What is vestibular papillomatosis? A study of its prevalence, aetiology and natural history

Vulvar inspection at the time of cervical cancer screening: European Society of Gynaecological Oncology (ESGO), International Society for the Study of Vulvovaginal Disease (ISSVD), European College for the Study of Vulval Disease (ECSVD), and European Federation for Colposcopy (EFC) consensus statements

BACKGROUND

Vulvar squamous cell carcinoma incidence is increasing, especially among women under 60, largely attributed to human papillomavirus infections. Precursor pre-invasive vulvar lesions are frequently underdiagnosed. Routine vulvar inspection during cervical cancer screening could offer an opportunity for the detection of these lesions.

OBJECTIVE

To emphasize the importance of integrating routine vulvar inspection during cervical cancer screening procedures and to raise awareness about the early detection of vulvar squamous cell carcinoma and its precursors to reduce the diagnostic delay of vulvar pathologies.

METHODS

A multidisciplinary task force comprising experts from 4 international scientific societies was formed. A focused literature review was conducted, and consensus statements were developed through a structured voting process to ensure clinical relevance and comprehensiveness.

RESULTS

The consensus defines key elements of normal vulvar anatomy, identifies potential pre-cancerous dermatoses, and highlights risk factors for vulvar malignancy. The consensus statements promote the integration of vulvar inspection into cervical cancer screening procedures, urging health care professionals across various levels to receive training and guidance in vulvar examinations and enhancing patient education. Health care providers are recommended to gather a brief history of vulvar symptoms, conduct comprehensive inspections of the vulvar area, and report any abnormalities. For patients with positive human papillomavirus or Pap tests, they should closely monitor vulvar findings, encourage self-examinations, and discuss risks for intra-epithelial or invasive neoplasia.

CONCLUSIONS

Establishing standardized practices in vulvar inspection during cervical cancer screening procedures along with public awareness, could significantly impact early detection and timely interventions of vulvar pathologies at cancer risk ultimately reducing the burden of vulvar cancers.

Vulvar vestibular papillomatosis: A diagnostic conundrum

Vulvar vestibular papillomatosis (VP) is considered a normal anatomical variant of the vulva. We present a 19-year-old girl with a history of "small itchy growths" on the vulva for 2 months without any associated discharge. These lesions were causing significant anxiety to the patient. Cutaneous examination revealed multiple, uniformly arranged, skin-colored, monomorphic micropapillae on the inner aspect of the labia minora. Biopsy showed mucosal hyperplasia with papillomatosis and loosely arranged subdermal tissue, no koilocytes were spotted. The diagnosis of vulvar VP was made. We want to highlight this clinical entity as most dermatologists are not familiar with this benign condition and easily confuse it with genital warts. This inexperience may result in unnecessary investigations causing psychological discomfort to the patient. We herein present such a case which brings out the diagnostic dilemma.

The Squamous Vaginal Papillomatosis in Prepubertal Female Twins: A Case Report

This is the first case describing vaginal papillomatosis with a fibroepithelial polyp of the vulva in a prepubertal girl and vaginal papillomatosis in her twin sister. Parents contacted pediatric urologist regarding their eight-year-old daughter (twin A), who had a growth next to the external urethral meatus. The girl was referred to a pediatric surgeon. The exophytic 3 cm long structure with necrosis on top was found. After obtaining informed consent from girl parents, pediatric surgeon removed the exophytic structure and perform cystoscopy and vaginoscopy for possible changes in the bladder and vagina. Cystoscopy findings were normal. On vaginoscopy, numerous macroscopic papillomatous structures were identified on the cervix and vaginal walls. Vaginal biopsies were performed on the areas affected by papillomatosis. Histopathologic examination showed a fibroepithelial polyp with a central fibrovascular core covered by squamous epithelium and vaginal squamous papillomatosis. The decision was made to perform vaginoscopy on her twin sister (twin B), too. On vaginoscopy, solitary small vaginal papillomas were also found. In this case manifestation of vaginal papillomatosis in twins might have been influenced by inheritance and the same bacterial and viral environment.

