Determining the Cause of Vulvovaginal Symptoms

Cross-cultural adaptation and psychometric evaluation of the Brazilian Portuguese version of the Vulvovaginal Symptoms Questionnaire

OBJECTIVE

The aims of this study were to perform a cross-cultural adaptation of the Vulvovaginal Symptoms Questionnaire (VSQ) into Brazilian Portuguese (VSQ-Br) and evaluate its measurement properties (structural validity, construct validity, internal consistency, and reliability).

METHODS

Cross-cultural adaptation was conducted through the translation, synthesis, and back-translation of the VSQ-Br. Subsequently, 314 women completed the Pelvic Floor Impact Questionnaire, Pelvic Floor Disorders Inventory, Medical Outcomes Study 36-Item Short-Form Health Survey, and VSQ-Br. Seven to 10 days later, participants completed the VSQ-Br for the second time. Data were submitted for confirmatory factor analysis. Cronbach α was used to verify internal consistency, and construct validity was assessed using Pearson correlation coefficient ( r ). Reliability was calculated using the intraclass correlation coefficient.

RESULTS

Confirmatory factor analysis showed that the questions were grouped into four domains (symptoms, emotions, life impact, and sexual impact). The model showed good fit (>0.95). The Cronbach α in this study was 0.85, reflecting adequate internal consistency. Adequate reliability was confirmed, with an intraclass correlation coefficient total score of 0.80. The VSQ-Br had a weak correlation with the pelvic domain of the Pelvic Floor Disorders Inventory, the pelvic organ prolapse domain of the Pelvic Floor Impact Questionnaire, and pain, vitality, and the social aspect domains of the Medical Outcomes Study 36-Item Short-Form Health Survey.

CONCLUSIONS

The VSQ-Br was validated and had acceptable measurement properties for assessing vulvovaginal symptoms in Brazilian women.

Prevalence, Antifungal Susceptibility and Etiology of Vulvovaginal Candidiasis in Sub-Saharan Africa: A Systematic Review with Meta-analysis and Meta-regression

Vulvovaginal candidiasis (VVC) is a commonly occurring form of mucocutaneous candidiasis in women. The aim of this study was to comprehensively investigate the prevalence, antifungal susceptibility, and etiology of VVC in sub-Saharan Africa (SSA). A search of studies was conducted in seven online databases and the reference lists of selected studies. Observational studies published between January 2000, to July 2021, that met the eligibility criteria were included. Meta-analyses with random and fixed-effects model, and subgroup analyses were performed using STATA 16.0. A total of 41 studies including 15 723 participants were included in the meta-analyses. The pooled prevalence of VVC was 33% (95% Confidence Interval (CI): 28 - 38%, I2 = 98%, p < 0.001). Pregnant women had 6% higher odds of having VVC compared to non-pregnant women (Odds Ratio (OR): 1.06, 95% CI: 0.99 - 1.13, p = 0.107). The odds of diagnosing VVC were 40% higher in symptomatic patients than general study population (OR: 1.4, 95% CI: 1.3 - 1.5, p < 0.0001). In 17 studies, a total of 2112 isolates of Candida species were reported: 1514 (71.7%) C. albicans, 510 (24.1%) non-albicans Candida (NAC) species and 88 (4.2%) unidentified Candida spp. Of the NAC species detected, C. glabrata (40.9%, n = 209), C. krusei (21.2%, n = 108) and C. tropicalis (22.7%, n = 116) were the most common. Resistance to fluconazole in C. albicans using disc diffusion methods ranged from 6.8% in Cameroon to 53.7% in Ethiopia. One-third of women in SSA have VVC, mainly caused by C. albicans. Data on the susceptibility of the Candida isolates to commonly used antifungal agents is limited and warrants further research.

