Vulvovaginal manifestations in Stevens-Johnson syndrome and toxic epidermal necrolysis: Prevention and treatment.

The prevalence of acute vulvovaginal involvement in toxic epidermal necrolysis can be as high as 70%; up to 28% of female patients will also develop chronic vulvovaginal sequelae. There is little consensus regarding prevention and treatment of the gynecologic sequelae of both Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). We review acute and chronic sequelae, including erosions, scar formation, chronic skin changes, urethral complications, adenosis, malignant transformation, vulvodynia, and dyspareunia. We provide comprehensive recommendations for acute and long-term vulvovaginal care in adult and pediatric SJS/TEN patients. Treatment should include an ultrapotent topical steroid, followed by a nonirritating barrier cream applied to vulvar and perineal lesions. A steroid should be used intravaginally along with vaginal dilation in all adults (but should be avoided in prepubertal adolescents) with vaginal involvement. Menstrual suppression should be considered in all reproductive age patients until vulvovaginal lesions have healed. Last, referrals for pelvic floor physical therapy and to surgical subspecialties should be offered on a case-by-case basis. This guide summarizes the current available literature combined with expert opinion of both dermatologists and gynecologists who treat a high volume of SJS/TEN patients.

Time-trend of hospitalizations for anogenital warts in Veneto region in the HPV vaccination era: a cross sectional study (2007-2018).

BACKGROUND: Human papillomavirus (HPV) is a common sexually transmitted pathogen and the cause of several cancers and of anogenital warts. With this study, we estimated the trend of hospitalizations for anogenital warts (AGWs) in the Veneto region (Italy) from 2007 to 2018. METHODS: The analysis included all the hospital discharge records of public and accredited private hospitals occurred in Veneto residents in the timespan 2007-2018. The ICD9-CM code 078.11 considered were those associated with condyloma acuminatum and those associated with surgical interventions for vulval/vaginal warts, penile warts anal warts. Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period. RESULTS: We observed an overall reduction of hospitalization rates for AGWs: from 15.0 hospitalizations every 100,000 Veneto residents in years 2007-08 to 10.9 hospitalizations every 100,000 Veneto residents in year 2017-18 (- 37.4%; p < 0.05). Reduction has been caused by a drop in hospitalizations in females - from a rate of 20.4/100,000 in 2007-2008 to a rate of 10.8/100,000 in 2017-18 (AAPC: -7.1; 95%CI: - 10.6;-3.4); while in males, we observed a slight - but not statistically significant - increase in hospitalization rates. CONCLUSION: The marked decline in hospitalization rates for AGWs in Veneto Region is probably attributable to the high coverage rates of HPV vaccination programs implemented since 2008.

Treating and preventing recurrence of recurrent genital acquired lymphangiectasia using lymphaticovenous anastomosis at genital area: A case report.

After the simple resection of genital acquired lymphangiectasia, a high recurrence rate is reported, as lymphatic fluid from the legs to the genital region continues. Here we report a case in which we treated and prevented recurrence of recurrent genital acquired lymphangiectasia with genital lymphaticovenous anastomosis (LVA). A 48-year-old woman underwent hysterectomy and pelvic lymph node dissection for uterine cervical cancer at 30 years of age. The patient consulted our department for lymphedema in bilateral legs and acquired lymphangiectasia in the major labia. Despite nine attempted genital acquired lymphangiectasia resections and LVA in the lower limbs, which was aimed to prevent the recurrence, it recurred within 1-2 months postoperatively. Then we injected indocyanine green (ICG) to the bilateral edge of the anus before 10th LVA. ICG flowed from the anus to the genital area and we performed acquired lymphangiectasia resection and genital LVA on this lymphatic vessel (one anastomosis). After 6 months postoperatively, no recurrence of acquired lymphangiectasia, lymphatic leakage, or cellulitis had occurred. We found that a lymphatic flow from the anus into genital acquired lymphangiectasia occurred in one of the patients and the genital LVA, anastomosis of that responsible lymphatic vessel to the vein, might prevent genital acquired lymphangiectasia recurrence after resectional treatment.

Nine-valent HPV vaccine efficacy against related diseases and definitive therapy: comparison with historic placebo population.

