[Burning Vulva: Significance of Surgery in Inflammatory and Precancerous Vulvar Pathologies]

Vuval pathologies manifested by allodynia and burning sensations can be due to infection, inflammatory dermatoses or other causes. Infective as well as certain inflammatory diseases, e.g. drug eruptions, allergic eczemas, irritative dermatitis/vulvitis, Behcet's Syndrome and pemphigus/pemphigoid usually respond well to conservative treatment. The category of inflammatory diseases also contains pathologies that in certain circumstances do require a surgical intervention, e.g. Lichen ruber planus/Lichen sclerosus, Condyloma, scars, premalignant lesions (VIN, genital M. Paget) and cancer. Vulodynia also can cause some stinging to the vulvar skin. The surgical aspects relating to the treatment of the benign and premalignant pathologies indicated above are mentioned in this mini-review.

Treatment of clitoral hypertrophy containing an os clitoris and urethra in a young greyhound dog: a detailed surgical description

This report provides a detailed description and images of a clitorectomy with a urethral transposition. As described, the clitorectomy is a straight-forward procedure, creating more normal female-like anatomy, and it resolves the clinical signs resulting from the exposed clitoris.

Human papillomavirus in vulvar vestibulitis syndrome

OBJECTIVE

To investigate the prevalence of human papillomavirus (HPV) in patients with vulvar vestibulitis syndrome by using a recently developed polymerase chain reaction (PCR) primer set that detects known papillomavirus types.

STUDY DESIGN

We retrospectively identified 38 patients with vulvar vestibulitis who underwent therapeutic surgical excision of the vestibule. Eleven controls without vestibulitis who underwent vestibular excision for conditions unrelated to HPV infection were identified prospectively. Surgical specimens were examined for the presence of HPV DNA by PCR amplification. DNA sequencing was used to determine HPV type.

RESULTS

The prevalence of HPV among patients with vestibulitis was 21% vs. 36% among controls. Group B HPV types accounted for 4 of the 10 (40%) HPV types found in patients with vestibulitis. Overall, in both patient and control samples, a spectrum of HPV types was identified, encompassing many branches of the HPV phylogenetic tree. No etiologic association was apparent.

CONCLUSION

This study did not support an association of HPV with vulvar vestibulitis. The low rate of observed infection in women with and without vestibulitis and the diversity of HPV types identified suggest incidental virus carriage rather than direct cause and effect. The underlying cause of this debilitating condition remains unknown.

ORIGINAL RESEARCH—SURGERY: Surgical Treatment of Vulvar Vestibulitis Syndrome: Outcome Assessment Derived from a Postoperative Questionnaire

INTRODUCTION

Vulvar vestibulitis syndrome (VVS) is the most common pathology in women with sexual pain. Surgery for VVS was first described in 1981. Despite apparently high surgical success rates, most review articles suggest that surgery should be used only "as a last resort." Risks of complications such as bleeding, scarring, and recurrence of symptoms are often used to justify these cautionary statements. However, there are little data in the peer-reviewed literature to justify this cautionary statement.

AIMS

To determine patient satisfaction with vulvar vestibulectomy for VVS and the rate of complications with this procedure.

METHODS

Women who underwent a complete vulvar vestibulectomy with vaginal advancement by one of three different surgeons were contacted via telephone by an independent researcher between 12 and 72 months after surgery.

MAIN OUTCOME MEASURES

The primary outcome measurement of surgical success was overall patient satisfaction with surgery. Additional secondary outcome measurements included improvement in dyspareunia, changes in coital frequency, and occurrence of surgical complications.

RESULTS

In total, 134 women underwent surgery in a 5-year period. An independent research assistant was able to contact 106 women, and 104 agreed to participate in the study. Mean duration since surgery was 26 months. A total of 97 women (93%) were satisfied, or very satisfied, with the outcome of their surgery. Only three patients (3%) reported persistently worse symptoms after surgery and only seven (7%) reported permanent recurrence of any symptoms after surgery. Prior to surgery, 72% of the women were completely apareunic; however, after surgery, only 11% were unable to have intercourse.

DISCUSSION

In this cohort of patients, there was a high degree of satisfaction with surgery for VVS. In addition, the risks of complications with this procedure were low, and most complications were transient and the risk of recurrence after surgery was also found to be low.

Surgical Treatment for the Vulvar Vestibulitis Syndrome

OBJECTIVE

To study the outcome and complications of surgical treatment for vulvar vestibulitis syndrome and to identify patient characteristics that may have influenced the outcome.

