Vulvovaginal sequelae in toxic epidermal necrolysis

OBJECTIVE

To evaluate the incidence of vulvar lesions during the acute and healing periods in toxic epidermal necrolysis (TEN), to describe the clinical aspects and functional consequences, and to evaluate surgical treatment.

STUDY DESIGN

During the acute period in 40 patients, cutaneous and mucous lesions were described on the day of hospitalization and daily thereafter. To evaluate the healing period, a questionnaire was sent to the same 40 patients to obtain information on symptomatology after the acute period, anatomic modifications, and the quality of sexual and other genital activity.

RESULTS

During the acute period, genital lesions were present in 28 of the 40 patients studied (70%). In 24/28 (89%) the lesions were vulvar only, and in 3/28 (11%) they were vulvovaginal. In one case vaginal involvement could not be proven because the patient was a virgin. During the healing period, sequelae occurred in 5 of the 40 patients (12.5%): four cases were known since the patients had visited the Department of Gynecology because of secondary effects, and one case was detected by the questionnaire. The symptoms occurred during hospitalization in 1 case, at the end of the second month in 2, at the 12th month in 1 and unknown in 1. The site was the vulva in all five cases and was the vulva and vagina in three. Again, the virgin could not be examined. The average interval between secondary effects and the original gynecologic visit was 7 months (3-12). The sequelae were treated surgically in two of the five affected patients: on the vulva, nymphoplasty, posthectomy and median perineotomy; in the vagina, sharp and blunt dissection, with use of a soft mold. The first patient had a recurrence six months after surgery, and the second had no recurrence but has been unable to engage in intercourse.

CONCLUSION

From our study of the involvement of the vulva and vagina during TEN and the sequelae, it is clear that detection from the questionnaire was insufficient. Some women can have synechiae without functional sequelae, and others can have minor involvement with important psychological repercussions. A prospective study with systematic examination of the vulvovaginal area and systematic follow-up for at least one year is needed. For therapy, a lubricant gel (perhaps topical steroids) could be useful. Placing a soft mold in the vagina as soon as possible, though difficult, and keeping it there until complete healing occurs can lead to infection. It is not clear that use of a mold would promote healing or be tolerated. Intercourse immediately after the acute period would be helpful but probably would not be welcome to the patients. However useful, a prospective survey would be difficult because it would entail many years of study.

Treatment of lichen sclerosus with carbon dioxide laser vaporization

We have treated 10 patients (five women and five men) with lichen sclerosus (LS), verified by histopathological studies from skin biopsies, with CO2 laser vaporization. All men studied had LS of the penile skin, of the women, three had extragenital lesions and two LS of the perineal skin. The mean follow-up time was 32 months (range 3-79 months). One man had both penile and urethral LS. All penile lesions of the five men were clinically cured by laser treatment: however, urethral lesions of one patient recurred despite three separate treatments. The two women with perineal LS improved after laser treatment. However, LS recurred on the treated are in one and on the margins of the treated area in another. Two women with LS on the skin of the breast became asymptomatic after treatment. One woman had several lesions on the skin of the trunk that improved after treatment but were not cured completely. The present study suggests that carbon dioxide vaporization may be an effective treatment of skin lesions in LS.

[Amelanotic melanoma of the vulva simulating lichen sclerosus et atrophicus]

Malignant melanoma of the vulva is an uncommon disease. The amelanotic subtype is only rarely mentioned. We report a 60-year-old patient with a 6 month history of vulvar pruritus. Ivory lesions combined with erosions and fine "cigarette paper'-like wrinkling were suspicious for lichen sclerosus et atrophicus. Histologically the diagnosis of an amelanotic malignant melanoma was made. Amelanotic melanoma may present with a wide variety of clinical features. Even in the uncommon location of the vulva, amelanotic melanoma should be suspected in any nonhealing nonpigmented lesion.

