Major Vestibular Glands Research Articles

(005) The Forgotten Region of the Vestibule: The 12:00 Location

Abstract Introduction The vestibule, consisting of the urethral meatus and minor and major vestibular glands, is a unique surface of endodermal tissue between Hart’s line, at the inner aspect of the labia minora, and the hymen, just at the vaginal opening. The vestibule releases mucinous lubrication during sexual arousal, achieved, in part, by robust vestibular innervation. Although not well studied, this likely consists of both somatic (perineal nerve), and autonomic (pelvic and hypogastric) nerves. The vestibule is commonly involved in entrance dyspareunia pathology related to infectious, dermatologic, hormonal, neurologic, pelvic floor, neuro-proliferative and other factors. Examination of the vestibule in symptomatic patients is best performed by vulvoscopy, and usually involves cotton swab testing of the 1:00, 3:00, 5:00, 6:00, 7:00, 9:00, and 11:00 locations, assessing for intensity of pain and degree of erythema. However, this examination does not assess the entire vestibule. The vestibule actually extends superiorly from just above the urethral meatus to just below the clitoris/right and left frenulum and laterally to Hart’s line. This may be considered as the “12:00” region of the vestibule; few providers examine there, and few surgeons excise the 12:00 region during vestibulectomy. Objectives The primary goal was to assess the relationship of the pathology of the 12:00 region to pathology in the usual vestibular locations. A secondary goal was to assess for presence of ostia of minor vestibular glands in the 12:00 region of the vestibule. Methods Women presenting to our clinic for sexual dysfunction were consented and underwent vulvoscopy with photography and cotton swab testing using a vulvoscope (Wallach Zoomscope) with attached camera (Cannon). Figure 1 shows cotton swab testing for pain and erythema at 12:00. Pain intensity was rated 0 – 10, with pain >3/10 considered clinically significant. Erythema was rated absent, mild, moderate or severe with any erythema considered clinically significant. Results Of 88 patients (mean age 42 +/− 19, range 13-83 years) with various sexual dysfunctions who underwent vulvoscopy with photography and cotton swab testing, 19 (22%) had absent pain and absent erythema throughout the usual vestibular locations as well as at the 12:00 location. Of 54 (61%) patients with positive findings of significant pain and erythema in at least 4 of the usual locations, 38 (70%) also had significant pain and erythema at 12:00. 26% of photographs examined revealed obvious single or multiple ostia of minor vestibular glands in the 12:00 region of the vestibule. Figure 2 shows 2 minor vestibular glands at 12:00. Conclusions While the vestibule extends from Hart’s line to the hymen including the usual 1:00, 3:00, 5:00, 6:00, 7:00, 9:00, and 11:00 locations, it also includes the region superiorly from just above the urethral meatus to just below the clitoris/right and left frenulum and laterally to Hart’s line. There are minor vestibular glands in this 12:00 region of the vestibule that can contain significant pathology. Providers are encouraged to consider the entire vestibule during diagnosis and treatment of women with sexual dysfunction. Disclosure No.

(197) Hormone Receptor Distribution and Innervation in Neuroproliferative Vestibulodynia: Immunohistochemical Evidence

