Isolated juvenile xanthogranuloma of clitoral connective tissue

Juvenile xanthogranuloma is a frequent childhood tumor and the only common non-Langerhans' cell histiocytosis. We present an unusual case of juvenile xanthogranuloma (JXG) of clitoral connective tissue in a 6-week-old girl.

Hair thread tourniquet syndrome in adolescents: a presentation and review of the literature

Hair thread tourniquet syndrome has been recognized since the 1600s when a strangulating hair was reported around the glans penis. Since that time sporadic reports have appeared in the literature describing strangulation of appendages by human hair. Most often the constriction involves fingers, toes, or the penis. There are several reports of clitoral strangulation. Most cases present to their primary care provider or emergency department. A high index of suspicion is required for diagnosis in order to prevent prolonged devascularization. We describe a hair thread tourniquet syndrome of the labia minora in a 13-year-old. It was successfully treated with exam under anesthesia and resection of the devascularized tissue. We believe this is the oldest patient described as well as the only description of hair tourniquet syndrome of the labia minora. Prompt recognition of this unusual condition is essential for treatment of this potentially serious problem.

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.

The Outcome after Cryosurgery and Intralesional Steroid Injection in Vulvar Lichen sclerosus Corresponds to Preoperative Histopathological Findings

BACKGROUND

Vulvar lichen sclerosus (LS) still presents a therapeutic challenge.

QUESTIONS

The aim of the present study was to investigate whether there is a correlation between preoperative histopathological findings in female LS and long-term results after cryosurgery and intralesional steroid injections.

MATERIAL AND METHODS

22 females with LS, mean age 65.3 +/- 10.5 years, were treated with cryosurgery (-186 degrees C) using the contact method with 1 freeze-thaw cycle per lesion and intralesional triamcinolone acetonide injection. The time between surgery and follow-up examination was 27.8 +/- 14.6 months. We compared the clinical outcome and the thickness of the epidermis, the zone of sclerosis and the inflammatory infiltrate in biopsy specimens taken before treatment.

RESULTS

In 14 of 22 patients, a relapse after cryosurgery occurred (median after 7.5 months). Patients would 'moderately' recommend cryosurgery for LS (2.2 +/- 0.9; minimum: 0, optimum: 4). Pruritus was significantly reduced (visual analog scale: preoperative 7.1 +/- 2.6 vs. postoperative 2.0 +/- 2.4; p = 0.001) even in patients with relapse (preoperative 7.6 +/- 2.4 vs. postoperative 3.1 +/- 2.28; p = 0.001). Women with relapse showed a significantly higher composed thickness of epidermis, sclerosis and inflammatory infiltrate (430 +/- 139.0 microm) than those without relapse (314 +/- 41.2 microm; p = 0.046).

CONCLUSION

In our patients, cryosurgery and intralesional steroid injections were efficient in the treatment of LS. Patients showing relapse had a thicker epidermis and a stronger inflammatory infiltrate. Therefore a treatment of LS should be performed at an early stage of the disease.

Pigmented apocrine hamartoma of the vulva: a report of two cases

Two cases of pigmented apocrine hamartoma of the vulva are reported; only one similar case involving the vulva was found in the literature. In each of the two cases, the lesion presented as a pigmented papule involving the labium minus of a young woman, and raised clinical concern for a malignant melanoma. On histological examination, the lesions were composed of tubules and cysts lined by melanin-containing apocrine cells and an outer layer of myoepithelial cells. The pigmentation appeared to be secondary to colonization of the apocrine cells by dendritic melanocytes.

[Anatomo-clinical confrontation. Vulvar melanosis]

Vulvar melanosis is a benign disorder that may suggest a malignant melanoma. We report the case of a woman in whom partial vulvectomy was performed to eradicate the melanotic macule. The lesion corresponds to increased accumulation of melanin inside keratinocytes in the absence of any melanocytic neoplasm.

Multiple pigmented follicular cysts of the vulva successfully treated with CO2 laser: case report and literature review

BACKGROUND

A pigmented follicular cyst is an uncommon epithelial cyst, typically occurring as a single asymptomatic pigmented papule or nodule on the head and neck of adult men. To the authors' knowledge, no previous cases of vulvar pigmented follicular cyst have been reported. Although benign, pigmented follicular cyst can affect quality of life when multiple and symptomatic.