Vulvovaginal hematomas complicating delivery. Rationale for drainage of the hematoma cavity

OBJECTIVE

To review the management of puerperal vulvovaginal hematomas and report on the use of closed system drainage in cases in which operative intervention was used.

STUDY DESIGN

A retrospective review of medical records for a five-year period was conducted. The charts of all patients in whom puerperal vulvovaginal hematomas occurred were reviewed and data extracted regarding possible etiologic factors, details of delivery, characterization of the hematoma, surgical intervention and type of drain used. Also recorded was length of stay and postoperative complications.

RESULTS

Eleven patients with hematomas were identified, for an incidence of 1/526. All patients received antibiotics; transfusion was required in eight patients. Drains were used in nine patients: Penrose in four and closed system drainage in five. All drains were brought through a separate site distant from the repair. There was one postoperative abscess, which resolved with wound care, resulting in no long-term morbidity.

CONCLUSION

Puerperal vulvovaginal hematomas may be a life-threatening event. Review of the literature and our experience suggests that aggressive operative management and the use of drains are beneficial in the management of these patients. Closed system drainage may be an effective adjunct in the management of vulvovaginal hematomas.

Post-traumatic vulvar endometriosis

We report a case of vulvar endometriosis presenting as a vulvar mass following trauma in a 12 years old, 3 months post-menarcheal girl. The presumptive etiology is the direct implantation of endometrial cells. Painful swelling of the vulvar mass appeared gradually during menses. Excision of suspected vulvar endometriosis is suggested as the definite treatment.

Recent problems with paracervical vasopressin: a possible synergistic reaction with nicotine

Vasopressin is now commonly used to control bleeding during surgery of the cervix. In larger intravenous doses, vasopressin can cause coronary artery vasoconstriction and increase systemic vascular resistance. Nicotine has a similar effect on the coronary circulation. The effects of combining both these drugs has not been studied. We describe a 22-year-old woman who developed severe hypotension and bradycardia after receiving a small dose of paracervical vasopressin. She was using a transdermal nicotine patch at the time of her surgery. We suspect her cardiac problems, and recently reported cardiac events in other women receiving small doses of paracervical vasopressin, could be caused by a synergism of the vasoconstrictive properties of nicotine and vasopressin. Caution is urged when vasopressin is to be administered to patients who smoke or use nicotine transdermal patches.

[A case of labial adhesions with urinary retention]

A 69-year-old woman was admitted to our hospital complaining of urinary retention. On examination, the labia was found to be fused extensively, with a pinhole opening at the midline. The adhesions were separated under spinal anesthesia. One year after operation, there remains no recurrence. Etiological factor in labial adhesions are thought to include a combination of local inflammation and estrogen deficiency. In our case, the patient had hip joint disease. Hip joint disease is shown to influence the formation of adhesions by interfering with perineal hygiene and decreasing sexual activity.

Surgical treatment of vulvar lichen sclerosus: a review

Surgical therapy of lichen sclerosus of the vulva consists of three main operations: vulvectomy (with or without a skin graft), cryosurgery, and laser ablation. It is indicated in two conditions, either when malignant transformation is present or is likely to occur, or when medical treatment has failed. The overall risk for malignant transformation of vulvar lichen sclerosus is low, ranging between 0 and 9 percent. However, specific histological criteria, such as mixed dystrophy, have recently been associated with higher malignancy rates. Vulvectomy is indicated only when these criteria are met. Both skinning and simple vulvectomies are associated with recurrence rates as high as 50 percent. However, better sexual function and cosmetic results have been reported in the former, especially with concomitant split skin grafting. Cryosurgery also has high recurrence rates, although short-term results are favorable. Although only small series have been reported, laser therapy seems to carry better long-term results than other modes of treatment. Convalescence is complete within 6 weeks posttreatment, and remission rates are as high as 85 percent at 3 years of follow-up. The high recurrence rate of all surgical modalities makes surgical treatment suitable only for patients who failed to respond to multiple medical treatments such as topical high potent steroid ointments, testosterone, and retinoids.