Abstract Introduction There are limited hormonal and neurological studies of the vestibule despite its importance to sexual health and its pathophysiologic role in entrance dyspareunia. It is widely accepted that the vulva and vagina have estrogen receptors, but little is known regarding the types and density of various hormone receptors in the vestibule. Tactile and pressure sensations of the vestibule during sexual activity are likely transmitted via pudendal (somatic) and pelvic (visceral) nerve branches. The vestibule also releases mucinous lubrication from minor and major vestibular glands, likely induced by efferent pelvic (parasympathetic) nerve activation and terminated by efferent hypogastric (sympathetic) nerve activation. Immunohistochemical (IHC) studies of nerve structures and of androgen, estrogen, progesterone receptors in human vestibular tissue would aid in better understanding of relevant physiologic functions of the vestibule. Objective To better understand vestibular hormonal and neurological physiology through IHC studies of vestibulectomy tissue and to help improve clinical management of vestibulodynia. Methods IHC was performed on 7 vestibular specimens with confirmation of NPV diagnosis by positive CD117 and PGP9.5 staining, consistent with excess mast cells and nerve endings, respectively. Specimens were also studied with primary antibodies (Anti-ERα, Ab 32063; Anti-AR, MI 06680; Anti-PR, Dako PGR636; Anti-Synapsin, Cell Signaling 5297T). Finally, sections were lightly counterstained with Gill-modified hematoxylin. Results Androgen and estrogen alpha receptors were richly expressed in tissue samples of all 7 patients. Dense labeling of both receptor types was noted in the germinal layer of the epithelium (Fig. 1a,b) and mucinous vestibular glands (Fig. 2a,b), with comparatively sparse expression in the subepithelial stroma. While labeling of progesterone receptors was highly variable (Fig. 3a,b), all samples showed evidence of moderate progesterone receptor labeling in the subepithelial stroma. Variability may be due to menstrual cycle phase in which samples were obtained. Synapsin labeling showed thin filamentous arrangement in the rete pegs, thicker filamentous arrangement in the subepithelial stroma, and dense labeling in blood vessel endothelium and epithelium of mucinous vestibular glands (Fig, 4a, b). Conclusions This preliminary study provides evidence of dense androgen and estrogen receptor expression in the vestibule, consistent with the observation that in patients with hormonal deficiency, entrance dyspareunia may be more successfully treated at the vestibule with combined testosterone and estradiol cream than with topical estradiol alone. Also consistent with these findings is that treatment with intravaginal DHEA, converted to testosterone and estradiol intracrinologically and subsequently diffusing to the vestibule, successfully resolves entrance dyspareunia. While the significance of variable vestibular progesterone receptor expression is unclear, the addition of topical progesterone in these patients may be considered. Synapsin staining in rete pegs, stroma, surrounding blood vessels, and mucinous vestibular glands supports functional sensory innervation and autonomic regulation of vestibular lubrication that occurs during sexual activity. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Endoceutics.

A vestibular examination must include the 12:00 region

ABSTRACT Introduction The vestibule is an endodermal tissue located on the skin surface between Hart's line at the inner aspect of the labia minora (ectoderm), and the hymen, at the vaginal opening (mesoderm). The vestibule contains the urethral meatus and minor and major vestibular glands. The vestibule releases mucinous lubrication during sexual arousal that is achieved, in part, by vestibular innervation, likely from somatic (pudendal branch) and autonomic (pelvic branch) nerves. As part of an evaluation of patients with entrance dyspareunia, providers should perform a cotton-tip swab test to assess pain intensity and degree of erythema. Typically, the locations assessed are the 1:00, 3:00, 5:00, 6:00, 7:00, 9:00 and 11:00 locations of the posterior and right/left anterior vestibule. This testing strategy, however, does not include the entire vestibule. The 12:00 region of the vestibule is located above the urethral meatus, just below the clitoris and medial to Hart's line. The 12:00 region can also be painful during cotton-tip swab testing. Few providers examine this region or consider it during treatment. Objective The main objective of this study was to compare the pain scores of cotton-tip swab testing and degree of erythema of the 12:00 region to those of the 1:00, 3:00, 5:00, 6:00, 7:00, 9:00 and 11:00 locations in women presenting with entrance dyspareunia. The secondary objective was to examine the 12:00 region for the presence of minor vestibular glands. Methods Women presenting to our clinic with complaints of entrance dyspareunia underwent vulvoscopy with photography and cotton-tip swab testing including the 12:00 region while using a vulvoscope (Wallach Zoomscope) with attached camera (Cannon). Pain intensity was rated by the patient (0 – 10), with pain >3 considered clinically significant. Erythema was rated by the provider (absent, mild, moderate or severe) with any erythema considered clinically significant. Results A total of 144 women (mean age 43 +/- 20, range 13-83 years) underwent vulvoscopy at the standard 1:00, 3:00, 5:00, 6:00, 7:00, 9:00 and 11:00 locations. In addition, they were tested concomitantly at the 12:00 location. Among this group of women, 26 (18%) had absent pain and absent erythema throughout all locations; 25 (18%) had positive findings of pain and erythema in at least 3 of the usual vestibular locations but not at 12:00; and 92 (64%) had pain and erythema in at least 1 of the usual vestibular locations and at 12:00. Photographs revealed 27% of those experiencing pain at the 12:00 had obvious single/multiple ostia of minor vestibular glands at that location. Conclusions Women with entrance dyspareunia commonly have pain and erythema at the 12:00 region of the vestibule. Photography reveals the presence of minor vestibular glands at the 12:00 location. Providers should examine the entire vestibule including the 12:00 region during examination. Providers should consider including the 12:00 vestibule when treating entrance dyspareunia with medication such as compounded testosterone and estradiol and/or surgery. Disclosure Work supported by industry: no.