OBJECTIVE

The objective was to describe the clinicopathologic features of vulvar pigmented follicular cyst and to evaluate the efficacy of CO(2) laser therapy in this region.

METHODS

A 62-year-old woman with multiple pigmented follicular cysts affecting the labia majora bilaterally is described. Owing to frequent inflammation and tenderness, continuous-wave CO(2) laser was used to treat the skin lesions under local anesthesia.

RESULTS

All cystic nodules were successfully ablated with CO(2) laser. The patient tolerated the procedure well and had a satisfactory cosmetic outcome.

CONCLUSION

CO(2) laser is a tolerable and effective therapeutic modality for multiple and symptomatic pigmented follicular cysts of the vulva.

Successful carbon dioxide laser therapy for refractory anogenital lichen sclerosus

BACKGROUND

Lichen sclerosus is a chronic inflammatory dermatitis that often occurs in the anogenital area and presents a therapeutic challenge. Traditional medical management includes potent topical corticosteroids and is marked by variable results.

OBJECTIVE

The objective was to describe the successful use of carbon dioxide laser ablation therapy in two women with refractory anogenital lichen sclerosus.

METHODS

A case is reported and the literature is reviewed.

RESULTS

Two women with medically recalcitrant anogenital lichen sclerosus were successfully treated with the carbon dioxide laser. Both patients tolerated the procedure well and had excellent surgical outcomes.

CONCLUSION

Lichen sclerosus recalcitrant to medical therapy presents a therapeutic challenge This may be successfully treated with the carbon dioxide laser with excellent surgical results and minimal risk.

Ciliated cyst of the vulva

Ciliated cyst of the vulva is a rare anomaly. The cyst is lined with columnar ciliated epithelium that resembles müllerian epithelium and is located on the superior portion of the labium minus, occasionally associated with pregnancy or exogenous progesterone. We describe a case of an 11-year-old Japanese girl with a ciliated cyst of the vulva and a history of atopic dermatitis. Epithelial cells in our case showed negative staining for estrogen receptor. The origin of the ciliated epithelium is still unknown. However, chronic inflammation of the vulvar vestibulae may contribute to the pathogenesis of ciliated cyst of the vulva.

[Urinary retention due to acquired closure of labia minor in a female with Sjögren syndrome]

A case of a 70 year old woman with acute urinary retention and primary Sjögren-Syndrome is presented. On clinical examination a total closure of labia minor was diagnosed. Surgical detachment of labia minor was performed and full recovery was achieved.

Extensive genital warts associated with HTLV-I infection

This is the first report of infection with HTLV-I associated with severe condylomatosis. Assessment of atypical or extensive genital warts should include testing for this retroviral infection.

Botulinum toxin a for vulvodynia: a case report

Vulvodynia is a poorly understood chronic pain condition, and patients who are refractory to standard therapies often pose a therapeutic dilemma. Current treatment modalities include antidepressants, anticonvulsants, biofeedback, pelvic floor physical therapy, and surgery; however, the options are limited for patients who fail to respond to these treatments. We present a case of refractory vulvodynia with severe dyspareunia successfully managed with a novel therapeutic approach combining botulinum toxin A and surgery.

PERSPECTIVE

The authors present a case of refractory vulvodynia that was successfully managed with a novel approach that combined botulinum toxin A and surgery.

Endometriosis in the Bartholin gland

A case of endometriosis infiltrating the Bartholin gland is presented. The initial diagnosis was a Bartholin gland cyst. The clinical diagnosis was made during the operation when chocolate-colored fluid poured into operation field. Laparoscopy was done during the same operation and minimal endometriosis was found. The presence of endometriosis may be considered as a diagnosis in cases with cystic mass in the Bartholin gland and laparoscopy might be performed to rule out the presence of intraperitoneal endometriosis if a woman is infertile.

Complete Adult Vulvar Fusion: A Case Report

BACKGROUND

Labial fusion is most commonly seen in prepubertal girls and in postmenopausal women affected by advanced lichen sclerosus et atrophicus. Postpartum labial fusion is a rare phenomenon for a woman with no evidence of hypoestrogenism.

