Vulvar Symptoms Research Articles

Patch testing for vulval symptoms: our experience with 282 patients.

Vulval allergic contact dermatitis (ACD) may be a primary disorder or may be associated with an underlying vulval dermatosis. Few studies have looked at the incidence of ACD and the allergens responsible for it. We report the incidence of vulval ACD and the responsible allergens in 282 patients investigated over a 6-year period in a large teaching hospital. We performed a retrospective case notes review of all patients investigated for vulval symptoms in our tertiary referral contact dermatitis investigation unit. A total of 282 patients underwent patch testing. The overall incidence of ACD was 54%. The age range of patients was 14-89years. Pruritus was the most common presenting symptom. Nickel was the most commonly found allergen, but was usually not relevant. Fragrances and topical antibiotics/anaesthetics were less commonly detected, but were almost always relevant to the presentation. Positive reactions were more commonly found in patients who had long-standing symptoms and/or had used many products in the vulval area. Vulval ACD affects women of a wide age range, and presents with nonspecific symptoms such as pruritus and/or vulval irritation. Patients may have experienced symptoms for many years before presenting to a dermatologist. The diagnosis of vulval ACD is more common in those who have been exposed to many potential sensitizers.

Gynecologic Examination of the Prepubertal Girl

1. Amanda M. Jacobs, MD* 2. Elizabeth M. Alderman, MD* 1. *Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx, NY. * Abbreviations: AAP: : American Academy of Pediatrics HPV: : human papillomavirus NAAT: : nucleic acid amplification test The prepubertal genitalia in girls varies in appearance and function compared with the pubertal genitalia of adolescent girls and as such is subject to a unique spectrum of disorders that require appropriate screening, identification skills, and management. After completing this article, readers should be able to: 1. Describe techniques necessary for examining the external genitalia of prepubertal girls. 2. Identify the normal variations and natural history of the female prepubertal external genitalia. 3. Identify, evaluate, and manage common vulvar symptoms in prepubertal girls: labial adhesions, vaginal irritation, bleeding, itching, discharge, and ulcers. Genital examination should be a routine part of a comprehensive physical examination for any girl at any age. The vulva of a prepubertal girl has a unique appearance compared with that of a postmenarchal girl. It is important to become familiar with the normal variations of the genital anatomy of a prepubertal girl, including the vulva’s features and characteristics, so that abnormalities are recognized (Fig 1). Abnormalities, such as the imperforate hymen, signs of sexual abuse, or rare malignant tumors, require prompt evaluation and treatment. Labial adhesions are frequently noted; vulvar symptoms, such as irritation and erythema, are common, and most causes are benign. Causes of vaginal discharge in prepubertal girls vary from those of pubertal females. Figure 1. Anatomical terms for structures of the prepubertal female introitus. Reprinted from Figure 1 in Fortin K, Jenny C. Sexual abuse. Pediatr Rev . 2012;33(1):19-32. The performance of a thorough genital examination can be challenging and anxiety provoking for young patients, their caregivers, and health care clinicians. Patients may be apprehensive about the examination because many children have been counseled not to allow that area …

Attributes and Barriers to Care of Pelvic Pain in University Women

Study ObjectiveTo describe rates of pelvic pain in university women ages 18 and older and to explore the barriers to adequate health care for pelvic pain in this population. DesignA cross-sectional study (Canadian Task Force classification II-2). SettingUniversity of Florida, Gainesville, FL. PatientsA total of 2000 female students at the University of Florida were randomly selected for participation. InterventionsThe 2000 sample members were sent a questionnaire to be completed online. Measurements and Main ResultsThe online questionnaire was hosted through the REDCap electronic data capture tool hosted at the University of Florida. This questionnaire included demographic items, general health and health behavior questions, measures to assess different types of pelvic pain (e.g., dysmenorrheal; dyspareunia; urinary, bowel, and vulvar pain), items regarding barriers to care for pelvic pain problems, and quality of life measures. Data were exported to SAS software (SAS Institute Inc., Cary, NC) for analysis. Of the 2000 subjects who received the questionnaire invitation, 390 filled out the questionnaire, yielding a response rate of 19.5%. Respondents’ ages ranged from 18 to 62 with a mean of 23 years. A total of 72.8% of respondents reported experiencing pelvic pain over the past 12 months. Dysmenorrhea was reported by nearly 80% of participants, over one third of participants noted deep dyspareunia, and a significant proportion of participants reported symptoms related to bowel movements. Vulvar symptoms, including superficial dyspareunia, were reported by 21.5% of participants. Most participants with pelvic pain (78.8%) have not received any diagnosis for their pain, whereas 73.6% reported not yet having visited a doctor. Significant barriers to receiving adequate medical care were reported, including difficulty with insurance coverage and physicians’ lack of time and knowledge or interest in chronic pelvic pain conditions. ConclusionPelvic pain in younger women is a critical public health issue experienced by a significant portion of the population. Significant awareness deficits and barriers to care exist. Careful study of the barriers to receiving adequate medical care reported by these women will allow researchers to describe how best to improve care for these syndromes.