Angiolymphoid hyperplasia with eosinophilia of the vulva

Vulvar angiolymphoid hyperplasia with eosinophilia is a rare benign itchy vascular lesion that, because of its nonspecific clinical features, requires biopsy for accurate diagnosis. Surgical excision is the preferred method of treatment.

Flashlamp-excited dye laser therapy of idiopathic vulvodynia is safe and efficacious

OBJECTIVE

The management of chronic vulvovaginal pain, not explicable on specific histologic grounds, presents a major problem in referral centers for lower genital tract diseases.

STUDY DESIGN

This article reports on a two-step protocol in a sample of 175 medical nonresponders, drawn from a 2-year cohort of 725 women with vulvovaginal pain. The first maneuver was the use of a flashlamp-excited dye laser to selectively photocoagulate symptomatic subepithelial blood vessels in 168 women; the second was the microsurgical removal of chronically painful Bartholin's glands in 52 women not responsive or not suited to flashlamp-excited dye laser photothermolysis.

RESULTS

Dye laser response rates were independent of whether patients manifested macroscopic foci of painful erythema ("vestibular adenitis") or just colposcopically apparent hyperemia-ectasia of the individual blood vessels ("pruritic papillomatosis") (56% vs 45% after a single surgical procedure; 76% vs 65% after serial retreatment; p not significant). Conversely, response rates were much lower among women in whom pressure on the Bartholin's glands produced sharp, lancinating pain (15% vs 66% after a single surgical procedure; 22% vs 93% after serial retreatment; p < 0.001). Forty-two (85%) of 50 patients with flashlamp-excited dye laser failure had deep pain; however, the impasse to progress was broken by gland removal. Final response rates were 92.5% (complete response 62%; partial response 30%) in the "surface-only" group and 80.3% in the "surface-plus-deep" group (chi 2 = 14.9; p < 0.001). The major complication was acute bacterial cellulitis, occurring in the first postoperative week. Modification of the treatment protocol to include topical antibiotics with an occlusive dressing reduced the cellulitis rate from 17.2% to 2.5%. In four women (1.8%) Koebner-like exophytic condylomas also developed within 1 month of flashlamp-excited dye laser surgery.

CONCLUSION

The availability of a safe, efficacious, and relatively noninvasive treatment should reduce the need for resective surgery in most patients with idiopathic vulvodynia.

[Fournier gangrene]

Fournier's gangrene is a relatively rare, mixed aerobic and anaerobic soft tissue infection in the perineoscrotal area. Although it is convenient to give it a separate name, it is really either necrotizing fasciitis or nonclostridial myonecrosis of the scrotal and perineal areas. The condition frequently develops from perineal diseases, including perianal abscess, and fistulas, inflamed haemorrhoids and indwelling urethral catheter. In patients with Fournier's gangrene morbidity is extreme and mortality high. This article is based on a retrospective study of 15 cases of Fournier's gangrene, 13 in male and 2 in female patients. A combination of surgery and antibiotics was used to treat 9 patients. The last 6 cases were treated with a combination of surgery, antibiotics and hyperbaric oxygen. In 13 cases, the diagnosis was made on the basis of the fulminating progression of the infection to a scrotal gangrene, identification of multiple underlying pathogenic organisms and toxaemia. In the 2 female patients, a similar infection developed in the labia majora and perineum and extended to the buttocks and the anterior abdominal wall.

Ultrasound and hookwire needle placement for localization of a hydrocele of the canal of Nuck

BACKGROUND

Hydrocele of the canal of Nuck is a mobile mass entity that can be difficult to locate and excise. We report the use of ultrasound scan and a hookwire needle to localize and stabilize this mass, making its excision easier.

CASE

A 24-year-old white female presented with a 6-month history of a painful vulvar mass associated with increased discomfort with prolonged standing. Thorough evaluation revealed a suspected hydrocele that was easily palpable in the standing position but not in the lithotomy position. Translabial ultrasonography and a hookwire needle were used to localize and stabilize the mobile vulvar mass, eliminating the need for extensive surgical exploration.

