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Diagnosing and Treating Vulvar Conditions: Tricks of the Trade

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1 Diagnosing and Treating Vulvar Conditions: Tricks of the Trade
Michael S. Policar, MD, MPH UCSF School of Medicine

2 Objectives Explain 3 differences between lichen sclerosus and lichen simplex chronicus. List the 3 major presentations of Bartholin duct conditions and the preferred treatment for each. List the 3 main causes of vulvar pain and 2 treatment options for each. List the 3 possible conditions in the differential diagnosis of a tender cystic mass of the vulva.

3 Presentations of Vulvar Conditions
Vulvar itching Dermatoses Vulvovaginitis Vulvar papules and nodules Genital warts VIN, SC cancer Pigmented lesions Chronic vulvar pain Vestibulodynia Vulvodynia Acute vulvar pain Abcess, cellulitis Vulvar ulcers Trauma

4 The “Itchy Vulva” The Lichens: LS, LSC, LS+LSC
Systemic: psoriasis, lichen planus Eczemas: atopic dermatitis, contact dermatitis (irritant, allergic) Fungal vulvitis: candidal, tinea Recurrent genital herpes VIN (Vulvar Intraepithelial Neoplasia)

5 Vulvar Skin Complaints: History
Nature and duration of symptoms Previous treatment and response Personal, family history: eczema, psoriasis Other sites involved: mouth, eyes, elbows, scalp All medications applied to vulva Antibiotics, hormones, steroids, etc Skin care: soaps, baby wipes, menstrual pads, new clothing, scrubbing, etc New sexual partner(s); barrier contraceptives

6 Vulvar Dermatoses New Terminology Old Terminology
Lichen sclerosus - Lichen sclerosus et atrophicus - Kraurosis vulvae Squamous cell - Hyperplastic dystrophy hyperplasia Neurodermatitis Lichen simplex chronicus Other dermatoses - Lichen planus, psoriasis VIN Hyperplasic dystrophy/atypia - Bowenoid papulosis - Vulvar CIS

7 Lichen Sclerosus: Natural History
Most common vulvar dystrophy Bimodal ages: children, older women Cause: unknown; probably autoimmune Chronic, progressive, lifelong condition Most common in Caucasian women Can affect non-vulvar areas Squamous cell carcinoma 3-5% lifetime risk 30-40% SCCA develops with LS

8 Lichen Sclerosus: Findings
Symptoms Itching, burning, dyspareunia, dysuria Signs Thin white “parchment paper” epithelium Fissures, ulcers, bruises, or hemorrhage Submucosal hemorrhage Depigmentation (white) or hyperpigmentation in “keyhole” distribution: vulva and anus Introital stenosis and loss of vulvar architecture Reduced skin elasticity

9 Lichen Sclerosus: Treatment
Preferred treatment Clobetasol (Temovate) 0.05% BID x 2-3 wk, to QD Taper to med potency steroid 2-4x/month for life Testosterone ointment is time honored, but little evidence to support Adjunctive therapy: anti-pruritic therapy Atarax or Benedryl PO, especially at night Doxypin, QHS or topically If not effective: amitriptyline PO Perineoplasty may help dyspareunia, fissuring

10 Lichen Simplex Chronicus = Squamous Cell Hyperplasia
Irritant initiates “scratch-itch” cycle Candida Chemical irritant, allergen Lichen sclerosus Presentation: always itching; burning, pain, and tenderness Thickened leathery red (white if moisture) raised lesion In absence of atypia, no malignant potential If atypia present , classified as VIN

11 L. Simplex Chronicus: Treatment
Removal of irritants or allergens Treatment Triamcinolone acetonide (TAC) 0.1% ointment BID x4-6 weeks, then QD Other moderate strength steroid ointments Intralesional TAC once every 3-6 months Anti-pruritics Hydroxyzine (Atarax) mg QHS Doxepin mg PO QHS Doxepin (Zonalon) 5% cream; start QD, work up

12 Lichen Sclerosus + LSC “Mixed dystrophy” deleted in 1987 ISSVD System
15% all vulvar dystrophies LS is irritant; scratching causes LSC DDX: LS with plaque, candida, VIN Treatment Clobetasol x12 weeks, then steroid maintenance Stop the itch!!

13 Psoriasis 30% have family history
Triggered by stress, drugs, infections, alcohol, cold Usually involves extensor skin beyond the vulva elbows, knees, scalp, nails Genital involvement: mons, vulva, crural folds Pruritis, soreness Red epithelial patches with elevated silver scales Rx: Dovonex, topical steroids

14 Lichen Planus Probable autoimmune disease
May present as purple, well-demarcated, flat topped papules on oral, genital tissues Erythematous erosive lesions on vestibule or in vagina Vulvar burning or pruritus 50% of women with classic LP will have genitalia involved DDX: LS, syphilis, herpes, chancroid, Behcet’s DX: biopsy essential

15 Lichen Planus: Treatment
No one satisfactory treatment exists Emollients, vulvar care; treat superinfection Vulva: clobetasol ointment with taper Vagina: Anusol HC 25 mg supp; ½-1 supp PV BID x4 weeks, then taper Short course of oral steroids if necessary Vaginal dilators to prevent scarring Other Rx: Tacrolimus 0.1% (Protopic) BID, Acitretin, methotrexate, Dapsone