Treatment of recurrent Langerhans cell histiocytosis of the vulva with lenalidomide.

e16555 Background: Langerhans cell histiocytosis (LCH) of the female genital tract is an extremely rare disease. We report a 14 year follow up of a patient with LCH successfully treated with lenalidomide in the relapsed setting. Methods: N/A. Results: A 43 year old Ethiopian woman initially presented to another institution with a nodular lesion on her left vulva with biopsy consistent with LCH. Metastatic workup at the time did not reveal evidence of distant disease. The patient was initially treated with radiotherapy to the vulva and 2 years later she was diagnosed with recurrent disease in the vulva and underwent a wide local excision. Six months afterwards she developed a lesion on her right labium majus consistent with disease recurrence. She was treated with radiotherapy again and underwent a wide radical vulvar excision. She recurred only 3 months later and was started on salvage therapy with thalidomide, 3 years after the initial diagnosis. Within 2 months of starting thalidomide therapy, the patient experienced resolution of vulvar lesions and symptoms. She remained symptom free for 8 years while on thalidomide but then presented to our institution with a new central vulvar lesion after being off therapy for 4 months. Vulvar biopsy confirmed the presence of LCH. She was subsequently restarted on thalidomide and achieved symptom control for an additional 18 months before developing worsening pain and neuropathy associated with therapy. Imaging revealed no evidence of metastatic disease. We then started lenalidomide therapy at dose of 10 mg daily for 21 days in a 28 day cycle and subsequently increased the dose to 25 mg daily continuously. She achieved marked improvement in vulvar symptoms within a month of initiation of lenalidomide. She has tolerated therapy well with no neuropathy or cytopenias. Conclusions: Primary vulvar LCH is a rare disease with no standard therapies. Thalidomide has been described in the literature as an effective treatment option. We describe the use of lenalidomide as an alternative and well tolerated therapy in the relapsed setting. Further investigation is required to determine whether lenalidomide is a viable first line therapy for this rare disease.

Allergic Contact Dermatitis of the Vulva

To describe the incidence of allergic contact dermatitis in patients presenting with vulvar symptoms and to identify the most common allergens, investigators employed patch testing to a standard series and a gynecologic series. Ninety women with itching, burning, pain, or discharge in the vulvar area and a clinical suspicion of allergic contact dermatitis were tested. The median number of patch tests applied per patient was …

Allergic Contact Dermatitis of the Vulva

Allergic contact dermatitis (ACD) of the vulva arises as a primary condition or develops secondary to topical agents. We aimed to describe the incidence of ACD in patients presenting with vulvar symptoms and to identify the allergens of most importance. Using a database of the patch testing results from 3 geographically distinct sites, we identified patients tested to a gynecologic series between 2003 and 2010. Patients had patch testing to the standard European battery and a gynecologic series. Patch testing was in line with accepted universal methods: application on day 1, allergen removal and initial reading on day 3, and final reading on day 5. Ninety patients were included. Thirty-five (39%) had a relevant positive result. The 5 allergens with the highest number of cases with a relevant reaction were natural fragrance mix 2%, balsam of Peru, benzocaine 5%, fragrance mix 8%, and quaternium 15 1%. The most common gynecologic series allergen to cause a relevant reaction was terconazole. Allergic contact dermatitis is a frequent finding in patients presenting with vulvar symptoms. We identified a relevant positive result to patch testing in 39%. We found fragrances, medicaments, and preservatives to be of most relevance.