Benign "lumps and bumps" of the vulva: A review

Vulvar dermatology represents a challenge for many providers. Given that the vulva is both a gynecologic and dermatologic organ, patients with cutaneous lesions involving the vulva may present to primary care, gynecology, or dermatology. Particularly within dermatology, the vulva remains understudied, which can lead to anxiety among providers regarding appropriate next steps in the diagnosis and management of vulvar lesions. Thus, the purpose of this review is to highlight commonly encountered anatomic variants and benign neoplasms of the vulva, distinguish them from key pathologic mimickers, and provide guidance to practicing dermatologists on what may constitute normal vulvar variations.

[Vulvar inflammatory dermatoses]

Vulvar skin disease is a common reason for consultation. The vulva, like the rest of the skin, can be affected by numerous diseases of various etiologies, but its particular anatomic and physiologic characteristics create additional diagnostic and therapeutic difficulties. The study of vulvar disease is emerging as a new branch of dermatology. In this article, we examine the characteristics of the normal vulva, and perform a brief, structured review of vulvar inflammatory dermatoses, which comprise a heterogeneous group of diseases in which a broad, multidisciplinary approach is essential.

Vulvar malignant melanoma associated with human papillomavirus DNA: report of two cases and review of literature

Oncogenic human papillomavirus (HPV) types such as HPV 16 are known to play a crucial role in the development of anogenital carcinomas. The etiology of anogenital malignant melanoma is unknown. We report two case of vulvar malignant melanoma in which multiple HPV types including HPV 16 and putative novel HPV types (alb-1, alb-2, alb-7, and alb-10) were identified by degenerated nested polymerase chain techniques (polymerase chain reaction) in both the malignant melanoma and surrounding skin. One melanoma was associated with lichen sclerosus, and the other, with melanoma in situ and pigmented vulvar squamous papillomatosis. These melanomas harbored HPV types alb-7, and HPV 16 as well as alb-1, respectively. HPV types 16, 20, 21, 36, alb-2, and AJ001060 were detected in vulvar skin affected by lichen sclerosus. Vulvar squamous papillomatosis harbored HPV types 28 and alb-10. HPV 16 was physically integrated into the host genome in lichen sclerosus skin and possibly in the melanoma associated with pigmented vulvar squamous papillomatosis. Twenty-two percent (4 of 18) of normal control specimens from skin tumor excisions were found to harbor HPV DNA (HPV types 3, 54, and alb-7); none of these control samples harbored multiple HPV DNA. These findings of multiple HPV DNA and integrated HPV 16 in skin associated with vulvar malignant melanoma indicate that HPV may play a role in the development of vulvar malignant melanoma. The role of HPV could be either direct through infection of melanocytes or indirect as a cofactor with free radicals in chronic fibroinflammatory vulvar disorders such as lichen sclerosus.

Human papillomavirus with co-existing vulvar vestibulitis syndrome and vestibular papillomatosis

OBJECTIVE

The role of HPV infection in cases of vulvar papillomatosis and vulvar vestibulitis syndrome is still unclear and data from the literature is controversial. In this study we intended to investigate the prevalence of viral infection, with a multidisciplinary approach, in cases with a co-existence of the two patterns.

METHOD

Sixteen consecutive cases with diagnosis of vulvar vestibulitis syndrome and co-existence of vestibular papillomatosis were enrolled in the study and investigated by the means of vulvar cytology, vulvoscopy, histology, ViraPap and Polymerase Chain Reaction.

RESULT

Cytology, vulvoscopy and histology did not demonstrate suitable accuracy for the diagnosis. Viral DNA identification revealed two (12.50%) positive cases using PCR and one (6.25%) positive case with ViraPap.

CONCLUSION

The results of the present investigation indicate that even in cases of co-existing vulvar papillomatosis and severe vulvar vestibulitis syndrome, the prevalence of HPV infection is too low to be considered causal.

