Labial Adhesion: New Classification and Treatment Protocol.

STUDY OBJECTIVE: To determine the subtypes of labial adhesion (LA) and arrange treatment options accordingly. DESIGN AND SETTING: Patients who presented to our clinic with LA between July 2016 and February 2018 were divided into 4 groups. Location of the adhesion area, thickness of the adhesive tissue, and response to topical steroid (betamethasone valerate 0.1% ointment) therapy were identified as common features. PARTICIPANTS: Seventy-five prepubertal girls. INTERVENTIONS AND MAIN OUTCOME MEASURES: To determine the subtypes of the LA and evaluate the treatment response of patients in each subtype group. RESULTS: LA was divided into 4 subtypes according to their common characteristics. For patients with type I, 2 weeks of topical steroid treatment resulted in complete recovery (100%). For those with type II, 12 (80%) patients had complete response to topical steroid treatment for an average of 3 weeks. Type III and IV patients were completely unresponsive to topical steroid treatment. CONCLUSION: Classification of LA patients into subtypes and determination of treatment on the basis of this classification make a major contribution in planning the treatment of patients, not by trial-and-error, but using a predetermined strategy.

Evaluation of treatments for Bartholin's cyst or abscess: a systematic review.

BACKGROUND: No consensus on the management of symptomatic cysts or abscesses of the Bartholin's gland exists. OBJECTIVES: To assess the effectiveness and safety of surgical interventions for a symptomatic Bartholin's cyst or abscess. SEARCH STRATEGY: We searched bibliographical databases from inception to April 2019. SELECTION CRITERIA: Randomised trials evaluating a surgical intervention for the treatment of a symptomatic Bartholin's cyst or abscess. DATA COLLECTION AND ANALYSIS: Eight trials, reporting data from 699 women, were included. Study characteristics and methodological quality were recorded for each trial. Summary estimates were calculated using random-effects methods. MAIN RESULTS: When considering the recurrence of a symptomatic Bartholin's cyst or abscess, the evidence was consistent with notable effects in either direction (risk ratio [RR] 0.76; 95% confidence interval [CI] 0.41-1.40) when comparing marsupialisation with incision, drainage and insertion of a Word catheter. Limited inference could be made when comparing marsupialisation with incision, drainage and silver nitrate insertion (RR 1.00; 95% CI 0.57-1.75), and incision, drainage and cavity closure (RR 0.25; 95% CI 0.01-4.89). There was limited reporting of secondary outcomes, including haematoma, infectious morbidity and persistent dyspareunia. CONCLUSIONS: Current randomised trial evidence does not support the use of any single surgical intervention for the treatment of a symptomatic cyst or abscess of the Bartholin's gland. PROSPECTIVE REGISTRATION: PROSPERO: International Prospective Register of Systematic Reviews; CRD42018088553. TWEETABLE ABSTRACT: Further research is needed to identify an effective treatment for #Bartholin's cyst or abscess. @jamesmnduffy.

Classic and Hypertrophic Vulvar Lichen Planus.

OBJECTIVES: Three types of lichen planus (LP) occur on the vulva: erosive, classic, and hypertrophic. The latter 2 occur on keratinized skin and little is known about their clinicopathologic appearance. MATERIALS AND METHODS: Vulvar biopsies of keratinized skin reported as LP or "lichenoid" between 2011 and 2017 were reviewed. Inclusion required age of older than 18 years, a lichenoid tissue reaction, and insufficient abnormal dermal collagen to diagnose lichen sclerosus. Clinical and histopathologic data were collected and cases were categorized as hypertrophic, classic, or nonspecific lichenoid dermatosis. Descriptive statistics were performed and groups were compared with the Fisher exact test. RESULTS: Sixty-three cases met criteria for inclusion. Twenty-nine (46%) cases were categorized as hypertrophic LP, 21 (33%) as classic LP, and 13 (21%) as nonspecific lichenoid dermatosis. There were no significant differences in age, primary symptom, biopsy location, or duration of disease between the 3 groups. When compared with classic and nonspecific disease, hypertrophic LP was less likely to have comorbid dermatoses and more likely to be red, diffuse, have scale crust, and contain plasma cells in the infiltrate. Nonspecific disease had similar clinical features to classic LP but was less likely than the other 2 categories to have a dense lymphocytic infiltrate and exocytosis. CONCLUSIONS: Vulvar LP on keratinized skin has a diversity of appearances and presents a clinicopathologic challenge. Further research is required to understand the natural history of hypertrophic LP and the underlying diagnosis of nonspecific lichenoid cases.