CONCLUSION

Ultrasound scanning and needle localization is a useful technique to identify and stabilize a mobile mass, making its surgical excision possible without extensive exploration and trauma.

[Orifice dyspareunia: the surgeons point of view]

Various organic lesions can give rise to superficial dyspareunia. Easily surgically treated, they must be recognised: 1) minor hymenal abnormalities: cribriform, microperforate, septate, fleshy or hyperelastic hymens; 2) vaginal abnormalities: longitudinal or transverse septum; 3) post obstetrical or post operative vulvar outlet stenosis; 4) sexual trauma: tears of the vestibular fossa or hymenal tears; 5) stenosing lichen sclerosus, lichen planus, bowenoid papulosis and Bowen's disease; 6) focal vestibulitis associated with more or less obvious psychological outcomes.

Detection with the polymerase chain reaction of human papillomavirus DNA in condylomata acuminata treated with CO2 laser and microwave

BACKGROUND

The recurrence rates of condyloma acuminata are high. The reasons for the relatively high relapse rates with different treatments are unknown.

METHODS

Twelve specimens of condylomata acuminata of the vulva were excised from 12 patients and divided into three parts. One part was untreated, the second and the third parts were treated with CO2 laser and microwave, respectively. DNA was then extracted from tissue by proteolytic digestion and amplified by the polymerase chain reaction. Dot blots were performed with the use of radiolabeled consensus and human papilloma virus (HPV) type-specific probes.

RESULTS

HPV DNA was amplified in 100% of untreated specimens (6-HPV 6; 6-HPV 11), and in 83.3% and 50% of specimens treated with CO2 laser and microwave, respectively. There was a significant difference in detection between untreated and microwave-treated specimens (chi 2 = 4.18, P < 0.05).

CONCLUSION

Microwave damages HPV DNA more effectively than CO2 laser.

Treatment of vulvar lichen sclerosus in the elderly: an update

Lichen sclerosus et atrophicus is a disorder of the skin that can occur anywhere on the body and in all age groups but mainly affects middle-aged and elderly women in the vulvoperineal area. It consists of ivory or pink papules or macules that eventually coalesce into thin, gray, parchment-like areas. Clinically, the main symptoms are severe and intractable itching and vaginal soreness with dyspareunia. Although it has been described to be associated with an increased risk for epithelial malignancy this, in fact, very rarely occurs. The exact nature of LSA is still unknown. The accumulation of evidence does little to clarify its pathogenesis and etiology. The different reports indicate at least three general possibilities; autoimmune, metabolic, and more recently infectious etiology. The coexistence of such diverse findings in one disease entity may indicate one of the two; either we are facing a group of very similar conditions, which will be separated in the future into several closely related clinical entities, each with its own etiology, or that all findings represent a complex multi-step single pathogenetic mechanism. The latter possibility seems more probable because it has previously been suggested that B. burgdorferi, a recent prime suspect in the pathogenesis of LSA, may induce both metabolic and autoimmune abnormalities in the course of infection. New therapeutic options and attitudes emerge that dramatically improved the conservative treatment of this disease (Table 5).(ABSTRACT TRUNCATED AT 250 WORDS)

[Degenerative vulvar Buschke-Loewenstein tumor]

The authors report the case of a degenerative Buschke-Löwenstein tumor located on the vulva. The authors stress the unusual nature of this disorder, recall its etiopathogenic factors and insist on the necessity for surgery to avoid a transition to malignancy.

