Vulvar Disorders Research Articles

Identifying Competencies in Vulvar Disorder Management for Medical Students and Residents

The study aimed to perform a content validation process by surveying vulvar disorder experts to identify evidence-based competencies appropriate for use in developing vulvar curricula for medical trainees. We identified 65 potential vulvar disorder competencies from literature review and expert opinions. Survey participants rated these competencies from 1 (not at all important) to 4 (highly important) in the training of 3 different groups of learners as follows: medical students, obstetrics and gynecology residents, and dermatology residents. We administered the survey to all US-based clinical members of the International Society for the Study of Vulvovaginal Disease as of September 2008 (n = 90). The content validity index and asymmetric CI were calculated for each curricular competency for each group of learners separately and used to identify competencies for use in curricula development. Forty-seven surveys were returned, yielding a response rate of 52.2%. Obstetrician-gynecologists represented 66% of the study sample, followed by dermatologists (15%), and nurse practitioners (9%). Seventy-nine percent of experts received their training by self-teaching, which included mentored experiences (62%) and attending conferences or courses (62%). Only 19% received vulvar training during residency and 11% during fellowship. Four curricular competencies met content validity criteria for medical students, 60 competencies for obstetrics and gynecology residents, and 47 competencies for dermatology residents. The differences between the 2 groups of residents focused on vulvovaginal pain and infection, examination, and procedures of the vagina. The competencies identified in this study can aid in the development of targeted curricula for medical students, obstetrics and gynecology residents, and dermatology residents.

2011 ISSVD Terminology and Classification of Vulvar Dermatological Disorders

The study aimed to formulate an easy clinical approach that may be used by clinicians of all backgrounds to diagnose vulvar dermatological disorders. The International Society for the Study of Vulvovaginal Disease appointed a committee with multinational members from the fields of dermatology, gynecology, and pathology and charged the committee to formulate a clinically based terminology and classification of vulvar dermatological disorders. The committee carried out its work by way of multiple rounds of e-mails extending over almost 2 year's time. The committee was able to formulate a consensus report containing terminology, classification, and a step-wise approach to clinical diagnosis of vulvar dermatological disorders. This report was presented and approved by the International Society for the Study of Vulvovaginal Disease at the XXI International Congress held in Paris, France, on September 3 to 8, 2011. The authors believe that the approach to terminology and classification as well as clinical diagnosis contained in this article allows clinicians to make highly accurate diagnoses of vulvar dermatological disorders within the clinical setting. This, in turn, will reduce the need for referrals and will improve the care for women with most vulvar disorders.

Clinical Scoring System for Vulvar Lichen Sclerosus

Vulvar lichen sclerosus (LS) is a chronic inflammatory and mutilating disease, which goes often undetected for years. Advanced disease severely affects quality of life like sexual disorders and is also associated with an increased risk of vulvar cancer. To develop and validate a patient-administered symptom score and a physician-administered clinical score for the diagnosis and evaluation of vulvar LS. We included 24 patients with established LS diagnosis and 49 with other vulvar disease. The physician-administered score was based on six clinical features and the patient-administered score was a symptom-based four-item composite score. We determined inter-item correlations and internal consistency of both scores, and estimated sensitivities, specificities, likelihood ratios, and posttest probabilities for different cutoffs of the physician-administered score. Characteristics of patients with and without LS were compared using χ(2) and unpaired t-test as required. We then determined Cronbach's alpha as a measure of the overall consistency of scores and calculated positive and negative likelihoods. Lack of redundancy of items (correlation coefficients < 0.90) and internal consistency (Cronbach's α ≥ 0.70) suggested that final composite scores were valid and yielded excellent power to rule in LS. Scores may be useful for assessing symptoms of vulvar disorders, to ease diagnosis of LS and to evaluate treatment response over time.

Cutaneous Vulvar Streptococcal Infection

This study aimed to determine the etiology of fine superficial fissures in women with vulvar pain. The charts of women with vulvar complaints seen in the Mucosal Disorders Clinic at Northwestern University between April 2006 and May 2008 were reviewed. Outcome measures included mucocutaneous examination findings and results of microbiological swab cultures in the presence of fine, superficial, vulvar and/or perianal fissures. The presence of concomitant vulvar disorders was noted. Sixteen women who presented with vulvar pain were found to have fine, superficial, vulvar and/or perianal fissures with minimal or no erythema on examination. None had inflammatory vaginitis. Group B β-hemolytic streptococcus (Streptococcus agalactiae) was recovered in 6 (37.5%) patients. All women with group B β-hemolytic streptococcus-positive cultures had a concomitant vulvar disorder; however, fissures were present despite appropriate treatment directed at the concomitant vulvar dermatosis. Three patients reported improvement in vulvar pain after treatment with antibiotics, and fissures had resolved by the time of follow-up examination in these 3 patients. Group B β-hemolytic streptococcus may cause painful fine superficial fissures and minimal erythema of vulvar skin. Obtaining microbiological cultures should be considered in the evaluation of vulvar pain even in the absence of purulent inflammatory vaginitis. The search for documentation and treatment of this relevant pathogen is a departure from published recommendations.