METHODS

Relevant patient characteristics were extracted retrospectively from the medical records of 155 women aged 40 years or younger who had received surgical treatment for vulvar vestibulitis syndrome. To assess outcome and complications, 126 of these 155 women (81%) participated in a telephone interview, conducted 1 to 4 years after surgery.

RESULTS

After surgery 93% of the patients could have sexual intercourse compared with 78% before surgery; this increase was statistically significant (Mantel-Haenszel odds ratio 3.43, 95% confidence interval [CI] 1.48-7.96). In 62% of the women (95% CI 53-70%), sexual intercourse was painless after surgery. Eighty-nine percent (95% CI 84-95%) would recommend surgical treatment to other women experiencing vulvar vestibulitis syndrome. There were no major complications. Decreased lubrication during sexual arousal was the most frequently reported adverse effect (24%, 95% CI 16-32%), followed by the development of a Bartholin's cyst (6%, 95% CI 2-10%). More of the women aged 30 years or younger reported that they could have sexual intercourse after surgery, and more of them would recommend surgical treatment to other patients than women aged 31 years or older.

CONCLUSION

Surgical treatment for vulvar vestibulitis syndrome achieved high success rates with an acceptable rate of complications. Age of 30 years or younger was associated with a better outcome.

LEVEL OF EVIDENCE

III.

Modified vulvar vestibulectomy: simple and effective surgery for the treatment of vulvar vestibulitis

OBJECTIVE

To evaluate the success of a simple modified vestibulectomy in treating vulvar vestibulitis.

STUDY DESIGN

Fifty-nine patients with vulvar vestibulitis refractory to nonsurgical treatment underwent modified vestibulectomy. Response was defined as return to normal coitus and was graded as complete, partial or non-responsive.

RESULTS

The postoperative follow-up period was 6 months-10 years. Thirty-nine (73.6%) patients reported complete response, 7 (13.2%) had partial response, and 7 (13.2%) were non-responsive to surgery.

CONCLUSION

Surgery is an effective treatment for vulvar vestibulitis refractory to conservative treatment. Simple modified vestibulectomy is considerably less invasive, technically simpler and probably less time consuming. Postoperative results employing this surgical procedure are found to be in line with postoperative results reported by others who employ surgical methods that are more extensive.

Hyperinnervation and mast cell activation may be used as histopathologic diagnostic criteria for vulvar vestibulitis

OBJECTIVE

Vestibulitis is currently diagnosed based only on clinical criteria. To achieve histopathological diagnostic criteria, we carried out a computerized image analysis method.

METHODS

Vestibular tissues removed from 40 women with severe vestibulitis were immunostained for mast cell count and degranulation by C-kit and mast cell tryptase, respectively. Vestibular nerve cells total area was evaluated after S-100 stain. Controls were 7 women aged 18-48. The images were converted to a digital signal, and analyzed using Image Proplus V4 software.

RESULTS

We found a significant increase in inflammatory infiltrate, number of mast cells and degranulated mast cells in vestibulitis compared to normal controls. The inflammatory cells were localized around the superficial minor vestibular glands. The total nerve fiber area was ten times higher in vestibulitis patients than in controls. A significant positive correlation was found between the total nerve fiber area and the number of mast cells in the vestibulitis group of patients.

CONCLUSION

We documented two diagnostic histopathological criteria for vestibulitis: (1) the presence of eight or more mast cells per 10 x 10 microscopic field, and (2) the total calculated area of the nerve fibers is ten times higher than expected. These findings re-establish the inflammatory nature of the vestibulitis. It is speculated that the trigger for the local outburst of nerve fibers could be related to the activation of the mast cells by a topical agent.

Increased innervation of the vulval vestibule in patients with vulvodynia

BACKGROUND

Vulval vestibulitis is a condition characterized by the sudden onset of a painful burning sensation, hyperalgesia, mechanical allodynia, and occasionally pruritus, localized to the region of the vulval vestibulus. It is considered the commonest subset of vulvodynia. Pain precipitated in the absence of nociceptor stimuli might be triggered by previous peripheral nerve injury, or by the release of neuronal mediators, which set off inappropriate impulses in nonmyelinated pain fibres sensitizing the dorsal horn neurones. The pathophysiology of vulval vestibulitis is still unclear.