Prevalance of Vulvovaginal Candidiasis in women of reproductive age group

Background : Vulvovaginal Candidiasis is a common problem in women of reproductive age group with overgrowth of fungus Candida due to loss of imbalance between normal vaginal flora, Candida and immune defense mechanisms. Most common Candida species is C. albicans. However, the incidence of non-albicans species is on the rise. Direct microscopy and vaginal cultures are a valuable tool for identifying Candida species so that appropriate therapy may be given to eliminate the vaginal source of infection rather than treating vulval symptoms. Objectives :The main objectives of the present study were to estimate the incidence of Candida infections in women of reproductive age and identify the species of Candida causing such infections. 150 women were subjected to speculum examination and vaginal swabs were collected for culture, direct microscopy and candida isolation. Results : 53.3% of women in their early reproductive years were found to suffer from Candida infections of which 86% were Candida albicans species. Conclusion : Culture for Candida species routinely maybe a valuable tool not only to treat vaginal symptoms effectively but also to avoid usage of unnecessary antifungal agents.

Role of Vulvar Care Guidelines in the Initial Management of Vulvar Complaints

This study aimed to determine the effectiveness of vulvar care guidelines as the initial treatment of vulvar complaints. A chart review was conducted at the Saint Louis University Vulvar and Vaginal Disease Center. Women with vulvar symptoms in the absence of specific identifiable causes were evaluated and given guidelines for vulvar care. An 11-point Likert scale was used to rate symptoms at the initial and follow-up visits. Compliance level was determined. A decrease in mean scores was shown for dyspareunia (7.5 ± 2.0 to 4.6 ± 3.1, p < .001), burning after intercourse (6.8 ± 2.7 to 3.4 ± 2.4, p = .10), vulvar burning (5.7 ± 2.6 to 2.1 ± 1.9, p < .001), vulvar itching (4.9 ± 2.8 to 2.5 ± 2.6, p < .001), and vulvar pain (5.8 ± 2.8 to 2.2 ± 3.0, p < .01). The mean dyspareunia difference scores were significant between the low- and high-compliance groups. Vulvar care guidelines are successful for the management of vulvar complaints.

Screening and follow up of vulval skin disorders

Vulval squamous cell carcinoma is relatively rare; however, up to 20% of women have significant vulval symptoms during their lifetime. Formal screening programmes for vulval disease have not been established. The evidence for the use of vulval cytology and vulvoscopy is reviewed. No randomised-controlled trials have compared follow-up regimens, and although a few consensus documents have been published, formal guidelines are lacking in Grade A evidence. With increasing pressure on healthcare resources, the possibility of identifying high-risk groups to optimise the use of follow up in specialist clinics is explored. Vulval disease is uncommon and there is no evidence that screening would decrease incidence. If high-risk groups can be identified, follow up should take place in specialised vulval clinics with experienced clinicians who are trained in vulval disease. Women with uncomplicated vulval conditions should be discharged to patient-initiated follow up or primary care. Central to the reduction of mortality and morbidity is increased awareness of vulval conditions among women and improved education of healthcare professionals, with particular understanding of the importance of physical examination.

Vulvar Manifestations of Crohn's Disease

Crohn's disease is an inflammatory bowel disorder with several well-known extraintestinal manifestations, such as erythema nodosum, uveitis, and arthritis. Less commonly observed are vulvar manifestations, which have primarily been discussed in case reports or small case series. These cases generally highlight patients with histopathology limited to noncaseating granulomas. As these histological findings are identified in bowel biopsies from only approximately 50% of patients with gastrointestinal Crohn's disease, there is likely an under-recognition and underdiagnosis of vulvar lesions as Crohn's disease manifestations. We describe the largest case series to date involving patients with vulvar Crohn's disease, discuss the varied clinical presentations, and describe the histopathological findings, which include noncaseating granulomas, ulcerations, lymphatic lesions, and even dysplasia and carcinoma. Our findings underscore the importance of keeping vulvar Crohn's disease on the differential diagnosis when faced with a range of vulvar symptoms and suggest that regular gynecological surveillance in patients with Crohn's disease may be of benefit.

