Crohn's disease of the vulva

Clitoral Abscess: A Case Report Highlighting an Uncommon Source of Gynecological Emergency

Clitoral abscess is a rare gynecological condition with limited literature reports. This case report aimed to contribute to the understanding and management of clitoral abscesses, particularly in cases without identifiable causes. A 26-year-old sexually active woman with no significant medical history presented with severe perineal pain originating specifically in the clitoral region. The onset of symptoms, characterized by pulsatile perineal pain worsening over several days, was localized to the clitoris. Clinical examination indicated a clitoral abscess, confirmed through surgical incision and drainage. The medical treatment consisted of the administration of oral analgesics, flucloxacillin at a dose of 500 mg for seven days, and non-steroidal anti-inflammatory agents. The procedure preserved the dorsal artery of the clitoris, with bacteriological analysis revealing polymicrobial organisms. Post surgery, the patient recovered fully with no complications. By sharing details about this unusual clinical case and its effective treatment, we contribute to advancing the collective knowledge in the field. This dissemination supports a deeper understanding and facilitates informed decision-making for healthcare professionals.

Successful multidisciplinary treatment of the rare pathology of vulvar Crohn's disease

A woman in her 50s with a medical history of rheumatoid arthritis (RA) and hypothyroidism presented with 3 months of vaginal pain and swelling. Physical examination showed vulvar oedema and erythema, ulcerations of the inferior vulva that extended to the buttocks and introitus with erythema and superficial erosions. MR pelvis showed a fibroid in the uterus but otherwise was unremarkable. Biopsies of the vagina showed extensive acute and chronic inflammation, necrosis and granulomas without concern for malignancy, which was consistent with a diagnosis of cutaneous Crohn's disease. MR enterography, upper endoscopy and colonoscopy revealed no gastrointestinal manifestations of Crohn's. She was treated initially with corticosteroids and metronidazole as well as vulvectomy and graft placement. Azathioprine was added to her regimen due to lack of response; however, despite 6 weeks of this therapy, the ulcerations did not heal thus infliximab was initiated. After 8 weeks the lesions had completely resolved.

Granulomatous myopathy: Sarcoidosis and beyond

Non-necrotizing granulomatous inflammation is a rare but easily recognized histopathological finding in skeletal muscle biopsy. A limited number of diseases are known to be associated with non-necrotizing granulomatous myopathy. Once identified, a careful evaluation for evidence of extramuscular granulomatosis and other signs suggestive of sarcoidosis is warranted as about half of the patients have sarcoid myopathy. In addition, the presence of granulomatous myopathy should trigger a search for clinical and pathological clues of inclusion body myositis (IBM), which accounts for most of the remaining patients and can coexist with sarcoidosis. Recognizing the features of IBM in patients with granulomatous myopathy can potentially spare the patients from unnecessary exposure to immunosuppressive therapies. In patients whose granulomatous myopathy remain unexplained, further investigations should aim at identifying myasthenia gravis and other autoimmune disorders, especially those known to cause granulomatous inflammation in other organs. Laboratory investigations should include acetylcholine receptor, antimitochondrial, antineutrophil cytoplasmic, thyroglobulin, and thyroid peroxidase autoantibodies. In the appropriate clinical context, exposure to immune checkpoint inhibitors and chronic graft-vs-host disease can be causes of granulomatous myopathy. In cases of unexplained granulomatous myopathy, natural killer/T-cell lymphoma should be considered and careful histopathological examination for atypical cells and appropriate immunostaining is crucial. Identifying the etiology of granulomatous myopathy in each patient can guide appropriate treatment.

Metastatic Vulval Crohn's Disease With Good Outcome on Ustekinumab

Vulval Crohn’s disease is a rare manifestation of Crohn’s disease. Although it is usually caused by a fistulating process, it may be a result of a metastatic disease process as well, the exact mechanisms of which are not well understood yet. Vulval Crohn’s disease may occur before the onset of bowel symptoms and may continue to be active while bowel symptoms are quiescent. Coupled with the fact that most vulval Crohn’s lesions are similar to other disease processes, it can prove to be a diagnostic challenge. Due to its rarity, no guidelines for treatment exist; however, most reports agree that when symptoms are not controlled with antibiotics and topical steroids, immunosuppressive medications such as oral steroids and biological agents are the way forward. Although surgery may be an option, data suggest that its use is scarce. We report the case of a 47-year-old Caucasian woman with bilateral metastatic vulval Crohn’s disease from a district hospital in the United Kingdom who responded well to ustekinumab. This is one of the first few cases reporting good clinical outcomes with the agent.