OBJECTIVES

The objective of this study was to evaluate the nerve fibre density and pattern, in specimens of vulval vestibulus, in normal subjects and in patients with vestibulitis, and provide objective diagnostic criteria for this condition. Methods Twelve patients with a history of the vestibulitis type of vulvodynia, and eight normal subjects underwent biopsy of the posterior wall of the vulval vestibule. Quantitative immunohistochemistry was performed, using antisera to the general neuronal marker protein gene product (PGP) 9.5, and to the neuropeptide calcitonin gene-related peptide (CGRP), on 15- microm sections.

RESULTS

There was a statistically significant increase of density and number of PGP 9.5 immunoreactive in the papillary dermis of patients with vulvodynia of the vestibulitis type, compared with those of controls. However, the distribution pattern of the innervation showed no significant change. There were no significant differences in CGRP staining between patients and controls.

CONCLUSIONS

It is concluded that the increase of PGP 9.5 immunoreactive nerve fibres, in patients with vulvodynia, may be either secondary to nerve sprouting, or may represent neural hyperplasia. Increased innervation may be applied as an objective diagnostic finding in vulval vestibulitis syndrome.

Outcome of surgical treatment for superficial dyspareunia from vulvar vestibulitis

OBJECTIVE

To evaluate the results of surgical treatment for superficial dyspareunia, as manifested by patient satisfaction, as well as epidemiologic characteristics of women with this medical problem.

STUDY DESIGN

A questionnaire was sent to 69 women six months after the operation. It included questions about treatment before surgery and the impact of pain on the sexual relationship before and after the operation. Demographic, social and general health data were recorded before the operation. All patients returning the questionnaire were examined.

RESULTS

Fifty-four (78%) patients replied. Half of those abstained from sexual relations before surgical treatment. Sixty-seven percent of patients required more than six visits to various physicians, before vestibulitis was diagnosed. Prior to surgery, 80% of patients received conservative treatment, whereas after surgery only 34% required it. A moderate to excellent improvement was reported after surgery by 45 (83%) patients. Repeat surgery (n = 7) resulted in further improvement in four patients. There were no major operative complications. Forty-five patients (83%) were satisfied with the results and would recommend the surgery to other women with this clinical problem.

CONCLUSION

Surgical treatment for superficial dyspareunia from vestibulitis is quite safe and results in a high rate of patient satisfaction.

Evaluation of the surgical treatment of vulvar vestibulitis

OBJECTIVE

To assess the efficacy of perineoplasty in the management of vulvar vestibulitis.

STUDY DESIGN

Forty-two women who had undergone operative perineoplasty for the treatment of vulvar vestibulitis completed a questionnaire, a mean of 4.8 years postoperatively.

RESULTS

Vulvodynia was constant or daily in 29 (69%) before surgery and in eight (19%) of respondents after surgery. In all, 27 (80%) of 34 women who had preoperative vulvar discomfort reported that the discomfort was much better or absent following surgery. Before surgery, 26 (70%) of 37 women who were not celibate for reasons other than vulvar vestibulitis, were celibate because of vulvar vestibulitis or always had pain during coitus and sometimes had to discontinue coitus because of pain. In contrast, only two (5.7%) of 35 women had this degree of dyspareunia following surgery. Similarly, 28 (85%) of 33 sexually active women who had dyspareunia before surgery reported that intercourse was much less painful or pain-free following surgery.

CONCLUSION

Perineoplasty has a role in the management of vulvar vestibulitis for women who do not achieve satisfactory relief of vulvodynia and/or dyspareunia with nonoperative treatments.

Vulvar vestibulitis: physical or psychosexual problem?

OBJECTIVE

To examine whether vestibulitis has a physical or a psychosexual etiology.

DATA SOURCES

MEDLINE was searched to retrieve publications dating from January 1981 through June 1998 that evaluated the outcomes of surgical treatment and the psychosexual theory of the origin of vestibulitis. INTEGRATION: Articles were analyzed for methods of subject selection and surgery, surgical outcome, and length of follow-up.

RESULTS

A significant decrease in symptoms (complete responses + partial responses) was reported by 89% of 646 women who had perineoplasty for vulvar vestibulitis. Complete resolution of dyspareunia with surgical treatment was reported in 72% of 512 women whose cases were reviewed in studies in which complete responses and partial responses were evaluated separately. Women with vestibulitis did not differ from the normal population with respect to marital satisfaction, psychologic distress, or psychopathology. A suggestion that childhood sexual abuse caused vestibulitis has not been confirmed. The findings of somatization and shyness might be explained as results rather than causes of vulvar vestibulitis.

