VULVAR DISORDERS LISTED.....(some)

[Guest guest]

HI Everyone, cleaning out some files (can't sleep) and looking for something else I ran across this one. I think you'll enjoy it. It discusses various vulvar disorders and some treatments. Certainly not everything is listed as I'm certain this is a shorter version of a longer one I have somewhere. Fair warning it is long. ; ) I think 'newbies' may find it enlightening as well as some of us 'oldies' *chuckle* to refresh our memories.

Dee ~ ; )

Vulvar Disorders The Primary Care of Women -

Signs and Symptoms of Vulvar Disorders Pruritis - This is the most common symptom of vulvar disease. Itdenotes intense itching and/or burning. Ulcerative lesions - These suggest a granulomatous sexually transmitteddisease or cancer. Appropriate cultures or biopsies (if suspect cancer)should be diagnostic. Solid tumors - May represent cancer. These should be widely excised andsent for microscopic/pathologic examination. Usually solid tumors arewell circumscribed. Skin dystrophy (white lesions) - These represent a variety ofconditions. Colposcopy should be performed to identify those areas mostrepresentative of disease and biopsies submitted from these areas. Fullthickness biopsies should be sent. Pigmentation - Color changes depend on the vascularity of the dermis,the thickness of the epidermis and the amount of either melanin or bloodpigment present. a.. It may appear white due to decrease in vascularity (lichensclerosus) or increase in the keratin layer (lichen simplex). Vitiligo,a hereditary disorder, results from a loss or absence or melanin,presents as a white lesion. Leukoderma is also a white lesion thatoccurs as a temporary loss of pigment in a scar formation followinghealing of an ulcerated area.

b.. Red lesions are produced by a thinning or ulceration of theepidermis, a vasodilatation of inflammation or an immune reaction, orthe neovascularization of a neoplasia. Acute candidiasis is an exampleof vulvar erythema due to inflammation and a local immune response.There is an invasive dermoid cancer that produces a velvety red lesionthat spreads over the entire vulva. Psoriasis and Paget's disease alsoproduce red lesions.

c.. Dark lesions result from an increase in amount orconcentration of melanin or blood pigment. Transient dark lesions occurfollowing trauma. A persistent dark lesion is usually a nevus or amelanoma. Melanosis is a benign, darkly pigmented, flat lesion that isoften confused with melanoma. Finally, vulvar skin may darken followingapplication of estrogen cream as it gets healthier.

Vulvar Dystrophies

Lichen Simplex ChronicusLichen simplex chronicus is a hypertrophic dystrophy that results fromchronic vulvovaginal infection or chronic irritation. It is also termedneurodermatitis. It manifests as a well demarcated plaque usually foundon the labia majora and is associated with hyperpigmentation andlichenification (increased skin markings). Occasionally it presents as ahyperkertanized lesion and if it becomes chronic, the lesion should bebiopsied to exclude dysplasia.

The presenting complaint is pruritis, which persists after the original cause of the itching has resolved. An "itch-scratch-itch" cycle begins the chronic pruritic condition, which may result in the development of nodules. Topical steroids and antihistamines help to control itching. However, behavior modification to interrupt the itching cycle may need to be implemented.Lichen PlanusThis condition is an erosive or desquamative infection of the vulva thatco-exists with desquamative vaginitis. (DIV) The disorder occurs mostfrequently among women over the age of 40 and presents with complaints of dyspareunia, chronic burning, pruritis, and seropurulent orserosanguinous discharge. In addition, oral lesions are found in morethan half of patients. The vaginal vestibule and the inner aspects ofthe labia minora appear erythematous and eroded with scalloped borders. White papules or erosions are visible on the vulva.

Highly keratinized areas on the perineum reveal the characteristic flat-topped, polygonal plaques that are found on nonmucosal areas. As the condition progresses, the clitoral hood may become fused and scarring of the vulva is evident by resulting hypopigmentation. Within the vagina, erosions are common and over time, scarring and a foreshortening of the vaginal vault itself may result in difficulty in speculum examination.Skin biopsy establishes the diagnosis. It is important to excludedysplasia in hypertropic, white lesions. Treatment employs medium tohigh-potency steroid creams. For resistant or highly keratinizedlesions, intralesional injection or systemic steroid treatment isnecessary. Use of hydrocortisone vaginal suppositories help reducescarring as well as treating the symptoms.Lichen SclerosusThis disorder is the most common cause of atrophic dystrophy. Its originis unknown, but suspected to be autoimmune, it is a chronic condition that usually affects postmenopausal, caucasian women. During the initial onset, the lesions or tissue may be reddish or purple in appearance and involve the vulva, perinuem and perianal areas. As the condition progresses, polygonal ivory-colored plaques appear.