Profile of Nonvenereal Female Genital Dermatoses: A Cross-Sectional Study From Eastern India

OBJECTIVE

Nonvenereal genital dermatoses may be a reason for considerable concern to the patient and often pose diagnostic dilemma to the treating physicians. The objective of the present study was to find out the demographical and clinical profile of nonvenereal genital dermatoses including systemic comorbidities in a tertiary care hospital.

MATERIALS AND METHODS

This was an observational study, carried out at the outpatient department of dermatology of a tertiary care hospital of Eastern India over a period of 12 months. Female patients with genital lesions were included in the study after excluding venereal disease. Results were tabulated and analyzed.

RESULTS

A total of 189 female patients were evaluated having 39 different dermatoses. The age ranged from 2 months to 72 years with most patients belonged to the fourth decade and 70.4% patients were from reproductive age group. Most of the patients were literate (81%) and hailing from rural areas. Most of them were homemakers and belonged to lower socioeconomic status (42.3%). Itching (77.3%) was the most common presenting complaint followed by burning sensation (9.5%). Common dermatoses encountered were vulval candidiasis (40.7%), lichen sclerosus (15.3%), tinea cruris (13.8%), lichen planus (4.2%), vitiligo (3.2%), irritant contact dermatitis (2.6%), psoriasis (2.6%), lichen simplex chronicus (2.1%), among others. Most common associated comorbidity was diabetes mellitus.

CONCLUSIONS

This study provides important data on the spectrum of vulvar diseases in Eastern Indian patients and emphasizes the importance of proper and timely diagnosing nonvenereal vulvar dermatoses.

Vulvovaginal candidiasis: An overview of mycological, clinical, and immunological aspects

AIM

To provide an overview of clinical, immunological, and mycological aspects of vulvovaginal candidiasis (VVC).

METHODS

A literature search was conducted to find relevant articles about different aspects of VVC. Related data from retrieved articles were summarized in different headings.

RESULTS

VVC has a global distribution and Candida albicans is the leading cause of infection except for specific patient groups like postmenopausal, diabetic, or immunocompromised women. VVC has a range of clinical presentations, accordingly, its diagnosis should be based on clinical examination coupled with laboratory investigations. The best therapeutic regimen depends on the patient's conditions and the causative agent. Moreover, factors like drug resistance of the causative agents and different mutations in the immunity-related genes could affect the treatment outcome.

CONCLUSION

As a globally distributed disease, VVC needs further attention, especially in areas related to the treatment failure and recurrence of the disease.

Guidance for gynecologists utilizing telemedicine during COVID‐19 pandemic based on expert consensus and rapid literature reviews

Background

COVID‐19 has impacted delivery of outpatient gynecology and shifted care toward use of telemedicine.

Objective

To rapidly review literature and society guidelines and create expert consensus to provide guidance regarding management of outpatient gynecology scenarios via telemedicine.

Search strategy

Searches were conducted in Medline and Cochrane databases from inception through April 15, 2020.

Selection criteria

Literature searches were conducted for articles on telemedicine and abnormal uterine bleeding, chronic pelvic pain, endometriosis, vaginitis, and postoperative care. Searches were restricted to available English language publications.

Data collection and analysis

Expedited literature review methodology was followed and 10 943 citations were single‐screened. Full‐text articles and relevant guidelines were reviewed and narrative summaries developed.

Main results

Fifty‐one studies on the use of telemedicine in gynecology were found. Findings were reported for these studies and combined with society guidelines and expert consensus on four topics (abnormal uterine bleeding, chronic pelvic pain and endometriosis, vaginal discharge, and postoperative care).

Conclusions

Guidance for treating gynecological conditions via telemedicine based on expedited literature review, review of society recommendations, and expert consensus is presented. Due to minimal evidence surrounding telemedicine and gynecology, a final consensus document is presented here that can be efficiently used in a clinical setting.

Guidance for gynecologists using telemedicine during COVID‐19 based on rapid literature review, review of society recommendations, and expert consensus in accessible format.

