Noninvasive vulvar lesions An illustrated guide to ... - Urogyn.org
Noninvasive vulvar lesions An illustrated guide to ... - Urogyn.org Noninvasive vulvar lesions An illustrated guide to ... - Urogyn.org
Noninvasive vulvar lesions: An illustrated guide▲The aim of therapy is to eliminate the pruritus(FIGURE 2).Signs and symptomsVulvar skin is typically white or pink.Biopsy will confirm the diagnosis, revealinga markedly thickened keratin layer(hyperkeratosis) and irregular thickeningof the Malpighian ridges (acanthosis).Inflammatory changes are also present,especially when there are areas ofexcoriation.FIGURE 2Squamous cell hyperplasiaTreatment is similarto therapy for lichen sclerosusPotent topical corticosteroids are the backboneof treatment; clobetasol is the preferreddrug. The frequency of application isidentical to that described for lichen sclerosus,and response to therapy usually takes 2months. In the interim, it is advisable to prescribeother medications for the pruritus.Lichen sclerosus and squamous cell hyperplasiasometimes coincide. Fortunately, thetherapies are quite similar and both conditionstend to respond.75-year-old woman. The skin isthickened and may be leathery.• History of yeast infection, 64%• Vulvar burning, 57%• Vulvar itching, 46%• Problems with sexual response, 33%Women with vulvar dysesthesia whoappear to have urinary tract symptomsshould undergo a urine culture, though itwill often be negative and antibiotic therapywill have little effect.Intense pruritus and aggressivescratching lead to excoriations.❚ VulvodyniaThis disorder consists of chronic vulvardiscomfort due to itching, burning, and/orpain that causes physical, sexual, and psychologicaldistress. 3,4 Once referred to asessential vulvodynia, it now is defined asgeneralized vulvar dysesthesia.Signs and symptomsWomen with this condition tend to havedifficulty localizing their pain. They oftenpresent with a complaint of recurrent yeastinfection or constant irritation at theintroitus. Dyspareunia may or may not bea presenting symptom, although intercourseoften triggers this condition. Tightpants or rough undergarments also maytrigger symptoms.Common symptoms. In a study bySadownik, 5 women with vulvar dysesthesiareported the following symptoms:• Dyspareunia, 71%A diagnosis of exclusionThe pain of dysesthesia appears to be neuropathicin origin in that it mimics pain ofthe sensory nervous system. It may be diffuseor focal, unilateral or bilateral, constantor sporadic. Thus, it is a diagnosis ofexclusion.Recommended therapiesVulvar dysesthesia should be regarded as achronic pain syndrome and treated accordingly,with emphasis on generalizedimprovements in health and attitude ratherthan single-therapy approaches.Potent topical corticosteroids are usuallyof no benefit. Nor does topical estrogenproduce long-term relief.Once all possible causes of symptomsare excluded, refer the patient for education,support, and treatment of depression,if present. Occasionally, topical anestheticswill provide short-term relief.At least 2 vulvar pain societies—theNational Vulvodynia Association and theCONTINUEDFAST TRACKVulvodynia painmay never subsidecompletelywww.obgmanagement.com December 2006 • OBG MANAGEMENT 69
Noninvasive vulvar lesions: An illustrated guide▲Vulvar Pain Foundation—have newsletters,outreach programs, and Web sites.❚ Vulvar vestibulitisA more readily definable condition in thesame category as vulvodynia is so-calledvulvar vestibulitis, also known as localizedvulvodynia (as classified by the new ACOGCommittee Opinion on vulvodynia).Signs and symptomsThe defining presentation is severe pain onvestibular touch (eg, entry at intercourse),with tenderness to pressure localized withinthe vulvar vestibule in a horseshoe distributionpattern encompassing 3, 6, and 9o’clock on the vestibule. Erythema is oftenpresent, especially at the 5 and 7 o’clockpositions (FIGURE 3).Patients have no symptoms during normaldaily activities, but complain of dyspareuniaand an inability to use tampons.TABLE 1Distinguishing vulvar vestibulitis and dysesthesiaVULVAR VESTIBULITISPain is usually not constantErythema in sensitive areasLidocaine quells sensitivityCause is dermal inflammationESSENTIAL VULVAR DYSESTHESIAPain is a constant burning sensationNo erythema or abnormal appearanceLidocaine has no effectCause is allodynia (heightenednerve sensitivity)TABLE 2Impressive track recordfor surgical treatment of vestibulitis% RESPONSESTUDY COMPLETE PARTIAL NONEBornstein et al 7 76 24 0Bergeron et al 12 63 37 0Kehoe and Luesley 13 60 29 11Mann et al 14 66 21 13Schover et al 15 47 37 16Marinoff and Turner 16 82 15 3Adapted from Bornstein et al 7Diagnostic strategiesVulvar vestibulitis can be diagnosed usinga moistened cotton-tip applicator. Pressureapplied in the area of the urethral meatuswill result in minimal discomfort, but pressurein the horseshoe area of the vestibulewill cause exquisite discomfort.Careful inspection at 5 and 7 o’clockin the vestibule usually uncovers intenseerythema over an area of 4 or 5 mm. Todistinguish vestibulitis from dysesthesia,see the comparison in TABLE 1.Recommended therapiesTreatment of vulvar vestibulitis is complex.It is important to see the patientoften to ensure that this syndrome is trulypresent rather than vulvar dysesthesia.Xylocaine jelly should be given in anattempt to relieve symptoms; topicalsteroid ointments are another option.Women with persistent symptoms aredifficult to treat medically. Earlier theoriespointing to infection as the cause ofvestibulitis have been discounted.Some experts believe that foods containingoxalates precipitate these symptoms.It may be advisable to have the patientreduce the content of oxalates in her diet inan effort to address all possible remedies.For refractory cases, consider surgeryConsider surgical removal of the tendervestibule if all other therapies fail to provideadequate relief. Surgery for this indicationhas a high success rate (TABLE 2). 