Rates of self-reported urinary, gastrointestinal, and pain comorbidities in women with vulvar lichen sclerosus

EuroGuiderm guideline on lichen sclerosus-introduction into lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness. It may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are redness and oedema, typically followed by whitening of the genital skin; sometimes fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS, highlight important aspects in the care of LS patients (part 1), generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

EuroGuiderm guideline on lichen sclerosus-Treatment of lichen sclerosus

INTRODUCTION

Lichen sclerosus (LS) is an inflammatory skin disease affecting all ages. LS typically involves the anogenital site where it causes itching and soreness; it may lead to sexual and urinary dysfunction in females and males; however, it may be asymptomatic. First signs of LS are usually a whitening of the genital skin, sometimes preceded by redness and oedema; fissuring, scarring, shrinkage and fusion of structures may follow in its course. LS is associated with an increased risk of genital cancer. LS has a huge impact on the quality of life of affected patients, and it is important to raise more awareness of this not uncommon disease in order to diagnose and treat it early.

OBJECTIVES

The guideline intends to provide guidance on the diagnostic of LS (part 1), highlight important aspects in the care of LS patients, generate recommendations and treatment algorithms (part 2) on topical, interventional and surgical therapy, based on the latest evidence, provide guidance in the management of LS patients during pregnancy, provide guidance for the follow-up of patients with LS and inform about new developments and potential research aspects.

MATERIALS AND METHODS

The guideline was developed in accordance with the EuroGuiDerm Methods Manual v1.3 https://www.edf.one/de/home/Guidelines/EDF-EuroGuiDerm.html. The wording of the recommendations was standardized (as suggested by the GRADE Working Group). The guideline development group is comprised of 34 experts from 16 countries, including 5 patient representatives.

RESULTS

Ultrapotent or potent topical corticosteroids in females and males, adults and children remain gold standard of care for genital LS; co-treatment with emollients is recommended. If standard treatment fails in males, a surgical intervention is recommended, complete circumcision may cure LS in males. UV light treatment is recommended for extragenital LS; however, there is limited scientific evidence. Topical calcineurin inhibitors are second line treatment. Laser treatment, using various wave lengths, is under investigation, and it can currently not be recommended for the treatment of LS. Treatment with biologics is only reported in single cases.

CONCLUSIONS

LS has to be diagnosed and treated as early as possible in order to minimize sequelae like scarring and cancer development. Topical potent and ultrapotent corticosteroids are the gold standard of care; genital LS is often a lifelong disease and needs to be treated long-term.

Risk Factors for Lichen Sclerosus: A Case-Control Study of 43,000 Finnish Women

OBJECTIVES

Lichen sclerosus (LS) is an inflammatory skin disease probably arising from an interplay of genetics, local irritation, and autoimmune processes. We identified potential risk factors for the disease using data from nationwide Finnish registries.

METHODS

We identified all women diagnosed with LS within specialized health care during 1998-2016 (n = 10,692) and selected 3 age-matched population control women for each case. We calculated odds ratios (ORs) for possible risk factors using conditional logistic regression.

RESULTS

Dermatological autoimmune conditions were strongly associated with LS (OR = 15.1, 95% confidence interval [CI] = 13.6-16.7 for morphea; OR = 10.3, 95% CI = 5.02-19.0 for lichen planus; OR = 6.86, 95% CI = 5.65-8.33 for alopecia; OR = 2.20, 95% CI = 1.88-2.56 for vitiligo). A diagnosis of Crohn or celiac disease increased the odds of LS (OR = 1.80, 95% CI = 1.71-1.89; OR = 1.49, 95% CI = 1.28-1.73, respectively) as did urge and stress incontinence (OR = 1.79, 95% CI = 1.71-1.87; OR = 1.28, 95% CI = 1.22-1.35, respectively).The odds of LS were lower in women after a diagnosis of type 1 diabetes (OR = 0.43, 95% CI = 0.41-0.45), coronary artery disease (OR = 0.41, 95% CI = 0.38-0.43), and rheumatoid arthritis (OR = 0.38, 95% CI = 0.36-0.41).Parous women had higher odds of LS (OR = 1.11, 95% CI = 1.04-1.17) than nulliparous ones, but increasing number of births decreased the risk. Lichen sclerosus was not associated with socioeconomic status nor the urbanicity level of the place of residence.