CONCLUSION

We do not agree that vestibulitis is a psychosexual problem and one that should not be treated surgically. A high rate of success can be achieved with proper surgical treatment.

Vulvar vestibulitis treated by modified vestibulectomy

OBJECTIVE

A prospective study to evaluate the success of a modified vestibulectomy in treating vulvar vestibulitis.

METHODS

Fifty seven consecutive women with vulvar vestibulitis and suitable for surgery based on the criteria: superficial dyspareunia, erythematous vestibular region, positive Q-tip test, symptoms reduced with local anesthetic cream. A modified vestibulectomy with or without a modified Fentons procedure was performed. Response was based on return to normal coitus, 3 months after surgery.

RESULTS

Most women suffered from chronic conditions (median duration of symptoms = 18 months). The median age was 28 years (range 18-53). Any infections were treated prior to surgery. All but 4 (7%) had histological abnormalities, mainly non-specific inflammation. In 18% of women who had cervical cytology some abnormality was detected. Mean follow-up time was 12 months (range 2-42). Three women were not evaluable. Complete response to surgery was achieved in 33 (61.1%) of the women, partial response was achieved in 15 (27.8%). Six (11.1%) had persistent symptoms, four of whom has psychosexual problems.

CONCLUSION

Presently, surgery remains the most successful intervention for vulvar vestibulitis. Modified surgery which is less destructive seems to afford acceptable results. The completion of randomized studies are needed to recognise the optimum surgical procedure.

[Group A beta-hemolytic Streptococcus: an unusual etiology of perianal dermatitis in an adult?]

BACKGROUND

Perianal dermatitis usually occurs in children between 1 and 8 years of age. We report a sixth case in an adult.

CASE REPORT

A 33 year-old woman complained of perianal itching which quickly extended to the vulva and persisted in spite of anti-hemorrhoid and anti-fungal treatments. After 12 days, she had painful defecation, a well demarcated perianal and vulvar erythema and anal collection. Culture from a perianal swab isolated group A beta-hemolytic Streptococcus (ABHS). After surgical treatment of the collection and a 7 days oral amoxicillin regimen, the patient recovered with no recurrence.

DISCUSSION

Symptoms of perianal dermatitis are unspecific, leading to delayed diagnosis and underestimated frequency. Symptoms consist in perianal erythema. Swab culture shows ABHS. The mechanism of colonization of perianal area is not well defined. Although treatment with oral penicillin is usually effective, failures and relapses have also been reported. Complications such as deep infection or abcess formation are infrequent. A bacterial swab should be made in patients with persisting perianal erythma.

Vestibular nerve fiber proliferation in vulvar vestibulitis syndrome

OBJECTIVE

To evaluate nerve fiber density in vestibular specimens from women operated upon for vulvar vestibulitis.

METHODS

Forty-seven women with vulvar vestibulitis syndrome underwent modified posterior vestibulectomies. Vestibular specimens were analyzed after being stained for S-100 neural tissue protein. Women were followed up for 2 years.

RESULTS

In specimens from 44 of 47 patients, the densities and numbers of nerve fibers per square unit in the preparations were greater than those in specimens from six control women. In the patients, a statistically significant linear correlation was found between inflammation and nerve bundle density in the preparations (Spearman rank correlation coefficient rs=.41; P=.005). There were no signs of infectious etiology in any preparation. No or slight postoperative dyspareunia was reported by 38 of 42 women after 6 months, 36 of 39 after 12 months, and 26 of 28 after 24 months.

CONCLUSION

Vestibular neural hyperplasia may provide a morphologic explanation of the pain in vulvar vestibulitis syndrome.

Persistent vulvar vestibulitis: the continuing challenge

A continuing challenge in the management of women with vulvar vestibulitis is the patient who has not responded to surgical treatment. The main reason for persistent dyspareunia is failure to excise the sensitive periurethral tissue in the primary operation. In other cases, the Bartholin's glands may be the source of the pain. A low oxalate diet, the administration of interferon, and biofeedback training of the lower pelvic muscles-treatments that are used as a first-choice approach for vulvar vestibulitis, may all work in the postoperative patient. The management of a patient with residual vestibulitis should be conservative, and only when medical measures fail, do we consider additional surgical methods such as Bartholin's gland resection or repeat perineoplasty.