16 Vulvar “Eczema” Atopic dermatitis “Endogenous eczema”
Contact dermatitis: “Exogenous eczema” Irritant contact dermatitis (ICD) Allergic contact dermatitis ACD) Lichen Simplex Chronicus “End stage” eczema

17 Atopic Dermatitis Prevalence: 10-15% of population
If 2 parents with eczema, 80% risk to children Criteria for diagnosis Itching/ scratch cycle Exacerbations and remissions Eczematoid lesions on vulva and elsewhere (crural folds, scalp, umbilicus, extremities) Personal or family of hay fever, asthma, rhinitis, or other allergies Clinical course longer than 6 weeks

18 Atopic Dermatitis: Treatments
Avoid scratching; stress management Emollients (bland, petrolatum based) Topical steroids (moderate potency) Intralesional triamcinolone Tacrolimus (Protopic) 0.03% to 0.1% BID Oral antihistamines or doxypin 5% cream Intended mainly to relieve itching Sedation in 20% May cause contact dermatitis

19 Contact Dermatitis Irritant contact dermatitis (ICD)
Elicited in most people with a high enough dose Potent irritant: chemical burn Weaker irritant: applied repeatedly before sxs Rapid onset vulvar itching (hours-days) Allergic contact dermatitis (ACD) Delayed hypersensitivity 10-14d after first exposure; 1-7d after repeat exposure Atopy, ICD, ACD can all present with Itching, burning, swelling, redness Small vesicles or bullae more likely with ACD

20 Contact Dermatitis Common contact irritants
Urine, feces, excessive sweating Saliva (receptive oral sex) Repetitive scratching, overwashing Detergents, fabric softeners Topical corticosteroids Toilet paper dyes and perfumes Hygiene pads (and liners), sprays, douches Lubricants, including condoms

21 Contact Dermatitis Common contact allergens Poison oak, poison ivy
Topical antibiotics, esp neomycin, bacitracin Spermicides Latex (condoms, diaphragms) Vehicles of topical meds: propylene glycol Lidocaine, benzocaine Fragrances

22 Contact Dermatitis: Treatment
Exclude contact with possible irritants Restore skin barrier with sitz baths, compresses After hydration, apply a bland emollient White petrolatum, mineral oil, olive oil Short term mild-moderate potency steroids TAC 0.1% BID x10-14 days (or clobetasol 0.05%) Fluconazole 150 mg PO weekly Cold packs: gel packs, peas in a “zip-lock” bag Doxypin or hydroxyzine (10-75 mg PO) at 6 pm Replace local estrogen, if necessary If recurrent, refer for patch testing

23 General Vulvar Care Measures
Wear loose fitting clothing 100% cotton underwear Rinse underwear twice Low irritant soap; no use of fabric softeners 100% cotton menstrual pads Mild bathing soaps: Cetaphil, Kiss-My-Face, Basis Vulvar water rinse (or very soft toilet paper) Use vaginal lubricants: Replens, KY, Olive Oil

24 Measures for Vulvar Itching
Aveeno Oatmeal compresses or tub soaks Tea bags (compress, sitz, or tub) Cold pack, especially before bed Sedating antihistamines at bedtime Emollient during activities Aquaphor, SBR Lipocream, A&D ointment, petrolatum Doxypin 5% cream (20% will become drowsy)

25 Rules for Topical Steroid Use
Topical steroids are not a cure Use potency that will control condition quickly, then stop, use PRN, or maintain with low potency Limit the amount prescribed to 15 grams Ointments are stronger, last longer, less irritating Show the patient exactly how to use it: thin film L. minora are steroid resistant L. majora, crural fold, thighs thin easily; get striae At any suggestion of 2o candidal infection, use steroid along with topical antifungal drug

26 Evaluation: Recurrent VV Itching
Symptom diary Detailed search for anatomic causes (e.g., fistula) Saline, KOH slides during symptomatic period Vaginal pH, amine test Candidal culture and speciation, or PCR If at risk for glucose intolerance, check FBS If vaginitis is chronic, severe, recalcitrant, or if oral thrush or lymphadenopathy, consider HIV

27 CDC Classification of VVC
Uncomplicated VVC (80-90%) Sporadic or infrequent VVC, or AND Mild-to-moderate VVC, or AND Likely to be Candida albicans, or AND Non-immunecompromised women Complicated VVC (10-20%) Recurrent VVC, or Severe VVC, or Non-albicans candidiasis, or Uncontrolled DM, immunosuppression, pregnancy

28 VC: SEVEN DAY Therapy Rx: 1 application at bedtime for 7 days
Miconazole Monistat-7 2% cream, 100 mg sup Terconazole Terazol % cream Clotrimazole Gynelotrimin 7 1% cream, Mycelex mg tab Rx: 1 application at bedtime for 7 days OTC drugs in italics

29 VC: THREE DAY Therapy Butoconazole Femstat 3 2% cream
Miconazole Monistat mg supp Terconazole Terazol mg supp, 0.8% cream Rx: 1 application at bedtime for 3 days Alternative: Miconazole 2% cream BID x 3 days Clotrimazole 1% cream Clotrimazole 100 mg tab 2 QHS x 3 days OTC drugs in italics