Clinical approach to vulvovaginal cysts and abscesses, a review.

Vulvovaginal cysts are a common problem for women, causing significant pain, discomfort and impact on quality of life. For clinicians, classifying and differentiating these cysts from each other and selecting appropriate management can be challenging, yet there is no integrated classification system and little literature that broadly summarises a clinical approach. We aimed to create a useful tool for clinicians by providing a detailed summary of various vulvovaginal cysts and abscesses with a clear novel classification system and hierarchy for diagnosis and management, to aid clinicians in this process.

Classification of Hypertrophy of Labia Minora: Consideration of a Multiple Component Approach.

Labia minora hypertrophy of unknown and under-reported incidence in the general population is considered a variant of normal anatomy. Its origin is multi-factorial including genetic, hormonal, and infectious factors, and voluntary elongation of the labiae minorae in some cultures. Consults with patients bothered by this condition have been increasing with patients complaining of poor aesthetics and symptoms such as difficulty with vaginal secretions, vulvovaginitis, chronic irritation, and superficial dyspareunia, all of which can have a negative effect on these patients' sexuality and self esteem. Surgical management of labial hypertrophy is an option for women with these physical complaints or aesthetic issues. Labia minora hypertrophy can consist of multiple components, including the clitoral hood, lateral prepuce, frenulum, and the body of the labia minora. To date, there is not a consensus in the literature with respect to the classification and definition of varying grades of hypertrophy, aside from measurement of the length in centimeters. In order to offer patients the most appropriate surgical technique, an objective and understandable classification that can be used as part of the preoperative evaluation is necessary. Such a classification should have the aim of offering patients the best cosmetic and functional results with the fewest complications.

Vulvar dermatoses: a histopathologic review and classification of 183 cases.

BACKGROUND: Vulvar dermatoses are often difficult to classify due to histopathologic overlap. We aimed to report our experience at a single institution. METHODS: A total of 183 non-neoplastic, non-infectious vulvar biopsies were reviewed. Associations between histopathologic features and specific diagnoses were analyzed by Chi-squared tests. RESULTS: Twenty-two biopsies (12.0%) showed two concurrent processes. A limited differential rather than a definitive diagnosis was rendered in 15 cases (8.2%). The final diagnoses included lichen sclerosus (LS) (38.8%), lichen simplex chronicus (LSC) (29.0%), eczematous dermatitis (23.0%), Zoon vulvitis (8.2%), non-specific/resolved dermatitis (5.5%), hidradenitis suppurativa (2.7%), Behçet disease (2.2%), lichen planus (1.6%), ruptured cyst (1.6%), ulcer not-otherwise-specified (1.6%), psoriasis (1.1%), radiation dermatitis (1.1%), sebopsoriasis (1.1%), seborrheic dermatitis (1.1%), epidermolytic hyperkeratosis (0.5%) and granular parakeratosis (0.5%). Early LS and Zoon vulvitis were commonly included as part of a differential diagnosis. LS was associated with wiry collagen with lymphocyte entrapment (p = 0.0188). LSC was associated with zones of pale epithelium (p = 0.0084), and often displayed prominent fibroblasts (p = 0.0555). Zoon vulvitis was frequently misdiagnosed, and was associated with basal keratinocytic crowding (p < 0.0001). CONCLUSIONS: Our study has determined the relative frequencies of a wide variety of vulvar dermatoses, and identified new diagnostic clues for early LS, LSC and Zoon vulvitis.