Itch in Organs Beyond the Skin

PURPOSE OF REVIEW

The purpose of this review was to explore mechanisms, causes, and therapies of itchy conditions involving organs beyond the skin including the eyes, ears, nose, and genital region.

RECENT FINDINGS

Conditions which cause itch in these locations vary from skin diseases that extend to these areas (i.e., atopic dermatitis, seborrheic dermatitis, and psoriasis) to allergic conditions (i.e., allergic rhinitis and conjunctivitis) and to neuropathic conditions that relate to afferent nerve fiber damage (i.e., lumbosacral radiculopathies in genital disease) as well as some psychological components. Similar to the skin, itch in these locations involves a complex interaction between epithelial cells, unmyelinated C nerve fibers, and cytokines. There is also a significant component of neural sensitization phenomena. Mechanisms of itch beyond the skin are currently an understudied topic that affects millions of patients. Future research should be done in order to further understand the pathophysiology of itch in these body sites.

Lactoferrin in Aseptic and Septic Inflammation

Lactoferrin (Lf), a cationic glycoprotein able to chelate two ferric irons per molecule, is synthesized by exocrine glands and neutrophils. Since the first anti-microbial function attributed to Lf, several activities have been discovered, including the relevant anti-inflammatory one, especially associated to the down-regulation of pro-inflammatory cytokines, as IL-6. As high levels of IL-6 are involved in iron homeostasis disorders, Lf is emerging as a potent regulator of iron and inflammatory homeostasis. Here, the role of Lf against aseptic and septic inflammation has been reviewed. In particular, in the context of aseptic inflammation, as anemia of inflammation, preterm delivery, Alzheimer’s disease and type 2 diabetes, Lf administration reduces local and/or systemic inflammation. Moreover, Lf oral administration, by decreasing serum IL-6, reverts iron homeostasis disorders. Regarding septic inflammation occurring in Chlamydia trachomatis infection, cystic fibrosis and inflammatory bowel disease, Lf, besides the anti-inflammatory activity, exerts a significant activity against bacterial adhesion, invasion and colonization. Lastly, a critical analysis of literature in vitro data reporting contradictory results on the Lf role in inflammatory processes, ranging from pro- to anti-inflammatory activity, highlighted that they depend on cell models, cell metabolic status, stimulatory or infecting agents as well as on Lf iron saturation degree, integrity and purity.

A Dermatologist’s Approach to Genitourinary Syndrome of Menopause

Background:

Genitourinary syndrome of menopause (GSM) is a debilitating condition caused by hypoestrogenism that presents with vaginal dryness and dyspareunia as well as other genital, sexual, and urinary symptoms. Previously known as atrophic vaginitis, the term GSM is now used.

Objective:

To help familiarise dermatologists with diagnosing and managing GSM.

Methods:

In total, 218 articles were identified and reviewed by 2 independent authors using PubMed. Articles included were from December 2005 to December 2015. Sixty-seven articles met our inclusion criteria.

Results:

GSM is a clinical diagnosis, requiring the presence of symptoms that should be bothersome and not accounted for by another condition. A pH test may help with diagnosis as vaginal pH will be increased from acidic to neutral. The Papanicolaou test is not recommended because of poor clinical correlation. First-line treatment is low-dose local vaginal estrogen therapy, which has proven efficacy and safety. Serum estrogen levels are not significantly affected with the exception of creams containing high-dose conjugated equine estrogens. Other options have yet to be approved for use in Canada but show promise.

Conclusion:

GSM is a debilitating and common condition that suffers from barriers to diagnosis and treatment. Current treatments are well tolerated, rewarding, and effective with rapid onset.

Comparison between the efficacy of metronidazole vaginal gel and Berberis vulgaris (Berberis vulgaris) combined with metronidazole gel alone in the treatment of bacterial vaginosis

Background

Bacterial vaginosis is one of the most prevalent complications among reproductive-aged women. Antibacterial and antifungal effects of Berberis vulgaris have been demonstrated in vitro and in vivo.