CONCLUSIONS

Certain autoimmune diseases and urinary incontinence were associated with LS.

Comorbidity of Urogynecological and Gastrointestinal Disorders in Female Patients With Lichen Sclerosus

OBJECTIVE

Lichen sclerosus (LS) is a chronic inflammatory disease with a significant impact on quality of life. The aim of this cross-sectional case-control study was to characterize concomitant urogynecological and gastrointestinal disorders in female patients with LS.

METHODS

A medical records search between 2004 and 2012 yielded 455 women and girls (mean age 64 years) with LS. The study cohort was compared with a 10-fold age- and sex-matched control cohort. Gynecological cancers and their precursors; gynecological, urinary, and gastrointestinal disorders; and pain syndromes were evaluated.

RESULTS

The well-known association between LS and increased risk of vulvar cancer and its precursors was also found in our study (relative risk [RR] = 100.0; p < .001 and high-grade squamous intraepithelial lesions RR = 110.0; p < .001, respectively), but we also found an increased risk for cervical cancer (RR = 6.0; p = .005) and endometrial cancer (RR = 2.9; p < .001). Gynecological pain syndromes such as dyspareunia (RR = 20.0; p < .001) and interstitial cystitis (RR = 5.0; p < .001) and urinary incontinence (RR = 4.8; p < .001) were also increased. Among gastrointestinal disorders, we found increased risk for celiac disease (RR = 6.8; p < .001), diverticular intestine diseases (RR = 1.9; p < .001), functional intestinal disorders (RR = 2.3; p = .003), and anal and rectal fissures (RR = 2.4; p = .046).

CONCLUSIONS

We found that female patients with LS have an increased risk for gynecological cancers as well as for several urogynecological and gastrointestinal disorders. Increased awareness is required to identify and treat these concomitant disorders.

Evaluation of genital self-image and sexual dysfunction in women with vulvar lichen planus or lichen sclerosus

INTRODUCTION

Vulvar lichen planus (LP) and vulvar lichen sclerosus (LS) are chronic inflammatory diseases that affect women's sexual health. In this study, our aim was to investigate sexual function, anxiety level and genital self-image in vulvar LP and vulvar LS patients.

METHODS

This study was conducted on a total of 178 women who presented to the gynecology clinic between February 2019 and January 2020. The patients were divided into the following groups: group 1, vulvar LP (n = 21); group 2, vulvar LS (n = 59); group 3, fungal vulvitis controls (n = 48); and group 4, healthy controls (n = 50). The validated Female Sexual Function Index (FSFI), Beck Anxiety Index (BAI), and Female Genital Self-Image Scale (FGSIS) questionnaires were assessed in all women.

RESULTS

There were no significant differences among the groups with respect to age, parity, menopausal status, body mass index (BMI), vaginal intercourse past 1 month, marital status or educational status (p > .05). There were statistically significant differences between the vulvar LP and vulvar LS groups compared to control groups in terms of FSFI total scores and subscores (p < .001). When FGSIS and BAI scores were analyzed, significant statistical differences were found among the study groups (p < .001). A positive correlation was found between the FSFI and FGSIS scores in patients with vulvar LP and LS. Additionally, a negative correlation was found between the FSFI and BAI scores in patients with vulvar LP and LS.

CONCLUSIONS

Our study showed that sexual function, genital self-image and anxiety level were associated in vulvar LP and vulvar LS patients. Vulvar LP and vulvar LS patients with worse genital self-image have more sexual problems and anxious conditions.

Characteristics Among Premenarchal Girls With Lichen Sclerosus

OBJECTIVES

Lichen sclerosus (LS), a chronic inflammatory dermatosis localized in the anogenital region, is known to be associated with lower urinary tract symptoms (LUTS) in postmenopausal women; however, there is a paucity of data on prepubertal girls. We sought to characterize the relationship between LS, LUTS, and constipation among premenarchal girls.

