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.

Granulomatous cheilitis with granulomatous vulvitis: a rare association.

Granulomatous cheilitis and granulomatous vulvitis are rare disorders characterized by painless swelling of lips and vulva, respectively. Histopathology of both conditions show non-caseating epithelioid cell granulomas in the dermis. Both disorders have been associated with Crohn's disease rarely. Occurrence of the two conditions in the same patient is extremely infrequent. We hereby report, the association of granulomatous cheilitis with granulomatous vulvitis in a 30-year-old female.

[A woman with cayenne pepper spots]. / Een vrouw met roestbruine plekjes op de vulva.

A 52-year-old female with dyspareunia presented with red-brown maculae at the vulva.Biopsy revealed an inflammatory cell infiltrate mostly consisting of plasma cells, and the diagnosis 'vulvitis circumscripta plasmacellularis' was established.A biopsy is mandatory to confirm this rare benign inflammatory disorder of the vulva.

A case of idiopathic granulomatous cheilitis and vulvitis.

A 36-year-old woman presented with chronic recurring dermatitis of the vulva, perineum, and lips. The genital lesions had a 3-year history and were associated with slight pruritus and occasional pain. The lesions of the upper lip had a history of 6 months. The patient had been treated with cycles of antimycotics and topical steroids which only partially controlled the symptoms during treatment. Dermatologic examination showed erythematous, infiltrative dermatitis with edema of the labia majora and persistent edema of the upper lip (Fig. 1a,b). Routine blood chemistry, urine analysis, and chest X-ray were normal. Microscopic examination and cultures of vaginal swabs did not reveal any pathogenic bacteria or fungi. Histologic examination of a biopsy of vulval lesional skin showed lichenoid lymphocytic infiltration of the papillary dermis and small, nonnecrotic epithelioid granulomas in the deep dermis (Fig. 1c,d). No microorganisms, including acid-fast bacilli or fungi, were identified. Culture was negative for fungi. Polymerase chain reaction was negative for the mycobacterial genome. Histologic examination of a biopsy from the upper lip showed similar results. The pathology reports of both regions were compatible with a diagnosis of granulomatous cheilitis and vulvitis. To investigate concomitant asymptomatic inflammatory bowel disease, the patient underwent colonoscopy with retrograde ileoscopy and gastroscopy, which were both negative. The patient refused radiographic examination of the small intestine with a barium meal. The patient was treated with systemic metronidazole (500 mg/day). After 6 months of therapy, the upper lip showed significant improvement and erythema and desquamation in the genital area showed slight improvement, but genital edema was unaffected.

[Rosacea fulminans, pyostomatitis and pyovulvitis in Crohn's disease: dapsone as key factor in combination therapy]. / Rosacea fulminans, pyostomatitis und pyovulvitis bei morbus Crohn: dapson als entscheidender wirkstoff einer erfolgreichen kombinationstherapie?

Rosacea fulminans (also known as pyoderma faciale) has been reported to occur in association with Crohn's disease. It is still unclear whether the papulopustules and confluent nodules of rosacea fulminans represent a manifestation of mucocutaneous Crohn's disease or whether this association is a mere coincidence. A 46-year-old woman presented with the spontaneous outbreak of rosacea fulminans and pyostomatitis/pyovulvitis. Complete remission of the mucocutaneous symptoms was achieved with 2 months combination therapy with methylprednisolone, isotretinoin and dapsone. The patient's Crohn's disease, already diagnosed for 3 years, did not flare during this period.

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.

Idiopathic granulomatous vulvitis.

A 20-year-old woman initially presented with clinical evidence of an acute vulval inflammatory disorder incorrectly diagnosed as a Bartholin's abscess. Prolonged healing associated with infection followed attempts to incise and biopsy the area. Over a decade the condition has followed a chronic course with exacerbations and remissions and the vulva has become progressively more swollen and distorted. Lymphangiomas have developed. Histology showed non-necrotizing granulomas. Investigations for Crohn's disease and sarcoidosis were negative. Prednisone resulted in improvement during acute inflammatory episodes.

Estrogen receptor expression in vulvar vestibulitis syndrome.

OBJECTIVE: A pilot study was performed to investigate the relationship between vulvar vestibulitis syndrome and estrogen receptor expression. STUDY DESIGN: Women with a diagnosis of vulvar vestibulitis syndrome had tissue samples taken for vulvar estrogen receptor-alpha expression and this was compared with a control group. RESULTS: The study group showed a significant decrease in estrogen receptor expression, and 50% of the samples did not exhibit any receptor expression. CONCLUSION: There appears to be a subgroup of women with vulvar vestibulitis syndrome who exhibit abnormal estrogen receptor-alpha expression. This may be helpful in explaining why some women are resistant to medical treatment and may allow treatment to be prescribed more effectively.