P4-S3.06 Study on early infection of the low genital tract of female mice by different serotypes Ureaplasma urealyticum

ObjectiveTo observe the early inflammatory response by animal model with low genital tract Uu infection for investigating the relationship between the serovars and their pathogenicity.MethodsFifty 8–10-week-old, female BALB/c mice were...

A tertiary centre experience of vulval crohn's disease

IntroductionCrohn's disease affecting the vulva is rarely described and often difficult to treat. The authors describe their experience of 20 patients with vulval Crohn's disease, which to their knowledge is...

Prevalences of and risk factors for vulvar diseases in Nepal: a hospital‐based study

The vulvar diseases are common skin conditions, but their frequency and importance are often underestimated. This study is aimed to investigate the frequency and clinical patterns of vulvar diseases and the risk factors associated with these diseases in patients attending a tertiary care hospital in eastern Nepal. Patients with vulval symptoms or cutaneous lesions on the vulva were enrolled in the study. Laboratory investigations were carried out according to need. Equal numbers of age-matched females without vulval lesions or symptoms were selected from the outpatient department as controls. Of 5521 female patients attending the Dermatology Department's outpatient clinic during the study period, 105 (1.9%) had vulval symptoms and/or lesions. The most common types of vulvar disease were vulvar dermatoses (62.85%), pruritus vulvae (36.19%) and vulvodynia (0.95%). In vulvar dermatoses, infection was the most common (33.4%) manifestation, with a predominance of vulvovaginal candidiasis. Other dermatoses included: cysts and tumors (5.6%); pigmentary changes (vitiligo) (5.6%); inflammatory dermatoses (6.6%); atrophic vaginitis (1.8%); erosive disease (0.9%); and dermatosis caused by sexual abuse (1.9%). Use of nylon undergarments, occasional detergent use for washing clothes, and an irregular menstrual history were found to be associated with vulvar diseases. Our study findings indicate that the known frequency of vulvar diseases may represent only a small proportion of actual frequency. Further clinical and population-based research should be carried out with respect to the treatment, follow-up, and true prevalence of these diseases in the community.

A Case of Cutaneous Endometriosis following Vulvar Injury

Background Cutaneous endometriosis of the vulva following traumatic injury is rare. Case A 15-year-old presented to the emergency department complaining of vulvar swelling with painful papules and URI symptoms, 11 months after suffering a vulvar abrasion. She was admitted to the hospital for pain control and empiric antiviral therapy for a suspected herpes outbreak, although final herpes simplex virus (HSV) cultures were negative. She continued to experience similar episodic vulvar symptoms, and biopsy and surgical resection of the lesions revealed cutaneous endometriosis. Conclusion Although the vulva is a rare site for endometriosis, it should always remain a differential diagnosis when painful vulvar lesions are present.