30 VC: ONE DAY Therapy Clotrimazole Mycelex G-500 500 mg suppository
Tioconazole Vagistat % ointment Miconazole Monistat gm suppository Butoconazole Gynazole-1 2% bioadh cream* Rx: app at bedtime (*anytime) Fluconazole Diflucan 150 mg Rx: 1 tablet PO OTC drugs in italics

31 Uncomplicated VVC: Treatments
Non-pregnant 3, 7 day topicals equal efficacy and price Recommend: 3 day topical or fluconazole PO Mild or early case: any 1 or 3 day regimen If first course fails Reconfirm microscopic diagnosis Treat with alternate antifungal Rx Candidal culture to speciate No role for nystatin, candicidin

32 CDC 2002: Complicated VVC Severe VVC
Advanced findings: erythema, excoriation, fissures Treat for 7-14 days of topical therapy or fluconazole 150 mg PO repeat in 3 days Compromised host Conventional antimycotic tx for 7-14 days Pregnancy Topical azoles for 7 days

33 Candidia glabrata Vaginitis
Main symptom is intense vulvo-vaginal burning, rather than itching KOH : yeast spores and buds, not hyphae Treatments Best coverage (lowest MIC) with butoconazole Imidazoles for 7-14 days Boric acid 600 mg QD x 14 days Topical gentian violet Fluconazole not recommended (by CDC)

34 CDC 2002: Complicated VVC Recurrent VVC (RVVC)
> 4 episodes of symptomatic VVC per year Most women have no predisposing condition Partners are rarely source of infection Confirm with candidal culture, since often due to non-albicans species Early treatment regimen: self-medication 3 days with onset of symptoms

35 CDC 2002: Complicated VVC RVVC: Treatment
Treat for 7-14 days of topical therapy or fluconazole 150 mg PO q 72o x3 doses, then Maintenance therapy x 6 months Fluconazole mg PO 1-2 per week Itraconazole 100 mg/wk or 400 mg/month Clotrimazole 500 mg suppos 1 per week Boric acid 600 mg suppos QD x14, then BIW Gentian violet: Q week x2, Q month X 3-6 mo

36 Vaginal Candidiasis Tips
2/3 of women who believe that the have chronic or recurrent Candida don’t Verify diagnosis with PCR, fungal culture Consider Candida glabrata Different presentation, different treatments Oral or vaginal yoghurt doesn’t work because Lactobacillus strains don’t adhere to vaginal cells Predominant normal flora is L. crispatus, not L. acidophilus or L. bulgaricus

37 HPV Infection: Overview
Pendulum has swung widely over four decades Controversies persist regarding HPV transmission, treatment, and prevention PH model: STD protection  cancer prevention Primary prevention with HPV vaccine Once infected with HPV Most HPV infections are transient Women < 30 yo; LR types; immunocompetent Persistent HPV infection causes HG lesions Women > 30 yo; HR types; immunosuppressed

38 HPV Infection: Overview
Therapeutic eradication of HPV is not possible Goal is the control of existing and new lesions Treatment should be limited to High grade pre-invasive disease CIN (cervix), VaIN (vagina), VIN (vulva) Anal IN, Penile IN Genital warts that cause Irritative symptoms of vulva, anus, or penis Cosmetically objectionable lesions Treatment must not be worse than disease

39 EGW Treatment: General Principles
Advise patient to stop cigarette smoking Evaluate for trichomoniasis; treat if present No one treatment is ideal for all patients or all warts More than one modality may be necessary Should be used sequentially; not simultaneously Treatment must be individualized Size of the warts; extent, location of the outbreak Personal preferences, medical status of patient Experience of clinician Available treatment resources Cost considerations

40 Vulvar Papules: Differential Diagnosis
VIN or vulvar carcinoma Usually multifocal in premenopausal women Raised with irregular edges but not exuberant Red, white, or hyperpigmented Opaque white with vinegar application Condyloma latum Diagnostic of secondary syphilis Not as exuberant as condyloma accuminata Circular flat papules, usually in clusters If suspected, order syphilis serology (RPR or VDRL) Other lesions: molluscum contagiosum, skin tags, nevi, scars

41 Vulvar Papules: Evaluation
Exam of vulva, perineum, and anus If questionable, use vinegar for acetowhitening Biopsy Typical condys do not require biopsy Biopsy atypical condys, VIN, or vulvar carcinoma Cervical Pap smear for multicentric disease If perianal warts, evaluate anus by Pap + anoscopy Test for other infectious conditions GC, chlamydia, syphilis, HIV NaCl suspension for vaginal trichomoniasis

42 EGW: No Treatment Small asymptomatic vulvar and vaginal genital warts
Non-specific acetowhitening of laba majora, labia minora, or introitus (non-HPV) Vestibilar papillomatosis (non-HPV) In placebo-control groups of women with genital warts, 10-30% of cases resolve spontaneously within 3 months

43 EGW: Clinician Applied Treatments
TCA or BCA 85-90% Moderate vulvar, vaginal GW; not cervical GW Podophyllin 10-25% Resin is less effective, more irritating than TCA Cryotherapy (liquid N2, cryoprobe) Used for isolated vulvar, vaginal, cervical lesions Office excision Simple surgical excision: scissors or scalpel Electrocautery (coagulation), electrodessication