OBJECTIVE: Nine-valent human papillomavirus (9vHPV) vaccine efficacy against disease and cervical surgeries related to all nine vaccine components was assessed compared with a historic placebo population. This was not assessed in the 9vHPV vaccine efficacy trial since the trial was quadrivalent HPV (qHPV) vaccine-controlled, efficacy was measured for the five HPV types covered only by 9vHPV vaccine (HPV31/33/45/52/58), but not the four types covered by both vaccines (HPV6/11/16/18). METHODS: Three international, randomized, double-blind studies were conducted using the same methodology. In the 9vHPV vaccine study (NCT00543543), 7106 and 7109 women received 9vHPV or qHPV vaccine, respectively. In the historic qHPV vaccine studies (FUTURE I [NCT00092521] and II [NCT00092534]), 8810 and 8812 women received qHPV vaccine or placebo, respectively, based on the same eligibility criteria. Cervical cytological testing was performed regularly. Biopsy or definitive therapy specimens were assessed for HPV DNA. RESULTS: Among women negative for 14 HPV types prior to vaccination, incidence of high-grade cervical disease (9vHPV, n = 2 cases; placebo, n = 141 cases) and cervical surgery (9vHPV, n = 3 cases; placebo, n = 170 cases) related to the nine HPV types was reduced by 98.2% (95% confidence interval [CI], 93.6-99.7) and 97.8% (95% CI, 93.4-99.4), respectively. The 9vHPV vaccine did not prevent disease related to vaccine HPV types detected at baseline, but significantly reduced cervical, vulvar, and vaginal diseases related to other vaccine HPV types. CONCLUSIONS: Effective implementation of the 9vHPV vaccine may substantially reduce the burden of HPV-related diseases and related medical procedures. TRIAL REGISTRATIONS: clinicaltrials.gov: NCT00543543, NCT00092521, NCT00092534.

Factors predicting young women's willingness to conduct vulvar self-examinations in Korea.

Vulvar self-examination (VSE) is an essential examination that all women should perform monthly, as it enables potential patients to discover vulvar cancer in early stage. In this study, a survey was conducted to identify the factors that affect Korean young women's willingness to conduct VSE. Willingness to conduct VSE was higher if the perceived benefit and the individual health motivation were higher. However, it was lower if the perceived barriers were higher. The systematic strategies should be included in VSE education programs to increase perceived benefits of, and health motivation for conducting VSE while reducing the perceived barriers to VSE.

Vaginal health of postmenopausal women on nutraceutical containing equol.

OBJECTIVE: The aim of the study was to evaluate the effects of nutraceuticals containing equol on vaginal health of postmenopausal women with vulvovaginal symptoms and dyspareunia. METHODS: One hundred twenty-six natural postmenopausal women on +1b +1c (2 and 3-6 y after the final menstrual period, respectively) of the Stages of Reproductive Aging Workshop were enrolled in a nonrandomized trial. Of these, 72 women accepted to use nutraceutical (group A). The remaining 54 women refused the treatment and participated as the control group (group B). Group A was prescribed one tablet daily to take orally, for 8 months. All assessments were made at baseline and at 4 and 8 months. Determination of vaginal maturation index (VMI), evaluation of vaginal pH, and assessment of vaginal atrophy symptoms by the vaginal health index (VHI) were carried out. Dyspareunia score was also measured. RESULTS: Group A had a significant increase in VMI (68 ±â€Š5 vs 58 ±â€Š8) and improvement of vaginal pH (4.1 ±â€Š1.3 vs 5.1 ±â€Š1.7) compared with baseline, mainly after 8 months of treatment (P < 0.001). Group A had an improvement of VHI after 4 (13 ±â€Š3, P < 0.01) and 8 (16 ±â€Š2, P < 0.001) months of nutraceutical intake. Dyspareunia reduced after 8 months (5.1 ±â€Š1.3 vs 3.8 ±â€Š1.2, P < 0.001) but not after 4 months (4.7 ±â€Š1.1, P = 0.06) of treatment. Group B showed no changes from baseline evaluation (P = 0.22). CONCLUSIONS: Nutraceuticals containing equol could be effective in modulating postmenopausal symptoms, particularly vaginal symptoms, and could be well accepted by the women who usually do not wish to use hormone therapy or cannot use it for medical reasons.

[Varicose veins of small pelvis as a cause of vulvar varicosity and varicose veins of lower extremities]. / Varikoznye veny malogo taza kak prichina vul'varnogo varikoza i varikoznoi bolezni nizhnikh konechnostei.