Human papillomavirus. Subclinical and atypical manifestations

Subclinical HPV infections, together with latent infections, are probably the most likely outcome after exposure to HPV. Subclinical infection is associated with symptoms such as burning, fissuring, and dyspareunia in some patients. Only these patients should be offered treatment. Diagnosing and treating asymptomatic HPV infection cannot be recommended until better knowledge about the infectious potential of the infection in that phase is obtained. Recently, results have been presented showing a median duration of HPV infection of only 8 months, and after 24 months, only 9% of the women studied continued to be infected. This provides the possibility to reassure patients with HPV infection that it is most likely a transient infection, and one should not worry unduly. In light of this knowledge, it seems unwise to diagnose an asymptomatic infection for which no effective treatment is available and for which the natural history and consequences remain unclear; however, if these lesions were found to have the potential to transmit HPV, the patient should be so counseled.

Normal findings in vulvar examination and vulvoscopy

OBJECTIVE

To determine the normal vulvar findings by naked eye examination and by vulvoscopy in healthy women without vulvar complaints.

DESIGN

Observational study.

POPULATION

Forty healthy volunteers without vulvar complaints recruited via a newspaper advertisement.

METHODS

Vulvar examination, human papillomavirus (HPV) polymerase chain reaction of vulvar and cervical swabs, saline and KOH smears and vulvoscopy before and after the application of 5% acetic acid.

MAIN OUTCOME MEASURES

Prevalence of vestibular erythema, vestibular papillomatosis, HPV infection on the vulva and in the cervix and vulvoscopic findings.

RESULTS

The mean age of the women was 37.8 years (median 38.0, range 21-56). Nine women were current smokers and 21 had previously smoked. Naked eye vulvar examination showed vestibular papillomatosis in 13 women (33%) and vestibular erythema in 17 women (43%). The touch test was positive in 9 of the 17 women (53%) with vestibular erythema. Vulvoscopy after the application of acetic acid 5% showed an acetowhite vestibule in all women. Twelve women (30%) had acetowhite lesions outside the vestibule. Six women (15%) were positive for HPV DNA. The presence of HPV DNA did not correlate with vestibular erythema or vestibular papillomatosis. There was a weak association between HPV DNA and acetowhite lesions outside the vestibule (P = 0.055, Fisher's exact test). In this group the younger women significantly more often had vestibular papillomatosis (t-statistic = 3.07; P = 0.003) and women who smoke more often had a genital HPV infection (P = 0.016, Fisher's exact test).

CONCLUSIONS

Vestibular erythema, vestibular papillomatosis, and acetowhite lesions are common in this group of healthy women without vulvar complaints.

Diagnosis and treatment of vulvodynia

Vulvodynia is a complex multifactorial and multidisciplinary clinical syndrome of unexplained vulvar pain, sexual dysfunction, and psychological disability. Because of the absence of abnormal physical findings among such patients, vulvodynia was long thought to be solely a psychosomatic syndrome. The incidence or prevalence of vulvodynia has not been well studied. The recognition of specific subtypes of vulvodynia is important in the management of patients with vulvodynia. The most common subtypes are vulvar vestibulitis syndrome, cyclic vulvovaginitis and dysesthetic vulvodynia. Simple practice guidelines can be developed to facilitate the evaluation and management of such patients. Systematic epidemiological, etiological and therapeutic studies of vulvodynia are urgently needed.

Genital human papillomavirus infections in young women with vulvar and vestibular papillomatosis

Possible involvement of human papillomaviruses (HPV) in the development of vulvar and vestibular papillomatosis was investigated by using PCR to determine whether HPV DNA was present in lesions. Fourteen of 272 (5.1%) young women studied were found on gross and histological examination to have vulvar or vestibular papillomatosis. HPV DNA sequences were detected in cervicovaginal lavage specimens of 2 of 14 (14.3%) papillomatosis patients and 1 of 17 (5.9%) matched individuals in the control group without lesions. The difference in HPV prevalence between these two groups was not statistically significant (x2 = 0.51, p > 0.2). Furthermore, none of the 14 vulvar or vestibular papillomatosis biopsy tissues contained HPV DNA. The results suggest that vulvar and vestibular papillomatosis has an etiology other than HPV infection.