Vaginal labiaplasty: current practices and a simplified classification system for labial protrusion.

BACKGROUND: Vaginal labiaplasty has been described for the management of functional and aesthetic problems associated with protrusion of the labia minora. Despite increasing numbers of procedures performed, there is a paucity of data to guide treatment paradigms. This systematic review aims to establish a simple, unifying classification scheme for labial protrusion and summarize current labiaplasty techniques and practices. METHODS: A systematic literature review was performed using the PubMed database. Additional articles were selected after reviewing references of identified articles. RESULTS: The search returned 247 articles. After applying inclusion criteria to identify prospective and retrospective studies evaluating different techniques, outcomes, complications, and patient satisfaction, 19 articles were selected. Labiaplasty of the labia minora was described in 1949 patients. Seven different surgical techniques were used for labiaplasty, including deepithelialization, direct excision, W-shaped resection, wedge resection, composite reduction, Z-plasty, and laser excision. Patient satisfaction rates for each technique ranged from 94 to 100 percent. The most common postoperative complication for all techniques was wound dehiscence (4.7 percent). Key areas for perioperative patient management were defined. CONCLUSIONS: Labiaplasty is safe and carries a high satisfaction rate. However, current practices remain exceedingly diverse. The authors propose a simplified classification system based on the distance of the lateral edge of the labia minora from that of the labia majora, rather than from the introitus. Key areas for perioperative patient management include patient anesthesia, resection technique used, wound closure, and postoperative care. Further randomized studies using a standardized classification system are required to better compare different techniques and establish best practices.

Vulvar inflammatory dermatoses: an update and review.

Currently, urogenital complaints are among the most common problems encountered by family practitioners, gynecologists, and dermatologists. In response to the intricacy of vulvar disorders, the International Society for the Study of Vulvovaginal Disease was created to facilitate the exchange between clinicians and pathologists involved in the care of these patients. Recent classifications for inflammatory disorders and intraepithelial neoplasm have been proposed. In addition, vulvar skin biopsies are the most common source of intradepartmental consultation during dermatopathology sign-out. The purpose of this article is to review the various inflammatory dermatoses of the vulva and to update readers with new advances regarding these entities.

Incidence of genital warts in adolescents and young adults in an integrated health care delivery system in the United States before human papillomavirus vaccine recommendations.

BACKGROUND: Information on genital wart incidence in adolescents and young adults before human papillomavirus (HPV) vaccination is important for understanding the impact of the vaccine on the epidemiology of this early outcome of HPV infection. METHODS: The study population included 11- to 29-year-old enrollees of Northern California Kaiser Permanente between July 1, 2000, and July 1, 2005, before the availability of the HPV vaccine. We identified genital warts with an algorithm combining genital wart-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes (078.10, 078.11, and 078.19) with physician-recorded anatomic locations. We calculated sex- and age-specific incidence rates of genital warts and described the specific anatomic location of presentation, as well as recurrences of genital warts. RESULTS: We identified 1,682 cases of genital warts among 181,264 individuals. The incidence rate was highest among women (6.3/1000 person-years) and men (2.9/1000 person-years) aged 20 to 24 years old. Among women (n = 96,792), 63.4% of the 1240 incident genital wart cases occurred on the vulva and 21.1% on the cervix. Among men (n = 84,472), 91.6% of the 442 incident genital wart cases did not have a specific anatomic location recorded. Most people with an incident genital wart diagnosis (87.2%) did not have a recurrence during the observation period. CONCLUSIONS: Our study found that the incidence of genital warts was highest among persons aged 20 to 24 years using a unique method to identify the location of the wart. Information on incidence of genital warts before vaccine use provides baseline data that can be used to measure HPV vaccine impact.

[Review of current classification and terminology of vulvar disorders]. / Prehled soucasné klasifikace a terminologie onemocnení vulvy.