The 12:00 Region of the Vestibule: Often Overlooked during Examination and Treatment of Women with Entrance Dyspareunia

ABSTRACT Introduction The vestibule is an endodermal tissue located on the skin surface between Hart's line at the inner aspect of the labia minora (ectoderm), and the hymen, at the vaginal opening (mesoderm). The vestibule contains the urethral meatus and minor and major vestibular glands. The vestibule releases mucinous lubrication during sexual arousal that is achieved, in part, by vestibular innervation, likely from somatic (pudendal branch) and autonomic (pelvic branch) nerves. As part of an evaluation of patients with entrance dyspareunia, providers should perform a cotton-tip swab test to assess pain intensity and degree of erythema. Typically, the locations assessed are the 1:00, 3:00, 5:00, 6:00, 7:00, 9:00 and 11:00 locations of the posterior and right/left anterior vestibule. This testing strategy, however, does not include the entire vestibule. The 12:00 region of the vestibule is located above the urethral meatus, just below the clitoris and medial to Hart's line. The 12:00 region can also be painful during cotton-tip swab testing. Few providers examine this region or consider it during treatment. Objective The main objective of this study was to compare the pain scores of cotton-tip swab testing and degree of erythema of the 12:00 region to those of the 1:00, 3:00, 5:00, 6:00, 7:00, 9:00 and 11:00 locations in women presenting with entrance dyspareunia. The secondary objective was to examine the 12:00 region for the presence of minor vestibular glands. Methods Women presenting to our clinic with complaints of entrance dyspareunia underwent vulvoscopy with photography and cotton-tip swab testing including the 12:00 region while using a vulvoscope (Wallach Zoomscope) with attached camera (Cannon). Pain intensity was rated by the patient (0 – 10), with pain >3 considered clinically significant. Erythema was rated by the provider (absent, mild, moderate or severe) with any erythema considered clinically significant. Results A total of 144 women (mean age 43 +/- 20, range 13-83 years) underwent vulvoscopy at the standard 1:00, 3:00, 5:00, 6: 00, 7:00, 9:00 and 11:00 locations. In addition, they were tested concomitantly at the 12:00 location. Among this group of women, 26 (18%) had absent pain and absent erythema throughout all locations; 25 (18%) had positive findings of pain and erythema in at least 3 of the usual vestibular locations but not at 12:00; and 92 (64%) had pain and erythema in at least 1 of the usual vestibular locations and at 12:00. Photographs revealed 27% of those experiencing pain at the 12:00 had obvious single/multiple ostia of minor vestibular glands at that location. Conclusions Women with entrance dyspareunia commonly have pain and erythema at the 12:00 region of the vestibule. Photography reveals the presence of minor vestibular glands at the 12:00 location. Providers should examine the entire vestibule including the 12:00 region during examination. Providers should consider including the 12:00 vestibule when treating entrance dyspareunia with medication such as compounded testosterone and estradiol and/or surgery. Disclosure No

Hospital care pathway of women treated for Bartholin’s gland abscess and budget impact analysis of outpatient management: A national hospital database analysis