Laser versus loop electrosurgical excision in vulvar condyloma for eradication of subclinical reservoir demonstrated by assay for 2'5' oligosynthetase human papillomavirus

We studied, in an open clinical trial, 28 women with giant solitary human papillomavirus (HPV) lesions of the vulva that were treated by both laser and the loop electrosurgical excision procedure (LEEP), and analyzed the biopsy specimens of normal skin adjacent to the lesions for papillomavirus sequences by Southern blot hybridization and 2'-5' oligo-A synthetase (interferon) activity. The patients were reexamined after 3 weeks when a second treatment to the still infected areas was reapplied. They were reexamined for recurrence after 3 months: 4 patients harbored HPV-DNA genomes on the laser-treated side, adjacent to the original lesion, compared to 1 patient who developed recurrence on the LEEP side in a more distant, previously untreated, area. The optimal extent of laser or LEEP treatment necessary to reduce recurrence of vulvar condyloma remains to be established. Good in situ hybridization tests combined with the polymerase chain reaction and measurements of oligosynthetase activity to determine the types of cells involved at different sites of infection and to assess harboring of latent HPV genomes in histologically normal tissue are necessary in order to plan proper HPV treatment modality strategies.

Membranous hypertrophy of the posterior fourchette as a cause of dyspareunia and vulvodynia

Twenty-one women were treated surgically for entry dyspareunia and vulvodynia. The ages of the patients ranged from 18 to 39 years (mean, 24.5). Physical examination showed the presence of membranous hypertrophy of the posterior fourchette with consequent stricture of the vaginal introitus in all the patients. Eighty percent of the patients had erythema and tenderness of the vestibule, particularly in the posterior part. The histologic findings were somewhat enigmatic and quite unimpressive, frequently suggestive of chronic nonspecific inflammation; in only two cases were histologic changes suggestive of human papillomavirus infection observed. All the patients underwent excision of the posterior part of the vestibule with vaginal advancement under general anesthesia. Follow-up showed elimination of the symptoms in 19 patients and an improvement in the symptoms in the remaining 2.

Epithelial alterations adjacent to invasive squamous carcinoma of the vulva

The slides of 64 vulvectomy specimens from vulvar squamous carcinoma were reviewed in order to study the histopathologic changes adjacent to the neoplasia. Normal epithelium was found in 7 cases (11%) and epithelial alterations adjacent to carcinoma in 59 (89%). The epithelial alterations found were: nonneoplastic epithelial disorder (NNDV) in 38 cases (59%) and vulvar intraepithelial neoplasia (VIN) in 19 (30%). The distribution of NNDV was: 20 cases of epithelial hyperplasia (EH) (31%), 6 of lichen sclerosus (9%) and 12 of the mixed type (19%). Sixteen cases of VIN 3 (25%) were undifferentiated, and three cases were differentiated VIN. Eighteen of 19 VIN cases were associated with NNDV, and 8 cases of undifferentiated VIN were associated with human papillomavirus infection. There was no apparent relationship between the associated lesions and tumor size, depth of invasion, lymph node metastases and clinical stage. Nevertheless, we found a significantly higher frequency of associated lesions in poorly differentiated tumors (P > .01). The most important finding was a high association between EH (50%) and VIN (30%) with carcinoma. VIN cases were almost always (95%) associated with EH.

[Treatment of Bartholin's abscess. Marsupialization versus incision, curettage and suture under antibiotic cover--a randomized trial with a 6-months follow-up]

Treatment of Bartholin's abscess with incision and curettage of the cavity suture under antibiotic cover reduces the average healing time compared with conventional marsupialization. Recurrences were not more frequent after suture.

Outpatient management of Bartholin gland abscesses and cysts with silver nitrate

This study reports results of 52 patients with Bartholin abscesses or cysts who were managed by silver nitrate stick insertion into the cyst or abscess cavity for 48 hours. All patients showed complete healing within 15 days. However, 2 (3.8%) had recurrences within the first 2 months; 1 of these patients was treated with excision and the other by repetition of the same method with no further complaints. Silver nitrate application for Bartholin cysts or abscesses was found to be an effective, simple, inexpensive and the least anaesthetic requiring procedure, which can easily be carried out in the outpatient setting.