44 Self-Applied: Condylox 0.5%Gel
Purified podophylotoxin; derived from podophyllin Mechanism: mitotic spindle poison; blocks cell division Use: Apply BID for 3 days, then four days off Expect response by 4 wks; if so, use up to 8 wks Response rate (8 weeks): 80% of women Pregnancy category C Cost (AWP) is $57 per 4 week cycle

45 Condylox R 0.5% Gel Advantages Disadvantages
Good short term wart resolution rates Fewer adverse effects than podophyllin resin Shorter course, less expensive than Aldara Disadvantages Must apply correctly, consistently for optimal effect Mild-moderate pain, local irritation may occur Safety in pregnancy has not been established

46 Self-Applied: Aldara 5% Cream
Immune response modifier Stimulates natural killer cell, T-cell activity Induces a-interferon production from local tissues No antiviral effect or direct tissue destruction Apply to EGW every other day x3, then 2 days off Use Mon, Wed, Fri, then Sat, Sun off Wash off in morning using mild soap and water Expect response by 4 wks; if so, use up to 12 wks Pregnancy category B PHS price is $60 per 4 week cycle

47 Aldara 5% Cream Advantages Good short term wart resolution rates
Little toxicity; mainly erythema and irritation Pain or irritiation; discontination in < 2% Drug of choice in large vulvar EGW “blooms” in women and for immunosuppressed patients Disadvantages Must apply correctly and consistently May take longer for response than podofilox

48 Anal and Perianal Warts
25% women with vulvar warts have perianal warts Vaginal-to-anal self-inoculation + microtrauma Intra-anal warts often 2o to anoreceptive sex If perianal warts, examine for intra-anal warts Anal Pap; anoscopy if lesion extends upward Treatment Imiquimod (Aldara) cream Cryotherapy TCA/BCA

49 Genital Warts: Complex Treatments
CO2 Laser Extensive or refractory vulvar warts or VIN Topical 5-FU (Efudex): Extensive intravaginal condylomata accuminata Primary or recurrent VAIN Extensive surgical excision or electrocautery Extensive refractory lower genital tract lesions Interferon injections: Refractory vulvar lesions

50 PPFA Visit and Cost Distribution
VISITS COSTS Visit Number Number Pts. Pct. Distrib. Cumulative 1 115 23.0% 11.2% 2 170 34.0% 57.0% 24.7% 35.8% 3 87 17.4% 74.4% 17.8% 53.7% 4 52 10.4% 84.8% 13.6% 67.2% 5 28 5.6% 90.4% 9.2% 76.4% >5 48 9.6% 100.0% 23.6% The chart indicates the distribution of visits and costs based on the visit number where clearance was reached. The circles highlights that 25.6% of patients require 4 or more visits to clear while requiring almost half (46.4%) of all the resources to treat EGW. 25.6% 46.4%

51 PPFA First Line Treatment Analysis
MAXIMUM First Line Therapy No. Patients Avg. Visits Avg. Cost Visits Costs TCA 330 3.1 $262.93 17 $ 1,074.95 Cryotherapy 91 3.0 $440.79 $ 2,443.30 Aldara 42 2.4 $234.78 9 $705.35 TCA + Aldara 27 1.5 $241.12 4 $408.40 Cryo + Aldara 7 1.4 $270.03 2 $409.80 TCA + Condylox 3.5 $305.16 6 $457.86 Condylox 1 6.0 TCA was the predominant first line therapy for the five sites, however, the chart indicates that Aldara as a monotherapy or in combination with the ablative therapy is extremely efficient. The average number of patient visits required to achieve clearance after treatment with Aldara shows that is quite cost effective.

52 EGW Treatment Algorithm
Patient Presents with EGW First-time EGW Patient Recurrent EGW Patient Single location of lesions ? No Multiple locations Aldara, with Education Materials Yes Treat with TCA/Cryo No Patient cleared in < 3 visits Yes Treatment Completed

53 Vulvar Intraepithelial Neoplasia (VIN)
Due to infection with HPV 18 or LSC (no HPV) Graded I-III, based upon severity of atypia Sxs: itching, burning, ulceration 4 P’s Papule formation: raised lesion Pruritic: itching is prominent “Patriotic”: red, white, or blue (hyperpigmented) Parakeratosis on microscopy

54 Vulvar Intraepithelial Neoplasia
Location Multifocal: premenopause, im’compromised Unifocal in postmenopause May be multicentric Precursor to vulvar cancer; low “hit rate” Smoking cessation may improve outcome Tx: Wide local excision, laser ablation Recurrence is common (48% at 15 years)

55 Differential Diagnosis: Dark Lesions
Hyperpigmentation due to scarring Lentigo, benign genital melanosis Benign nevi VIN Invasive squamous cell carcinoma Malignant melanoma

56 Vulvar Melanoma: ABCD Rule
A: Asymmetry B: Border Irrigularities C: Color black or multicolored D: Diameter larger than 6 mm Any change in mole should arouse suspicion Biopsy mandatory when melanoma is a possibility

57 Fox-Fordyce Disease Disorder of apocrine glands
Found on mons, labia majora, axilla Cyclic pruritis; improves with menopause Treatments: OCs Retinoic acid