IntroductionBartholin's gland abscesses cause severe pain and are a source of frequent emergency room visits. The most widespread treatment in France is incision-drainage during hospitalisation. A Word catheter, whose efficiency and safety would be identical, could be used without the need for hospitalisation, thus reducing the costs of Bartholin's gland abscess management. DesignRetrospective cohort study. SettingFrench hospital (PMSI) database 2016-2017. Population3539 women with Bartholin's gland abscess. MethodFrom the PMSI database, we identified the population that was treated for incision-drainage of a Bartholin's gland abscess in 2016. We also looked for secondary hospitalisations occurring within 12 months of initial treatment of Bartholin's gland abscess using 2016 and 2017 PMSI database data. Main outcome(s)The identified population was described in terms of age, hospitalisation, length of stay and readmissions within 12 months and provided a 5-year budget impact analysis of the use of the Word catheter in France from a National Health Insurance perspective. ResultsIn 2016, 3539 women (36 +/- 11.8 years) were hospitalised for 3646 incisions of the major vestibular gland linked to a Bartholin's gland abscess. 11.38 % (403/3,539) underwent at least one new Bartholin's gland procedure during the following year. The use of the Word catheter would allow potential savings over 5 years of €7.4 million. ConclusionThe use of the Word catheter could be cost-saving. These results must be validated by a clinical research step evaluating efficiency in the French context, comparing the Word catheter and incision-drainage side-by-side.

Reproductive Tract Histology in South American Fur Seal Pups (Arctophoca australis).

In the present study, a detailed histological description of the female reproductive tract of South American fur seal (Arctophoca australis) pups has been conducted. The uterine tube was covered by cuboidal to columnar epithelium; nerve fibers were present in the mesosalpinx and beneath the muscular layer. The uterus was bipartitus; the endometrial surface of the horns was lined by a simple cuboidal or columnar epithelium with deep tubular glands; caudally ("the transition area"), the epithelium changed to pseudostratified columnar, few tubular glands were present and the myometrium increased in width. A bistratified epithelium internally coated the uterine body, whereas it changed to cylindrical stratified epithelium with a highly vascularized lamina propria and a strong muscular layer in the cervix; no endometrial glands were observed in this region. From the transition area of the uterus to the vagina there were several nerve fibers and ganglia belonging to the uterovaginalis plexus. In the vestibule, hymenal folds were poorly developed; adnexa structures included the major vestibular glands and a neurovascular structure similar to the vestibular bulb. Minor vestibular glands were associated with the clitoris. The skin of the perineum was lined by a keratinized stratified epithelium, pigmented, with sebaceous glands, sweat glands and hair follicles. This is the first detailed histological description of the reproductive tract of South American fur seal pups, including the glandular adnexa and nerve structures. These results contribute to the reproductive biology in Pinniped species, and give a better understanding of the utero-placental perfusion mechanism during diving. Anat Rec, 2017. © 2017 Wiley Periodicals, Inc. Anat Rec, 300:600-613, 2017. © 2016 Wiley Periodicals, Inc.