Vaginismus: an important factor in the evaluation and management of vulvar vestibulitis syndrome

Dyspareunia is a common complaint in general gynecological practice. Many patients with dyspareunia suffer from vulvar vestibulitis syndrome (VVS). This syndrome constitutes severe pain on vestibular contact or attempted vaginal entry, tenderness to pressure within the vulvar vestibule and physical findings of vulvar erythema of various degrees. As a last resort, and only when all conservative treatments have failed, surgery is attempted. It has been our observation that a considerable percentage of patients with VVS present with concomitant vaginismus. Furthermore, surgery is less successful in this subgroup of patients unless the vaginismus is first treated. This report describes the evaluation and treatment of 14 patients with VVS.

Toxic shock syndrome associated with vulvar necrotizing fasciitis

BACKGROUND

Fifty percent of toxic shock syndrome is associated with nonmenstrual etiologies such as postoperative wound infection.

CASE

A 44-year-old woman developed necrotizing vulvar fasciitis that was successfully treated with surgical debridement and broad-spectrum antibiotics. However, after improving for 3 days postoperatively, she developed fever, a generalized maculopapular rash, and renal and liver abnormalities. As her condition worsened, she developed hypotension and respiratory distress. After 5 days in the intensive care unit, she gradually improved. Her wound culture from admission grew multiple organisms, including Staphylococcus aureus that produced toxic shock syndrome toxin-1.

CONCLUSION

Toxic shock may occur in varied gynecologic settings, including pelvic and perineal infection. Successful management requires a prompt and aggressive response to multi-organ system failure.

Intralesional alpha interferon. Cost-effective therapy for vulvar vestibulitis syndrome

The cost-effectiveness of two treatment strategies for vulvar vestibulitis syndrome (VVS) was compared. Our prospective study consisted of 55 patients with human papillomavirus (HPV)- and non-HPV-associated VVS of at least 6 months' duration treated with intralesional recombinant alpha interferon injections, followed by surgery for nonresponders and responders compared with a hypothetical model of surgery alone. The setting was a private-practice multispecialty center for vulvovaginal disorders. Improvement was defined by patients' subjective evaluation of change in the level of introital dyspareunia and the ability to have sexual relations and objective evidence of change in the degree of erythema and tenderness to touch within the vestibule. Statistical analyses of the overall probability of improvement, overall costs and the cost per patient treated were done. Twenty-seven (49%) of 55 patients treated with alpha interferon had substantial or partial improvement. Of the 28 (51%) who did not improve following alpha interferon, 19 elected to have surgery. Surgery resulted in substantial improvement in 84% of the patients and partial improvement in 11%. Statistical analysis comparing the group treated with alpha interferon (some of whom went to surgery with the hypothetical model of surgical treatment alone) showed significant cost-saving in the group first treated with alpha interferon. At the level of effectiveness achieved in this study, intralesional alpha interferon as a first choice in the treatment of VVS is cost-effective.

Functional results in young women having clitoral reconstruction as infants

Nine young women who had clitoral recession for clitoromegaly as infants have been evaluated for anatomical appearance, psychosocial adjustment, and sexual function. Highly satisfactory anatomic results were obtained, although two patients required subsequent revision. The tested psychological parameters were essentially normal. Virtually all patients were sexually active and all but one have achieved regular painless orgasm. Surgical reconstruction has been accomplished by recessing the entire disfigured clitoris, thereby conserving all erectile tissue and preserving sensation. In addition to assessment of anatomical appearance, long-term follow-up of children with ambiguous genitalia requires regular evaluation of social, psychological, and sexual parameters.

Treatment of Bartholin's abscess. Marsupialization versus incision, curettage and suture under antibiotic cover. A randomized study with 6 months' follow-up

Conventional marsupialization was compared with incision plus curettage and primary suture of the abscess cavity under antibiotic (Clindamycin) cover in a prospective, randomized study of 32 patients with Bartholin's abscess. The median time to healing was 5 days less after suture than after marsupialization alone. The difference was statistically significant. 29 patients were followed up for 6 months. Recurrence of abscesses tended not to be more frequent after suture, making suture an attractive, safe and convenient alternative treatment for Bartholin's abscess.