CASE

A woman with a normal delivery and a normal postpartum examination presented 7 years later with a complete vulvar closure from the urethral opening to the posterior fourchette.

CONCLUSION

Complete vulvar fusion can rarely occur without any evidence of hypoestrogenism. It is managed by surgical incision and perineorrhaphic correction without sequelae.

Association between quantitative sensory testing, treatment choice, and subsequent pain reduction in vulvar vestibulitis syndrome

The chronic pain syndrome of vulvar vestibulitis is a major cause of sexual dysfunction, and complete cure is not always achieved. The aim of the study was to determine whether the psychophysical characteristics of systemic pain perception predict treatment choice and outcome. Ninety women with vulvar vestibulitis syndrome were evaluated by using quantitative sensory testing with heat pain threshold measurements and pain scores for suprathreshold stimuli applied to the forearm, blood pressure measurements, and an assessment of the number of other pain disorders. Women were free to choose a surgical procedure (ie, vestibulectomy), one of the possible nonsurgical treatments (eg, biofeedback, cognitive-behavioral therapy, or hypoallergic agents), or to avoid treatment entirely. Eight months later, women reported the success of the treatment on the basis of reduction in the level of vulvar pain. Vestibulectomy demonstrated the best therapeutic effectiveness (chi2, 26.4; P <.0001). Women who chose this type of treatment had lower pain scores (P =.038) and fewer pain syndromes other than the vulvar pain (P =.025). Logistic regression analysis, controlling for the effect of vestibulectomy, indicated that lower experimental pain scores (P =.044), fewer pain disorders (P =.023), and higher systolic blood pressure (P =.039) are predictive variables for reduction of vulvar pain. An assessment of systemic pain perception might be helpful in choosing the optimal treatment and in predicting its success.

PERSPECTIVE

The present study suggests that pain perception variables might be of value in the prediction of treatment choice and outcome among women with vulvar vestibulitis.

Vulvar lichen sclerosus : pathophysiology and treatment

Lichen sclerosus is a chronic disorder of the skin and mucosal surfaces, and is most commonly seen on the female genital skin. It also occurs on other areas of the body. Any age group may be affected, although it is seen more often in elderly women. The exact cause of lichen sclerosus is unknown. There have been reports of family members with lichen sclerosus; thus it may have a genetic link. There is also the possibility of an autoimmune connection. Currently, ultra-potent topical corticosteroids are the medical treatment of choice. Other treatments that have been utilized for this condition include testosterone, progesterone, tacrolimus, surgery, and phototherapy. Surgery should be reserved for symptomatic patients who fail to respond to multiple medical treatments, as there is a high recurrence rate following surgery. The risk of developing squamous cell carcinoma of the vulva approaches 5% in women with vulvar lichen sclerosus, and therefore close surveillance by the healthcare provider and patient is needed. This review discusses the history, clinical features, pathophysiology, and treatment of lichen sclerosus of the vulva, as well as pregnancy issues and sexual function in patients with this condition. In addition, problems specific to children with lichen sclerosus are reviewed.

Management of Bartholin's duct cyst and gland abscess

Bartholin's duct cysts and gland abscesses are common problems in women of reproductive age. Bartholin's glands are located bilaterally at the posterior introitus and drain through ducts that empty into the vestibule at approximately the 4 o'clock and 8 o'clock positions. These normally pea-sized glands are palpable only if the duct becomes cystic or a gland abscess develops. The differential diagnosis includes cystic and solid lesions of the vulva, such as epidermal inclusion cyst, Skene's duct cyst, hidradenoma papilliferum, and lipoma. The goal of management is to preserve the gland and its function if possible. Office-based procedures include insertion of a Word catheter for a duct cyst or gland abscess, and marsupialization of a cyst; marsupialization should not be used to treat a gland abscess. Broad-spectrum antibiotic therapy is warranted only when cellulitis is present. Excisional biopsy is reserved for use in ruling out adenocarcinoma in menopausal or perimenopausal women with an irregular, nodular Bartholin's gland mass.