P142 Evaluating the vulval service within our genitourinary (GU) medicine department

BackgroundVulval disorders with their psychosocial and psychosexual impact are frequently encountered within GU clinics. Dedicated specialist clinics should ideally be multidisciplinary with input from dermatology, GU and gynaecology; however this is not always feasible. A need for this service was recognised at our urban clinic—thus in 2005, a monthly vulval dermatoses clinic was set up and led by a GU physician with training in genital skin disease. In 2009 a monthly vulvodynia clinic was set up, staffed by a trained GU physician and psychosexual counsellor.AimsTo review our service provision over a 1-year period.MethodsRetrospective notes review of monthly vulval dermatoses and vulvodynia clinics were performed from November 2010–2011.ResultsThere were 145 vulval clinic appts; patients were only counted once—94 notes were reviewed. Vulval dermatoses clinic (n=40; 20 new, 20 f/u): median age 36 (IQR 29–44); referred by GUM 85%, derm/gynae 10%, GP 5%. Referral symptoms: itching (23), burning (8), dyspareunia (6), vulval pain (5), other (12); median length of symptoms 2 yrs (IQR 1–3). Predominant conditions were: psoriasis 28% (11) and lichen sclerosis 28% (11). Vulvodynia clinic (n=54; 24 new, 30 f/u): median age 28 (IQR 25–32); referred by GUM 67%, GP 26%, gynae/derm 7%. Referral symptoms: superficial dyspareunia (42), vulval pain (11), itching (2); median length of symptoms 2 yrs (IQR 1–5). Diagnosis of vulvodynia made in 74% (40/54). 22/40 were seen for f/u, 73% (16/22) reported at least 50% improvement in their symptoms with treatment.ConclusionOur vulval service meets the needs of a significant number of symptomatic women allowing timely diagnosis, management and f/u. Recognising the multifactorial nature of vulval disorders means patients receive a thorough assessment in one clinic visit with a GU screen, dermatology review and psychosexual input, thus providing a service tailored to the patient.

Evaluation of Sexual Function in Brazilian Women with Recurrent Vulvovaginal Candidiasis and Localized Provoked Vulvodynia

Recurrent vulvovaginitis is an important trigger for inflammatory processes that in many cases may result in vulvovaginal pain. Vulvodynia, a vulvar disorder, can also cause a lot of pain in the female genitals. The sexual function in women with vulvodynia or recurrent vulvovaginitis will possibly be negatively affected and therefore should be evaluated. To assess sexual function in women with recurrent vulvovaginal candidiasis (RVVC) and localized provoked vulvodynia (LPV) in comparison with women without lower genital tract dysfunction. A 1-year cross-sectional study evaluated sexual function in 58 women (11 with RVVC, 18 with LPV, and 29 controls) seen at a university outpatient clinic. Sexual function was assessed by taking into account the results obtained from the application of the Female Sexual Function Index (FSFI) questionnaire. Kruskal-Wallis, Mann-Whitney, chi-square, and Fisher's tests were used for statistical analysis. FSFI, a validated questionnaire in Portuguese. There were no significant differences in the three groups with respect to age, marital status, schooling, race, body mass index, contraceptive method, and parity. The FSFI questionnaire total score found was 25.51 (±5.12), 21.17 (±5.15), and 29.56 (±3.87) for the RVVC, LPV, and control groups, respectively. The scores were significantly statistically lower in the study groups compared with the control group (P<0.05). Women with RVVC and LPV also had lower total scores compared with 26.55 values, considered a cutoff score for sexual dysfunction in literature. The LPV group showed a significant difference and scored worse in the domains of arousal, lubrication, orgasm, satisfaction, and pain but not in the domain of sexual desire. The same occurred with the RVVC group but only for the domains of orgasm and satisfaction. Women with RVVC and LPV had significantly more symptoms of sexual dysfunction than women without lower genital tract diseases.