New concepts in vulvodynia.

Vulvodynia is chronic vulvar burning/pain without clear medical findings. The etiology of vulvodynia is unknown and health care professionals should thoroughly rule out specific, treatable causes or factors such as dermatoses or group B Streptococcus infections. Vulvodynia is divided into 2 classes: vulvar vestibulitis syndrome is vestibule-restricted burning/pain and is elicited by touch; dysesthetic vulvodynia is burning/pain not limited to the vestibule and may occur without touch/pressure. After diagnosis, critical factors in successful patient management include education and psychological support/counseling. Unfortunately, clinical trials on potential vulvodynia therapies have been few. Standard therapy includes treating neuropathic pain (eg, tricyclic medications, gabapentin) thought to play a role. Additional therapies may be considered: pelvic floor rehabilitation combined with surface electromyography, interferon alfa, estrogen creams, and surgery. Importantly, any therapy should be accompanied by patient education and psychological support. Because definitive data on effective therapies are lacking, further clinical investigations of treatment options are warranted.

[Perianal Bowen's disease: a case report and review of the literature]. / Perianal Bowen's disease: a case report and review of the literature.

Perianal Bowen's disease is a uncommon, slow growing, intraepidermal squamous-cell carcinoma (carcinoma in situ) of the anal region and may be a precursor to squamous carcinoma of the anus. It is associated with cervical and vulvar intraepithelial neoplasia and have human papillomavirus as a common cause. Both sexes and all races are affected, with the highest prevalence in patients aged 20 to 45 years. The symptoms of anal Bowen's disease are unspecific and the clinical findings are uncharacteristic and include pain, itching, bleeding and a disturbing lump. Biopsy and histopathologic examination is required for diagnosis and to distinguish other perianal dermatoses; thus an anogenital warts that fail to respond to conventional therapy, or change in appearance, warrant a biopsy and, where the technique is available, DNA typing to identify the viral pathogen. Infact the etiologic agent, the human papillomavirus (HPV), has been classified by DNA techniques into at least 42 types, of which 16 and 18 are considered to carry a high risk for cancer. The intraoperative findings is a lesion at the anocutaneous line: perianal or intra-anal tumor, erosion or ulceration as well as lichenoid lesion or hyperpigmentation. The disease has a proclivity for recurrence and there are many controversies concerning treatment that effectiveness remains uncertain and range from aggressive wide local excision with skin grafting when necessary to laser vaporization (argon or CO2), radiotherapy or a new immune response modifier (Imiquimod). We report a case of a 50-years-old woman with recurrence of Bowen's disease associated with vulvar HPV infection and review the literature.

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.

Outcome of surgical treatment for superficial dyspareunia from vulvar vestibulitis.

OBJECTIVE: To evaluate the results of surgical treatment for superficial dyspareunia, as manifested by patient satisfaction, as well as epidemiologic characteristics of women with this medical problem. STUDY DESIGN: A questionnaire was sent to 69 women six months after the operation. It included questions about treatment before surgery and the impact of pain on the sexual relationship before and after the operation. Demographic, social and general health data were recorded before the operation. All patients returning the questionnaire were examined. RESULTS: Fifty-four (78%) patients replied. Half of those abstained from sexual relations before surgical treatment. Sixty-seven percent of patients required more than six visits to various physicians, before vestibulitis was diagnosed. Prior to surgery, 80% of patients received conservative treatment, whereas after surgery only 34% required it. A moderate to excellent improvement was reported after surgery by 45 (83%) patients. Repeat surgery (n = 7) resulted in further improvement in four patients. There were no major operative complications. Forty-five patients (83%) were satisfied with the results and would recommend the surgery to other women with this clinical problem. CONCLUSION: Surgical treatment for superficial dyspareunia from vestibulitis is quite safe and results in a high rate of patient satisfaction.

Granulomatous vulvitis, granulomatous cheilitis: a single diagnosis?

We report two cases of labial swelling (oral and vulvar) with a granulomatous histology in patients with a history of Crohn's disease. The differential diagnosis of granulomatous vulvitis and cheilitis, as well as the symptomatology and treatment of vulvar and oral Crohn's disease are further discussed. To our knowledge, reported cases of vulvar and oral Crohn's disease are quite scarce in the literature, but the disease might be underdiagnosed. We hope to contribute to an earlier recognition and a better management of the vulvar and oral mucocutaneous lesions of Crohn's disease.

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.