MATERIALS AND METHODS

We conducted a retrospective chart review of premenarchal girls presenting at the pediatric adolescent gynecology and pediatric urology clinics at our institution diagnosed with vulvar LS during a 4-year period. Demographics, clinical presentation, time from onset of urinary and/or bowel symptoms to LS diagnosis, and treatment response were assessed. Analysis was completed using median, range, and nonparametric statistical analysis where appropriate.

RESULTS

Nineteen premenarchal girls with LS met inclusion criteria. The median age at LS diagnosis was 6.2 years (range = 3.3-13.3 yrs). Most girls (12/19, 63.2%) presented with LUTS during LS evaluation, and 11 (57.9%) of 19 patients had constipation. Pruritus and hypopigmentation were the most frequently encountered LS symptom and sign, respectively. Fourteen (73.7%) of the 19 girls had resolution/improvement of LS symptoms after LS treatment. Of the 12 patients with LUTS, 7 (58.3%) had resolution/improvement of LUTS symptoms, 3 (25.0%) had unchanged voiding symptoms, and 2 (16.7%) had unknown changes.

CONCLUSIONS

Although further studies are needed to better characterize the relationship between LUTS, constipation, and LS, our findings suggest that premenarchal subjects presenting with LUTS should be assessed for LS. Likewise, patients presenting with LS should be assessed for LUTS and constipation.

Is urinary incontinence associated with lichen sclerosus in females? A systematic review and meta‐analysis

Background

Lichen sclerosus (LS) is a scarring chronic inflammatory disease with a predilection for genital skin in both sexes. The aetiology of LS is controversial, but evidence increasingly suggests that the occluded exposure of susceptible epithelium to urine is involved in the pathogenesis of genital LS in males. This theory has not yet been robustly investigated in females.

Objectives

This review and meta‐analysis examined whether there is an association between urinary incontinence (UI) and genital lichen LS in females.

Methods

We performed a comprehensive search of MEDLINE, Embase and CINAHL to identify observational studies assessing the prevalence of UI in females with LS. DerSimonian and Laird random‐effects models were used to estimate the overall pooled prevalence and risk ratio compared to controls. Heterogeneity was assessed.

Results

In total, eight studies met the inclusion criteria and five studies were included in a meta‐analysis. Three studies were graded as moderate quality and five were poor. The pooled prevalence for UI in LS was 0.35 (95% confidence interval [CI] 0.13–0.58, I² = 98.4%). The risk ratio of UI in LS was 0.97 (95% CI 0.53–1.75, I² = 87.5%).

Conclusion

There appears to be no difference between patients with LS and those without LS in terms of UI. Studies are limited by clinical and methodological quality and heterogeneity is high. Well‐designed prospective studies are needed.

The prevalence of self-reported medical comorbidities in patients with vulvar lichen sclerosus: A single-center retrospective study

OBJECTIVE

To compare the demographics and self-reported medical comorbidities of patients with vulvar lichen sclerosus (VLS) with those of women with other vulvar conditions.

METHODS

Intake questionnaires for patients presenting to the University of Michigan Center for Vulvar Diseases between 1996 and 2019 were entered into a de-identified database (n = 1983). Responses to questions about thyroid disease, urinary symptoms and signs, gastrointestinal conditions, and pain conditions were collected.

RESULTS

A total of 1983 women, including 865 patients with VLS and 1118 patients without VLS were enrolled. Pearson's χ² analysis showed that age, hypertension, anorectal fissures, peptic ulcer disease/gastroesophageal reflux disease, urinary incontinence, fibromyalgia, thyroid disease, kidney problems, liver problems, and cancer were significantly associated with VLS when compared between the VLS and non-VLS groups (P < 0.01). However, multiple regression analysis demonstrated that only age, thyroid disease, and anorectal fissures were strongly associated with VLS (P < 0.01).

CONCLUSION

Increasing age, thyroid disease, and anorectal fissures were significantly associated with VLS. The association between anorectal fissures and VLS likely represents a sequela of the disease rather than a true comorbidity.

Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review

Objective. Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. With numerous controversies as regards to the nomenclature, diagnosis and its association with neoplastic conditions, we decided to conduct a scoping review on this subject. Data Source. A review protocol was developed, and the Knowledge Resource Services website was used to do a search of articles pertaining to VLS with keywords “Vulvar,” “Vulval,” “diagnosis,” “lichen sclerosus et atrophicus,” “kraurosis,” “vulvar dystrophy,” and “Lichen Sclerosus”. Study Selection. The search was limited to published data from the last ten years, i.e., from July 2009 onwards and in the English language. A total of 338 articles pertaining to VLS were obtained. Older data were accessed if particular information was sought for. Results & Conclusion. The presentation is bimodal, i.e., one in prepubertal girls (average age: 7.6 years) and the other in peri- and postmenopausal women (average age: 52.6 years). However, many cases also present during reproductive years. Studies suggest a multifactorial origin as far as etiology is concerned, including a genetic, autoimmune, hormonal, and local infectious background. It affects the genital labial, perineal, and perianal areas and manifests as a patchy, thin, glistening, ivory-white area. Diagnosis is mainly based on clinical features. Biopsy is seldom required. It has been well established as a precursor lesion of dVIN and vulvar carcinoma.

Comparison of Serum Vitamin D Levels in Relation to Bowel and Bladder Symptoms in Women with Vulvar Diseases

Objectives: We sought to investigate associations between vitamin D levels and bowel and bladder disorders in women with vulvar diseases. Methods: This is a planned sub-analysis of a cross-sectional study comparing the prevalence of bowel and bladder symptoms in women with biopsy-proven vulvar lichen sclerosus (LS) to a control group of women with non-lichenoid vulvar diseases. All subjects were recruited from a tertiary referral vulvar care clinic in a university-based practice. Serum vitamin D levels were measured and subjects self-completed questionnaires during study recruitment. Pelvic floor disorders were determined from the following questionnaires: Rome III Functional Bowel Disorders Questionnaire, the Bristol stool scale, the Medical, Social and Epidemiologic Aspects of Aging Questionnaire, and the Overactive Bladder-8 Question Version. Results: 181 women with vulvar diseases were included: 88 with LS and 93 with non-LS vulvar diseases. The mean age was 52.5 ± 15.3 years, and 94.5% were Caucasian. Vitamin D levels (26.8 ± 13.1 vs 29.5 ± 19.0 ng/mL), prevalence of low vitamin D levels (51.1% vs 45.2%), and vitamin D supplementation (42.0% vs 47.8%) were similar in women with and without LS (p ≥ 0.27). These factors did not differ between women with and without overactive bladder (OAB) (vitamin D levels 30.1 ± 17.8 vs 26.3 ± 14.8 ng/mL), urinary incontinence (27.9 ± 15.2 vs 26.4 ± 11.0 ng/mL), constipation (26.7 ± 14.8 vs 28.5 ± 16.8 ng/mL), or irritable bowel syndrome (IBS) (30.8 ± 22.1 vs 27.6 ± 13.4 ng/mL). Conclusions: In this cohort of women with vulvar diseases, vitamin D levels and supplementation were not significantly different amongst women with vulvar lichen sclerosus or other non-lichenoid vulvar diseases. Furthermore, vitamin D levels are not serum biomarkers for OAB, urinary incontinence, constipation, or IBS.

Lower Urinary Tract Symptoms in a Chronic Pelvic Pain Population

OBJECTIVES

This study aimed to characterize the prevalence of lower urinary tract symptoms in a chronic pain population.

METHODS

In this observational cohort study, patients referred to a female pelvic pain clinic completed several validated questionnaires assessing bladder symptoms, central sensitization, pain symptoms, depression, anxiety, and neuropathic pain. Patients diagnosed as having interstitial cystitis were excluded. Patient demographic characteristics and survey responses were compared across American Urological Association Symptom Index (AUA-SI) severity categories. Multivariable logistic regression was performed to identify independent predictors of moderate-to-severe AUA-SI scores.