Objectives

This study aimed to compare the therapeutic effects of the vaginal gel of Berberis vulgaris 5% (in metronidazole base) with metronidazole vaginal gel 0.75% on bacterial vaginosis on 80 patients referred to the Hajar Hospital from January 2012 to April 2013.

Methods

This study was a randomized clinical trial research on 80 women affected by bacterial vaginosis, who were randomly divided into two groups of 40 participants. Diagnostic criteria were Amsel’s criteria and Gram stain. Berberis vulgaris 5% (in metronidazole gel base) or metronidazole vaginal gel for five-night usage was prescribed to each group, and after two to seven days therapeutic effects and Amsel criteria were assessed. Data analysis was performed by SPSS 16 using Student t-test, chi-square, and ANOVA tests.

Results

Findings of the study showed a statistically significant difference with regard to treatment response between the study groups (p<0.001), and the Berberis vulgaris group had a better response than the metronidazole gel group. The patients in groups of Berberis vulgaris in a metronidazole gel base did not experience any relapse, but, in the metronidazole group, 30% of patients experienced relapse during three weeks’ follow-up.

Conclusions

Findings of the study showed that adding Berberis vulgaris fruit extract on metronidazole improve the efficacy of bacterial vaginosis therapy.

Clinical trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT ID: IRCT201411102085N13.

Funding

Shahrekord University of Medical Sciences supported this research.

Allergic contact dermatitis of the vagina and perineum: causes, incidence of, and differentiating factors

Review of allergic contact dermatitis of the vagina and perineum, including causes, incidence of, and differentiating factors. The causes include common allergens found in everyday products. The true incidence of contact dermatitis of the vagina and perineum is unknown, however, it is a common problem facing clinicians. The differentiating factors include itching, erythema, and persistence.

Pruritus in female patients

Pruritus is a frequent symptom in many dermatological diseases. In this review we want to focus on not only itch problems specific to women, namely, pruritic vulvodermatoses, but also the specific pruritic dermatoses of pregnancy. The specific characteristics of the vulva and the hormonal changes during the different age periods make these dermatoses very particular. It seems that vulvar diseases are still underdiagnosed and undertreated. Pruritic vulvar diseases have a huge impact on quality of life. The most common pruritic diseases will be discussed, such as atopic and contact dermatitis, psoriasis, lichen sclerosis, lichen planus, and infectious vulvaginitis. We focus on the diagnostic issue of these diseases and will consider the general principles of therapy.

Measuring the nature and duration of symptoms of cervical cancer in young women: developing an interview-based approach

BACKGROUND

Some young women experience delays in diagnosis of cervical cancer, but little research about ways of studying these delays has been published. A major challenge is that gynaecological symptoms are common in young women, but cervical cancer is rare. This study describes the development and testing of a measure for studying delays in diagnosis in young women with cervical cancer.

METHODS

Prospective development of an interview measure and testing of its ability to reliably and systematically collect relevant data in two large hospitals in London, UK using 27 women aged 18-40 diagnosed with cervical cancer in the previous two years. We developed a semi-structured interview schedule and data extraction form to systematically collect data on symptoms (including nature and duration) and risk factors for delayed diagnosis from young women with cervical cancer. We piloted the measure among young women with cervical cancer (audiorecording it with their permission), refining it iteratively. To complete the measure, we developed a database for managing the data and a manual for using the schedule. Two researchers extracted data from the recorded interviews to assess inter-rater reliability.

RESULTS

The final interview schedule yielded quantitative data on the nature and duration of symptoms and risk factors for delayed diagnosis. Inter-rater reliability was high. In the pilot, 12 of the 27 women were diagnosed via symptomatic presentation. Median time from the symptom triggering presentation to presentation was one month (interquartile range 0-4 months). Median time from presentation to diagnosis was three months (interquartile range 1-8.5 months).

