Vulvar Ulcers: An Algorithm to Assist With Diagnosis and Treatment.

OBJECTIVES: Vulvar ulcers can be challenging to diagnose, manage, and treat. Ulcers can be nonspecific in appearance and have many etiologies. Description of the lesion is very important. METHODS: An interactive vulvar ulcer algorithm was created to aid in the evaluation, diagnosis, and treatment of vulvar ulcers. RESULTS: The algorithm flowchart begins with careful history and physical examination. Pending these, specific tests can be obtained to aid in diagnosis. The algorithm also links to appropriate treatments. The algorithm can be accessed on the International Society for the Study of Vulvovaginal Disease Web site ( issvd.org ). Each underlined word in the algorithm is a hyperlink that leads to a wealth of information on the topic that providers can use to direct testing and aid in diagnosis and treatment. CONCLUSIONS: The vulvar ulcer algorithm can help clinicians with diagnosis and treatment plans.

Outcomes After Lysis of Adhesions and Dilator Placement for Treatment of Vulvovaginal Agglutination Due to Lichen Planus.

OBJECTIVE: The aim of the study is to determine intraoperative and postoperative surgical outcomes for the treatment of vulvovaginal agglutination secondary to lichen planus (LP) following a standard protocol using intraoperative dilator placement and postoperative intravaginal steroid use. MATERIALS AND METHODS: This was a retrospective chart review of patients who underwent surgical management of vulvovaginal agglutination due to LP following a protocol that included surgical lysis of vulvovaginal adhesions, intraoperative dilator placement and removal 48 hours later, and high-potency intravaginal corticosteroid and regular dilator use thereafter. Demographic and clinical data were abstracted from the medical record and analyzed using descriptive statistics. RESULTS: Thirty-four patients, with mean age 51.2 ± 11 years and body mass index 32.8 ± 8.5 kg/m 2 , underwent lysis of vulvovaginal adhesions between 1999 and 2021 with 8 different surgeons at a single institution. The mean preoperative, immediate postoperative, and 6-week postoperative vaginal lengths were 2.8 ± 1.8 cm ( n = 18), 8.0 ± 1.9 cm ( n = 21), and 7.9 ± 2.2 cm ( n = 16), respectively. The mean estimated blood loss intraoperatively was 16 ± 15 mL. No patients had a documented surgical site infection or reoperation within 30 days after surgery. Of patients who had it documented ( n = 26), 70% (18/26) reported postoperative sexual activity. Where documented, 100% (18/18) reported preoperative dyspareunia, while 17% (3/18) did postoperatively. Six percent (2/34) had recurrent severe agglutination and 3% (1/34) underwent reoperation. CONCLUSIONS: Lysis of vulvovaginal adhesions, intraoperative dilator placement, and postoperative intravaginal corticosteroids with dilator use is a safe and effective treatment option to restore vaginal length for those with vulvovaginal LP.

Fertility and Pregnancy Outcomes After Conservative Management of Adenocarcinoma In Situ of the Cervix.

OBJECTIVE: The aim of the study was to evaluate the pregnancy outcomes of women who underwent conservative management of adenocarcinoma in situ (AIS). MATERIALS AND METHODS: We conducted a retrospective chart review of patients diagnosed with AIS at a single tertiary institution between January 1, 1991, and December 31, 2019. We collected demographic data, AIS-specific information, and fertility outcomes and performed bivariate analyses to compare demographic characteristics and AIS-specific information between patients with and without hysterectomy after diagnosis. Patients with conservative management who achieved pregnancy were described. RESULTS: Among 87 patients with AIS, 38 (44%) underwent a hysterectomy within 6 months of diagnosis and 49 (56%) underwent conservative management. Six of 19 patients (32%) had residual AIS despite undergoing definitive management after an excisional procedure with negative margins and negative endocervical curettage (ECC). Nine of 19 patients (47%) had residual AIS after an excisional procedure with positive margins and/or a positive ECC. Patients who opted for conservative management were younger (median = 31.6 [interquartile range = 27.4-34.9] vs 38.5 y [32.3-44.8 y], p < .001) and nulligravid. Among patients with conservative management, there were 15 pregnancies and 14 live births (29%). Seven were preterm, although 2 were for medical indications. CONCLUSIONS: Residual AIS in patients with negative margins and ECC leading to definitive hysterectomy (32%) and the rate of preterm birth (36%) were higher than previous reports and nationally reported rates. However, only 1 patient had a preterm birth before 34 weeks. These findings reflect important information for counseling patients who elect for conservative management of AIS.