58 Hidradenoma Benign tumor 0.5-2 cm diameter Solid consistency
“Milk line” location (interlabial sulcus) Benign tumor 0.5-2 cm diameter Solid consistency Often umbilicated center Non tender Treatment: shells out easily with excision Path mimics adenocarcinoma

59 Paget’s Disease Occurs in milk line
Extramammary disease may invovle genital, perianal and axillary areas Lesions are brick red, scaly, velvety eczematoid plaque with sharp border S/S: itching, burning, bleeding Cellular origin unclear Treatment: excision with > 3 mm border from visible margin Local recurrence rate is 31-43%

60 Tips for Vulvar Biopsies
Where to biopsy Homogeneous : one biopsy in center of lesion Heterogeneous: biopsy each different lesions ELA-Max (10% lidocaine cream) applied minutes pre-op may be sufficient for anesthesia Skin local anesthesia Use smallest, sharpest needle: insulin syringe Inject s-l-o-w-l-y Most lesions will require ½ cc. lidocaine or less Stretch skin; rotate 3 or 4 mm Keyes punch

61 Tips for Vulvar Biopsies
Lift circle with forceps or needle; snip base Hemostasis with AgNO3 stick, Monsels, Gelfoam, hemostatic mesh Separate pathology container for each area biopsied

62 Chronic Vulvar Pain Syndromes
Vestibulodynia (VBD): painful vestibule Vulvar vestibulitis syndrome Vulvodynia (VVD): painful vulva Dysesthetic (Essential) vulvodynia Pudendal neuralgia Vulvar pain of known cause Lichen sclerosis, L planus, Behcet dz, Crohn dz Dermatitis: allergic/ irritant/ eczema/ LSC Infections: Candida, Herpes, Bartholinitis Trauma, scarring

63 Vulvodynia: More Questions Than Answers
Little agreement regarding definition, epidemiology, diagnosis, management, etiology, and Pressing need for large-scale, controlled studies to explore these issues in greater detail Defined as chronic vulvar pain in which other pathologic etiologies have been ruled out, but duration of pain is not agreed upon Pain lasting from 3 to 6 months is typically considered to be “chronic” Vulvodynia - More Questions Than Answers There is little agreement regarding the definition, diagnosis, management, etiology, and epidemiology of vulvodynia.

64 Vulvodynia: Age-Specific Incidence
Percent of Women Vulvodynia - Age-Specific Incidence In a study by Harlow and Stewart of 4915 women aged 18 to 64 years who were identified through town census directories, a self-administered questionnaire was used to query participants on any itching, burning, periodic knifelike or sharp pain, and excessive pain on contact in the lower genital tract. The highest incidence of complaints was among women younger than 25 years of age. The incidence decreased through age 44 and then remained relatively constant through age 64. With regard to individual complaints, pain on contact and limitation or prevention of intercourse were more common among younger patients and less common among those aged 55 to 64 years. Reference: Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003;58:82-88. <25 25-34 35-44 45-54 55-64 Age at First Onset (y) Harlow BL, Stewart EG. J Am Med Womens Assoc. 2003;58:82-88.

65 Vulvodynia: Ethnicity
Percent of Women Vulvodynia - Ethnicity Among 4915 women queried about the incidence of unexplained chronic pain via a self-administered questionnaire, Hispanic women were at greater risk, whereas the incidence of vulvar pain was similar between white and African-American women. As shown in the slide, a large number of women could not readily classify themselves as belonging to one of the designated racial/ethnic categories. Reference: Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003;58:82-88. Hispanic African American White Asian Other Nonwhite Harlow BL, Stewart EG. J Am Med Womens Assoc. 2003;58:82-88.

66 Vulvodynia: Symptoms Pain – Knifelike; with genital area contact
Itching – With or without pain Burning – Persistent Dyspareunia – Pain and discomfort on penetration Sexual response – Hypervigilance for coital pain Skin changes – Erythema, scaling, fissures Vulvodynia - Symptoms Women with vulvodynia usually present with vulval pain, burning, and itching. They frequently complain of dyspareunia and problems with sexual response. One retrospective chart review study found that 18% of patients complained of skin changes. References: Sadownik LA. Clinical profile of vulvodynia patients. A prospective study of 300 patients. J Reprod Med. 2000;45: Hansen A, et al. Characteristics and initial diagnoses in women presenting to a referral center for vulvovaginal disorders in J Reprod Med. 2002;47: Sadownik LA. J Reprod Med. 2000;45: ; Hansen A, et al. J Reprod Med. 2002;47: ; Welsh BM, et al. Med J Aust. 2003;178: ; Payne KA, et al. Eur J Pain. 2005;9:

67 Vulvodynia: Psychosocial Assessment
Women reporting vulvar and nonvulvar pain are twice as likely as asymptomatic women to report: History of depression (P<0.001) Chronic vaginal infections (P<0.001) Poorer quality of life (P<0.001) Greater stress Strongest correlates of chronic vulvar pain are self-report of vaginal infections and stress Vulvodynia - Diagnosis: Psychosocial History Vulvodynia has a significant impact on a woman’s quality of life and can often result in depression and stress. Thus, it is important for clinicians to ask patients about their psychosocial situation. Reference: Bachmann GA, Rosen R, Arnold LD, et al. Chronic vulvar and gynecological pain: prevalence and characteristics in a self-reported survey. J Reprod Med. 2006;51:3-9. Bachmann GA, et al. J Reprod Med. 2006;51:3-9.