Treatment of large lower genital tract condylomata acuminata with local excision plus topical acetic acid. A preliminary study

OBJECTIVE

To evaluate recurrence after excision plus a brief topical application of 99% acetic acid for anovulvar condylomata acuminata.

STUDY DESIGN

Thirty women having extensive involvement of the lower genital tract with condylomata acuminata were selected for treatment. In all cases treatment was done on an outpatient basis under local anesthesia. On finalizing the excision, topical 99% acetic acid was briefly applied for (3 seconds) to the surgically treated surface, 0.2 mL for each 10 cm2 of anovulvar surface, with a sterile cotton applicator; immediately afterward, the anovulvar surface was washed with sterile water for 1 minute to neutralize the 99% acetic acid. The primary end point was to measure the rate of local recurrence after therapy.

RESULTS

Twenty-six of 30 patients (86.6%) had complete resolution of large genital tract condylomata acuminata with 1-3 local excisions plus brief topical application of 99% acetic acid. Four of 30 patients (13.3%) experienced local recurrence after therapy.

CONCLUSION

In this preliminary study, local excision plus a brief topical application of 99% acetic acid with rapid neutralization with sterile water under local anesthesia was well tolerated, without serious local complications and with an acceptable rate of recurrence (13.3%).

The surgical treatment of labial adhesions in pre-pubertal girls

STUDY OBJECTIVE

A review of our experience with the surgical treatment of labial adhesions refractory to medical treatment.

DESIGN

Retrospective review.

SETTING

University tertiary care hospital same-day surgery center.

PARTICIPANTS

Nine prepubertal females, age 3-6 yrs, presenting with thick, symptomatic labial adhesions refractory to medical management.

INTERVENTION

All patients underwent surgical lysis of labial adhesions under general anesthesia. Adhesions were incised sharply and the cut edges were reapproximated with 7-0 chromic suture by a pediatric urologist (JGB).

MAIN OUTCOME MEASURES

Duration of recurrence-free follow-up.

RESULTS

No patient had recurrence in an average of 8.6 months of follow-up. Surgery was well tolerated in all cases.

CONCLUSION

This technique effectively treats and prevents the recurrence of moderate to severe labial adhesions that are unresponsive to medical therapy.

Anal shift: preliminary results

BACKGROUND/PURPOSE

Perineal ectopic anus in female infants is not a very uncommon congenital anomaly. The close proximity of the ectopic anus with the vulva and the stenosed opening seen in large majority of cases necessitate some form of surgical correction. A variety of surgical procedures like cutback, posterior anal transposition, PSARP, or ASAPR, with or without diverting colostomy have been described in the literature. However, in dealing with a case of ectopic anus, the authors thought a much simpler surgical correction would suffice giving an aesthetically and functionally acceptable perineum. This new and simple surgical procedure developed by Ashok Shah, Anal Shift is described in this report.

METHODS

Twelve female infants with anterior ectopic anus, between 3 and 18 months of age who had undergone surgical correction by this new method (Anal Shift) is reported. Five of these children had severe and 2 had mild anal stenosis. The new technique described in detail includes shifting and creation of a new anus in the anatomically normal site and construction of the perineal body. Colostomy was not done in any of them.

RESULTS

The cases had been followed up for 12 to 24 months. Anal function was normal with satisfactory vulvo-anal distance without any stenosis. One patient had superficial anterior wound dehiscence; she underwent reoperation with good results.

CONCLUSIONS

Anal Shift is a simple surgical procedure. It does not necessitate lateral dissection, therefore, the rectal support and the neurovascular supply to the rectum remains undisturbed, eliminating any chance of retraction. The anterior half of the neoanus does not have a suture line, thereby minimizing the chances of stricture formation. Anal Shift appears to be a safe, simple and satisfactory surgical procedure to correct anterior ectopic anus in girls without a colostomy.

Condylomata gigantea in anal and perianal region: surgical and CO2 laser treatment

CASE REPORT

We present a case of 28-year-old female patient with condylomata gigantea (Buschke-Lowenstein tumor) in anal and perianal region with propagation on vulva and vagina. The local surgical excision and CO(2) laser treatment were performed. Histological examination showed presence of HPV type 11 without malignant potential.