Severe vulvar vestibulitis. Relation to HPV infection

OBJECTIVE

To determine whether patients with human papillomavirus (HPV)-associated vestibulitis present differently from patients with HPV-negative disease and whether the presence of HPV is a predictor of the outcome of surgical treatment by perineoplasty.

STUDY DESIGN

Thirty-eight women with severe vulvar vestibulitis who underwent surgical perineoplasty were found to have HPV DNA in the vestibule by polymerase chain reaction. Thirty-six other women with severe vestibulitis had no HPV DNA in the surgical specimen. The two groups were compared with regard to demographic, social and medical variables as well as physical findings in the vestibule and response to operative treatment.

RESULTS

Both groups were found to be similar in respect to age (mean 25.9 +/- 7.93 versus 25.47 +/- 5.8, respectively), parity, education, smoking habits, contraceptive use, presence of primary vestibulitis, presence of dysuria and involvement of the whole vestibule (both anterior and posterior). More unmarried than married women were infected with HPV (P < .002). There was no significant correlation between the presence of HPV and the outcome of surgical treatment (P < .6, relative risk = 0.9, 95% confidence interval = 0.5-1.5).

CONCLUSION

Although HPV DNA was found in more than half of women with vestibulitis, it appears to play no role in the presentation or response to surgical therapy for vulvar vestibulitis.

Predicting the outcome of surgical treatment of vulvar vestibulitis

OBJECTIVE

To identify predictive factors for success or failure of perineoplasty for severe vulvar vestibulitis.

METHODS

Seventy-nine women with severe vulvar vestibulitis underwent perineoplasty by a single surgeon during 1992-1994. Sixty (76%) who experienced a complete response were compared with 19 (24%) who had an incomplete response. Using univariate and then multivariate (logistic regression) analysis, the two groups were compared with regard to preoperative demographic, social, and medical variables, as well as physical findings in the vestibule.

RESULTS

The complete- and incomplete-response groups were similar in all comparisons except for constant vulvar pain of vestibular origin (in addition to dyspareunia) and the presence of symptoms since first coitus. On multiple logistic regression, these characteristics had odds ratios (and 95% confidence intervals) of 4.97 (1.49, 16.63) and 5.83 (1.74, 19.55), respectively.

CONCLUSION

An incomplete response to perineoplasty may be anticipated in women with vulvar vestibulitis associated with dyspareunia since their first episode of intercourse and in those with associated persistent vulvar pain. Treatment approaches other than surgery should be considered for such patients.

The surgical treatment of vulvar vestibulitis syndrome: a follow-up study

This study evaluated the effectiveness of vestibulectomy in relieving coital pain and improving sexual function in women diagnosed with vulvar vestibulitis. Vulvar vestibulitis syndrome, a chronic, nonspecific inflammation of the vulvar vestibule, probably represents the most frequent subtype of premenopausal dyspareunia. Participants were 38 women who underwent vestibulectomy at a university hospital between 1986 and 1994. Telephone interviews were conducted to assess whether vestibulectomy or other subsequent treatments affected coital pain and sexual functioning. Length of postoperative follow-up ranged from 1.1 to 10 years, with a mean of 3.3 years. Vestibulectomy yielded a positive outcome for 63.2% of the participants and moderate to no improvement for the other 36.8%. The surgery was linked to a significant increase in intercourse frequency for the entire sample and to an increase in oral and manual stimulation for the women with successful surgical outcomes. No other factors were significantly associated with treatment outcome.

Combination of subtotal perineoplasty and interferon for the treatment of vulvar vestibulitis

PURPOSE

To evaluate the efficacy of a combination of subtotal perineoplasty and interferon (IFN) infiltration of the remaining anterior vestibule in the treatment of vulvar vestibulitis.

BASIC PROCEDURES

Nineteen women with vulvar vestibulitis were randomized to undergo either a total perineoplasty or a subtotal perineoplasty without removal of the anterior vestibule. The second group was further treated 6 weeks later with injection of the anterior vestibule by IFN. Differences in outcome between the groups were analyzed using Fisher's exact test.

MAIN FINDINGS

The combination of subtotal perineoplasty and IFN injections was successful in 7 of 10 women, similar to the outcome of the group undergoing total perineoplasty (6 of 9 patients).

CONCLUSION

A combination of subtotal perineoplasty and IFN injections to the anterior vestibule is as effective as total perineoplasty and has less surgical complications.