68 Work-up of Patient Presenting with Pain Only
Pain Alone Normal on examination Abnormalities on examination Pain localized and provoked by pressure Pain poorly localized and spontaneous Work-up of Patient Presenting with Pain Only This algorithm can be used to diagnose vulvar pain. It should be noted that there is considerable overlap between vulvar pain conditions and that an individual patient may present with more than one type. Localized pain without itching provoked only by penetration in a young woman is likely to be the result of vulvar vestibulitis. On the other hand, an older woman presenting with poorly localized unprovoked pain may have dysesthetic vulvodynia. Reference: Welsh BM, et al. Management of common vulval conditions. Med J Aust. 2003;178: Vulvar vestibular syndrome likely (typically younger age)* Dysesthetic vulvodynia likely (typically older age)† Diagnosis depends on examination Welsh BM et al. Management of common vulval conditions. MJA 2003; 178: ©Copyright The Medical Journal of Australia - reproduced with permission.

69 VVS: Epidemiology VVS has two common times of onset
15% RA women: introitus painful to touch ½ “mild”; doesn’t affect activities ½ sig. dyspareunia; ½ asked for help VVS has two common times of onset 1o VVS: onset as teen; present in mother 2o VVS: onset post-partum; no family hx Many causes investigated, none proven Chronic candida, HPV not causes Connection with interstitial cystitis

70 VVS: Presentation Symptoms Signs
Pain symptoms on touch or vaginal entry Absence of symptoms during daily activities Avoidance of pants with tight inseam Avoidance of tampons due to insertional pain Signs Inflamed patches of skin or regions of vestibule Positive “swab test”: Intense pain during rolling of moistened cotton swab over red areas on vestibule Skin beyond ½ cm of inflamed area non-tender

71 VVS: Diagnosis ISSVD diagnostic criteria
“Definitive test” for VVS (Goetsch) Perform swab test 4% lidocaine with cotton app, wait a few minutes Repeat test; if pain is sig. diminished, dx is VVS ISSVD diagnostic criteria Severe pain on touch or attempted entry Tenderness to pressure localized within vestibule Only finding is vestibular erythema Symptoms must have been present for > 6 months No evidence of vaginitis or vulvar dermatoses

72 Vulvar Pain, Burning: Diagnosis
Pain mapping KOH suspension for candida If negative, culture and speciate That’s it!!!... In the absence of lesions, no role for Vestibular or vulvar biopsy HPV screening (Hybrid Capture) HSV culture or antibody testing

73 VVS: Management Ineffective Therapies Antifungals
Topical or systemic antibiotics Antivirals (acyclovir) Dietary restriction of oxalates Interferon injections Laser therapy

74 VVS: Stepwise Approach to Treatment
Vulvar skin care measures Topical steroids: estrogen, cortisone Local anesthetics Neuropathic pain medications Tricyclic antidepressants Anti-seizure drugs Physical therapy and biofeedback Surgery Vestibulectomy

75 Vulvar Pain Measures Acute pain: ice pack applied to vulva
Episodic relief (30 minutes before intercourse) Lidocaine Xylocaine jelly 2%, Xylocaine ointment 5% EMLA cream (lidocaine 2.5% + prilocaine 2.5%) L-M-X 4 Cream (4% lidocaine) L-M-X 5 Anorectal Cream (5% lidocaine) Dispense 30 gm tube; limit to 2.5 gm/application Avoid oral contact of partner Avoid benzocaine, diphenhydramine additives

76 Vulvar Pain Measures Overnight topical anesthetics
Apply ointment to introitus + vaginal cotton ball Topical sedatives for relief if itching Doxepin (Zonalon) 5% cream Start once a day, then work up Systemic Tricyclics: amitriptyline (10-25 mg) QHS Nortriptyline, desipramine fewer side effects Anticonvulsants Gabapentin (Neurontin), carbamazepine (Tegretol)

77 Tricyclics for Vulvar Pain
Must take daily, not “as needed” May take weeks to “kick-in” May have good days and bad days, even with tx Start at low dose, then work up every week Start with 10 mg…progress to mg. Because of sedation, dry mouth, take at bedtime If excessively tired in am, take after dinner Once pain is controlled, slowly taper If too fast, get bounce-back pain, nausea, fatigue

78 VVS: Surgical Therapy Woodruff”s vestibulectomy (perineoplasty)
Surgical excision of vestibule, with undermining of vagina and “pull through” to cover defect 60-89% cure rate Adverse effects Removal of glands necessary for sexual lubrication 1 month recovery Scar tissue; May mildly disfigure vulva Potential recurrence of symptoms after 6 months