CONCLUSIONS

We have developed a reliable tool for measuring the nature and duration of symptoms in young women with cervical cancer. Pilot data suggest that a substantial proportion of women experience delay between first presentation and diagnosis.

Vaginal infections update

Vaginal symptoms are one of the leading reasons that women visit their health care providers. Women often self-diagnose and may treat themselves inappropriately. This article describes the etiology, risk factors, symptoms, diagnosis, and treatment of the 3 most common vaginal infections: bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis.

Gynaecological symptoms reported by young women: examining the potential for earlier diagnosis of cervical cancer

BACKGROUND

Cervical cancer occurs at a younger age than most adult cancers. A pre-malignant stage can be identified at screening and treated. Screening begins at the age of 25 years in England, so in women younger than this, and in those who decline screening, cervical cancer can only be identified with symptoms. Aim. To identify the frequency of attendance for gynaecological conditions by young English women.

DESIGN

Historical cohort study using electronic primary care records.

METHODS

A cohort of English women aged 15-29 years was prepared from the General Practice Research Database. All gynaecological consultations were identified and collated. Frequencies of gynaecological consultation were analysed in three age bands: 15-19, 20-24 and 25-29 years and by calendar year.

RESULTS

The number of women available for study for each year ranged from 32 968 to 45 807. The percentage of women having any gynaecological consultation increased from 17.7% to 33.3% over the 7 years. If contraception is excluded, the percentages are 11.3% in 2003, rising to 20.1% in 2009. The rise in consultations occurred in all age bands and across most symptom categories. Post-coital bleeding and inter-menstrual bleeding-the two classic presentations of cervical cancer-were reported by 0.5% and 1.6% of women in 2009.

CONCLUSIONS

Gynaecological complaints are frequent in primary care, though the symptoms of possible cervical cancer only represent a small minority of the total. Although the chance of cancer in young women with abnormal vaginal bleeding is very small, visualization of the cervix is appropriate.

Oncogenic HPV infection resembling pseudocondyloma of vulvae: a descriptive study of 31 cases

OBJECTIVE

Report a special type of human papillomavirus infection resembling pseudocondyloma of vulvae. The characteristics of the clinical manifestation and subtypes of the HPV infection were studied.

METHODS

Thirty-one women with unprotected sex and genital warts resembling pseudocondyloma of vulvae were involved in this study. The clinical and histological manifestations were characterized. The genotypes of human papillomavirus were determined by a reverse hybridization of polymerase chain reaction (PCR) RESULTS: Thirteen HPV genotypes were detected from 31 cases. Of 13 genotypes, 3 were non-oncogenic and 10 were oncogenic. At least, one of oncogenic genotypes was detected from each patient. Among 31 cases, 10 were found with one genotype of the HPV infection, 14 with 2 genotypes of HPV and 7 with at least 3 genotypes. The most common genotype was genotype 16 that was detected from 15 of 31 samples (48%).

CONCLUSION

There is a special type of oncogenic HPV infection clinically resembling pseudocondyloma of vulvae. Some of the patients who were infected with this type of HPV infection may have been misdiagnosed as pseudocondyloma of vulvae in the past time.

Vulval Disease in the Postmenopausal Patient: A Guide to Current Management

In spite of overwhelming evidence that vulvovaginal symptoms plague up to 46% of menopausal and perimenopausal women, and that there persists a reluctance to seek help among patients, adequate vulval and sexual histories are still woefully rare in general gynaecology clinics. This review aims to present the key points of an effective vulval history and an overview of the accepted current management of vulval disease postmenopause, in order that our patients feel encouraged to present with their problems.

Vulvar pain after spondylosyndesis procedure: a presentation of 2 cases

Vulvar pain can be a difficult and frustrating problem for patients and practitioners. Often, no specific etiology can be determined for these symptoms. Treatment can be long and difficult as well.Spondylosyndesis is a common surgical procedure where the vertebrae are fused to decrease motion. There are several indications for this procedure. We report 2 patients who developed vulvar pain postoperatively after a spondylosyndesis procedure. Neither patient had a history of vulvar pain before their procedure. Of note, both patients had had a previous spondylosyndesis procedure in the past.Damage to lumbar nerves during spondylosyndesis procedures may precipitate vulvar pain in some patients.