Use of complementary and alternative medicine in recurrent vulvovaginal candidiasis—Results of a practitioner survey

The mainstream long term management of recurrent vulvovaginal candidiasis (RVVC) often results in poor outcomes. It is expensive and unacceptable for many women who therefore have incorporated complementary and alternative medicine (CAM) into their personal care plan. To ascertain clinicians' knowledge of CAM and their recommendations for the use of CAM and non-pharmacological management in women with RVVC. Anonymous, single page, self completed survey using convenience sampling at a vulval disorders meeting in New South Wales, Australia in 2009. Sixty six health professionals (medical practitioners, dermatologists, nurses and allied health professionals). Most clinicians reported asking about their patients' use of CAM and non-pharmacological management of RVVC, although only around half reported recommending it. CAM management included lactobacillus, oral and vaginal yoghurt, vinegar, garlic, Chinese medicine and tea-tree oil. Non-pharmacological management included dietary changes and use of cotton undergarments. Lactobacillus was the most commonly recommended CAM. CAM is popular with patients and many clinicians actively recommend its use in RVVC despite limited supporting evidence. Further research in the area of CAM and RVVC is long overdue.

Developing an interdisciplinary consultation service for vulvar disorders

Diseases of the vulva often cause severe impairment and long-term problems for the affected women. Adequate treatment requires expert knowledge on the part of treating dermatologists and gynecologists. This was the reason for the initiation of an interdisciplinary consultation service for vulvar diseases at the University Hospital of Lübeck. Over a period of 2½ years, 208 patients were seen in the new consultation service. Cases were classified as inflammatory diseases, neoplastic diseases, infectious diseases, vulvodynia, or genodermatoses. The effectiveness of treatment was documented by photography, biopsy and - whenever applicable - a quality of life assessment using the Dermatology Life Quality Index (DLQI). Inflammatory dermatoses were diagnosed in 133 patients and neoplas-tic diseases in 32 patients. Infection was diagnosed in 25 patients, vulvodynia in 8, genodermatoses in 3 and other diseases in 7. The DLQI was assessed in 140 patients. Of these, 55 patients had a DLQI > 10 (0-30), indicating severe or extreme impairment of quality of life. A follow-up DLQI was collected in 81 patients, showing a significant improvement. The patients and both hospital facilities benefitted from the interdisciplinary consultation service. The initial high costs in terms of medical staff and time was compensated by the development of diagnostic and treatment algorithms. Overall, the concept received positive feedback from patients and medical staff members.

Cytology of the vulva: feasibility and preliminary results of a new brush

Objective:Taking a biopsy is a standard procedure to make the correct diagnosis in patients with suspicious premalignant vulvar lesions. The use of a less invasive diagnostic tool as triage instrument to determine whether biopsy is necessary may improve patient comfort especially in patients with chronic vulvar disorders that may warrant consecutive biopsies. This study was conducted to investigate whether vulvar brush cytology is feasible and may be used to detect (pre)malignant vulvar lesions.Methods:A pilot study was performed with patients having clinically normal vulvar skin, lichen sclerosus (LS), usual or differentiated vulvar intraepithelial neoplasia or squamous cell carcinoma. A total of 65 smears were taken with the use of a vulvar brush and biopsies were performed for histopathological analysis.Results:Out of 65 smears, 17 (26%) were discarded because of poor cellularity. A total of 28 of 29 (97%) smears with a histological proven (pre)malignancy had a smear classified as ‘suspicious’ or ‘uncertain’. Cytology classified 11 smears as ‘non-suspicious’, of which 10 (91%) were indeed normal skin or LS. The accuracy, based on the presence of a lesion, for (pre)malignant lesions with the use of the brush showed a sensitivity of 97% and a negative predictive value of 88%.Conclusion:Vulvar brush cytology is feasible and may be a first step in the development of a triage instrument to determine whether subsequent biopsy of a clinically (pre)malignant lesion is necessary.

Vulvar Lymphangioma Circumscriptum

Vulvar lymphangioma circumscriptum is a rare, benign proliferation of the lymphatic system that presents a diagnostic and management challenge. It may be confused with condyloma acuminata, molluscum contagiosum, or other vulvar disorders. Treatment options include observation, surgical excision, laser ablation, or sclerosing therapy. We report 3 cases, 2 associated with vulvar squamous cell carcinoma and 1 with hidradenitis suppurativa.