Association Between Vulvovaginal Discomfort and Activity of Inflammatory Bowel Diseases

BACKGROUND & AIMS

Inflammatory bowel diseases (IBD) affect 200-400 people per 100,000 in the United States, about half of whom are women. We aimed to define the prevalence of vulvovaginal symptoms and association with IBD activity in a large cohort of women.

METHODS

Women more than 18 years old with IBD (1250) completed an online survey querying the presence and severity of vulvar or vaginal itch, burn, or irritation, vaginal discharge or dryness, and vulvovaginal pain. The survey collected information on demographic features and IBD activity (categorized using the Manitoba index). Women with and without symptoms were compared using bivariate analyses. Logistic regression evaluated associations between IBD severity and vulvovaginal symptoms, adjusted for diagnosis, menopause, smoking, depression, and use of medications to treat IBD.

RESULTS

A total of 512 (41%) women reported at least 1 moderate-severe vulvovaginal symptom. All vulvovaginal symptoms except vaginal dryness were more common in women with active IBD. In a multivariate model controlled for menopause, smoking, t-score from the PROMIS depression instrument, and use of IBD medications, women with constant or frequent active IBD, based on Manitoba index scores, had increased odds for moderate-severe vulvovaginal symptoms (odds ratio, 1.68; 95% CI, 1.22-2.32) compared to women in remission. Vulvovaginal discomfort frequently or always decreased interest in sex (n=336; 28%) or ability to have sex (n=207; 16%).

CONCLUSIONS

In an online survey of 1250 women, we found that women with more active IBD have increased prevalence of vulvovaginal discomfort, compared to women in remission. These symptoms affect sexual health.

Crohn's disease of the vulva

Crohn's disease (CD) of the vulva is a rare, yet under recognized condition. Fistulae arising from the digestive tract account for the greater part of genital lesions in CD. However, cutaneous so-called metastatic lesions of the vulva have been reported in the literature. They are clinically challenging for gastroenterologists as well as for gynecologists, with numerous differential diagnoses, especially among venereal diseases, and require a multidisciplinary approach. The most frequently observed features of the disease are labial swelling, vulvar ulcers, and hypertrophic lesions. Biopsy samples for histological study are mandatory, in order to establish the diagnosis of vulvar CD. Treatment options include oral prolonged courses of metronidazole and systemic immunosuppressive therapy such as corticosteroids and azathioprine, with promising data published on the efficacy of infliximab. Surgery remains restricted to medical treatment failures or resection of unsightly lesions. Prospective studies or case series with long follow-up data are still missing to guide the treatment of this condition.

Gynecologic rarities: a case of periclitoral abscess and review of the literature

Periclitoral abscess is a rare entity, with publications limited to case reports. We present here a case of periclitoral abscess in a 17 year old patient, which was treated with incision and drainage. We also review all the similar cases that have been reported in the English literature until now.

Granulomatous lymphangitis of the scrotum and penis. Report of a case and review of the literature of genital swelling with sarcoidal granulomatous inflammation

BACKGROUND

Acquired lymphedema of the genitalia is a rare childhood presentation and is more common in elderly individuals secondary to pelvic/abdomenal malignancy or its therapy or worldwide due to filariasis.

OBJECTIVE

Herein, we report a case of a healthy 11-year-old boy who presented with a 1-year history of chronic, asymptomatic scrotal and penile swelling. Biopsy revealed edema, lymphangiectases and peri- and intralymphatic sarcoidal type granulomas. This histologic pattern of granulomatous lymphangitis is most commonly associated with orofacial granulomatosis (granulomatous cheilitis and Melkersson-Rosenthal syndrome) and Crohn's disease. Treatment with topical steroids and physical support has resulted in marked improvement. No systemic disease (Crohn's disease) is evident 1 year later. Literature review revealed 44 cases of genital lymphedema with non-infectious granulomas. The majority of these young patients had Crohn's disease, frequently with anal involvement and a minority, both with and without Crohn's disease, had orofacial granulomatosis.

CONCLUSIONS

Granulomatous lymphangitis should be considered in the differential diagnosis of chronic idiopathic swelling of the genitalia, particularly in younger individuals. Further clinical examination, additional laboratory studies and close follow-up for co-existing or subsequent development of Crohn's disease should be performed. The overlap between granulomatous lymphangitis of the genitalia, Crohn's disease and orofacial granulomatosis suggest that granulomatous lymphangitis of the genitalia may represent a forme fruste of Crohn's disease.