RESULT

Three months later, there was no recurrence.

Defective sexuality and female circumcision: the cause and the possible management

AIM

To verify the effect of circumcision on female sexuality and to define the need for clitorolabioplasty in these cases.

METHODS

Thirty uncircumcised controls, 30 minorly circumcised, 30 minorly circumcised mutilated, and 57 circumcised cases having clitoral cysts were selected on random bases at Kasr El Aini School of Medicine. Sexuality was assessed by a special questionnaire sheet prepared by the authors to fit the circumcised cases. Clitorolabioplasty and clitoral cyst excision were also done in cases of sexual defects.

RESULTS

Sexuality was not affected in minorly circumcised cases. However, sexuality was markedly affected in the mutilated cases. The scores for sex desire and arousal and for orgasm were especially affected in such cases. These defects were not detected in cases having clitoral cysts until late, when cysts enlarged. The role of clitorolabioplasty in restoration of sexuality was confirmed. The loss of certain clitoral and labial bulk, necessary for orienting the woman towards her genitalia and initiating her interest in their function, was responsible for the occurrence of such defects; this was able to be restored by surgery.

CONCLUSION

Counseling parents about these sexual defects and asserting the need for correcting the mutilation, which resulted from these circumcisions, are effective steps in banning such procedures.

[3 cases of vulvar epidermal cysts after female genital mutilation]

We report three cases of tumors of the vulva following an excision during childhood, in patients aged 22 to 25. The achieved surgical removal gave correct aesthetic and functional results. Histological examination of these tumors revealed epidermal cyst containing keratin. Because of clinical, psychological and social impact of female excision, steps should be taken against such traditional practices.

Type III female genital mutilation: clinical implications and treatment by carbon dioxide laser surgery

OBJECTIVE

The purpose of this study was to examine clinical implications of type III female genital mutilation and to evaluate the use of carbon dioxide laser surgery to restore vulvar opening and to treat associated epithelial inclusion cysts.

STUDY DESIGN

Twenty-five infibulated patients underwent carbon dioxide laser treatment. Seven of the women (28%) were pregnant, between 10 and 37 weeks of gestation. Vulvar examination revealed five cases of epidermal inclusion cysts. One pregnant patient, with a cyst that was 7 cm in diameter, was at 24 weeks of gestation. Deinfibulation was performed in an outpatient setting with local anesthesia. A colposcopy-guided laser beam was used to create an incision along the fusion midline of the labia majora. In case of vulvar epidermal inclusion cyst, the capsule was opened and emptied of sebaceous contents; the inner surface of the cyst was vaporized completely.

RESULTS

The carbon dioxide laser procedure restored a complete vulvar opening in all 25 patients. The complete vaporization of cyst capsule was possible in all five cases. No case of intraoperative or postoperative complication occurred. The average duration of follow-up was 11 months. Four patients who underwent deinfibulation antenatally had labor with spontaneous vaginal delivery and no evidence of perineal trauma.

CONCLUSION

On the basis of the advantages that were observed, deinfibulation treatment must be offered to all infibulated patients. The procedure is particularly appropriate during pregnancy to prevent childbirth complications. Laser carbon dioxide has been proved to be a suitable technique for the treatment of female genital mutilation when inclusion cysts are associated with it.

Lymphangioma circumscriptum of the vulva following surgical and radiological therapy of cervical cancer

BACKGROUND

Lymphangioma circumscriptum of the vulva rarely develops after postoperative pelvic irradiation.

GOAL

The goal was to describe two cases of lymphangioma circumscriptum and their treatment and present a brief review of the literature.

STUDY

Two female patients, aged 75 years and 46 years, presented with persistent edema, papules, and vesicles of the labia majora, which had developed 15 and 9 years after hysterectomy, lymph node dissection, and subsequent irradiation of cervical cancer. The external diagnosis was genital warts.

RESULTS

In both cases histology revealed lymphangioma circumscriptum of the vulva. Whereas the older woman's condition responded well to laser treatment, keloids developed in the second patient at the site of carbon dioxide laser vaporization.