Anterior sagittal anorectoplasty for rectovestibular and anovestibular fistula

Rectovestibular (or anovestibular) fistula is the most common form of anorectal anomaly in female infants. In the surgical repair of these malformations, anal transplantation has been in widespread conventional use. Based on the idea of posterior sagittal anorectoplasty, we devised a new approach, anterior sagittal anorectoplasty, in which, in the lithotomy position, the anterior portion of sphincter muscles are cut through a median perineal skin incision and then the rectum is pulled through the center of these muscles to make its opening at the normal position. The operation has been performed in 12 patients with satisfactory results.

[Haemophilus influenzae and genital infection]

We report nine cases of H. influenzae genital infections in women. Six patients had a total of 7 episodes of Bartholin glands abscess. One patient developed a post-caesarean endomyometritis on the 16th post-delivery day. The remaining patient developed an amniotic fluid infection in the 32nd week of pregnancy. All the nine H. influenzae strains were sensitive to ampicillin. We assess the rising importance of H. influenzae as an etiologic agent of female genital tract infections.

Dysplastic vulvar nevi

Of several pigmented vulvar lesions, the dysplastic nevus, a know precursor of malignant melanoma, has been described only twice. Focusing on pigmented vulvar lesions, 18 were excised among approximately 500 unselected parturients. Three lesions showed clinical and histologic characteristics of a dysplastic nevus. The patients with a dysplastic vulvar nevus were 21, 27, and 30 years old, respectively; all three had multiple torso and limb nevi and two had anamnestic features of the dysplastic nevus syndrome. Only one was aware of her vulvar lesion. All dysplastic nevi were brown or black and were larger than 5 mm in diameter. Our cases suggest that dysplastic vulvar nevi may be more frequent than previously thought. We suggest that the puerperium is a suitable time for a definite histologic diagnosis of large-size lesions with variegated pigmentary patterns and irregular borders that occur on the vulvar skin. Likewise, in other patients with suspected dysplastic vulvar nevi, excisional biopsy is recommended.

Recurrent necrotizing fasciitis of the vulva. A case report

Necrotizing fasciitis most often occurs in the context of prior trauma or surgery. Predisposing medical conditions include diabetes mellitus, arteriosclerosis, obesity, hypertension and prior irradiation. De novo occurrence in the vulva, in the absence of prior injury, surgery or irradiation, has been reported rarely. Necrotizing fasciitis of the vulva in the diabetic patient may have an insidious onset but requires an early diagnosis and aggressive surgical episode of fasciitis occurred in an obese, diabetic woman. Aggressive, wide excision of all infected vulvar, mons and thigh tissue, followed by aggressive medical and surgical postoperative care, resulted in minimal morbidity. Prompt recognition and aggressive care are required to treat this condition.

Complications of laser therapy in the gynecological patient: a review of four patients

Complications of gynecological laser treatment for perineal disease have been seen with increasing frequency. This may be the result of more women undergoing therapy with this method. Four women presenting with unstable perineal scarring are discussed.

Laser therapy of vulvar lichen sclerosus et atrophicus

Seven patients with a histologic diagnosis of lichen sclerosus et atrophicus of the vulva were treated by laser ablation of the affected area to a depth of 1.0 to 2.0 mm. The inpatient procedure was performed under general anesthesia with a carbon dioxide laser unit. Healing was complete 6 weeks postoperatively. All but one patient was free of recurrent symptoms at follow-up, which ranged from 12 to 37 months. Laser ablation is an acceptable treatment for patients who have symptoms due to lichen sclerosus of the vulva that are refractory to other measures.