The article is a literature review presenting modern data on applied anatomy of the pelvic veins, diagnosis and treatment of pelvic varicose veins, pelviperineal reflux and vulvar varicosity, lower limb varicose veins, which were caused by pathological reflux from varicose pelvic veins. Presented is the information on tactical approaches in treatment of combined varicose veins of the pelvis and lower limbs, surgical decision-making for correction of pelviperineal reflux, methods of operative and phlebosclerosing interventions on pelvic and superficial veins of the perineum and lower limbs.

Decline in hospitalization for genital warts in the Veneto region after an HPV vaccination program: an observational study.

BACKGROUND: Human papillomavirus (HPV) is one of the most common sexually transmitted pathogens. This observational study was conducted to estimate the trend of hospitalization for genital warts (GWs) in the Veneto region (Italy) from 2004 to 2015. METHODS: All patients with GWs were identified in the hospital discharge records of all public and accredited private hospitals that related to Veneto residents and contained the ICD9-CM code 078.11 associated with a genital surgical procedure (vulval/vaginal warts, penile warts and anal warts). Annual total and sex- and age-specific hospitalization rates and trends were calculated and correlated with the different HPV vaccine coverage over the study period. RESULTS: An annual rate of 11.8 per 100,000 population (8.6 per 100,000 males, and 14.8 per 100,000 females) was found, corresponding to 6076 hospitalizations for condyloma (53.3% vulval/vaginal, 35.8% anal, 8.3% penile, and 2.6% both penile or vulval/vaginal and anal). Among females, the rate of overall GWs remained stable to 2007 (19.1 per 100,000), then dropped significantly, reaching a rate of 11.3 per 100,000 in 2015 (average annual percent changes [AAPC]: -6.1%; 95% CI: -8.4; -3.7). For males, the overall rate increased over the study period (from 6.4 per 100,000 in 2004 to 10.8 per 100,000 in 2015; AAPC: 3.8%; 95% CI: 1.2; 6.4). Among the potentially vaccinated females (12- to 20-year-olds) there was a 62.1% decrease in the number of vulval/vaginal warts from the years 2010-2012 to the years 2013-2015 due to an increase in the HPV coverage rate. A similar reduction among males was observed in the same period and the same age group for penile warts (-68.2%). CONCLUSION: GWs have an important impact on the health services and data suggest that GW-related hospitalization rates rapidly decline in a population with a high HPV vaccination coverage (about 75%). Further efforts should be made to better clarify the epidemiological picture regarding HPV-related diseases, with particular regard to sexual behavior.

Efficacy of combination therapy of oral zinc sulfate with imiquimod, podophyllin or cryotherapy in the treatment of vulvar warts.

AIM: Zinc sulfate is beneficial in the treatment of epithelial warts. We conducted this study to compare the efficacy of combination therapy of oral zinc sulfate with conventional treatments in the treatment of vulvar warts. MATERIAL AND METHODS: This study was a randomized controlled trial. The sample size was 42 in each group. Women aged 20-50 years were placed by the block randomized method into six groups: the podophyllin-, imiquimod- and cryotherapy-treated groups, and another three groups receiving 8-week combination therapy of 400 mg oral zinc sulfate with one of the above-mentioned treatments. Data were analyzed using anova and Fischer's exact test with spss16. RESULTS: A total of 228 patients were recruited and completed the study in six treatment groups. No significant difference was observed in the response to treatment among these groups. Relapse after 6 months was significantly higher in the podophyllin-, imiquimod- and cryotherapy-treated patients compared to patients receiving these treatments in combination with oral zinc sulfate (P<0.05). CONCLUSIONS: Combined therapy of oral zinc sulfate with conventional treatments of vulvar warts appears to reduce the relapse rate.

Reduced prevalence of vulvar HPV16/18 infection among women who received the HPV16/18 bivalent vaccine: a nested analysis within the Costa Rica Vaccine Trial.

