Erosive vulvar lichen planus: a cohort at risk for cancer?

OBJECTIVE: To determine the occurrence of cancer, including vulvovaginal squamous cell carcinoma (SCC), among women after diagnosis of erosive vulvar lichen planus (LP). STUDY DESIGN: Retrospective review of 113 patients diagnosed with erosive vulvar LP over an 8-year period (average follow-up, 5 years). RESULTS: A diagnosis of cancer was made in 5 women after diagnosis of erosive vulvar LP. Of these, 1 had stage II vulvar SCC after treatment for stage IIB cervical cancer, and 2 with oral LP had subsequent diagnoses of oral or esophageal SCC. The remaining 2 cancer diagnoses included cervical adenocarcinoma in situ and rectal adenocarcinoma. CONCLUSION: Of 113 women with erosive vulvar LP, 1 had subsequent development of vulvar SCC. Estimating the risk of SCC among women with vulvar LP is difficult because of the low prevalence of each disorder. Additionally, given the age of the patient and multifocal involvement, association with human papillomavirus was likely. Rather, this cohort exemplifies the need for long-term evaluation in the management of vulvar LP.

Langerhans' cell histiocytosis of the vulva: the Iowa experience.

BACKGROUND: Vulvar presentation of Langerhans' cell histiocytosis (histiocytosis X) is rare. Symptoms and signs at the time of presentation can include pruritus, pain, dyspareunia, burning, discharge and presence of a discrete lesion and/or generalized ulceration. Once a diagnosis of Langerhans' cell histiocytosis is made, there is no formal treatment protocol. This report highlights 2 clinical cases diagnosed and treated at a tertiary care center. CASES: We report the case histories of 2 women who presented to the Vulva/Vaginal Disease Clinic at the University of Iowa. The first patient, a 76-year-old woman, had a 1-year history of vulvar pruritus. The second patient, a 39-year-old woman, had a 3-month history of a clitoral growth. CONCLUSION: Presentation of Langerhans' cell histiocytosis as a vulvar primary condition is rare and probably underdiagnosed as its clinical presentation can vary. Such patients often have been treated for recurrent yeast or presumed herpes simplex virus infections. Langerhans' cell histiocytosis should be considered as a differential diagnosis in females who present with chronic pruritus, pain, ulcerations or intermittent rashes.

Prolonged vaginal and oral metronidazole for refractory Trichomonas vaginalis: a case report.

BACKGROUND: Resistant Trichomonas vaginalis infection is typically treated with increased doses of oral metronidazole. Because of side effects that limit compliance, such treatment may be ineffective. CASE: A young woman had an 8-year history of T vaginalis that was refractory to multiple courses of metronidazole, tinidazole and intravaginal paromomycin. After microscopic examination confirmed trichomonads, she began an extended, 14-day course of combined oral and vaginal metronidazole. Six weeks later her symptoms were unchanged, but microscopy revealed fewer trichomonads. After a 5% acetic acid vaginal wash and dilute silver nitrate bladder instillation, she was given the same treatment for 21 days. Symptoms and trichomonads resolved, and 3 years later she remained asymptomatic. CONCLUSION: Prolonged vaginal and oral metronidazole, in combination with bladder and vaginal irrigation, should be considered in women with refractory T vaginalis.

Prolapsing vaginal cyst: a case report.

BACKGROUND: Miillerian duct cysts are remnants of the embryologic paramesonephric ducts. When remnants persist in the vagina, the patient may present with a cyst, which is usually asymptomatic and < 2.0 cm in diameter. CASE: A 33-year-old woman with a 4-year history of a cystic vaginal mass presented after the cyst rapidly enlarged and protruded. She reported discomfort with walking and increased vaginal pressure. The pedunculated, 8-cm cyst was surgically removed. Pathology revealed miillerian duct origin. CONCLUSION: Although millerian duct cysts are commonly described as small and located in the anterolateral vaginal wall, they should be included in the differential diagnosis of any large, protruding vaginal mass.

Erosive vulvar lichen planus: retrospective review of characteristics and outcomes in 113 patients seen in a vulvar specialty clinic.

OBJECTIVE: To describe the characteristics of women diagnosed with erosive vulvar lichen planus and the outcome of treatment utilized by a single practitioner. STUDY DESIGN: A retrospective review of 113 women with erosive vulvar lichen planus. Data were abstracted, including demographic information, medical history, vulvar symptom scores and treatments utilized. Dyspareunia and vulvar symptom scores before and following treatment were compared. RESULTS: The mean age at presentation for women with lichen planus was 50 years. Comorbid medical and vulvar conditions were commonly noted. Sexually active women noted an improvement in dyspareunia symptom score and report of pain-free intercourse. Other symptoms described by women at the first visit included: burning (n = 76), itching (69), pain (43) and abnormal discharge (71). While these symptoms were significantly reduced at the final visit (p < 0.05 for each), the presence of vulvovaginal symptoms commonly waxed and waned in this group. Overall, 33% had resolution of symptoms, and 19% had improvement without resolution of symptoms. CONCLUSION: This cohort extends our understanding of the characteristics of women with erosive vulvar lichen planus and emphasizes its characteristically chronic course. While the recognition of erosive vulvar lichen planus may prevent unnecessary medical and surgical procedures, continued efforts to improve treatment should be investigated.