The postmenopausal vulva

Vulval symptoms are common among postmenopausal women. A wide range of pathology underlies often similar presentations. Vulval care with emollients is the first‐line treatment in most vulval conditions. Vulval disease is a growing specialty across gynaecology, dermatology and genitourinary medicine. Learning objectives: To recognise the impact of vulval health on quality of life. To use a systematic approach to clinical diagnosis in most cases. To recognise cases requiring vulval biopsy. To promote uniformity in nomenclature and treatment. Ethical issues: Should women with vulval disorders be seen by multidisciplinary teams or by vulval specialists? Please cite this article as: Kingston A. The postmenopausal vulva. The Obstetrician &amp; Gynaecologist 2009;11:253–259.

Avoid Empiric Treatment for Vulvar Skin Disorders

Avoid Empiric Treatment for Vulvar Skin Disorders

Effects of vulvodynia on quality of life

The experiences of women with vulvodynia are poorly understood. We sought to determine the effects of vulvodynia on quality of life. We conducted a survey of 280 patients in a university-based vulvar disorders clinic. Skin-related quality of life was measured with a vulvar-specific version of Skindex-29. The response rate was 95%; 101 patients (36%) had vulvodynia, and 179 patients (64%) had other vulvar conditions. Women with vulvodynia had significantly worse quality of life than patients with many other dermatologic conditions, and worse functioning than women with other vulvar conditions (mean functioning scores [+/-SD] of patients with psoriasis, other vulvar conditions, and vulvodynia were 23 +/- 27, 34 +/- 24, and 44 +/- 22, respectively, P = .05). A diagnosis of vulvodynia was the strongest independent correlate of poor quality of life (eg, for poor functioning, odds ratio = 1.8, 95% confidence interval 1.0-3.1). Limitations are single academic medical center and comorbid illnesses determined by self-report. Vulvodynia has broad and substantial effects on quality of life.

Collins test in patients with vulvar pruritus

E-mail address: sicantal3@yahoo.com. Pruritus is the most common symptom of vulvar disorders. The prevalence of vulvar pruritus in the female population is unknown, as is the prevalence of most of the conditions responsible for the itching [1]. It is important to recognize that vulvar pruritus is a symptom and not a disease, and optimal management should be to search for the underlying cause of the problem so that appropriate treatment can be given. In particular, it is important to differentiate between benign, premalignant, and malignant conditions [1]. Biopsy is the primary diagnostic tool for vulvar lesions [2]. The important question here is to accurately determine the site of the biopsy. To increase the sensitivity and specificity of vulvar biopsy, Collins toluidine blue test can be used to define more accurately the areas of vulvar abnormalities [1]. The present study was conducted at Al-Yarmouk Teaching Hospital and Al-Habibiya Maternity Hospital in Baghdad, Iraq, between September 2004 and June 2005. A total of 100 women aged between 40 and 60 years suffering from vulvar pruritus of variable duration were included in the study. All women gavewritten consent for participation. Each patient had a full history taken and underwent a complete physical examination. Exclusion criteria were infections, contact dermatitis, psoriasis, seborrheic dermatitis, use of barrier contraception, ulcer or mass of the vulva, or any visible lesions of the vagina and cervix. To identify areas of vulvar abnormalities, toluidine blue was applied to the vulva. Dark blue colored areas that might represent abnormal skinwere biopsied. If therewas no abnormal staining, a biopsywas taken from the most pruritic areas of the vulva to detect false-negative cases. All biopsies were examined by one histopathologist.

Website reviews @ TOG

In this issue we focus on dermatological conditions related to obstetrics and gynaecology. There is a significant array of information available, both for clinicians and for women, regarding vulval disorders. We have included websites with information on skin disorders of pregnancy.

Features of patients with vulvar dermatoses in dermatologic and gynecologic practice in Turkey: Is there a need for an interdisciplinary approach?

Vulvar dermatoses are very common problems in women and they are associated with significant morbidity. The aims of the present study were to evaluate the features of patients with vulvar diseases in gynecology and dermatology out-patient clinics in Turkey, and to determine the need for a multidisciplinary vulvar clinic in this country. A total of 310 patients with vulvar problems as their primary complaints were included in the study. There were 144 women from a dermatology clinic and 166 women from a gynecology clinic. The following factors were recorded for all patients: physical examination findings, menarche age, age at first intercourse, education level, marital status, clinical diagnoses and associated gynecologic problems. There were no significant differences between the two groups when the mean age, menarche age and age at first intercourse were compared (P > 0.05). The number of unmarried women was statistically significantly higher in the dermatology group than in the gynecology group (P < 0.0001). The number of women who graduated from high school and university was also statistically significantly higher in the dermatology group than in the gynecology group (P < 0.01). The frequency of gynecologic problems was statistically significantly higher in the gynecology group than in the dermatology group (P < 0.001); however, dermatologic conditions were the most frequent diagnosis overall (33.54%). Forty patients in the gynecology group were referred to the dermatology clinic. The approach to patients with vulvar disorders varies from country to country. However, multidisciplinary clinics seem to improve the understanding of vulvar diseases, to make correct diagnoses and to raise patients' quality of life. The need for a multidisciplinary vulvar clinic should not be ignored by the physicians in Turkey.