RESULTS

A total of 177 patients were included in the analysis. American Urological Association Symptom Index data showed that 48.8% of patients had mild, 31.2% had moderate, and 20.0% had severe symptoms. Patients reporting moderate or severe AUA-SI scores had higher mean Central Sensitization Inventory (CSI) scores (46.7 ± 16.0 vs 32.9 ± 13.8, P < 0.0001), McGill scores (median, 25 [interquartile range, 16-38] vs 13 [5-27]; P = 0.0003), Patient-Reported Outcomes Measurement Information System depression T-scores (median, 53.9 [interquartile range, 46.2-61.6] vs 51.2 [37.1-55.3]; P = 0.009), Pelvic Pain and Urgency/Frequency Symptoms Scale scores (18.4 ± 6.2 vs 12.5 ± 5.4, P < 0.0001), and Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs scores (median, 10.5 [interquartile range, 3.0-16.5] vs 6.0 [1.0-12.0]; P = 0.02). The odds of moderate-to-severe AUA-SI symptoms were higher with a positive PUF and CSI score and were lower with a diagnosis of vestibular pain.

CONCLUSIONS

There is a high prevalence of lower urinary tract symptoms among patients with chronic pelvic pain. Vestibulodynia was associated with lower odds of bladder symptoms. High PUF and CSI scores were significantly associated with moderate-to-severe bladder symptoms.

The Gastrointestinal Pain Pointer: A Valid and Innovative Method to Assess Gastrointestinal Symptoms

Abdominal pain is a chronic condition experienced by approximately 20% of individuals in the United States. The purpose of the study was to assess the validity of the Gastrointestinal Pain Pointer as a measure of abdominal pain intensity. A prospective longitudinal time-series study design was utilized. The sample included 93 outpatients (58.1% female). Participants met Rome III criteria for irritable bowel syndrome (n = 32) or were healthy controls (n = 61). The Gastrointestinal Pain Pointer, a new electronic pain assessment tool, was used to assess self-reported abdominal pain intensity among participants before and after ingestion of an intestinal permeability test solution across 11 time points over a 5-hour time period. The results were compared with the Short-Form McGill Pain Questionnaire. The Gastrointestinal Pain Pointer was found to be valid in the assessment of abdominal pain intensity. The tool is a novel and valid measure of abdominal pain intensity that enhances the ability for clinicians to better quantify, in real time, patient-related pain outcomes for both clinical care and research.

Anti-Inflammatory and Tissue Regenerative Effects of Topical Treatment with Ozonated Olive Oil/Vitamin E Acetate in Balanitis Xerotica Obliterans

Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder, considered the male genital variant of lichen sclerosus. Anti-inflammatory drugs are commonly used in BXO. We evaluated the effects of an innovative formulation of ozonated olive oil with vitamin E acetate (OZOILE®) on the inflammatory status and tissue remodeling in male children with BXO. The mRNA transcripts of proteins involved either in inflammation or in dynamics of tissue regeneration were analyzed by quantitative real-time PCR, in foreskins affected by BXO removed from patients untreated or treated with OZOILE® cream for 7 days before circumcision. We found a significant reduction in mRNA levels of IL-1β, TNF-α, INF-γ, transglutaminase 2 and NOS2 in foreskins treated with OZOILE® in comparison to untreated ones (p < 0.001). No significant differences were observed in NF-κB activation in the specimens obtained from treated and untreated patients. Hence, OZOILE® treatment up-regulated hypoxia-inducible factor (HIF)-1alpha, vascular endothelial growth factor (VEGF) and E-cadherin gene expression (p < 0.001). The treatment with OZOILE® showed effective results in children affected by BXO by reducing the inflammatory process and stimulating mechanisms for tissue regeneration of the foreskin. A randomized clinical trial on a large number of children affected by BXO might be useful to verify the efficacy of topical treatment with OZOILE®.

New insights into potential risk factors and associations in genital lichen sclerosus: Data from a multicentre Italian study on 729 consecutive cases

BACKGROUND

Limited data are available on risk factors associated with lichen sclerosus and no data are available on gender differences in genital lichen sclerosus (GLS).

OBJECTIVE

This multicentre study aimed at identifying potential risk factors for GLS, through data collection from a large, mixed-sex sample of patients comparing gender-related differences in relation to data from the general population.

METHODS

This was a cross-sectional study on 729 subjects (53.8% females, 46.2% males) affected with GLS, consecutively observed within a network of 15 Italian dermatology units. The following information was collected: demographic data, anthropometric measures, comorbidities, family history of LS, clinical features and symptoms related to GLS.