Immune activation enhances epithelial nerve growth in provoked vestibulodynia

Provoked vestibulodynia manifests as allodynia of the vulvar vestibular mucosa. The exact mechanisms that result in altered pain sensation are unknown. Recently, we demonstrated the presence of secondary lymphoid tissue, which is the vestibule-associated lymphoid tissue in the vestibular mucosa, and showed that this tissue becomes activated in provoked vestibulodynia. The purpose of this study was to examine whether expression of intraepithelial nerve fibers and nerve growth factor are related to immune activation in provoked vestibulodynia. Vestibular mucosal specimens were obtained from 27 patients with severe provoked vestibulodynia that was treated by vestibulectomy and from 15 control subjects. We used antibodies against the protein gene product 9.5, the neuron specific neurofilament, and nerve growth factor for immunohistochemistry to detect intraepithelial nerve fibers and nerve growth factor expressing immune cells in the vestibular mucosa. For intraepithelial nerve fibers, we determined their linear density (fiber counts per millimeter of the outer epithelial surface, protein gene product 9.5) or presence (neuron specific neurofilament). Nerve growth factor was analyzed by counting the staining-positive immune cells. Antibodies against CD20 (B lymphocytes) and CD3 (T lymphocytes) were used to identify and locate mucosal areas with increased density of lymphocytes and the presence of germinal centers (ie, signs of immune activation). B-cell activation index was used to describe the overall intensity of B-cell infiltration. We found more protein gene product 9.5-positive intraepithelial fibers in vestibulodynia than in the control samples (6.3/mm [range, 0.0-15.8] vs 2.0/mm [range, 0.0-12.0]; P=.006). Neuron specific neurofilament -positive intraepithelial fibers were found in 17 of 27 vestibulodynia cases (63.0%) and in none of the control cases. Protein gene product 9.5-positive intraepithelial fibers were more common in samples with more pronounced immune activation. The density of these fibers was higher in samples with than without germinal centers (6.1/mm [range, 4.3-15.8] vs 3.0/mm [range, 0.0-13.4]; P=.020). A positive correlation between the fiber density and B-cell activation index score of the sample was found (Spearman's Rho, 0.400; P=.004; R2=0.128). No significant difference, however, was found in the density or presence of nerve fibers between samples with high and low T-cell densities. We identified areas of minor and major vestibular glands in 16 of the patient samples and in 1 control sample. Protein gene product 9.5-positive nerve fibers were found more often in glandular epithelium surrounded by B-cell infiltration than in glands without B cells (P=.013). Also, the presence of neuron specific neurofilament-positive fibers in glandular epithelium was associated with B-cell infiltrates (P=.053). Nerve growth factor-positive immune cells were more common in mucosal areas with than without B-cell infiltration and intraepithelial nerve fibers. Excessive epithelial nerve growth in provoked vestibulodynia is associated with increased B-cell infiltration and the presence of germinal centers. This supports the fundamental role of immune activation in provoked vestibulodynia.

Frequency of haemophilus somnus in the semen of bulls in Iran as determined by polymerase chain reaction

Haemophilus somnus is a small, pleomorphic, gram-negative and coccobacillusbacterium that has been identified as a common inhabitant of the sheath in bulls and the vagina and major vestibular gland in cows. The purpose of this study was to determine the frequency of H. somnus infection in the semen samples of bullsin Iran. H. somnus was isolated from 40 of 185 (21.62%) bull's semen. Results showed high frequency of H. somnus infection in artificially prepared semen that is used for artificial insemination. The findings of this study indicate that semen samples of bulls that are used for artificial insemination are important sources ofH. somnus infection in Iran. In addition, it can be concluded that this bacteriummay normal flora of the bovine prepuce and that dissemination from the male bovine reproductive tract and it can be related to H. somnus -associated diseases.To control and prevention of the distribution of H. somnus, examination of bull's semen for artificial insemination seems to be necessary. Key words: Bulls, Haemophilus somnus, semen, artificial insemination, polymerase chain reaction, Iran.

Crystallographic investigation of the dried exudate of the major vestibular (Bartholin's) glands in women

Objective The aim of this study was to investigate the dried secretion of human major vestibular glands in order to establish its crystallographic pattern and to compare the data with those obtained for other human genital biopolymers. Study design After air drying, samples were examined comparatively under transmitted and polarized light. At first sight, dehydrated vestibular fluid exhibits a fern-like crystallographic pattern very similar in appearance to those described in mid-cycle cervical mucus and bulbo-urethral fluid. Results Dendritic structures fill the central space of all preparations, prolonged by apparently amorphous peripheral fucus-like expansions. Spherulitic interdendritic crystalline microstructures (ICMs) can be considered a constant feature of dried vestibular exudate. In contrast with dendritic formations, fucus-like expansions and isolated spherulites are anisotropic under polarized light. Anisotropy appears to be the guise of a luminescent border lining the dendrites or bright nodules shining on a dark background. Conclusion The study confirms the close physico-chemical proximity of vestibular secretion, mid-cycle cervical mucus and bulbo-urethral fluid. However, if isotropic dendritic formations and anisotropic structures are grossly similar, the number and size of the anisotropic ICMs are typical of human vestibular secretion. The different patterns of ICMs observed in these three human biological hydrogels demonstrate differences in the salt concentrations.

