The management of genital condylomas, intraepithelial neoplasia, and vulvodynia

Argon plasma versus electrofulguration in the treatment of anal and perianal condylomata acuminata in patients with acquired immunodeficiency virus

Purpose:

To compare the effectiveness of anal and perianal condylomata treatment using argon plasma and electrofulguration.

Methods:

From January 2013 to April 2014, 37 patients with anal and perianal condylomata, who had been diagnosed through proctological examination, oncotic cytology, polymerase chain reaction (PCR) and histology, underwent treatment with argon plasma and electrofulguration. The perianal and anal regions were divided into two semicircles. Each semicircle was treated using one of the methods by means of simple randomization. Therapeutic sessions were repeated until all clinical signs of infection by HPV were eliminated. The patients were evaluated according to several variables like the genotype of HPV, HIV infection, oncological potential per genotype, oncotic cytology and histology.

Results:

Among all the variables studied, only immunosuppression due to HIV influenced the results, specifically when the fulguration method was used. There was no significant difference in effectiveness between argon and fulguration based on lesion relapse (p > 0.05). However, among HIV-positive patients, fulguration presented worse results, with a significant difference (p = 0.01).

Conclusion:

Regarding treatment of anal and perianal condylomata acuminata, comparison between applying fulguration and argon demonstrated that these methods were equivalent, but use of fulguration presented more relapses among HIV-positive patients.

Preinvasive diseases of the cervix, vulva, and vagina

OBJECTIVES

To discuss the epidemiology, treatment, and psychosocial implications of preinvasive disease of the lower genital tract.

DATA SOURCES

Review articles, research studies, and government publications.

CONCLUSIONS

Routine cervical cytology has been one of the most successful public health screening programs accomplished over the last 50 years. However, our success has plateaued. The focus now is to address existing barriers to screening and treatment, and to develop an effective triage protocol for the management of abnormal cervical cytology. IMPLICATIONS FOR NURSING CARE: Nurses as patient advocates are best prepared to meet the culturally sensitive, financially, and geographical challenges of addressing barriers to screening and treatment.

Clinical approach to dyspareunia

Dyspareunia needs to be addressed from an integrated patient-centered perspective. This review analyzes the organic causes of pain during intercourse. Factors that are often underevaluated in the clinical setting include hormonal, inflammatory, muscular, iatrogenic, neurologic, vascular, connective, and immunitary causes. Psychosexual factors, such as vaginismus, loss of libido, arousal disorders and sexual pain-related disorders, often overlap. A preliminary clinical approach aimed at integrating different biological and psychosexual etiologies in a comprehensive manner is discussed in this article.

Vulvodynia: the challenge of "unexplained" genital pain

Vulvodynia is a clinical syndrome that may include unexplained vulvar pain, sexual dysfunction, and psychological disability. It is a multifactorial syndrome that should be diagnosed, if possible, with an intradisciplinary approach. This article discusses the diagnosis and treatment of vulvodynia, starting with a summary of the complex nervous system within the pelvis. Different clinical pictures and different subtypes of the syndrome have been described in order to identify the etiologic aspects that are essential for diagnosis and subsequent treatment. Clinical evaluation should stress attention to detailed "pain-mapping" and evaluation of past and present history. The gynecological examination should be an overall patient evaluation, incorporating global physical impression, change in posture due to pain and careful examination of the pelvic floor. Examination of the pelvic floor is frequently omitted. Leading to an incorrect diagnosis of psychogenic pain. Such a misdiagnosis can result in the dismissal of appropriate treatment. Proper evaluation requires a comprehensive, multidisciplinary approach that includes medical, rehabilitative, and psychological issues.

Viral sexually transmitted infections: current management strategies

Viral sexually transmitted infections are a major health problem associated with considerable morbidity. This article reviews the current strategies used in the management of infections such as genital warts, genital herpes and molluscum contagiosum. Pros and cons of different treatment regimens have been discussed with an emphasis on a selective approach to therapy. The importance of education, counselling and follow-up is highlighted and issues relating to the associated psychosexual morbidity have been addressed. Treatment of these infections in pregnancy and HIV has also been described.

Local and distant skin flaps in the reconstruction of vulvar deformities

OBJECTIVES

The purpose of this study was to evaluate the safety and efficacy of skin flaps in vulvar reconstructive surgery.

STUDY DESIGN

A retrospective review was performed on 207 consecutive flaps on 191 assessable women referred between 1992 and 1996. Outcome measures were wound closure, healing, restoration of coital function, and final result after any secondary revision.

RESULTS

Primary closure without tension was possible in all but one instance, and 186 (89.9%) wounds healed by primary intention. Of 146 contractures, 95.8% were reparable by simple sliding flaps (YV advancement or "maple leaf"). Conversely, all the 99 tissue deficits required a pivoting design (random transposition, Martius, pudendal thigh, and gracilis or gluteus myocutaneous flaps). Primary success rates decreased sharply with worsening deformity, underlying disease, and complexity of flap design. There were 65 complications among 42 individuals, and 21 women required subsequent Z plasty or a second flap. Nonetheless, disease was cured and function restored in 178 (93.2%) patients.

CONCLUSIONS

Sliding or pivoting vulvar flaps are generally reliable. Complex flaps are more difficult, but there are seldom any simpler surgical options.