In the anogenital area, the lesions may be pink orhypopigmented with a "crinkling" appearance that occur as result ofatrophy. With chronicity, abrasions become apparent and a resorption ofthe labia minora and scarring of the clitoral hood occurs. This producesthe hourglass configuration characteristic of the disease. Vaginalinvolvement does not occur, differentiating this condition from lichenplanus.Intense pruritis (itch) is the primary complaint but not always and can become debilitating as the condition progresses. In older women, the course is chronic and progressive. The incidence of malignancy is as high as 4-6% and therefore, biopsy should be performed periodically to exclude development of dysplasia. Treatment consists of application of bland emollients and topical steroids. Testosterone ointment 2% has been helpful in some individuals and in some cases the use of estrogen creams to restore architecture has proven helpful. Vulvectomy and laser surgery has not proved to be beneficial as the condition recurs in the remaining tissue and is not suggested.

Estrogen DeficiencyLoss of estrogen results in atrophy, dryness and fragility of the vulva.This may lead to development of fissures, splits, erosions and dyspareunia. (painful sex) The labia majora become atrophic, hypopigmented and experience a loss of hair. The labia minora appear to be reabsorbed into the majora and the introitus may decrease in size and become stenotic (narrowed) . Changes in the vaginal flora secondary to loss of estrogen result in increased incidence of vulvovaginal infections.

Hypoestrogenic conditions, (low estrogen) such as hysterectomy, perimenopause and menopause, produce a thinning of the vaginal and vulvar epithelium due to the loss of adipose tissue. These tissues are subject to increased irritation, abrasion and dermatologic conditions as the result of the loss of elastic support and lubrication which contains lactobacilli that maintain the vaginal environment.

Women complaining of dyspareunia (painful sex) and a scant, watery discharge (may be blood tinged) may be experiencing atrophic vaginitis regardless of age. Using pH paper, test the vaginal environment. A finding of 6.0 to 7.0 in the absence of other infection is a sign of poor estrogen support and a likelyhood of atrophic vaginitis.

Psoriasis of the VulvaThis condition is a common finding and usually appears on the monssymphysis and labia as erythematous plaques. Occasionally the lesionsare covered by a silvery-white micaceous scale, which are diagnostic.The lesions are variably pruritic and may extend to the labiocruralfolds where painful fissue formation occurs. Psoriasis does not extendinto the vagina. Treatment consists of soaks and low-potency steroidcreams.Vulvodynia - Painful vulva

This term refers to the condition of chronic vulvar discomfort that isdescribed as burning, stinging or rawness for which 'no cause' can beidentified. In actuality, the causes are likely multiple. A subdivisioninto 5 groups distinguishes findings and similar complaints. The firstfour have a basis for etiology, while the last group does not.Vulvar dermatoses, which include lichen sclerosus, lichen planus andcontact dermatitis, comprise the first three in the group.

Cyclic candidiasis or recurrent yeast infections are identified in the second group.

Squamous papillomatosis that surround the vulvar vestibule and the posterior introitus, form the third group. These lesions were once believed to be normal findings but are now thought to result from HPV.

Vulvar vestibulitis comprises the fourth category and is characterized by pain to vestibular touch or vaginal entry and by vulvar erythema. Lidocaine preparations and intralesional injections of interferon have provided some relief in the category."Essential" or dysesthetic vulvodynia has no cause and is the finaland fifth category.

The diagnosis of Essential vulvodynia is made after exclusion of other sources from the first four categories. Patient history of burning that may be debilitating and extreme discomfort on palpation assist in arriving atthe diagnosis. It may be considered a pudendal neuralgia and tricyclicantidepressants may be useful in treatment. (Postherpetic neuralgia andglossodynia have responded in a positive way to tricyclicantidepressants.) Amitriptyline 10 mg q hs and increasing to 75 mg qdhas been recommended.

Other conditions:

Diabetes MellitusDiabetes is most commonly associated with chronic pruritus vulvae. It iscaused by chronic vulvovaginal candidiasis. Glycosuria is not requiredto develop this condition. Systemic control is necessary, however,because the vulvar skin in uncontrolled diabetes undergoeslichenification and secondary infection. Such infection may result inacute vulvar abscesses, chronic subcutaneous abscesses and drainingsinuses. Management consists of diabetic control and treatment of yeast.Crohn's DiseaseA small percentage of women with this disorder develop primarynoncaseating granulomas on the vulva. They manifest as painful,indurated areas of swelling with fistulas or draining sinuses.Recalcitrant conditions often indicate active GI disease and surgery maybe necessary. Secondary manifestations include aphthae, erythema nodosumand puoderma gangrenosum.Bechet's DiseaseThis is a rare disorder characterized by recurrent oral and genitalulcerations and development of uveitis. In addition, arthritis,thrombophlebitis and CNS involvement may also exist. The cause isunknown. Lesions on the vulva appear as shallow ulcers on the labiaminora and usually do not extend into the vagina. As the diseaseprogresses, the lesions become larger and deeper and may result in scarformation. If the disease is severe, the eye and CNS are involved andprompt treatment with systemic steroids is necessary.