Confronting the challenges of postmenopausal urogenital health

The global population is aging, especially in Western industrialized nations. In the USA, 38% of adults are over the age of 45 and 13% of adults are over the age of 65 years. Moreover, postmenopausal women now comprise 60% of adults aged over 65 years of age, a proportion that will rise as the population ages. This article reviews some of the more common urogenital health issues among older women. Changes to urogenital morphology and physiology are discussed, highlighting the impact on tissue atrophy, sexuality, prevalence of certain vulvar dermatoses, susceptibility to infection and urinary continence. We review treatment approaches, challenge some of the current paradigms and discuss the need for future research.

Nursing considerations in patients with vaginitis

Vaginitis is defined as an inflammation of the vagina. It can result in symptoms of any or all of the following: discharge, itching and pain, and often irritation or infection of the vulva. There is no specific cause for vaginitis, and many other conditions can cause the symptoms. Vaginitis is a distressing condition that affects many women of reproductive age and beyond, and encompasses candidiasis (also known as thrush), bacterial vaginosis, and trichomoniasis. It can occur in a single episode, or recur throughout a woman's lifetime. Some women will seek medical help, but many more self-treat with over-the-counter medications, suspecting the recurrence of Candida in particular. This article aims to explore the causes, signs and symptoms, and treatments of vaginitis to provide nurses with the necessary background information to feel more confident in dealing with women's health issues.

Chronic Pain of the Vulva without Dermatologic Manifestations: Distinguishing among a Spectrum of clinical Disorders

The causes of chronic vulvar pain are many and when not accompanied by obvious physical signs they are difficult to unravel. Many common vulvar dermatoses can manifest without obvious erythema or mucocutaneous lesions, as can some less common disorders of both infectious and allergic origin. In addition localized and generalized vulvar dysesthesia, recently defined chronic pain syndromes of neurogenic origin, can also occur in the vulvar area.

Chronic vulvovaginal symptoms in early stages are often presumptuously labeled as vulvovaginal candidiasis (VVC) by patients and clinicians alike, which can delay accurate diagnosis. When presented with chronic vulvar pain unaccompanied by verifiable signs, the clinician must effect a sensitive integration of a detailed medical history, including temporal associations of all potential exposures, with more definitive diagnostic tools. Effective use of those available tools can improve initial diagnosis, thus allowing prompt initiation of effective therapy. Optimal therapy will recognize the significant psychological distress that accompanies any chronic pain syndrome.

Investigation of the sensitivity of a cross-polarized light visualization system to detect subclinical erythema and dryness in women with vulvovaginitis

OBJECTIVE

An enhanced visualization technique using polarized light (Syris v600 enhanced visualization system; Syris Scientific LLC, Gray, ME) detects surface and subsurface ( approximately 1 mm depth) inflammation. We sought to compare the Syris v600 system with unaided visual inspection and colposcopy of the female genitalia.

STUDY DESIGN

Erythema and dryness of the vulva, introitus, vagina, and cervix were visualized and scored by each method in patients with and without vulvitis.

RESULTS

Subsurface visualization was more sensitive in detecting genital erythema and dryness at all sites whether or not symptoms were present. Subsurface inflammation of the introitus, vagina, and cervix only was detected uniquely in women with vulvar vestibulitis syndrome (VVS). A subset of women presenting with VVS exhibited subclinical inflammation of the vulva vestibule and vagina (designated VVS/lichen sclerosus subgroup).

CONCLUSION

Enhanced visualization of the genital epithelial subsurface with cross-polarized light may assist in diagnosing subclinical inflammation in vulvar conditions heretofore characterized as sensory syndromes.