Algorithms for Managing Vulvovaginal Symptoms-a Practical Primer.

PURPOSE OF REVIEW: To present a comprehensive systematic approach for diagnosing correctly the cause(s) of bothersome genital symptoms. RECENT FINDINGS: We searched the PUBMED for practical clinical guidelines, written by a multidisciplinary team of healthcare providers directed for diagnosing bothersome genital symptoms. This search was performed by a professional information specialist using the keywords "vulvovaginal," "vulvar," "multidisciplinary diagnosis," "interdisciplinary consultation," and "vulvology." We found numerous publications defining the criteria for diagnosing specific disorders, but only a few publications presented a multidisciplinary clinical algorithm for diagnosing bothersome vulvovaginal symptoms. The authors, from three different specialities, gathered together (online), in aim to present a comprehensive systematic approach for accurate diagnosing of bothersome vulvovaginal symptoms. Six principles for accurately diagnosing a woman with bothersome genital symptoms were endorsed: (1) locate the discomfort (vulva, clitoris, vestibule, vagina, cervix, pelvis); (2) consider more than one entity; (3) evaluate each symptom separately (it is common to have more than one entity necessitating treatment for each); (4) use pH and wet mount microscopy; (5) obtain a follow-up visit in 2-4 weeks; (6) perform a biopsy for dermatological conditions that are resistant to treatment.

Hidradenitis suppurativa.

Hidradenitis suppurativa is a chronic relapsing disorder of the folliculopilosebaceous units (FPSUs). Its negative impact on quality of life is extreme, mainly due to the lack of early recognition, accurate diagnosis, and appropriate management. The support structure of the FPSUs is defective. Under the influence of endogenous reproductive hormones, exogenous hormones, androgens and their precursors in dairy products, and other dietary factors, the follicular unit is plugged and distended by retained keratin. Friction, shearing forces, and pressure lead to rupture and leakage of the ductal contents from the weakened FPSU, causing an inflammatory reaction mediated mainly by the innate immune system. Therapy requires patient comprehension and cooperation, counseling, aggressive hormonal and dietary modification, avoidance of the trauma that leads to rupture, active multimodal anti-inflammatory therapy, and early unroofing and debridement. The full therapeutic program is needed to avoid the aggressive surgery required if the condition is not diagnosed early and managed appropriately.

Hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic, inflammatory, scarring condition involving the intertriginous skin of the axillary, inguinal, inframammary, genital, and perineal areas of the body. It is also referred to as acne inversa and Verneuil disease. Follicular occlusion is the primary event in HS. It is now accepted that the first pathogenetic change is in the pilosebaceous follicular ducts, like acne, and so there has been a move to rename this disorder acne inversa. Despite the legitimate argument that hidradenitis suppurativa is a misnomer, the term has become generally accepted.

Approach to the diagnosis and treatment of vulvar pain.

Vulvar pain is a common problem, affecting up to 16% of women. The pain and discomfort seriously impacts their quality of life, and is compounded by the increasing frustration encountered in their search for appropriate medical advice. Their pain can be localized or generalized, constant or intermittent, with or without visible changes. For practitioners, the correct diagnosis and treatment of vulvar pain is a challenge. There is an extensive differential diagnosis, from problems that are simple and immediately visible to those that are much more complex and truly invisible. This review provides an approach to the diagnosis of vulvar pain. It outlines the wide range of etiologies for vulvar pain, and provides details of the most vexing in a comprehensive look at vulvodynia, including definition, theory, diagnosis, and therapy.

Vulvar disease pearls.

The vulva is a neglected area of the skin, hidden away by ignorance, embarrassment, and taboo with the result that women with vulvar diseases, desperate for help, suffer needlessly and waste millions of dollars on inadequate or inappropriate treatment. As the skin experts, dermatologists are vital for vulvar care. This article covers a range of subjects from normal anatomy to atypical presentations of common infections, such as candidiasis and herpes simplex virus. Tips are presented on the management of common vulvar dermatoses and there is a brief overview of pearls in diagnosis and therapy. Dermatologists are uniquely qualified to care for this area.

The vulvodynia guideline.

OBJECTIVE: To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia. MATERIALS AND METHODS: Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition. RESULTS: Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient. CONCLUSIONS: Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

Genital ulcers caused by Epstein-Barr virus.

In North America, the most common cause of vulvar ulcers is infection with herpes simplex virus. However, Epstein-Barr virus can also cause vulvar ulcers, and may be underrecognized. Unlike herpes simplex virus, Epstein-Barr virus is not necessarily sexually transmitted. Therefore, it is particularly important to include in the differential diagnosis of genital ulcers for patients for whom a diagnosis of a venereal infection has important psychosocial consequences. We report three cases of acute primary Epstein-Barr virus infection in which the presenting symptoms were vulvar ulceration.

Contact dermatitis of the vulva.

Vulvar diseases rarely stand alone. They are often caused or worsened by primary irritant or allergic contact dermatitis, and this should be considered when evaluating any vulvar complaint. All irritants should be avoided in all women, and those with vulvar dermatoses should be patch tested to help define or rule out allergens.