[Laser in gynecology]

During the last decade, the use of laser technology has become more common in operative gynaecology in Norway. The first modality to be introduced was the carbondioxide, CO2-laser, used together with the colposcope for the treatment of cervical intraepithelial dysplasia and condylomata. The same laser has also been employed through laparoscopic technique, with the aid of modern microvideofacilities. Finally, using the hysteroscopic technique, the Neodymium-Yttrium-Aluminium-Garnet, the Nd-YAG-laser, has been introduced for treating intrauterine conditions. The use of laser in operative gynaecology makes it necessary to change the attitude towards indications for operation. The possibilities are challenging, and the effect on the length of postoperative convalescence is especially rewarding. The introduction of lasers in gynaecology could have far-reaching consequences for efficient use of hospital resources.

Necrotizing fasciitis: a complication of squamous cell carcinoma of the vulva

Necrotizing fasciitis is an often fatal, often initially unrecognized condition. Although it was first described over 60 years ago, occurrence in the vulva was only first recognized in 1972. The condition is most often associated with diabetes, prior injury, surgery, or irradiation. Aggressive surgical excision is required, early in the course of the disease, to salvage the patient. An association with vulvar carcinoma in a nondiabetic patient has not been previously reported. We report such a case, with a poor outcome, because surgical intervention was not possible until late in the course of the disease.

Puerperal haematomas

Forty-seven out of 31,628 patients delivered in our hospital over the past 5 years developed puerperal genital tract haematomas. Four cases, representing different types of haematoma which required different managements, were presented to illustrate this problem. A literature review was also made.

[Surgical treatment of vulvar stenosis. Technic description]

A surgical technique for the treatment of vulvar stenosis is described. The recto-vaginal space is approached by the cutaneous route, starting with incisions for resection of 2 skin triangles arranged as butterfly wings on either side of the midline. The sclerous cicatricial tissue between rectum and vagina is widely exposed and incised so that the lower part of the posterior vaginal surface can be dissected and mobilized without any risk of damaging the mucosa, since the tractions required for cleavage are exerted on the cutaneous side of the bridle. It is only at this stage that a median sagittal cutaneo-mucosal incision of the bridle is carried out, followed by a transverse suture without tension. This easily performed technique has been used in 11 cases without complication and with satisfactory long-term functional results.

Treatment of vulvar craurosis and leucoplakia by split skin grafting

In the treatment of a 72-year-old patient with vulvar craurosis and leucoplakia which had been proven resistant to earlier surgical and medical treatment attempts--the authors employed a split-skin graft from the forearm. The methods of the successful treatment with regard to the skin and its grafting, as well as the post-operative case, are described.

Carbon dioxide laser treatment for vulval papillomatosis (vulvodynia)

Genital papillomatosis accompanied by distressing vulval symptoms is often termed vulvodynia. Common presenting symptoms are vulvar burning, pruritus and dyspareunia. Sixteen patients with vulval papillomatosis (vulvodynia) have been treated by carbon dioxide laser therapy over a 4-year period. Initial responses at 6 weeks appeared encouraging but with follow-up it became apparent that the relapse rate was high, with a mean symptom-free interval of 4.6 months. Of the 16 patients treated, only three remain symptom free. In view of our findings, we recommend that laser therapy should not be offered as a primary procedure, if at all, for patients with vulval papillomatosis.

Window operation: an alternative treatment method for Bartholin gland cysts and abscesses

Recently, we developed the "window operation" as a more effective way to treat Bartholin gland cysts and abscesses. The window operation was used to treat 25 Bartholin cysts and 22 Bartholin abscesses during a 3-year period from October 1, 1986 to September 30, 1989. Under local anesthesia, a small piece of skin including the cyst wall was excised in an oval shape, and suturing was performed along the excised margin. Postoperative antibiotics were given in cases of acute inflammation. A new mucocutaneous junction was observed at the 4-week postoperative checkup. No complications or recurrences have been observed during the study period. The window operation can be an alternative method of treatment for Bartholin gland cysts or abscesses.