Bladder and bowel symptoms among women with vulvar disease: are they universal?

OBJECTIVE: To compare the prevalence of painful bladder syndrome, recurrent urinary tract infections, urinary leakage and irritable bowel syndrome between women with specific vulvar disorders and controls. STUDY DESIGN: Women with a primary diagnosis of vulvar intraepithelial neoplasia (dysplasia), vulvar vestibulitis (vestibulitis), contact vulvitis, atrophic vulvovaginitis, lichen simplex, lichen sclerosus and lichen planus, were compared to women presenting for annual examinations. RESULTS: As compared to controls, painful bladder syndrome was more prevalent among subjects with dysplasia, vestibulitis and contact vulvitis; a history of recurrent urinary tract infection was more prevalent among subjects with contact vulvitis; and urinary incontinence was less prevalent in subjects with lichen sclerosus. Irritable bowel syndrome was more prevalent among subjects with dysplasia, vestibulitis, lichen sclerosus, lichen planus and lichen simplex than controls. CONCLUSION: The prevalence of bladder and irritable bowel symptoms varies between vulvar disorders.

Risk factors for painful bladder syndrome in women seeking gynecologic care.

The aim of this cross-sectional study was to report risk factors for painful bladder syndrome in women. We surveyed 645 women presenting for care to general gynecology clinics and a vulvar specialty clinic using a standardized questionnaire and validated outcome measures. We used two definitions for painful bladder syndrome, based on the O'Leary-Sant interstitial cystitis symptom and problem indices. Of those women surveyed, 29.5% met broader criteria and 8.5% met more restrictive criteria for painful bladder syndrome. After adjusting for confounders, bladder pain was significantly associated with current smoking, irritable bowel syndrome, and a generalized pain disorder. Tobacco use, the only modifiable association noted on multivariate analysis, has not been previously identified to our knowledge.

Vulvar cellular angiofibroma: a case report.

Cellular angiofibroma is a benign growth initially described in 1997, with few reports to date. A 31-year-old woman presented with a 3-year history of a small left labial mass, which had recently increased in size to 5 cm, and was clinically thought to be a lipoma. A simple excision was performed. Histologically, the mass was consistent with a cellular angiofibroma. Ten months later, the growth has not recurred. Cellular angiofibroma is a rare, benign mesenchymal lesion typically occurring on the vulva, and should be considered in the differential diagnosis of a painless, soft, vulvar mass.

Leiomyosarcoma of the vulva: a case report.

BACKGROUND: Leiomyosarcoma of the vulva is a rare gynecologic malignancy, comprising approximately 1% of vulvar cancers. CASE: A 36-year-old woman was referred for a slowly growing painless vulvar mass that was initially thought to be a Bartholin's duct cyst but was cancerous upon biopsy. A modified radical vulvectomy was performed, and pathology revealed a grade 1 leiomyosarcoma. Thirteen months later, the tumor had not recurred. CONCLUSION: Vulvar cancer must be considered in patients with a suspected Bartholin duct cyst that demonstrates atypical features. A biopsy should be obtained if the mass appears firm or solid on palpation, is ulcerated or presents in a slightly different location from the usual area of the Bartholin gland.

Vulvar disease: a pelvic floor pain disorder?

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.

Antifungal susceptibilities of Candida species causing vulvovaginitis and epidemiology of recurrent cases.