79 Vulvar Vestibulitis: Surgery
At 6-month follow-up, 60% to 89% of patients show improvement and approximately 10% have deteriorated Higher SES, older age, and participation in psychological evaluation/postoperative sex therapy predict better outcomes Childlessness, deep dyspareunia, and diffuse genital pain predict poor outcomes Vulvodynia – Treatment: Surgery for Vulvar Vestibulitis In severe cases, patients may undergo a surgical procedure known as perineoplasty or vestibulectomy. A review of the literature suggests that at 6-month follow-up, 60% to 89% of patients will show improvement and approximately 10% will have deteriorated. There are some drawbacks to surgery, including the risks and costs, removal of glands necessary for sexual lubrication, scar tissue, and potential recurrence of symptoms after 6 months. Schover and colleagues reported that women of higher socioeconomic status, older women, and women willing to participate in a psychological evaluation and postoperative sex therapy had better surgical outcomes. Those who were childless and had deep dyspareunia and diffuse genital pain had poor surgical outcomes. References: Masheb RM, Nash JM, Brondolo E, Kerns RD. Vulvodynia: an introduction and critical review of a chronic pain condition. Pain. 2000;86:3-10. Schover LR, Youngs DD, Cannata R. Psychosocial aspects of the evaluation and management of vulvar vestibulitis. Am J Obstet Gynecol. 1992;167: Masheb RM, Nash JM, Brondolo E, Kerns RD. Pain. 2000;86:3-10. Glazer HI, et al. J Reprod Med. 1995;40:

80 Essential Vulvodynia Pudendal neuralgia is likely cause
Seen mainly in older women Presentation Poorly localized pain; diffuse and variable hypersensitivity May cause constant, unremitting burning Altered perception to light touch Vulva and introitus appear normal No effect of topical lidocaine Treatment Low dose TCAD:desipramine, imipramine, amitriptylene Gabapentin, carbamazepine, venlafaxine

81 Posterior Fourchette Fissure
Tender shallow ulcer or fissure at 6 o’clock of introitus Causes severe dyspareunia (or apareunia) “Paper cut” acute pain Possible causes LS, apthosis, chronic candida, OB laceration, ? atrophy Diagnosis: biopsy usually not helpful

82 Posterior Fourchette Fissure
Management Emollients and moisturizers Elamax cream 30 min before intercourse Water or oil-based lubricant with intercourse High potency topical steroids; steroid injection Cox: add topical estrogen (Estrace) cream to corticosteroid Local destruction (AgNO3 or electrocautery) Surgery: perineoplasty, Y-V flap

83 - National Vulvodynia Associationn
Resources - National Vulvodynia Associationn V Book chapters: “It Hurts” “Sexual Healing” -

84 The Vulvodynia Guideline
Haefner, HK, et al. Journal of Lower Genital Tract Disease 2005; 9:40-51 Links and Resources ASCCP guidelines The Vulvodynia Guideline Reproductive HC links Vulvar Skin Conditions and Colposcopy

85 Patient Resources International Society for the Study of Vulvovaginal Disease: National Vulvodynia Association: Vulvar Pain Foundation: Interstitial Cystitis Association: Patient Resources The following websites can provide useful resources for educating your patients about vulvodynia and vulvar pain.

86 Bartholin Duct Conditions
Bartholin duct and gland at 5, 7 o’clock cephalad (deep) to hymeneal ring Makes serous secretion to “lubricate” introitus If BG duct is transected or blocked, fluid accumulates Non-infected: BD cyst Infected: BD abcess or cellulitis All treatments are designed to drain and create a new duct

87 Bartholin Duct: Infectious Conditions
Bartholin duct cellulitis Red induration of lat’l perinuem , no abcess Most commonly due to skin streptococcus Tx: PO cephalosporin, moist heat Will either resolve or point as abcess Treat immunecompromised women aggressively Bartholin duct abcess Fluctulent abcess; pus with needle aspiration Tx: I&D, insert Word catheter x 6 weeks Culture pus for gonorrhea Cephalosporin if cellulitis; metronidazole if anaerobic

88 Bartholin Duct: Non Infectious
Bartholin duct cyst Nontender cystic mass Treat only if symptomatic or recurrent Tx: marsupialize or insert Word catheter x 6 weeks Bartholin duct carcinoma Most common in women over 40 Can be adenoca, transitional cell, or squamous cell Firm non-tender mass in region of Bartholin gland Suspect if recurrent BD cyst or abcess with firm base after drainage

89 Vulvar Ulcer: Differential Diagnosis
Genital Herpes Syphilis Chancroid “Tropical STD”: granuloma inguinale, LGV Behcet’s Disease: mouth, eye, genital ulcers Crohn’s Disease: Knife-cut ulcers, GI-cutaneous fistulae Lichen planus, lichen sclerosus

90 Genital Ulcers: Management
Syphilis VDRL or RPR Chancroid Test for H ducreyi (culture, PCR, DNA) Herpes simplex Early lesion: HSV culture, PCR, or DFA Late lesion: DFA or cytology Type-specific HSV serology Biopsy if Bechet’s or Crohn’s suspected Presumptively treat for “best guess” or syphilis + chancroid

91 Chancroid Due to Hemophilis ducreyi 10% also have syphilis or herpes
Co-factor for HIV infection Symptoms/ signs One or more painful genital ulcers Regional adenopathy; may suppurate (buboe) Lab: culture <80% sensitive; contact lab before sampling Treatment Azithromycin 1 gram PO Ceftriaxone 250 mg IM F/U in 7 days; treat partners within 10 days

92 Herpes Simplex Virus: Organism Tests
Sensit Specif Cost Comment PCR $$$$ Not in most labs HSV culture ELVIS rapid $$$ No typing ELVIS std $$$ Reflex typing Cytopathic $$ Phasing out Herpes DFA $$ Scrape; plate Cytology $$ Scrape; plate