BACKGROUND: Vaccine efficacy (VE) against vulvar human papillomavirus (HPV) infection has not been reported and data regarding its epidemiology are sparse. METHODS: Women (n = 5404) age 22-29 present at the 4-year study visit of the Costa Rica Vaccine Trial provided vulvar and cervical samples. A subset (n = 1044) was tested for HPV DNA (SPF10/LiPA25 version 1). VE against 1-time detection of vulvar HPV16/18 among HPV vaccinated versus unvaccinated women was calculated and compared to the cervix. Prevalence of and risk factors for HPV were evaluated in the control arm (n = 536). RESULTS: Vulvar HPV16/18 VE (54.1%; 95% confidence interval [CI], 4.9%-79.1%) was comparable to cervix (45.8%; 95% CI, 6.4%-69.4%). Vulvar and cervical HPV16 prevalence within the control arm was 3.0% and 4.7%, respectively. Independent risk factors for vulvar HPV were similar to cervix and included: age (adjusted odds ratio [aOR] 0.5 [95% CI, .3-.9] ≥28 vs 22-23]); marital status (aOR 2.3 [95% CI, 1.5-3.5] single vs married/living-as-married); and number of sexual partners (aOR 3.6 [95% CI, 1.9-7.0] ≥6 vs 1). CONCLUSIONS: In this intention-to-treat analysis, VE against vulvar and cervical HPV16/18 were comparable 4 years following vaccination. Risk factors for HPV were similar by anatomic site. CLINICAL TRIALS REGISTRATION: NCT00128661.

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.

Management of nonsexually acquired genital ulceration using oral and topical corticosteroids followed by doxycycline prophylaxis.

BACKGROUND: Data regarding the treatment of nonsexually acquired genital ulceration (NSAGU) are limited. OBJECTIVE: We sought to provide evidence for the safety and efficacy of topical and systemic corticosteroids followed by doxycycline prophylaxis for acute and recurrent NSAGU. METHODS: A retrospective chart review was conducted of patients with NSAGU treated in a private dermogynecology practice. RESULTS: A total of 26 girls and women with NSAGU were identified and divided into 2 groups: group A = 17 patients with moderate to severe ulceration treated in the acute stage with oral corticosteroid; and group B = 9 patients with mild ulceration treated in the acute stage with topical corticosteroid. Patients in group A, with a mean age of 27.9 years (range, 11-62 years), were treated with oral prednisolone commencing with 15 to 50 mg per day depending on severity. Sixteen (94%) achieved rapid pain relief and complete healing of ulcers within 16 days. Eight (47%) commenced doxycycline prophylaxis. Women in group B, with a mean age of 42.5 years (range, 26-67 years) were treated with topical corticosteroids. Eight (89%) had a history of recurrent ulcers and 6 (66%) commenced doxycycline prophylaxis. Of all 14 patients on doxycycline prophylaxis, none reported any recurrences during a mean follow-up of 18.3 months. There were no adverse effects caused by prednisolone. One patient experienced mild photosensitivity from doxycycline but continued to take it. LIMITATIONS: This was a retrospective case series from a single private practice-based population. CONCLUSION: Topical or oral corticosteroids followed by prophylactic doxycycline can be effective in rapidly resolving acute flareups and preventing recurrences of NSAGU. All patients responded to therapy without treatment-limiting side effects.

La importancia del pH en la prevención de la patología vulvovaginal / The importance of the pH in the prevention of vulvovaginal pathology

En condiciones fisiológicas, la vulva y la vagina se encuentran en un estado de equilibrio dinámico, en el que la situación hormonal, el pH y la respuesta inmunitaria constituyen los principales mecanismos de control. La vagina es una cavidad virtual abierta al exterior y, como tal, está expuesta fácilmente a agresiones externas que pueden alterar su integridad y facilitar la instauración de situaciones patológicas.Ciertos comportamientos, conductas higiénicas y hábitos de vida y sexuales pueden influir negativamente en su entorno, favoreciendo la contaminación vaginal y la aparición de infecciones, así como de trastornos vulvares de causa no infecciosa que pueden cronificarse y afectar a las relaciones sexuales y a la autoestima de la mujer (AU)

In physiological conditions the vulva and vagina are in a state of dynamic equilibrium in which the hormonal situation, the pH and the immuneresponse make up the main control mechanisms. The vagina is a virtual cavity that is open to the exterior and, therefore,is easily exposed to external agents that may alter its integrity and facilitate the development of pathological situations.Certain behaviour, hygienic habits, lifestyles and sexual practices may negatively influence the area of the vagina, increasing the chances of vaginal contamination and infections, as well as the development of vulvar disorders due to a non-infectious cause, which may become chronic and, consequently, affect the woman’s sexual relationships and self-esteem (AU)

Mucosal (oral and vulval) lichen planus in women: are angiotensin-converting enzyme inhibitors protective, and beta-blockers and non-steroidal anti-inflammatory drugs associated with the condition?