[Treatment of vulvar vestibulitis by posterior vestibulectomy. Twelve case reports]

Many patients with dyspareunia suffer from vulvar vestibulitis syndrome. When all conservative treatments have failed, surgery is attempted. We appreciated results and complications of this treatment. During 1993 and 1994, at the gynecological department of the intercommunal hospital of Creteil (France), twelve women suffering from this condition for longer than six months had undergone a posterior crescent-shaped vestibular excision followed by vaginal advancement. Three weeks after surgery, three partial dehiscences have been observed, which secondary healed. The average duration of follow-up was 8 months. The interview of the patients in January 1995 revealed: six patients obtained painless sexual intercourse, four patients improved significantly, one had no improvement and one complained of severe vulvar burning instead of dyspareunia. Our results are weighing against the initial enthusiasm to surgical treatment. Collaboration between gynecologists and psychologists to specify the indications and previous treatment of an associated vaginismus should be helpful for the treatment of these patients.

Vulvar vestibulitis subjects undergoing surgical intervention: a descriptive analysis and histopathological correlates

OBJECTIVE

We describe here a series of selected patients from an established vaginitis research clinic diagnosed with vulvovestibulitis (VV) who underwent surgical intervention for focal disease. Long-term results of surgical correction are reported and characteristic histopathology findings associated with vulvar vestibulitis are emphasized.

STUDY DESIGN

A retrospective chart review was carried out to extract relevant clinical, histologic, and outcome data. Tissue blocks of resected specimens were re-examined for specific inflammatory response.

RESULTS

Complete data and long-term follow up were available in 16 patients who underwent surgical intervention. All were cared for by the same practitioner (CM). The mean (+/- S.D.) age and gravidity on presentation were 26.9 +/- 5.3 years and 0.9 +/- 1.5, respectively. All but one was caucasian, and 70% were nulliparous. Symptoms included entry dyspareunia (100%), discharge (70%), burning (66%), itching (20%) and other (30%). All patients had focal tenderness; other findings were erythema (50%), acetowhite staining (80%), edema (20%), micropapules (20%) and condyloma (10%). After diagnosis, initial duration of conservative management was 9.4 +/- 6.9 months (1-26 months). No patients received interferon therapy. Because of persistent symptoms the 16 subjects underwent targeted partial perineoplasties. Initial histopathology results revealed chronic inflammation, parakeratosis, hyperkeratosis, edema, koilocytosis and acanthosis. When tissue blocks were cut and stained with Giemsa, large numbers of mast cells were identified. Mean postoperative follow up was 42.0 +/- 22.4 months (10-70 months). Follow up after surgery showed an overall improvement in 15/16 patients (93.8%).

CONCLUSIONS

VV affects primarily white, nulliparous women. In the carefully selected subject, surgical intervention has a high success rate, even on long-term follow up. Although the exact etiology for this condition has yet to be elucidated, the presence of mast cells supports an association with other genitourinary inflammatory syndromes such as interstitial cystitis; and allows for speculation about a possible role played by mast cell activation in the etiology of VV.

Simplified surgical revision of the vulvar vestibule for vulvar vestibulitis

OBJECTIVE

The prototype of surgical treatment for vulvar vestibulitis has been the Woodruff vulvoplasty. A simpler surgery could be less morbid, technically easier, and equally effective.

STUDY DESIGN

Twelve patients underwent vestibular revision, nine with local anesthesia. They were followed up for between 6 months and 6 years. Outcome was judged by ease of healing and relief of tenderness. This was a feasibility study.

RESULTS

Ten of 12 patients had complete resolution of vestibulitis. Two others had improvement. Other causes of dyspareunia remain in 2 subjects. Issues of patient histories, postoperative healing, and functional outcome are reported.

CONCLUSION

A simple surgery seems well suited to this problem. Additional causes of dyspareunia need to be recognized preoperatively and clarified. Development of granulation tissue in areas of wound separation can create sites of continued pain. Postoperatively, reflex vaginismus should be expected and needs therapy to complement the surgical treatment.

Perineoplasty compared with vestibuloplasty for severe vulvar vestibulitis

OBJECTIVE

To evaluate the efficacy of vestibuloplasty (vestibular undercutting without excision) to treat severe vulvar vestibulitis.

DESIGN

Prospective randomisation of patients scheduled for surgery to undergo either perineoplasty or vestibuloplasty. Differences in outcome between groups were analysed using Fisher's exact test.