RESULTS

Overweight and obesity, blood hypertension, hypothyroidism and an educational attainment equal or above upper secondary school level were more frequent among the study patients than among the general Italian population. Moreover, a family history of GLS was reported more frequently than expected among GLS patients. These factors were similar in males and females. The disease tended to occur later in females than in males.

CONCLUSIONS

Our findings suggest that metabolic factors, and possibly a sedentary lifestyle, may play a role in GLS pathogenesis in genetically predisposed patients, and that risk profile is similar in males and females despite some difference in the onset of symptoms.

Lower Urinary Tract and Functional Bowel Symptoms in Women With Vulvar Diseases and Controls

OBJECTIVES

This study aims to compare the prevalences of lower urinary tract symptoms (LUTS), irritable bowel syndrome (IBS) and constipation in women with vulvar diseases to those from the general population.

METHODS

Three groups of women were recruited from the University of Michigan Gynecology Clinics, women with: (1) biopsy proven lichen sclerosus (LS), (2) non-LS vulvar diseases (vulvar controls, VC), and (3) presenting for annual examinations (AE). All patients completed self-administered surveys and validated pelvic floor symptom questionnaires.

RESULTS

317 subjects were enrolled: 101 with LS, 86 VCs, and 130 AEs. Compared to women in the VC and AE groups, LS subjects were older and of higher parity, and also had a higher prevalence of overactive bladder and urinary incontinence. The IBS was more common in the LS and VC groups compared to the AE group but no difference in constipation was seen. Similar results were found when all women with vulvar disease (LS and VC) were compared to the AEs. Age (adjusted odds ratio [OR], 1.28; P = 0.003) and IBS (adjusted OR, 3.05; P < 0.001) were the 2 variables predictive of overactive bladder. Urinary incontinence was predicted by age (adjusted OR, 1.35; P = 0.002), vulvar disease categorization (adjusted OR, 2.31; P = 0.004) and IBS (adjusted OR, 4.51; P < 0.001).

CONCLUSIONS

We find a significantly greater prevalence of LUTS and IBS in women with vulvar disease compared to women presenting for annual gynecologic exams, but no difference in constipation. Similar rates of LUTS, IBS, and constipation were seen in women with LS and non-LS vulvar disease.

Responses to the McGill Pain Questionnaire predict neuropathic pain medication use in women in with vulvar lichen sclerosus

OBJECTIVE

The goal of this study was to test the hypothesis that responses to the McGill Pain Questionnaire are predictive of adjunctive neuropathic pain medication use by women with lichen sclerosus (LS).

MATERIALS AND METHODS

This is a retrospective chart review of 430 women with vulvar LS treated at a tertiary referral vulvar care clinic. Demographics, responses to the McGill Pain Questionnaire, and use of neuropathic pain medications were collected. Bivariate and multivariable logistic regression analyses were performed to identify factors significantly associated with use of neuropathic pain medications.

RESULTS

Of the 430 subjects, 119 (27.7%) used neuropathic pain medications for vulvar pain. Factors significantly associated with use of these medications include lower body mass index (odds ratio [OR] = 0.96, p = .02), non-White race (OR = 2.97, p = .05), and total McGill Pain Questionnaire score (OR = 1.05, p < .001).

CONCLUSIONS

Vulvar pain is a common presenting symptom in women with LS. Responses to the McGill Pain Questionnaire may be helpful in the long-term management of women with LS as a screen to identify those patients who might benefit from adjunctive neuropathic pain medication use.

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.

The co-occurrence of lichen sclerosus et atrophicus and celiac disease

A 53-year-old female patient was admitted to our clinic for generalized hypo/hyper-pigmented, partially firm and sclerotic plaques with undefined borders. As the skin biopsy taken from the lesion was compatible with lichen sclerosus et atrophicus (LSA), the patient was treated with ultraviolet A1 (UVA1) treatment. Upon follow-up, she developed abdominal pain and diarrhea. Further investigation (including endoscopic and laboratory tests) showed signs consistent with celiac disease. After 30 sessions of UVA1 treatment, the skin lesions partially regressed. We present this case because the co-occurrence of LSA and celiac disease is very rare.