Topical Misoprostol Therapy for Plasma Cell Vulvitis: A Case Series

To present the first reported case series of plasma cell vulvitis successfully treated with topical misoprostol. Three women with vulvar pain and lesions secondary to plasma cell vulvitis refractory to conventional therapy were treated with topical misoprostol compounded in white petrolatum. All three patients had resolution of pain and lesions within 6 weeks of starting topical misoprostol. All patients tolerated the 0.01% concentration; however, local side effects were seen with the higher 0.02% concentration. Plasma cell vulvitis is a rare and painful vulvar disorder that is often refractory to therapy. All three patients in this case series were successfully treated with topical misoprostol. The immunosuppressive effects of misoprostol are hypothesized to be the mechanisms of action of this novel therapy for plasma cell vulvitis.

Discussion

Objective: The purpose of this study was to compare the rates of painful bladder syndrome and functional bowel disorders in women with vulvar disease and control subjects. Study design: In this cross-sectional survey, a questionnaire that contained validated outcome measures was administered to women who were seeking care in a vulvar disease clinic and in general gynecology clinics. Results: Women who were seen at a vulvar disease clinic were 2.18 (95% CI, 1.19, 3.97) times more likely to have painful bladder syndrome and 2.13 (95% CI, 1.35, 3.35) times more likely to have functional bowel disorders than general gynecology clinic control subjects after multivariable analyses. Conclusion: Painful bladder syndrome and functional bowel disorders are more prevalent in women who are seen at a vulvar disease clinic than gynecology clinics control subjects. These associations may reflect a common origin for these disorders in certain women. These findings lay the groundwork for future research to investigate a potential pelvic floor pain disorder, which is a disease entity that would combine the diagnostic criteria for vulvar, bladder, and bowel pain disorders.

Differentiated Vulvar Intraepithelial Neoplasia (VIN)

Abstract: Squamous intraepithelial lesions of the vulva, known as vulvar intraepithelial neoplasia, or VIN, are considered to be precursors of invasive squamous cell carcinoma. About a third of invasive squamous cell carcinomas are associated with human papillomavirus (HPV), but no link with HPV is detected in the remaining two thirds. Among intraepithelial lesions, the ratio of HPV-associated to non–HPV-associated lesions is reversed. HPV-associated VIN of the warty (condylomatous) and basaloid types is the most common and best-recognized form of VIN. A rare variant, pagetoid VIN, mimics Paget disease because the abnormal cells grow in a nested pattern and have pale cytoplasm. In this report, we present a case that illustrates the features of an important but often-unrecognized type of VIN, the differentiated or simplex type. It is frequently observed adjacent to non–HPV-associated squamous cell carcinomas, but it also occurs independent of invasive cancer. It differs from the more familiar HPV-associated Bowenoid types of VIN in that the most atypical cells are confined to the basal portion of the epithelium, and the more superficial epithelium consists of differentiated squamous cells. The pattern of differentiation is abnormal, as keratinization is often premature and exaggerated, keratin pearls are present in the deep epidermis or rete ridges, intercellular bridges are more prominent than usual, suprabasal cells have atypical nuclei, and there are suprabasal mitotic figures. Differentiated VIN is a precursor of keratinizing squamous cell carcinoma, and it is important to recognize it and differentiate it from nonneoplastic vulvar disorders such as squamous hyperplasia and lichen sclerosus.

Vulvar disorders in prepubertal children

A. Irritant Dermatitis (Nonspecific vulvitis) (slide 43) Symptoms and signs: scant discharge, puritis, genital pain, dysuria, erythema and irriation No specific organism on culture Etiology appears to be hygiene habits Treatment: avoidance of irritants (soaps, shampoos, bubble baths, etc.), hygiene measures (appropriate wiping, bathing, avoidance of scented soaps and hygiene products, gentle soaps or non-soap alternatives, double rinsing of underclothing, avoidance of tight or moist clothing, breathable sleepwear),