CONCLUSION

CO2 laser treatment recently has been recommended for vulvar lymphangioma circumscriptum and is effective in vaporizing the communicating vessels to deeper cisterns. To our knowledge this is the first description of keloid development after laser therapy for vulvar lymphangioma circumscriptum, and such an effect should be considered before CO2 laser surgery is applied for this particular entity.

Prepubertal labial adhesions: evaluation of a referral population

OBJECTIVE

The purpose of this study was to assess patient demographics, clinical presentation, response to previous treatment, and current evaluation of prepubertal girls referred for gynecologic care of labial agglutination.

STUDY DESIGN

A retrospective chart review of all prepubertal female patients with labial agglutination referred from 1996 through 2001.

RESULTS

Twenty-three girls were diagnosed with labial agglutination during the review period. All of the diagnoses were made by a primary care provider. At the time of referral, most patients had received medical therapy, but had not obtained resolution of their labial agglutination with topical estrogen. Twenty-two of the 23 patients required manual separation of the labial adhesions. Findings most frequently revealed a pinpoint opening and thick (3-4 mm) adhesions with >90% of the vestibule adhered in 21 of 23 girls. Nine of 23 girls had recurrence of adhesions. Four girls required a repeat manual separation because of recurrent thick adhesions. One of 4 girls required a third manual separation. Five of the 9 recurrences were treated successfully with topical estrogen.

CONCLUSION

Gynecologists who treat patients with labial agglutination frequently may encounter children for whom medical treatment has failed. Patients whose condition does not respond to topical therapy may have thick adhesions and require manual separation.

[Incidence and management of condylomata acuminata by French general physicians]

OBJECTIVES

Condylomata acuminata (or genital warts) are sexually transmitted diseases caused by human papillomavirus. Until now, there has been no available epidemiologic data about this disease in France. We conducted a prospective study among French general practitioners (GPs) to estimate the incidence of consultations for external condylomata acuminata in general practice. We also assessed the management of patients with external condylomata acuminata by French GP's.

DESIGN

A panel of French general practitioners, members of the Sentinel network, had to fill-in prospectively a questionnaire for each patient with condylomata acuminata diagnosed between July and November 2000.

RESULTS

The annual number of consultations for external condylomata acuminata with French GP's was estimated at 23,000 (CI (95 p. 100) 21,000-25,000) including 15,000 new cases (CI (95 p. 100) 13,000-17,000). Taking into account the estimations we made at the same time in office-based private dermatologists, we estimated the annual incidence of external condylomata acuminata in France at 107/100 000 inhabitants. The management of patients with external condylomata acuminata by French GP's was in accordance with the European guidelines in 54 to 78 p. 100 of cases. French GP's mostly prescribed chemical treatment.

DISCUSSION

A proportion of cases of condylomata acuminata may have not been diagnosed. Similarly, some lesions may have been wrongly diagnosed as condylomata acuminata, but these proportions of false positive and false negative remain unknown. The incidence of external condylomata acuminata in France is similar to those estimated in others developed countries.

CO(2) laser therapy of vulval lymphangiectasia and lymphangioma circumscriptum

BACKGROUND

Lymphangiectasia is a disorder of superficial lymphatics resulting from obstruction of previously normal deep lymphatics, while lymphangioma circumscriptum describes a deep dermal and subcutaneous lymphatic malformation with secondary superficial ectatic changes. Previous case reports have suggested the effectiveness of CO2 laser treatment.

OBJECTIVE

To assess CO2 laser therapy for vulval involvement by these lymphatic disorders.

METHODS

A retrospective case review at St. John's Institute of Dermatology from 1996 to 1999 identified three women with vulval lymphangiectasia and two with vulval lymphangioma circumscriptum treated with the CO2 laser.

RESULTS

Patient tolerance of the procedure was good. Healing was complete within 1 month and occurred without change in skin texture. All patients reported considerable improvement in symptoms (mean follow-up 22 months, median 24 months, range 10-33 months). Focal recurrence and an area of localized persistence were noted in the two patients with lymphangioma circumscriptum.

CONCLUSION

CO2 laser therapy of vulval lymphangiectasia and lymphangioma circumscription is effective and well-tolerated; the latter may possibly be more resistant to treatment than the former.