OBJECTIVE: To summarize current terminology and classification of vulvar disorders. DESIGN: Review article. SETTING: Gynecologic oncology center, Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Medical School of Charles University, Prague. METHODS AND RESULTS: Vulvar disorders include wide spectrum of different diagnoses. Multidisciplinary collaboration is frequently needed in diagnostical and therapeutical process. It is essential to use unified terminology using standard dermatological terms, and unified classification for comprehensible communication between different medical professions. Current classification, which is based on Clinical-pathological criteria, was established by International Society for the Study of Vulvovaginal Disease. Recently, there was introduced Clinical classification, which groups disorders according to main morphological finding. CONCLUSIONS: Adequate and unified classification and terminology are necessary for effective communication during the diagnostical process.

2011 terminology of the vulva of the International Federation for Cervical Pathology and Colposcopy.

OBJECTIVE: This study aimed to present the clinical and colposcopic terminology of the vulva (including the anus) of the International Federation of Cervical Pathology and Colposcopy. MATERIALS AND METHODS: The terminology has been developed by the International Federation of Cervical Pathology and Colposcopy Nomenclature Committee during 2009-2011. RESULTS: The terminology is part of a comprehensive terminology of the lower genital tract, allowing for standardization of nomenclature by colposcopists, clinicians, and researchers taking care of women with lesions in these areas. The terminology includes basic definitions and normal findings that are important for the clinician lacking experience with management of vulvar disease. This terminology introduces definitions for abnormal findings recently accepted by the International Society for the Study of Vulvovaginal Disease and includes patterns to identify malignancy. CONCLUSIONS: The terminology differs from past terminologies in that it includes colposcopic patterns and anal colposcopy. Nevertheless, the role of the colposcope in the management of vulvar disease is limited.

Coexistence of two types of clinical lesions in childhood-onset mastocytosis.

The vast majority of mastocytosis appear in childhood, urticaria pigmentosa (UP) and mastocytomas being the most common types. Terms such as "xanthelasmoid mastocytosis", "pseudoxanthomatous mastocytosis" or "nodular mastocytosis" have been introduced in the literature to describe the presence of yellowish papular or nodular lesions. We describe two children with cutaneous mastocytosis showing yellowish lesions in combination with other skin lesions. A 10-year-old girl presented with asymptomatic lesions in her vulva at birth, and developed brownish macules on her trunk years after. An eight-year-old boy presented with multiple yellowish papular lesions on his trunk, neck and limbs coexisting with a few clinically anetodermic lesions. No systemic involvement was found and the skin biopsy confirmed a cutaneous mastocytosis in both cases. The two patients are currently asymptomatic and are being periodically followed up. Mastocytoses may show a variety of clinical lesions, sometimes leading to misdiagnosis. Although there are previous reports, involvement of the mucosae and secondary anetoderma are not common findings in cutaneous mastocytoses. We consider that cutaneous manifestations of mastocytoses compose a clinical spectrum, thus explaining the coexistence of different clinical lesions and the development of uncommon presentations.

Reactive fibroblastic and myofibroblastic proliferation of the vulva (Cyclist's Nodule): A hitherto poorly described vulval lesion occurring in cyclists.

Perineal nodules occurring in male cyclists are reported in the literature, although the histologic features are not extensively documented. There has been little description of similar lesions in the female population. We describe 4 cases in which a vulval nodule or swelling developed in competitive female cyclists aged 15 to 45 years. The lesions were unilateral and occurred on the right or left labium majus (2 cases each). The histologic features were similar in all cases and consisted of a haphazard admixture of adipose tissue, variably cellular hyalinized tissue containing bland spindle-shaped fibroblasts, blood vessels, and nerve fibers. In some areas, thick cords of fibrous tissue imparted a keloid-like appearance. Other histologic features included plump mesenchymal cells with round or ovoid nuclei and abundant eosinophilic cytoplasm resulting in an epithelioid, plasmacytoid, or ganglion-like appearance (2 cases), a lymphocytic infiltrate around blood vessels (3 cases), foci of fat necrosis (1 case), and collections of elastic fibers (2 cases). One case recurred, the histologic features of the recurrent lesion being identical to the original. The overall morphologic appearances, especially in the cases with plump mesenchymal cells, bore some resemblance to proliferative fasciitis. Immunohistochemically, the cells were estrogen receptor positive and the plump mesenchymal cells were smooth muscle actin positive, in keeping with myofibroblasts. Desmin, S100, CD34, and HMGA2 were negative. Pathologists should be aware of this pseudoneoplastic lesion occurring on the vulva, which arises in a specific clinical setting and has the potential to be misdiagnosed as a variety of other mesenchymal lesions. We term this lesion as reactive fibroblastic and myofibroblastic proliferation of the vulva or "cyclist's nodule."

