Telephone triage: diagnosis of candidiasis based upon self-reported vulvovaginal symptoms.

OBJECTIVE: The study aimed to determine which self-reported vulvovaginal symptoms are most consistent with candidiasis confirmed by yeast culture and to establish guidelines to determine who can be appropriately treated by telephone triage versus office examination for women with vulvovaginal symptoms. MATERIALS AND METHODS: A retrospective chart review of 105 patients seen in the Saint Louis University Vulvar and Vaginal Disorders Specialty Center during a 14-month period was performed after institutional review board approval. Patient's age, medication use, symptom scores on a Likert rating scale for vaginal/vulvar pain, burning, itching, dyspareunia, wet-mount results, and yeast culture results were recorded. Differences in the occurrence of vaginal/vulvar symptoms of any severity between women with positive and with negative yeast culture results were calculated using χ2 and Fisher exact tests. Differences in symptom scores of any severity were compared between women with positive and with negative yeast culture results using nonparametric Kolmogorov-Smirnov test, owing to a lack of normality of the distributions. Sensitivity of 75% or greater and specificity of 67% or greater were sought for all 9 recorded symptoms. Multiple logistic regression analysis was used to determine which symptoms and their cutoff values were significant independent predictors of a positive yeast culture result. Receiver operating characteristic curve analysis was used to determine the efficacy of individual symptoms and combinations of symptoms for predicting a positive yeast culture result. A value of p < 0.05 was used to denote statistical significance. RESULTS: Four vulvovaginal symptoms met cutoff criteria for analysis to predict a positive yeast culture result: vaginal burning, vulvar burning, vulvar itching, and clitoral pain. Vaginal burning with a score of 6 or greater (p < 0.001) and vulvar itching with a score of 5 or greater (p < 0.05) were significant independent predictors of a positive yeast culture result. Women with both a vaginal burning score of 6 or greater and a vulvar itching score 5 or greater had a positive predictive value of 91.7% (22/24). Vaginal discharge was not shown to be predictive of candidiasis. CONCLUSIONS: Diagnosis of candidiasis using self-reported vulvovaginal symptoms by telephone triage is difficult. Self-reported scores for vaginal burning of 6 or greater and for vulvar itching of 5 or greater are significant indicators of a positive yeast culture result. Vaginal discharge was not predictive of a diagnosis of candidiasis. A symptom chart can aid office staff in telephone triage of symptomatic women.

Management of lichen sclerosus with triamcinolone ointment: effectiveness in reduction of patient symptom scores.

OBJECTIVE: To determine whether topical triamcinolone ointment effectively reduces patient's symptoms for the management of lichen sclerosus (LS). MATERIALS AND METHODS: A retrospective chart review of LS patients seen during 2004 to 2008 in the Saint Louis University Vulvar Clinic was conducted. Inclusion criteria were biopsy-confirmed LS and age 18 years and older. Data were collected at the initial visit and at 6 to 10 weeks, 3 months, and 6 months of follow-up. Effectiveness was assessed using symptom scores on a Likert scale. Data were analyzed using either paired t tests or nonparametric Wilcoxon signed rank tests using a p value less than.05 to denote statistical significance. RESULTS: Of 41 women, 34 met inclusion criteria. Vulvar pruritus was the most frequently reported vulvar symptom, occurring in 32 (94.1%) of 34 women. Dyspareunia, vulvar burning, and vulvar pain were reported in 17 (54.8%) of 31, 22 (64.7%) of 34, and in 13 (38.2%) of 34 women, respectively. Statistically significant reductions in mean symptom scores between the initial and the 6- to 10-week follow-up visits were found for dyspareunia, vulvar burning, vulvar pruritus, and pain (p values < .05 to < .001) and at 3-month follow-up visits for dyspareunia, vulvar burning, and vulvar pruritus (p < .05). Complete symptom relief was reported for 8 (47.1%) of 17 women with dyspareunia, 19 (86.4%) of 22 women with vulvar burning, 23 (71.9%) of 32 women with vulvar pruritus, and 12 (92.3%) of 13 women with vulvar pain. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Topical triamcinolone ointment is an effective treatment for the management of LS based on the significant reduction of patient symptom scores. Inherent risks with long-term use of high-potency corticosteroids should prompt all practitioners to consider triamcinolone ointment as a safer long-term treatment for patients with LS.

Fistula-in-ano: an uncommon cause of chronic vulvar symptoms.

BACKGROUND: Rectal and anal fistulae are frequently missed diagnoses. Symptoms of fistula-in-ano may mimic other chronic vulvar conditions. CASES: Three patients presented with chronic symptoms including nonhealing ulcer, pruritus, dyspareunia, and discharge for 6-18 months. High clinical suspicion and rectal examination with concomitant perineal probing was useful in making a diagnosis. Once the diagnosis of fistula-in-ano was made, surgical correction was successful. CONCLUSION: When evaluating persistent vulvar problems, the clinician's differential diagnoses should include less common causes. The goals of treatment for fistula-in-ano should be to eliminate the nidus of infection and to preserve the anal sphincter during the repair.

Self-reported yeast symptoms compared with clinical wet mount analysis and vaginal yeast culture in a specialty clinic setting.

OBJECTIVE: To determine the validity of patients' self-reported symptoms of vulvovaginal candidiasis and the accuracy of clinical wet mount examinations compared with vulvovaginal yeast culture results in a specialty clinic. STUDY DESIGN: A retrospective chart review of new patients seen at the Saint Louis University Vulvar and Vaginal Disease Clinic from January 2005 to March 2006 was performed. Patients' age, medication use, symptom scores on a rating scale for vaginal/vulvar pain, burning, itching, dyspareunia and wet mount analyses were compared with yeast culture results. RESULTS: Of 153 patients, 40 had positive yeast cultures (prevalence rate 26.1%). Compared with yeast cultures, self-reported symptom scores >4 resulted in high sensitivity (90%) and low specificity (7%). Positive wet mount result showed low sensitivity (18%) and high specificity (99%). Patient symptom scores were a poor predictor of yeast infections based on yeast culture results. No correlation was found among wet mount, self-reported symptoms and yeast culture results. No significant difference between age or symptom scores to culture result was found. CONCLUSION: Wet mount analysis for recurrent or persistent patient symptoms should be reevaluated. Self-reported symptoms are not reliable for diagnosis. Wet mount analysis resulted in low sensitivity. Yeast cultures should be considered the gold standard for identification of vulvovaginal candidiasis in persistent or recurrent cases.

Vulvodynia.

Vulvar pain and discomfort are common conditions which can truly make the patient's life miserable. It is relatively common, but can be a difficult condition to evaluate and treat. This article serves to give the primary care physician a basic framework with which to begin treatment for such patients.