Photodynamic therapy of vulvar and vaginal condyloma and intraepithelial neoplasia using topically applied 5-aminolevulinic acid

BACKGROUND AND OBJECTIVES

To determine the feasibility of photodynamic therapy (PDT) of vulvar and vaginal condyloma and intraepithelial neoplasia (VIN, VAIN) and to compare PDT results with conventional treatments.

STUDY DESIGN/MATERIALS AND METHODS

Thirty-eight patients with vulvar or vaginal intraepithelial neoplasia (VIN) grade II/III (n = 22) or condyloma (n = 16) had 10% 5-aminolevulinic acid (ALA)-gel applied topically. After 2-4 hours, 80-125 J/cm(2) laser light at a wavelength of 635 nm was applied. PDT was compared to conventional treatments for condyloma (CO(2) laser evaporation) and for VIN III (laser evaporation, surgical excision).

RESULTS

The complete clearance rate for condyloma treated by PDT was 66% and the rate for IN was 57% (as determined by biopsy). Of the neoplasia patients, none with hyperkeratotic VIN (n = 4) responded, and only one of four with increased pigmentation cleared. No scarring occurred, and postoperative discomfort lasted 4.9 +/- 3.4 days. Reduced disease-free survival (DFS) was associated with multifocal VIN (P = 0.02, OR 2.17, 95% CI 1.15-4.08), but DFS did not vary with treatment mode.

CONCLUSIONS

Although PDT is not equally efficacious for all subgroups, PDT for condyloma and intraepithelial neoplasia appears to be as effective as conventional treatments, but with shorter healing time and excellent cosmetic results.

Clitoral cyst as a cause of ambiguous genitalia

BACKGROUND

Ambiguous genitalia need appropriate evaluation, because a serious disease can manifest as this condition.

CASE

A 28-year-old woman was referred with a "penis" present from age 12 years that enlarged throughout puberty but recently was unchanged. Differential diagnosis included true hermaphroditism; adrenal hyperplasia; clitoral, ovarian, and adrenal neoplasms; stromal hyperthecosis; polycystic ovarian syndrome; and exogenous androgen exposure. Free testosterone was not elevated. Dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, total testosterone, androstenedione, deoxycorticosterone, 11-deoxycortisol, chromosomal analysis (46,XX), an intravenous pyelogram, and pelvic ultrasound were normal. The patient elected surgical removal. The mass was a chronic inflamed epidermoid cyst.

CONCLUSION

If this patient had been appropriately evaluated earlier, she would have been spared anxiety and embarrassment over a simple epidermoid cyst.

Oxygen embolism after hydrogen peroxide irrigation of a vulvar abscess

We report a case of venous oxygen embolism in a 33-yr-old healthy woman after irrigation of a vulvar abscess with 25 ml of 3% hydrogen peroxide. Venous oxygen embolism was diagnosed by the development of sudden hypoxia associated with a decrease in end-tidal carbon dioxide concentration from 5.3 kPa to 3.2 kPa, and a 'mill-wheel' sound on cardiac auscultation soon after injection of the solution. The patient responded to corrective treatment including the Trendelenburg position and 100% oxygen. She made an uneventful recovery. We discuss the possible causative mechanism of this embolism, the different diagnostic methods, and the controversial aspects of available treatments. We emphasize that hydrogen peroxide is a dangerous and unsuitable agent for routine wound irrigation and debridement.

Isolated extraabdominal colonic tissue: What do we know about it?

A newborn presenting with an isolated ectopic colonic tissue arising from the vulva without any associated anomaly is reported. The clinicopathologic features of this rare entity are discussed with special emphasis on embryologic basis.

Amniotic membrane grafting to treat refractory labial adhesions postpartum. A case report

BACKGROUND

Labial adhesions are common in prepubertal children, but their occurrence postpartum is extremely rare.

CASE

A woman developed labial adhesions after a vaginal delivery. Topical estrogen cream was ineffective. Simple excision was performed, but the adhesions reformed two weeks later. Finally, amniotic membranes were used to cover the labia minora after they were separated by excision. The wound healed without adhesion formation.

CONCLUSION

Excision plus amniotic membrane grafting is effective for recurrent labial adhesions.