 16.0%. Pregnancy and type of delivery were not associated with vulvodynia. Women who had ever taken oral contraceptives were significantly more likely to have ever had vulvodynia (P<0.010). Candidiasis, genital herpes, urinary tract infections, depression, and premenstrual syndrome were associated with ever having had vulvodynia (P<0.01). Pain syndromes were associated with ever having had vulvodynia, especially fibromyalgia and bladder pain syndrome (P<0.001). Scoliosis and hysterectomy were also significantly associated (P<0.01). CONCLUSION: The prevalence of vulvodynia in Portugal is similar to that elsewhere. Three main groups of factors might lead to vulvodynia: local inflammatory factors, general pain susceptibility, and pelvic nerve interference.

Survey on Aesthetic Vulvovaginal Procedures: What do Portuguese Doctors and Medical Students Think? / Inquérito sobre procedimentos estéticos vulvovaginais: qual a opinião dos médicos e estudantes de medicina portugueses?

Abstract Objective To assess themedical doctors andmedical students' opinion regarding the evidence and ethical background of the performance of vulvovaginal aesthetic procedures (VVAPs). Methods Cross-sectional online survey among 664 Portuguese medical doctors and students. Results Most participants considered that there is never or there rarely is amedical reason to perform: vulvar whitening (85.9% [502/584]); hymenoplasty (72.0% [437/607]); mons pubis liposuction (71.6% [426/595]); "G-spot" augmentation (71.0% [409/576]); labia majora augmentation (66.3% [390/588]); labia minora augmentation (58.3% [326/559]); or laser vaginal tightening (52.3%[313/599]).Gynecologists and specialistsweremore likely to consider that there are no medical reasons to performVVAPs; the opposite was true for plastic surgeons and students/residents. Hymenoplasty raised ethical doubts in 51.1% (283/554) of the participants. Plastic surgeons and students/residents were less likely to raise ethical objections, while the opposite was true for gynecologists and specialists. Most considered that VVAPs could contribute to an improvement in self-esteem(92.3% [613/664]); sexual function (78.5% [521/664]); vaginal atrophy (69.9% [464/664]); quality of life (66.3% [440/664]); and sexual pain (61.4% [408/664]). Conclusions While medical doctors and students acknowledge the lack of evidence and scientific support for the performance of VVAPs, most do not raise ethical objections about them, especially if they are students or plastic surgeons, or if they have had or have considered having plastic surgery.

Resumo Objetivos Avaliar a opinião de médicos e estudantes de medicina relativamente à evidência e contexto ético para a realização de procedimentos estéticos vulvovaginais (PEVVs). Métodos Estudo transversal, consistindo de inquérito online a 664 médicos e estudantes de medicina portugueses. Resultados A maioria dos participantes considerou que nunca ou raramente há uma razão médica para a realização de: branqueamento vulvar (85,9% [502/584]); himenoplastia (72,0% [437/607]); lipoaspiração do mons pubis (71,6% [426/595]); aumento do "ponto G" (71,0% [409/576]); aumento dos grandes lábios (66,3% [390/588]); aumento dos pequenos lábios (58,3% [326/559]) ou aperto vaginal com laser (52,3% [313/599]). Ser ginecologista e especialista associou-se a maior probabilidade de considerar não haver razões médicas para a realização de PEVV; o oposto foi verdade para os cirurgiões plásticos e estudantes/internos. A himenoplastia levantou dúvidas em termos éticos em 51,1% (283/554) dos participantes. Cirurgiões plásticos e estudantes/internos relatarammenos dúvidas emtermos éticos; o oposto foi verdade para os ginecologistas ou especialistas. Amaioria considerou que os PEVVs podemcontribuir para uma melhoria na autoestima (92,3% [613/664]); função sexual (78,5% [521/664]); atrofia vaginal (69,9% [464/664]); qualidade de vida (66,3% [440/664]); e dor sexual (61,4% [408/664]). Conclusões Ainda que os médicos e estudantes de medicina reconheçam a falta de evidência e bases científicas para a realização de PEVVs, a maioria não levanta objecções em termos éticos, especialmente se forem estudantes, cirurgiões plásticos, ou se eles próprios tiverem sido submetidos a cirurgia plástica ou considerem vir a sê-lo.