Vulvodynia.

INTRODUCTION: Vulvodynia is increasingly recognized as a cause of sexual pain. Aim. The goal of this Continuing Medical Education article was to provide a comprehensive review of vulvodynia including terminology, possible etiologies, and offer treatment options. METHODS: A Medline search was conducted using several terms related to and including the terms vulvodynia, vulvar vestibulitis, vestibulodynia, and pudendal neuralgia. RESULTS: A thorough review of vulvodynia. CONCLUSION: Vulvodynia most likely represents several disorders without an identifiable cause in many cases. The management of these patients requires a sensitive provider who can coordinate a multidisciplinary approach to their care. Despite the lack of large-scale, placebo-controlled trials, several new treatment options exist.

Human papillomavirus (HPV) profiles of vulvar lesions: possible implications for the classification of vulvar squamous cell carcinoma precursors and for the efficacy of prophylactic HPV vaccination.

The term vulvar intraepithelial neoplasia (VIN) introduced in 1986 incorporates 3 grades of usual VIN (u-VIN I-III) and the differentiated VIN (d-VIN). Although u-VIN is etiologically associated with the human papillomavirus (HPV) infection, d-VIN represents an alternative HPV negative pathway of vulvar carcinogenesis. In 2004, the u-VIN I category was abandoned and u-VIN II and III were merged. Further, an alternative Bethesda-like terminology scheme presenting the term vulvar intraepithelial lesion was proposed recently. To analyze the impact of HPV profiles of vulvar precancerous lesions for their classification and to assess the presumable efficacy of the prophylactic HPV vaccination, 269 vulvar excisions representing lichen sclerosus, lichen simplex chronicus, condylomata acuminata, d-VIN, all grades of u-VIN and squamous cell carcinomas were subjected to the HPV typing by use of GP5+/6+ polymerase chain reaction and reverse line blot hybridization. The results showed different HPV profiles, and also differing frequency of multiple-type HPV infection and the age structure in patients with u-VIN II and III. The biologic heterogeneity within the u-VIN II category was also demonstrated. u-VIN I was distinguished as a rare disorder associated with high-risk HPV infection. We conclude that the original VIN terminology proposed in 1986 seems to be appropriate for the classification of vulvar squamous dysplastic lesions. The spectrum of HPV types found in vulvar squamous cell carcinomas indicates that the efficacy of HPV vaccination in preventing vulvar cancer might be diminished in the studied population, because the recently developed prophylactic vaccines are targeted against a limited number of HPV types.

Inflammatory dermatoses of the vulva.

Inflammatory, non-neoplastic epidermal alterations of the vulva can be correctly diagnosed using classification schemes applied to skin elsewhere on the body. A wide range of inflammatory disorders may occur on the vulva, and they may have a similar clinical presentation to HPV lesions. However, HPV is incurable and often is treated surgically. Accordingly, as inflammatory dermatoses commonly occur on the vulva and are often curable with topical therapy, an awareness of these entities and an ability to distinguish them from HPV are imperative.

The vulvodynia guideline.

OBJECTIVE: To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia. MATERIALS AND METHODS: Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition. RESULTS: Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient. CONCLUSIONS: Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.