There are limited data regarding the antifungal susceptibility of yeast causing vulvovaginal candidiasis, since cultures are rarely performed. Susceptibility testing was performed on vaginal yeast isolates collected from January 1998 to March 2001 from 429 patients with suspected vulvovaginal candidiasis. The charts of 84 patients with multiple positive cultures were reviewed. The 593 yeast isolates were Candida albicans (n = 420), Candida glabrata (n = 112), Candida parapsilosis (n = 30), Candida krusei (n = 12), Saccharomyces cerevisiae ( n = 9), Candida tropicalis (n = 8), Candida lusitaniae (n = 1), and Trichosporon sp. (n = 1). Multiple species suggesting mixed infection were isolated from 27 cultures. Resistance to fluconazole and flucytosine was observed infrequently (3.7% and 3.0%); 16.2% of isolates were resistant to itraconazole (MIC > or = 1 microg/ml). The four imidazoles (econazole, clotrimazole, miconazole, and ketoconazole) were active: 94.3 to 98.5% were susceptible at < or =1 microg/ml. Among different species, elevated fluconazole MICs (> or = 16 microg/ml) were only observed in C. glabrata (15.2% resistant [R], 51.8% susceptible-dose dependent [S-DD]), C. parapsilosis (3.3% S-DD), S. cerevisiae (11.1% S-DD), and C. krusei (50% S-DD, 41.7% R, considered intrinsically fluconazole resistant). Resistance to itraconazole was observed among C. glabrata (74.1%), C. krusei (58.3%), S. cerevisiae (55.6%), and C. parapsilosis (3.4%). Among 84 patients with recurrent episodes, non-albicans species were more common (42% versus 20%). A > or = 4-fold rise in fluconazole MIC was observed in only one patient with C. parapsilosis. These results support the use of azoles for empirical therapy of uncomplicated candidal vulvovaginitis. Recurrent episodes are more often caused by non-albicans species, for which azole agents are less likely to be effective.

Vulvar granuloma fissuratum: a description of fissuring of the posterior fourchette and the repair.

OBJECTIVE: To describe the characteristics of women who experience chronic fissuring of the posterior fourchette and the outcome of treatment administered. METHODS: We conducted a retrospective review of 42 women with granuloma fissuratum presenting for care between January 1, 1995, and December 31, 2003. Women underwent medical management first, and if improvement was minimal, perineoplasty was recommended. Dyspareunia and vulvar symptom scores, including itching, burning, and pain, before and after treatment were compared. RESULTS: Twenty women were managed nonoperatively, while 22 women underwent perineoplasty. The median age at diagnosis of granuloma fissuratum was 42.5 years (range 26-78). The fissure resolved in 13 of 20 women (65%) who were managed nonoperatively and in 21 of 22 women (95%) who underwent perineoplasty. Of the 11 women sexually active after perineoplasty, all had preoperative dyspareunia; it resolved in 7 (64%) women. Among the 13 women managed nonsurgically who had resolution of the fissure, 7 women were sexually active after treatment and dyspareunia resolved in 2 (29%) women. Other vulvar symptoms, such as burning, itching, pain, and discharge, showed no significant improvement after either surgical or nonsurgical treatment. CONCLUSION: Although fissuring is common with some vulvar dermatoses, such as lichen sclerosus and contact vulvitis, and often resolves with the appropriate medical management, fissuring may also occur as a primary finding and may benefit from perineoplasty.

Vulvodynia.

CONTEXT: Vulvodynia is a term used to describe chronic burning and/or pain in the vulva without objective physical findings to explain the symptoms. The terminology and classification of vulvodynia continue to evolve, and much remains to be understood about the prevalence, pathogenesis, natural history, and management of this distressing condition. STARTING POINT: James Aikens and colleagues showed that chronic vulval pain (vulvodynia or vulvar dysaesthesia) is associated with worse depressive symptoms (Am J Obstet Gynecol 2003; 189: 462-66). However, the increased scores for depression in this case-control study were attributed to sexual disinterest and experience of chronic pain rather than to features of depressive disorder. These results lend weight to the increasing need for better understanding of the pathogenesis of vulval pain and how to manage it appropriately. WHERE NEXT? The aetiology of vulvodynia and effectiveness of treatments need further study. Appraising the available literature, we have formulated a useful approach to patients with chronic vulval pain. There is a pressing need for further case-control studies of potential causes of vulvodynia and for randomised trials of interventions.

Erosive lichen planus of the vulva and vagina.

BACKGROUND: Erosive lichen planus causes erosion of the vulva and vagina and characteristic oral lesions. Dyspareunia is usual, and vaginal stenosis may occur. This report highlights the clinical features and the response to medical therapy. CASES: We report the case histories of three women who presented to the Vulvovaginal Disorders Clinic of the University of Iowa with long histories of dyspareunia and advanced vaginal scarring. In each case, the clinical diagnosis of erosive lichen planus was obvious but had not been made previously. All three women have responded well to topical treatment with tacrolimus 0.1% ointment. CONCLUSION: Erosive lichen planus should be suspected in a case of vaginal erosion or narrowing. Surgical management is inappropriate when the mucosa is eroded. Inspection of the mouth may confirm the diagnosis.

Ulcerative vulvitis in atypical Reiter's syndrome.

We report a case of atypical Reiter's syndrome occurring in a female patient who had severe, ulcerative vulvar disease develop in association with conjunctivitis, low back pain, stomatitis, and psoriasiform skin lesions. Vulvar lesions have rarely been described in Reiter's syndrome and are not well characterized.