93 Herpes Simplex Virus Serologic Tests
Use only “type-specific” tests for HSV-2 antibody Almost all HSV-2 is sexually acquired HSV-1 antibody orolabial or genitally acquired Envelope glycoprotein G (gG) HSV-type specific assays HerpeSelect-1 ELISA or HerpeSelect-2 ELISA HerpeSelect-1 and 2 Immunoblot G POCkit HSV-2, biokitHSV-2 (point of care) Sensitivity: 80-98%; specificity > 96%

94 HSV-2 Serologic Diagnostic Testing
History suggestive of HSV but no lesions to test If seronegative, not due to genital herpes If seropositive, HSV lesion or prior infection Culture negative recurrent lesion Suspected 1o herpes, if initial testing negative and more than 6 weeks prior If seropositive, HSV infection confirmed

95 HSV-2 Serologic Screening
Screen general population Should not be offered Universal screening in pregnancy Screening in HIV-positive patients Should generally be offered Screening in patients in partnerships with HSV-2 infected people Screening in patients at risk for STD/HIV Should be offered to select patients Guidelines for the Use of HSV-2 Type-Specific Serologies, CA DHS 2003

96 HSV-2 Serologic Screening
At risk for STD/HIV (current STD or HR behavior), offer to select patients [C] if: Patient is motivated to reduce risky behavior Patient is willing to use condoms or Rx consistently Risk reduction counseling will be provided Arguments against screening Limited evidence that counseling or Rx works Limited evidence that condoms will be used Little value if risk reduction counseling not given

97 Transmission of HSV-2 to Susceptible Partners with Suppressive Therapy
RCT of 1,484 hetero couples Valacyclovir 500 mg QD or placebo QD for 8 months Monthly HSV serology for susceptible partners The valacyclovir group showed 47% less HSV-2 transmission Lower frequency of shedding Fewer copies of HSV-2 DNA when shedding occurred NOTE: Shedding study was a substudy (N=89) of this one… source partners swabbed the genital region daily for 2 months for testing by PCR. If the source partner had recurrences, they were treated with episodic therapy of 500mg twice daily valacyclovir for 5 days, and then returned to randomly assigned medication. Corey L, Wald A, Patel R, Sacks SL, Tyring SK, Warren T, Douglas JM Jr, Paavonen J, Morrow RA, Beutner KR, Stratchounsky LS, Mertz G, Keene ON, Watson HA, Tait D, Vargas-Cortes M; Valacyclovir HSV Transmission Study Group. Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med Jan 1;350(1):11-20. Valacyclovir Group (N=743) Control Group (N=741) Corey et al, NEJM 2004; 350:11-20

98 Prevention of Genital Herpes
Incident HSV infection reduced by 1.7% over 1 year 96.4% don’t seroconvert in absence of treatment 1.9% seroconvert with treatment Must treat 59 people to prevent one case/ year Indications may include Discordant couples (reassess annually) Infected persons with multiple partners MSM HIV-positive Counsel regarding condoms, disclosure, abstinence * Discussed at the 2006 Guidelines Meeting

99 Genital Herpes and Antiviral Drugs
Primary Herpes Shortens median duration of lesions by 3-5 days Therefore, initiate within 6 days of onset May decrease systemic symptoms No effect on subsequent risk, frequency, or severity of recurrences Recurrent Herpes Shortens the mean duration by 1 day Initiate meds within 2 days of onset Best to start with onset of prodromal symptoms Patient should have supply of meds available

100 HSV: Adjunctive Therapy
Frequent dosing of NSAID (ibuprofen) or aspirin Sitz baths (TID) in cool or warm water or use milk compresses Burrows solution sitz baths (Domeboro) or Burrows compresses To avoid towel drying, use the cool setting of a hand dryer If urinary tract symptoms prominent, urinate in warm sitz bath Topical local anesthetics may provide limited relief

101 HSV: Suppression Therapy
Acyclovir given continuously to decrease frequency, severity of outbreaks Studies have shown befeficial effect for up to five years Will not affect natural history of HSV infection Prior pattern of recurrences after discontinuation Used for those with >6 recurrences per year After 1 year, discontinue to allow assessment of recurrent episodes Most widely used regimen is acyclovir 400 mg PO BID; may be increased to 3-5 times per day

102 Management of Vulvar Hematoma
Almost all are due to straddle injuries Initial management Pressure Ice packs Watchful waiting Complex management Use if extreme pain or failure of conservative mgt Incise inside hymeneal ring, evacuate clots Pack with strip gauze, sitzbaths

103 Additional References
Marzano DA, The bartholin gland cyst: past, present, and future. J Low Genit Tract Dis 2004 Jul;8(3): Bauer A, Vulvar dermatoses--irritant and allergic contact dermatitis of the vulva. Dermatology 2005;210(2):143-9. Smith YR, Vulvar lichen sclerosus : pathophysiology and treatment. Am J Clin Dermatol. 2004;5(2): Fischer G, Management of vulvar pain. Dermatol Ther 2004;17(1): Edwards L, Vulvar fissures: causes and therapy. Dermatol Ther 2004;17(1):111-6 Foster DC, Vulvar disease. Obstet Gynecol 2002; 100(1):

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