Vulvar pruritus-Causes, Diagnosis and Therapeutic Approach.

BACKGROUND: In Germany, 17-23% of the population suffers from chronic itching of the skin; in 5-10% of cases, the female genitalia are affected, specifically, the vulva. Vulvar pruritus is thus a common symptom that often markedly impairs the affected women's quality of life. METHODS: This review is based on pertinent publications that were retrieved by a selective search in MEDLINE/PubMed for articles on the pathogenesis, diagnosis, and treatment of vul- var pruritus. The search terms were (in German and English) "vulvärer Juckreiz," "pruritus vulvae," and "genital itch," alone and in combination with "Behandlung," "Therapie," or "treat- ment." RESULTS: The most common cause of vulvar pruritus is vulvo- vaginal candidiasis followed by chronic dermatoses, such as lichen sclerosus and vulvar eczema. Especially in refractory cases, an invasive or preinvasive lesion such as squamous epithelial dysplasia (VIN, vulvar intraepithelial neoplasia) should be borne in mind in the differential diagnosis. Rarer causes include infection, atrophy, and vulvodynia. The essen- tial elements of treatment are topical/oral antimycotic drugs and high-potency glucocorticoids, along with consistently ap- plied, basic moisturizing care and the avoidance of potential triggering factors. CONCLUSION: As vulvar pruritus has multiple causes, standard- ization of its diagnostic evaluation and treatment would be l efficacy and to meet the diverse needs of women who suffer from this condition.

Telephone triage: diagnosis of candidiasis based upon self-reported vulvovaginal symptoms.

OBJECTIVE: The study aimed to determine which self-reported vulvovaginal symptoms are most consistent with candidiasis confirmed by yeast culture and to establish guidelines to determine who can be appropriately treated by telephone triage versus office examination for women with vulvovaginal symptoms. MATERIALS AND METHODS: A retrospective chart review of 105 patients seen in the Saint Louis University Vulvar and Vaginal Disorders Specialty Center during a 14-month period was performed after institutional review board approval. Patient's age, medication use, symptom scores on a Likert rating scale for vaginal/vulvar pain, burning, itching, dyspareunia, wet-mount results, and yeast culture results were recorded. Differences in the occurrence of vaginal/vulvar symptoms of any severity between women with positive and with negative yeast culture results were calculated using χ2 and Fisher exact tests. Differences in symptom scores of any severity were compared between women with positive and with negative yeast culture results using nonparametric Kolmogorov-Smirnov test, owing to a lack of normality of the distributions. Sensitivity of 75% or greater and specificity of 67% or greater were sought for all 9 recorded symptoms. Multiple logistic regression analysis was used to determine which symptoms and their cutoff values were significant independent predictors of a positive yeast culture result. Receiver operating characteristic curve analysis was used to determine the efficacy of individual symptoms and combinations of symptoms for predicting a positive yeast culture result. A value of p < 0.05 was used to denote statistical significance. RESULTS: Four vulvovaginal symptoms met cutoff criteria for analysis to predict a positive yeast culture result: vaginal burning, vulvar burning, vulvar itching, and clitoral pain. Vaginal burning with a score of 6 or greater (p < 0.001) and vulvar itching with a score of 5 or greater (p < 0.05) were significant independent predictors of a positive yeast culture result. Women with both a vaginal burning score of 6 or greater and a vulvar itching score 5 or greater had a positive predictive value of 91.7% (22/24). Vaginal discharge was not shown to be predictive of candidiasis. CONCLUSIONS: Diagnosis of candidiasis using self-reported vulvovaginal symptoms by telephone triage is difficult. Self-reported scores for vaginal burning of 6 or greater and for vulvar itching of 5 or greater are significant indicators of a positive yeast culture result. Vaginal discharge was not predictive of a diagnosis of candidiasis. A symptom chart can aid office staff in telephone triage of symptomatic women.

The impact of the latest classification system of benign vulvar diseases on the management of women with chronic vulvar pruritus.