SETTING

The Vulvar Clinic and referral centre for vestibulitis, Kupath Holim Health System, Department of Obstetrics and Gynaecology, Carmel Medical Centre, Rapapport Faculty of Medicine, Hatechnion, Haifa, Israel.

SUBJECTS

Twenty-one women with vulvar vestibulitis.

RESULTS

Vestibuloplasty failed to relieve symptoms in 10 women, while perineoplasty resulted in complete resolution of symptoms in 9/11 women (P < 0.002).

CONCLUSIONS

The poor outcome of vestibuloplasty, if also reported by other centres, may render it an unacceptable treatment for vulvar vestibulitis. Vestibuloplasty aims to denervate sensitive vestibular tissue, and its failure may suggest that innervation disturbances are not the main cause of the syndrome.

Focal vulvitis: a psychosexual problem for which surgery is not the answer

In the last decade focal vulvitis has been identified as a distinct syndrome, characterized by unexplained burning vulvar pain and superficial dyspareunia. A 'Woodruff perineoplasty' has been recommended as a treatment method. A research project was conducted, investigating the long-term results of surgical treatment and the etiology of focal vulvitis. Results showed that the great majority of women continued to suffer from focal vulvitis after the operation, which leads to the conclusion that the procedure should be abandoned. Retrospective data revealed several immediate causes of mechanical and chemical irritation of the vulva. All women exhibited 'inadequate sexual behavior': having intercourse without a sufficient amount of lubrication and/or in the presence of hypertonia of the pelvic floor. Psychosexual processes were further characterized by deterioration of sexual and general well-being, resulting in lack of libido and depression, which contributed considerably to the problem. An integrated approach to treatment is recommended, which incorporates protection of the vulvar skin, relaxation of pelvic muscles and sexological treatment of the psychosexual and relational aspects.

Outpatient management of Bartholin gland abscesses and cysts with silver nitrate

This study reports results of 52 patients with Bartholin abscesses or cysts who were managed by silver nitrate stick insertion into the cyst or abscess cavity for 48 hours. All patients showed complete healing within 15 days. However, 2 (3.8%) had recurrences within the first 2 months; 1 of these patients was treated with excision and the other by repetition of the same method with no further complaints. Silver nitrate application for Bartholin cysts or abscesses was found to be an effective, simple, inexpensive and the least anaesthetic requiring procedure, which can easily be carried out in the outpatient setting.

Necrotizing fasciitis of the vulva

OBJECTIVE

We attempted to characterize the natural history of necrotizing fasciitis of the vulva.

STUDY DESIGN

The records of 29 nonpregnant women with necrotizing fasciitis of the vulva were evaluated.

RESULTS

These women experienced a rapidly progressing polymicrobial infection. Initially, the infections in many women were thought to be labial cellulitis, appearing mild and innocuous. Delays in recognition and aggressive surgical management were associated with increased morbidity and mortality. Of 15 women with a delay greater than 48 hours between presentation and treatment, 11 died. Twenty of 29 (69%) were diabetic, accounting for 11 of the 14 deaths.

CONCLUSION

Early diagnosis and aggressive surgical debridement in spite of mild symptoms will improve outcome in this serious disease process.

CO2 laser for suppurative hidradenitis of the vulva

Chronic suppurative hidradenitis is a disease of the apocrine glands occurring predominantly in the axillae of the anogenital region. Treatment, to date, has been frustrating. Prolonged antibiotic therapy and multiple incisions and drainage have been the usual form of therapy, but those surgical procedures leave patients with ugly scars; retracted, hypertrophic skin edges; and pitted, indurated and disfiguring abscesses. The only successful treatment to date has been wide excision of the entire apocrine gland-bearing tissues, such as radical vulvectomy, which often necessitates grafts to cover the surgically exposed areas. That has left patients with unsatisfactorily functioning vaginas and a mutilated appearance. Recently we instituted the use of the CO2 laser to treat these patients with the goal of eradicating the suppurative sinus tracts and the infected apocrine glands without removing large volumes of adjacent, unaffected tissue. Over the past eight years we treated 11 patients who had extensive, chronic hidradenitis of the anogenital area with the CO2 laser. The use of laser therapy for these patients has produced effective and less-mutilating results. Such treatment has been a successful option for treating this debilitating disease.