AIM: To determine whether there is an association between the use of angiotensin-converting enzyme (ACE) inhibitors, beta-blockers and nonsteroidal anti-inflammatory drugs (NSAIDS) in women with mucosal (oral and vulval) lichen planus (LP) compared with a control population. METHODS: This was a retrospective review of medical records in dedicated vulval and oral clinics in hospitals. The study population comprised 141 women with vulval LP and 106 women with oral LP. Medications taken at the time of diagnosis were recorded. RESULTS: Patients with mucosal LP were more likely to be on NSAIDS and beta-blockers, but less likely to be on ACE inhibitors compared with controls. All three groups were found to have an inverse relationship with ACE inhibitors, but no association was found between patients with oral LP and beta-blockers. CONCLUSIONS: Beta-blockers and NSAIDS are associated with LP, suggesting that withdrawal of these drugs should be considered. Further studies are needed to confirm or refute the inverse relationship between mucosal LP and use of ACE inhibitors.

Prevention of human papillomavirus infections and associated diseases by vaccination: a new hope for global public health.

Cervarix and Gardasil, 2 human papillomavirus (HPV) vaccines, have been approved and implemented globally in young adolescent women with the hope of reducing the incidence of cervical cancer several decades hence. This program is dependent on the concept of 'immunobridging': antibody titers generated in young adolescents that are the same or higher than generated in HPV-naive 16- to 26-year-old women, the population in which efficacy is proven. Likewise, realizing a decline in cervical cancer from young adolescent female vaccination depends on the duration of vaccine efficacy, and the population coverage reached. While we patiently wait for results from our young adolescent vaccination programs, newly released data indicates that the immunogenicity and efficacy of the vaccines for young adult women with prior HPV exposure is equal or superior to that seen for young adolescents. This same concept of immunobridging supported by limited efficacy data offers the potential to reduce cervical cancer precursors within just a few years in our young sexually active adult women, a population secondary to our young adolescents. The HPV vaccines are not therapeutic. Neither vaccine will inhibit an already HPV-infected basal epithelial cell which continues to transform differentiated epithelial layers into cervical dysplasias. There is a clinical hope, though, already supported by early data, that the vaccines are capable of neutralizing HPV virions in host tissues from both auto-inoculated infections and infections in other organs than the cervix, thereby making it possible for these vaccines to prevent less common HPV-associated cancers of the penis, vagina, vulva, anus, oral cavity and oro-pharynx. Both vaccines have been shown to be generally safe in the phase II and phase III randomized controlled trials over 3-6.4 years. Post-marketing surveillance of Cervarix and Gardasil continues to show that they are safe for most women despite rarely occurring serious events.

Vulvostomatodynia.

Burning mouth syndrome associated to vulvodynia (Vulvostomatodynia) is a rare condition and is often difficult to diagnose and treat. Tongue, lips, vestibule and others mucosal sites may be affected by a tiresome burning sensation, especially in menopausal and postmenopausal women. Patients seldom report genital symptoms to the dentist and dentists do not generally investigate about genital symptoms. Delays in diagnosis may affect the quality of life. We report the clinical features of five new cases of vulvostomatodynia. A thorough multidisciplinary medical management is necessary to improve symptoms and prevent from psychologic distress. Counselling and an understanding between patient and clinician/therapist are important for long-term results.

Ginecología infantil y juvenil en atención primaria / Infantile and adolescent gynaecology in primary care

El primer escalón del cuidado en Ginecología Infantil y Juvenil lo ofrecen los pediatras de Atención Primaria. Su integración en una Unidad de Ginecología Infantil y Juvenil es imprescindible para el funcionamiento de la misma. Nuestro objetivo en el presente artículo es repasar las principales patologías que encontramos en nuestra consulta de Pediatría en Atención Primaria y las conductas a seguir ante estos problemas

The first step in Infantile and adolescent gynaecology, is offered by Primary Care Paediatricians, so it is essential their integration in Children and Adolescent’s Gynaecology Unit. The aims of the present topic is to revise the principals pathologies that we can find in our paediatrics surgeries in Primary Care and the ways to act with this problems