Cytomegalovirus Infection in Pregnancy: Prevention, Presentation, Management and Neonatal Outcomes.

Congenital cytomegalovirus (cCMV) is the most common congenital infection in the United States, with 1 of 200 live births affected. It is the leading viral cause of intrauterine fetal demise and miscarriage. It is a common cause of neonatal hearing loss, second only to genetic factors. Yet, health care provider awareness remains low. The purpose of this article is to provide a brief overview of the epidemiology, presentation, diagnosis, and treatment of antenatal cytomegalovirus (CMV) infection and cCMV in the neonate. Maternal CMV infection in pregnancy often presents with mild cold-like symptoms or is asymptomatic. The virus can be vertically transmitted to a growing fetus, the risk of transmission and severity of fetal impact varying by timing of exposure during pregnancy. Most neonates born with cCMV show no signs at birth, yet 15% to 25% will have long-term adverse neurodevelopmental conditions. Misconceptions that cCMV cannot be prevented or that neonates born without signs of the disease will be unaffected are common. Evidence supporting antenatal education around behavioral change to lower a woman's risk of acquiring CMV during pregnancy is mounting. CMV infection during pregnancy should be co-managed with a maternal-fetal medicine specialist. There is early evidence for the use of antiviral medication in reducing risk of vertical transmission. Identification of cCMV during pregnancy may help ensure the neonate receives timely treatment after birth. Midwives can play an important role in providing antenatal education about cCMV risk reduction and in initiating a diagnostic evaluation when there is clinical suspicion.

Vulvar lichen sclerosus in the elderly: pathophysiology and treatment update.

Lichen sclerosus is a chronic skin condition that most commonly affects the anogenital skin of postmenopausal women. The aetiology of the condition is multifactorial. The most common presenting symptom is itching. Lichen sclerosus has a characteristic appearance. Diagnosis is made with vulvar biopsy. Treatment is important and the regimen most often includes topical corticosteroid ointments. Lifetime surveillance of the skin is imperative because of the increased risk of squamous cell carcinoma in patients with lichen sclerosus.

McGill pain questionnaire findings among women with vulvodynia and chronic yeast infection.

OBJECTIVE: To determine whether patients referred for vulvar pain or candidiasis had different characteristics of pain as measured by the McGill Pain Scale or the number of McGill categories chosen. STUDY DESIGN: Data were collected at the University of Michigan Center for Vulvar Diseases between April 1998 and March 2003. The association between the McGill pain score and the number of McGill categories selected with the diagnostic categories of vestibulodynia, generalized vulvodynia and chronic yeast infections were evaluated. RESULTS: A total of 196 women presented with vulvodynia (105 women with vestibulodynia, 91 women with generalized vulvodynia) and 50 women presented with Candida vulvovaginitis. The vulvodynia groups had McGill scores and numbers of categories selected that were increased compared with the Candida group (24.16+/-13.03 and 24.37+/-12.82 vs. 16.20+/-10.21 for the McGill score, p<0.001, and 9.22+/-4.11 and 9.87+/-4.44 vs. 7.30+/-3.70 for the numbers of categories selected, p = 0.002). CONCLUSION: Patients presenting with complaints of a yeast infection have a statistically lower McGill pain score and McGill pain indicators compared with patients with vulvar pain.

Intrauterine adhesions after manual vacuum aspiration for early pregnancy failure.

OBJECTIVE: To describe the occurrence of intrauterine adhesions after manual vacuum aspiration for early pregnancy failure. DESIGN: Case series. SETTING: Tertiary care center. PATIENT(S): Three women with intrauterine adhesions after manual vacuum aspiration for the treatment of early pregnancy failure. INTERVENTION(S): Chart review. MAIN OUTCOME MEASURE(S): Hysteroscopic diagnosis of intrauterine adhesions after manual vacuum aspiration. RESULT(S): Three cases of symptomatic intrauterine adhesions after manual vacuum aspiration. CONCLUSION(S): Intrauterine adhesion formation may follow manual vacuum aspiration for early pregnancy loss.