7Some surgeons have attempted treatmentwith laser ablation, but most havefound excision more satisfactory, withfaster recovery and excellent cosmesis.Schneider and colleagues 8 had 69women complete a questionnaire 6 monthsafter surgery, 54 (78%) of whom replied.Moderate to excellent improvement wasreported by 45 women (83%); 7 had repeatsurgery, after which 4 improved.❚ Pigmented lesionsAre they cancer precursors?Precursors of malignant melanoma of theFAST TRACKHallmark ofvestibulitis: Severepain on touch,with tendernesslocalized withinthe vestibulein a horseshoepatternWEB RELATEDSee the Web version of this articleat www.obgmanagement.comfor a list of selected foodsand their oxalate contentwww.obgmanagement.com December 2006 • OBG MANAGEMENT 73
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<strong>Noninvasive</strong> <strong>vulvar</strong> <strong>lesions</strong>: <strong>An</strong> <strong>illustrated</strong> <strong>guide</strong>▲The aim of therapy is <strong>to</strong> eliminate the pruritus(FIGURE 2).Signs and symp<strong>to</strong>msVulvar skin is typically white or pink.Biopsy will confirm the diagnosis, revealinga markedly thickened keratin layer(hyperkera<strong>to</strong>sis) and irregular thickeningof the Malpighian ridges (acanthosis).Inflamma<strong>to</strong>ry changes are also present,especially when there are areas ofexcoriation.FIGURE 2Squamous cell hyperplasiaTreatment is similar<strong>to</strong> therapy for lichen sclerosusPotent <strong>to</strong>pical corticosteroids are the backboneof treatment; clobetasol is the preferreddrug. The frequency of application isidentical <strong>to</strong> that described for lichen sclerosus,and response <strong>to</strong> therapy usually takes 2months. In the interim, it is advisable <strong>to</strong> prescribeother medications for the pruritus.Lichen sclerosus and squamous cell hyperplasiasometimes coincide. Fortunately, thetherapies are quite similar and both conditionstend <strong>to</strong> respond.75-year-old woman. The skin isthickened and may be leathery.• His<strong>to</strong>ry of yeast infection, 64%• Vulvar burning, 57%• Vulvar itching, 46%• Problems with sexual response, 33%Women with <strong>vulvar</strong> dysesthesia whoappear <strong>to</strong> have urinary tract symp<strong>to</strong>msshould undergo a urine culture, though itwill often be negative and antibiotic therapywill have little effect.Intense pruritus and aggressivescratching lead <strong>to</strong> excoriations.❚ VulvodyniaThis disorder consists of chronic <strong>vulvar</strong>discomfort due <strong>to</strong> itching, burning, and/orpain that causes physical, sexual, and psychologicaldistress. 3,4 Once referred <strong>to</strong> asessential vulvodynia, it now is defined asgeneralized <strong>vulvar</strong> dysesthesia.Signs and symp<strong>to</strong>msWomen with this condition tend <strong>to</strong> havedifficulty localizing their pain. They oftenpresent with a complaint of recurrent yeastinfection or constant irritation at theintroitus. Dyspareunia may or may not bea presenting symp<strong>to</strong>m, although intercourseoften triggers this condition. Tightpants or rough undergarments also maytrigger symp<strong>to</strong>ms.Common symp<strong>to</strong>ms. In a study bySadownik, 5 women with <strong>vulvar</strong> dysesthesiareported the following symp<strong>to</strong>ms:• Dyspareunia, 71%A diagnosis of exclusionThe pain of dysesthesia appears <strong>to</strong> be neuropathicin origin in that it mimics pain ofthe sensory nervous system. It may be diffuseor focal, unilateral or bilateral, constan<strong>to</strong>r sporadic. Thus, it is a diagnosis ofexclusion.Recommended therapiesVulvar dysesthesia should be regarded as achronic pain syndrome and treated accordingly,with emphasis on generalizedimprovements in health and attitude ratherthan single-therapy approaches.Potent <strong>to</strong>pical corticosteroids are usuallyof no benefit. Nor does <strong>to</strong>pical estrogenproduce long-term relief.Once all possible causes of symp<strong>to</strong>msare excluded, refer the patient for education,support, and treatment of depression,if present. Occasionally, <strong>to</strong>pical anestheticswill provide short-term relief.At least 2 <strong>vulvar</strong> pain societies—theNational Vulvodynia Association and theCONTINUEDFAST TRACKVulvodynia painmay never subsidecompletelywww.obgmanagement.com December 2006 • OBG MANAGEMENT 69
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