Vulvar vestibulitis--subgroup with Bartholin gland duct inflammation

Some women with vulvar vestibulitis have tenderness at the Bartholin gland duct opening and associated dyspareunia. Forty-four patients with severe incapacitating dyspareunia of up to 5 years' duration were studied. Microscopic examination revealed a chronic inflammation located near the Bartholin gland duct opening. No etiologic agent was evident. Of 30 women treated initially with laser vaporization of inflamed areas, 13 (43%) showed significant improvement. Sixteen patients were treated with perineoplasty and all improved significantly; all became functional sexually although eight had previously failed laser therapy. Women with vulvar vestibulitis can be identified easily with a simple Q-tip touch technique directed at the duct opening. This diagnosis should be considered in the evaluation of women with obscure etiologies of dyspareunia.

[Perineoplasty for vulvar vestibulitis]

28 premenopausal women with severe dyspareunia were diagnosed as having vulvar vestibulitis. A modified perineoplasty, consisting of removal of the vestibule and exteriorization of the vagina to cover the denuded area and to relax a tight perineum, was performed. 70% of 26 women with adequate follow-up experienced significant relief of vulvar discomfort. In young women with dyspareunia, vestibulitis may be a significant, remediable, causative factor.

Vulvar vestibulitis syndrome

Eighty-six patients were treated for vulvar vestibulitis syndrome. Prospective history forms and retrospective questionnaires were used to identify the frequency of various features of this condition and to assess the subjective responses of the patients to various methods of therapy. The term vulvar vestibulitis syndrome should be adopted as the standard description of this disorder.

Focal vulvitis: a characteristic syndrome and cause of dyspareunia. Features, natural history, and management

Based on the study of 67 affected women during a period of 15 years, we report the clinical features and natural history of focal vulvitis, a unique syndrome characterized by severe and persistent superficial dyspareunia and the presence of one to 11 (median three) minute, exquisitely tender areas of focal inflammation or ulceration on the mucosa of the vestibule. Three fourths of all lesions occur around the Bartholin gland ducts or between them posteriorly. Histopathologic study of tissues from seven patients has not shown a characteristic pattern of inflammation and fails to confirm a reported association between these lesions and the minor vestibular glands. These histologic studies and an in-depth clinical and epidemiologic investigation in nine patients, including microbiologic studies to identify infection by herpes simplex virus. Neisseria gonorrhoeae, Staphylococcus aureus, beta-hemolytic streptococci, Chlamydia trachomatis, mycoplasmas, Candida sp., trichomonads, or Mycobacterium sp., have not established an infectious etiology for this syndrome or evidence that it represents an unusual form of an autoimmune disease or Behcet's syndrome. Treatment with topical antimicrobial or corticosteroid creams, antibiotics given systemically, or cryotherapy has not been of demonstrable benefit. Approximately one half of patients eventually experience spontaneous remission but many appear to remain symptomatic indefinitely. Surgical excision of the hymenal ring and contiguous mucosa of the vestibule has brought relief and permitted resumption of sexual activity in seven of eight treated patients. While promising, operation should be reserved for patients who have experienced unremitting dyspareunia associated with the characteristic focal inflammatory lesions for at least 6 months.

Treatment of abscesses in the vulva. Conventional open treatment versus primary suture under antibiotic cover

Seventy patients were treated for a subcutaneous abscess in the vulva. In 35 consecutive patients the abscess was treated conventionally with deroofing of the abscess and wet dressings. In the other 35 consecutive patients the abscess was treated by incision, curettage and primary suture under antibiotic cover with a single dose of clindamycin. In the conventionally treated group the median stay in hospital was 7 days and the median healing time 18 days. In the group treated by primary suture the median stay in hospital was 2 days and the median healing time 7 days (P less than 0.0001). Recurrence of abscess was observed in one patient in each group. No other complications were observed in either group. It is concluded that vulvar abscesses may be treated safely and advantageously by primary suture under antibiotic cover.

Advanced hidradenitis suppurativa of the vulva. A report of three cases

Advanced suppurative hidradenitis resulting from chronic, progressive, inflammatory involvement of apocrine sweat glands often fails to respond to conservative treatment. Extensive surgical excision of all the infected areas with aggressive postoperative wound care in two of three patients provided relief from this debilitating disease. Skin grafting promoted wound healing in addition to improving cosmetic results. Advanced chronic hidradenitis suppurativa of the vulva should be treated with surgery, and conservative management is justifiable only if preparatory to surgical excision.