The impact of vulvar lichen sclerosus on sexual dysfunction

BACKGROUND

Lichen sclerosus (LS) is a chronic inflammatory condition that is known to arise on the vulva. Many women with LS report vulvar pain, often affecting a patient's quality of life. In this study, the sexual function of LS patients, with and without pain, was compared to control populations.

MATERIALS AND METHODS

A case-control study to examine the relationship between LS and sexual dysfunction was conducted. A total of 335 women presenting to the gynecology clinic were included in the study: 197 women with biopsy confirmed LS were compared to two control groups (95 asymptomatic women were "healthy" controls and 43 women had vulvovaginal candidiasis) on self-reported current health complaints, medical and surgical history and current symptoms such as pain and itching, type and frequency of sexual activity, and satisfaction with sexual activity.

RESULTS

Women with LS reported less frequent sexual activity than healthy controls (p=0.007) and Candida controls (p=0.04). Currently sexually active women with LS were significantly less likely to report vaginal intercourse (71.6%) than healthy controls (89.0%, p=0.003) or Candida controls (100%, p=0.0003), even though similar proportions of all three groups reported that vaginal intercourse was important. Satisfaction towards the quality of current sexual activity was significantly lower among women with LS compared with both the healthy and Candida control groups. 23.7% of women with LS reported that sexual activity was rarely or never satisfactory as compared with 0% of healthy controls (p<0.0001) and 6.5% of Candida controls (p=0.03).

CONCLUSION

Women with LS have less frequent sexual activity and less satisfying sexual activity when compared with controls.

General health status and incidence of first-onset temporomandibular disorder: the OPPERA prospective cohort study

Temporomandibular disorder (TMD) overlaps with other health conditions, but no study has examined which of these conditions increase the risk of developing first-onset TMD. The authors prospectively evaluated the relationship between health status at enrollment and subsequent incidence of TMD in 2,722 men and women. Participants aged 18 to 44 years had no history of TMD and were clinically free of TMD when enrolled in 2006 to 2008 at 4 U.S. study sites in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) prospective cohort study. First-onset examiner-classified TMD developed in 260 people over a median 2.8 years of follow-up. Cox regression estimated the association between health conditions and TMD incidence while accounting for potential confounders. Incidence of first-onset TMD was 50% higher for people with low back pain (adjusted hazard ratio [AHR] = 1.50, 95% confidence limits [CLs]: 1.08, 2.10) and 75% higher for people with genital pain symptoms (AHR = 1.75, 95% CLs = 1.04, 2.93) than people without a history of these pain disorders. Digit ratio, a marker of intrauterine exposure to sex hormones, was significantly associated with TMD incidence. Other independent predictors of first-onset TMD were sleep disturbance and cigarette smoking. These findings reveal multiple influences of health status on incidence of first-onset TMD.

PERSPECTIVE

This article examines health conditions that commonly overlap with TMD to determine which ones predict first-onset TMD. A history of low back pain and genital pain conditions at baseline were important predictors. Novel findings were that disrupted sleep and conditions in utero may increase incidence of first-onset TMD.

Agents that act luminally to treat diarrhoea and constipation

Diarrhoea and constipation are common clinical complaints that negatively affect quality of life, reduce work productivity and lead to considerable health-care expenditure. A variety of therapies have been used to treat these conditions. Unlike drugs that require systemic absorption to exert their effects, luminally acting agents improve diarrhoea and constipation by altering intestinal and/or colonic motility, as well as mucosal absorption and secretion, through a variety of mechanisms. Examples of luminally acting agents for diarrhoea include peripherally acting opiate analogues, enkephalinase inhibitors, bile-acid binding agents, nonabsorbed antibiotics, probiotics, bismuth-containing compounds, berberine and agents with possible effects on intestinal secretion or permeability. Luminally acting drugs for constipation include bulking agents, surfactants, osmotics, stimulants, chloride-channel activators, probiotics, drugs that increase delivery of bile acids to the colon and natural therapies such as prunes and hemp seed extract. As the physiological effects of luminally acting drugs are largely confined to the gastrointestinal tract, these agents are unlikely to cause adverse effects outside of the gastrointestinal tract.