Venlafaxine for Depression and Glossovulvodynia

To the Editor: Gaitonde et al1 first reported a case of a patient with both burning mouth syndrome (BMS) and vulvodynia. Petruzzi et al2 reported 5 serial cases of vulvostomatodynia. They comment that BMS and vulvodynia may share a common cause. The cause of “dynias” is currently unknown. Here, we report a case of a woman with glossovulvodynia and underlying affective disorder. Venlafaxine brought about dramatic improvement in the patient's symptoms. Case report. Ms A, a 48-year-old woman, started to develop a severe burning sensation in the vulva, palate, throat, and tongue in February 2009. She was evaluated by her dermatologist, neurologist, and dentist. A complete laboratory test was undertaken, with vitamins B12 and B6, folic acid, iron, zinc, thyroid hormones, glucose, and autoimmune panel analyzed. Allergologic study findings were within normal limits. There was no evidence of infection, trauma, or dermatitis in the oral cavity or vulva. Temporomandibular joint function was within the normal range, and she had no prosthetic device. Local and systemic diseases were excluded. She was diagnosed with glossovulvodynia. The patient was treated with trazodone, alprazolam, escitalopram, and paroxetine, with no improvement of her symptoms. She was referred to our psychiatric outpatient clinic in June 2009. Ms A said that she had lost interest in activities that she previously found pleasurable. She could not follow a conversation and felt insecurity and pessimism. She said everything was “going bad” and that she did not have enough money to make ends meet. Her family said she was irritable. She was very anxious and exhibited psychomotor restlessness, depressed mood with guilt, and hypochondriac and ruinous delusions. She suffered from global insomnia and hyporexia. She had diminished ability to think or concentrate. Oral and vulvar symptoms were registered using a 10-cm Visual Analog Scale (VAS; 0 = no pain to 10 = extreme pain); her initial VAS score was 9. The patient completed the Beck Depression Inventory (BDI)3; her initial BDI score was 40. She was diagnosed with major depressive disorder, a severe single episode with mood-congruent psychotic features and melancholic symptoms according to DSM-IV-TR classification. We started administration of venlafaxine (the initial dosage was 37.5 mg/d and the dosage was then gradually increased to 225 mg/d) and lorazepam (2.5 mg/d), with excellent progress: after 10 weeks of treatment, dysesthetic sensations disappeared and Ms A's mood improved until total resolution of the disorder (final VAS score = 0, final BDI score = 5). Glossodynia, or BMS, and vulvodynia are among the psychodermatologic disorders. Therefore, strong relationships with psychopathologic disorders exist, basically with affective disorder, as in the case we report.4 Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI). It has been repeatedly suggested that depression and pain may share a common psychopharmacology. SNRIs have been studied extensively and have demonstrated efficacy for painful symptoms associated with depression, diabetic neuropathy pain, and chronic pain with or without depression. SNRIs produce higher rates of response and remission from major depression than the selective serotonin reuptake inhibitors (SSRIs), and SNRIs are more effective in the treatment of pain than SSRIs.5–7 In the case we report, we think that venlafaxine resolved the dysesthesias due to its antidepressive effect and because of the disappearance of affective disorder. A detailed assessment of the coexisting psychopathologic disorders is necessary to choose the proper treatment of “dynias.” Nevertheless, many studies support the analgesic effect without taking account of antidepressive effect, so it should resolve other “dynias” when the affective component is not so important.5,6

Management of skin lesion of female external genitalia

Patients with vulval symptoms are met frequently in gynaecological practice. The complaint is often long-standing and distressing and frequently induces a feeling of despair in both patient and doctor. The diagnosis and management of vulval dermatoses require such a multidisciplinary approach and the importance of this has been amply demonstrated by the evolution of combined clinics. Vulval disease in many societies can be the subject of unnecessary and exaggerated shame and embarrassment, hence their frequency and importance have been underestimated.

Paediatric vulval lichen sclerosus

Lichen sclerosus (LS) in children is uncommon; however, it is an important differential diagnosis in any pre-pubertal child presenting with chronic vulval symptoms. The long-term prognosis is unknown; however, recent data suggests that the assumption that the condition will resolve at puberty may be incorrect. Children with LS require long-term management with topical corticosteroids, which remains the treatment of choice, as well as long-term follow up. We review the current literature on paediatric vulval LS.

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.

Anogenital allergic contact dermatitis, the role of spices and flavour allergy

In patients with vulval or anogenital dermatitis, irritant contact dermatitis is more common than allergic contact dermatitis. The reported frequency and relevance of contact sensitivity in anogenital dermatitis varies greatly. To determine the frequency and relevance of contact sensitization in a Dutch group of female patients with chronic anogenital complaints. We reviewed patch test results of 53 women with chronic anogenital complaints, with sole vulval symptoms in 29 women and sole perianal in 5, in whom inflammatory skin diseases like lichen sclerosus, lichen planus, psoriasis, as well as infectious diseases were unlikely or excluded as a cause of their symptoms. All women were tested with the European baseline series plus additional test series according to their personal history. Thirty-five patients (66%) showed one or more positive test reactions. Seven of these patients (20%) had one or more clinically relevant positive reactions, most often to flavours and spices. A considerable number of patients with anogenital dermatitis have a contact sensitization. Clinically relevant reactions were mainly found to spices and flavours. This is in contrast to the data reported in the literature that shows most contact allergies in vulval patients to ingredients of topical medication.

Vulvar and Vaginal Symptoms Are Common in Pregnancy

Vulvar and Vaginal Symptoms Are Common in Pregnancy