Adenocarcinoma of the Major Vestibular Gland in a Cow

Adenocarcinoma of the Major Vestibular Gland in a Cow

Histochemical studies on the dependence of secretory function of the major vestibular gland (Bartholin's gland) on ovarian steroid hormones in the cat.

The dependency of the secretory function of the feline major vestibular gland (Bartholin's gland) on the ovarian steroid hormones was studied histochemically. After estrogen (estradiol-17 beta or diethylstilbestrol), progesterone or a combination of these was administered to cats which were previously ovariohysterectomized, the major vestibular glands were removed, embedded in paraffin, sectioned, and stained by alcian blue, periodic acid-Schiff or peroxidase-labeled lectin (peanut agglutinin and wheat germ agglutinin). The vividly positive reactions to the stainings applied were observed in the secretory epithelial cells of the major vestibular glands in the estrogen treated animals. The dependency of the secretory function of the major vestibular glands on the estrogen was demonstrated in this study.

Histology and histochemistry of the bovine reproductive tract caudal to the cervix part I. The vestibule and associated glands

Intact multiparous bovine reproductive tracts at various stages of the oestrous cycle were examined post mortem. The mean (±SD) length of the vestibule was 115·6 ± 12·82, volume of the suburethral diverticulum 4·0 ± 1·33 ml, and weight of the major vestibular gland was 6·9 ± 2·58 g. 26·5% of reproductive tracts had macroscopically visible cysts along the major vestibular gland duct. At all stages of the oestrous cycle and at all positions examined, the vestibular epithelium was stratified squamous containing variable numbers of lymphocytes and polymorphonuclear leucocytes. Lymphatic nodules associated with the epithelium, seen throughout the vestibule, were most commonly observed around the clitoris. Histochemically, the branched mucus-secreting tubules of the major vestibular glands contained neutral, sialated and sulphated mucins.

Secretory Glycoproteins of Major Vestibular Glands (Bartholin's Glands) in Female Calves

The nature of mucins synthetized by the major vestibular glands of normal female calves and animals treated by anabolic drugs was investigated by usual histochemical methods and by lectin conjugate methods: Canavalia ensiformis (Con A), Limulus polyphemus (LPA), Lotus tetragonolobus (LTA), Arachis hypogaea (PNA), Ricinus communis (RCA I), Glycine max (SBA) and Triticum vulgaris (WGA). Two main secretory cell types, i.e. acinar and tubular cells, could be distinguished. The former produced sialomucins, whereas the latter produced neutral mucins. WGA and PNA showed strong binding to all secretory cells while LTA, RCA I and SBA exhibited a weaker affinity. Treatment with anabolic drugs enhanced O-acetyl sialic acid synthesis and we noted de novo synthesis of sulfomucins. However, the staining intensity of LTA was stronger than in control calves. Tubular secretory cells of treated animals revealed an intense secretion of neutral mucins but, in contrast, all tested lectins were less intensively bound. The present study provides additional histochemical information on Bartholin's glands. A shortened procedure is proposed to detect animals treated with anabolic drugs when morphological changes are lacking.

Hemophilus somnus in the reproductive tracts of slaughtered cows: location and frequency of isolations and lesions.

One hundred bovine female reproductive tracts were examined for the presence of Hemophilus somnus, and fifty were examined for gross and microscopic lesions. H. somnus was isolated from eight of 100 tracts. The isolation was made from the vagina in seven cows. Of 24 tracts in which the major vestibular gland was sampled, three were positive at this site, and two of these three also had the organism isolated from the vagina. Further investigations into the role of the major vestibular gland as a source for continuing infections of the reproductive tract of cattle were indicated. In this investigation, H. somnus was as likely to be found in a region without lesions as one with lesions.

On the anlage of the bulbo‐urethral (Cowper's) and major vestibular (Bartholin's) glands in the human embryo

On the anlage of the bulbo‐urethral (Cowper's) and major vestibular (Bartholin's) glands in the human embryo