BACKGROUND: The management of women with chronic benign vulvar dermatoses has been one of the most difficult and challenging aspects of women's healthcare for a long time. AIM: Our aim was to compare the ability to approach the specific diagnosis of nonneoplastic and noninfectious vulva diseases, between the new classification system and the old classification system. METHODS: One hundred women with chronic vulvar pruritus were included in the study. After detailed examination of the vulva, all visible lesions were biopsied, with normal skin included. All specimens was sent for dermatopathology and examined simultaneously under a binocular microscope by two pathologists. Specific diagnosis if possible and histopathological findings were classified according to both the 1987 and 2006 International Society for the Study of Vulvar Diseases (ISSVD) classifications. The ratios that were able to be approached on the specific diagnosis, with the aid the two classification systems, were compared. RESULTS: Specific clinical diagnosis by both pathological and after using clinicopathological correlation was possible in 69 out of 91 patients (75.8%) according to the 1987 ISSVD classification, and in 81 out of 91 patients (89.0%) according to the ISSVD 2006 classification system. The difference in the clinical diagnosis ratios between the two classification systems was statistically significant ( P < 0.05). In a subgroup of women without specific diagnosis at the time of pathological examination, clinical diagnosis was made in 28 out of 50 women (56%) after using the clinicopathological correlation according to the ISSVD 1987 classification, whereas, specific diagnosis was made in 39 out of 49 (79.6%) women after using the clinicopathological correlation according to the ISSVD 2006 classification. The difference was statistically significant in terms of the ratio of the ability to achieve a specific diagnosis (P < 0.01). CONCLUSION: ISSVD 2006 classification of nonneoplastic and noninfectious vulvar disease is more useful than the former classification, in terms of approaching the specific diagnosis of vulvar dermatoses.

Clinical care of vulvar pruritus, with emphasis on one common cause, lichen simplex chronicus.

Vulvar pruritus is a common and distressing condition for patients, and its presentation is often delayed and complicated by home remedies. The true prevalence cannot be accurately estimated. Vulvar pruritus is a symptom, and an underlying cause must be sought and not assumed. This is best accomplished by obtaining a careful history of vulvar care regimens and treatments, performing a detailed physical examination, and considering a broad differential diagnosis. This article provides a practical and clinical approach to the evaluation of vulvar pruritus and then focuses specifically on one common cause, lichen simplex chronicus.

Nena de 7 anys amb pruïja a làrea genital / No disponible

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A retrospective study of relevant diagnostic procedures in vulvodynia.

OBJECTIVE: To identify objective clinical signs of vulvodynia and determine specific diagnostic tests for vulvodynia in women referred to a vulvar outpatient clinic for vulval complaints. STUDY DESIGN: A retrospective study was performed of the medical records of 201 consecutive Danish patients suspected of suffering from vulvodynia who were referred to a vulvar outpatient clinic (Department of Gynecology, Rigshospitalet University Hospital) between October 2003 and January 2006. RESULTS: Of 201 women, 117 were diagnosed with vulvodynia and 84 had other diagnoses. Of the women diagnosed with vulvodynia in the vulvar clinic, 88.9% were correctly diagnosed before referral. The women with vulvodynia were more likely to report dyspareunia (chi2 = 7.89, p = 0.005) and stinging pain (chi2 = 3.74, p = 0.05). The nonvulvodynia group was more likely to report a tendency toward fissures (chi2 = 5.94, p < 0.05). CONCLUSION: Self-reported dyspareunia and stinging pain are strongly associated with vulvodynia. Self-reported pruritus and a tendency toward fissures are not likely to be associated with vulvodynia. Whether vulvar biopsies should be performed regularly when redness and pain is present must be explored further in prospective studies.

Threadworm: an infrequent clinical finding in a genitourinary medicine clinic attendee presenting with ano-genital irritation.

A 24-year-old lady presented to an evening genitourinary (GU) clinic with a short history of vulval and anal irritation. On perianal examination, several threadworms were visible. Symptoms resolved with oral mebendazole and strict personal and environmental hygiene. Threadworm is a common and easily treatable cause of pruritus ani, yet is underreported in GU literature. If the history is suggestive, consider performing the diagnostic cellophane test and/or prescribing empirical treatment.

Siringomas vulvares: una causa infrecuente de prurito vulvar / Vulvar syringoma: a rare cause of vulvar pruritus

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Itch and burning pain in women with partial vaginismus with or without vulvar vestibulitis.

Fifty-three women with partial vaginismus with or without vulvar vestibulitis and 27 asymptomatic women estimated sensations of burning pain and itch at 20 standardized moments during a standardized penetration situation, including vaginal muscle contractions. Forty-three women with partial vaginismus (81.1%) reported burning pain, 23 (43.4%) itch, and 22 (41.5%) both complaints, compared to 0% of the asymptomatic women. In 17 of 22 cases, burning pain preceded the appearance of itch and in four cases the two complaints coincided. The median time from the moment when burning pain started until itch appeared was 150 seconds.

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.

Vulvar disease.

Unique embryologic and immunologic aspects of the vulva contribute to the diagnostic and therapeutic challenges of managing vulvar problems. Individual variations in care of the genital region, defined by personal and societal "norms," may at times exacerbate vulvar problems. Three dimensions are considered in the evaluation of a vulvar problem: 1) lesion type, 2) lesion location, and 3) associated systemic and laboratory findings. This review of vulvar disease highlights a number of common and problematic vulvar conditions. Treatment options for vulvar conditions are covered with an expanded discussion of newer immune response modifiers.