Anovestibular fistula to Bartholin's gland

BACKGROUND

Acquired fistulation from the anal canal to Bartholin's gland has not been reported before. This fistula has been identified in 11 women treated between 1991 and 1995.

METHODS

All discharge diagnoses during this period were searched. The clinical records of patients managed for this diagnosis were reviewed.

RESULTS

Eleven women aged 24-49 years were identified. Seven of 11 fistulas arose in association with inflammatory bowel disease (five Crohn's disease, two ulcerative colitis). Patients typically presented with the vulval passage of flatus and faeces or acute sepsis of Bartholin's gland. Time to diagnosis of the fistula ranged from 1 to 15 (median 8) months after the onset of symptoms. Anatomically, all fistulas were high trans-sphincteric or suprasphincteric. All eight fistulas for which repair was attempted (five in the presence of inflammatory bowel disease) remain healed at short-term follow-up. Proctocolectomy was undertaken in two patients with severe Crohn's colitis.

CONCLUSION

Ano-Bartholin's fistulas, although rare in general surgical practice, present with troublesome symptoms and may be repaired successfully. Gynaecologists and surgeons should be aware of this clinical entity to avoid unnecessary delays in treatment.

Cutaneous Crohn's disease in children

BACKGROUND

Although cutaneous Crohn's disease is well recognized in adults, in children it is extremely rare.

OBJECTIVE

Our purpose was to describe five children with cutaneous Crohn's disease and to review the literature.

METHODS

The medical records of five children with cutaneous Crohn's disease were retrospectively reviewed for clinical features and laboratory data. An extensive review of the literature was conducted.

RESULTS

Five children, one boy and four girls, 6 to 12 years of age at onset, had cutaneous manifestations of Crohn's disease. Three had genital swelling, and the other 2 had buttock abscesses. Most were seen before the diagnosis of gastrointestinal Crohn's disease was made. There have been 80 cases of cutaneous Crohn's disease described, including our series. Only 14 were in children. Two thirds of children with cutaneous Crohn's disease had genital involvement compared with about half of the adult cases. Sixteen of the 80 patients had cutaneous lesions without preceding gastrointestinal Crohn's disease. Of these, approximately 70% had genital lesions.

CONCLUSION

Although Crohn's disease is common in children, cutaneous manifestations are rarely a presenting sign. However, when cutaneous Crohn's disease is present in children, it commonly precedes the gastrointestinal disease.

Vulval Crohn's disease: difficulties in diagnosis

Four patients with chronic vulval inflammation are described. The histological features of non-caseating granulomata and multinucleated giant cells are compatible with Crohn's disease, but only two patients had proven gastrointestinal involvement. The clinical and histological characteristics of Crohn's disease and other granulomatous inflammations of the vulva are discussed and the literature is reviewed.

Metastatic Crohn's disease responding to metronidazole

Metastatic Crohn's disease is a rare cutaneous manifestation of intestinal Crohn's disease, for which existing treatment is unsatisfactory. We report a case of perianal and vulval Crohn's disease which cleared completely on a 4-month course of metronidazole without adverse effects. The patient remained in remission I year later. The merits of long-term treatment with metronidazole are discussed.

Crohn's disease of the vulva--two further cases

Crohn's disease of the vulva is a rare disease, only eight cases having been described in the literature (Parks, Morson & Pegum, 1965; Mountain, 1970; Ansell & Hogbin, 1973; Devroede et al., 1975; Kao, Paulson & Askin, 1975; Levine, Barton & Grier, 1982). Two additional cases are presented, one of whom is the sixth reported with metastatic Crohn's disease of the vulva.

Small erythematous mucosal plaques: an endoscopic sign of Crohn's disease

A non-ulcerated granulomatous lesion of the large bowel mucosa has been found in 11 patients, nine of whom already had or eventually developed classical features of Crohn's disease. These lesions, which are multiple, consist of small well-circumscribed raised erythematous plaques surrounded by normal mucosa. At biopsy there is focal haemorrhage of the lamina propria, rupture of the crypts, release of mucus, and frank granulomatous reaction with giant cell formation. The lesion may be reversible or be followed by the classical mucosal ulcerations. They may occur in the presence or the absence of classical lesions of Crohn's disease elsewhere in the gastrointestinal tract. As this non-ulcerated lesion may occur in isolation, it may provide the initial clue to the diagnosis of Crohn's disease.