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Genitourinary syndrome of menopause is a comprehensive term that groups genital, urinary and sexual signs and symptoms mainly due sex hormone deficiency and aging, with a crucial impact on quality of life of midlife women. While this broad definition captures the common underlying physiopathology and the frequent overlap of symptomatology, improving knowledge about different components of genitourinary syndrome of menopause may be relevant for individualized treatment, with possible implications for efficacy, compliance and satisfaction. This narrative review focuses on the vulvar component of genitourinary syndrome of menopause, highlighting anatomical and functional peculiarities of the vulva that are responsible for some of the self-reported symptoms, as well as specific signs at physical examination. Increasing evidence points towards a pivotal role of vulvar vestibular health in the occurrence of sexual pain, one of the most common and distressing symptoms of genitourinary syndrome of menopause, which should be evaluated with validated scales taking a biopsychosocial perspective. This is an essential step in the recognition of different phenotypes of genitourinary syndrome of menopause and in the assessment of the most effective diagnostic and therapeutic algorithm. Menopausal vulvar health deserves more research into tailored non-hormonal and hormonal treatment options., Competing Interests: Declaration of competing interest Rossella E. Nappi had past financial relationships (lecturer, member of advisory boards and/or consultant) with Boehringer Ingelheim, Ely Lilly, Endoceutics, HRA Pharma, Procter & Gamble Co, TEVA Women's Health Inc. and Zambon SpA. At present, she has on-going relationship with Abbott, Astellas, Bayer HealthCare AG, Besins Healthcare, Exeltis, Fidia, Gedeon Richter Merck Sharpe & Dohme, Novo Nordisk, Palatin Technologies, Pfizer Inc., Shionogi Limited, Theramex, and Viatris. None of these are relevant to the present work. All the other authors have nothing to disclose., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Competing Interests: Competing interests: None declared.

Objective: To evaluate the use of a novel skin barrier protectant in a patient treated with radiotherapy for vulvar cancer., Methods: This case report was conducted in a radiotherapy department with two women undergoing radiotherapy for vulvar carcinoma. A novel skin barrier protectant was evaluated in one patient; the other underwent the institutional standard skin care protocol. Skin reactions and pain were evaluated using the Radiotherapy Oncology Group Criteria., Main Results: The patient who was treated with the skin protectant showed accelerated healing toward the end of radiotherapy, and this was accompanied with a decrease in pain (maximum pain score 6/10). In comparison, the patient treated with the standard skin care protocol had an extended healing process, experienced a higher pain level (maximum pain score 9/10), and required more nursing care., Conclusions: This case report is the first to suggest that this novel skin barrier protectant could effectively manage acute radiodermatitis in patients with cancer. This case report hopes to lay the foundation for future randomized controlled trials with a larger and broader patient population.

Background: Device-based therapeutic approaches have been developed to treat women’s genitourinary post-menopausal symptoms. Fractional carbon dioxide laser resurfacing (FxCO2) has been demonstrated to be safe and effective in the treatment of GSM symptoms, however the results begin to wane by 12-months post-treatment., Objective: This study aims at assessing the application of an at-home transvaginal red and infrared light device as a maintenance treatment commencing 12 months following FxCO2 laser treatment for genitourinary syndrome of menopause (GSM)., Study Design: Subjects completing 12-month follow-up after three fractional CO2 laser vulvovaginal treatments received an at-home device and monitored for GSM symptoms with long-term follow-up to 12 months (2 years post-laser)., Methods: 10 post-menopausal subjects completing 12-months follow-up after three FxCO2 vulvovaginal treatments for GSM were treated with an at-home red and infrared LED device. Treatment consisted of intravaginal application three times per week, and subjects were followed to 1, 3, 6, and 12 months. Subjects completed the vaginal assessment scale subject satisfaction, and QUID to assess for vulvovaginal and stress urinary incontinence (SUI) symptoms., Results: Vulvovaginal symptoms measured by VAS were mean 89% improved at 12-month follow-up after FxCO2 and maintained at 73% improved over baseline (2 years post-laser) following an additional 12 months of at-home transvaginal light therapy (P<0.05). VAS symptoms gradually increased over the 12 months maintenance period by a mean of 17% (P<0.05). Mean subject satisfaction was 0 at baseline, 1.86 at 1 year following FxCO2, and 1.00 after an additional 1 year of at-home light therapy. SUI symptoms as measured by QUID were mean 81% improved at 12-month follow-up after FxCO2and maintained at 38% improved over baseline (2 years post-laser) following an additional 12-months of at-home light therapy (P<0.05). SUI symptoms gradually increased by a mean of 43% over the 12-month maintenance period (P<0.05)., Conclusions: At-home transvaginal red and near infrared light therapy commencing at 12 months post-FxCO2 vulvovaginal treatment in a post-menopausal population maintained statistically significant improvements in vulvovaginal and SUI symptoms over the additional12-month period (2 years post-laser); however, a gradual return of symptoms suggests that laser re-treatment or combination withhormone therapy may be necessary to maintain optimal outcomes.J Drugs Dermatol. 2020;19(11):1076-1079. doi:10.36849/JDD.2020.1012.

Common benign chronic vulvar conditions include genitourinary syndrome of menopause (formerly called vulvovaginal atrophy), lichen sclerosus, lichen planus, lichen simplex chronicus, and vulvodynia. Genitourinary syndrome of menopause results from the hypoestrogenic state that leads to atrophy of normal vulvar and vaginal tissues. It is typically treated with lubricants, moisturizers, and intravaginal estrogen. Lichen sclerosus is an inflammatory condition characterized by intense vulvar itching. It is treated with topical steroids or, in some cases, topical calcineurin inhibitors. Patients with lichen sclerosus are at risk of vulvar squamous cell carcinoma and should be monitored closely for malignancy. Lichen planus is an inflammatory autoimmune disorder that can affect the vulva and vagina in addition to other skin and mucosal surfaces. The first-line treatment is topical steroids, and significant scarring can occur if left untreated. Lichen simplex chronicus manifests as persistent itching and scratching of the vulvar skin that leads to thickened epithelium. Breaking the itch-scratch cycle, often with topical steroids, is the key to treatment. Vulvodynia is a common vulvar pain disorder and is a diagnosis of exclusion. A multimodal treatment approach typically includes vulvar hygiene, physical therapy, psychosocial interventions, and antineuropathy medications.

Objective: To assess the efficacy of non-hormonal, hyaluronic acid (HLA)-based vaginal gel in improving vulvovaginal estrogen-deprivation symptoms in women with a history of endometrial cancer., Methods: For this single-arm, prospective, longitudinal trial, we enrolled disease-free women with a history of endometrial cancer who underwent surgery (total hysterectomy) and postoperative radiation. Participants used HLA daily for the first 2 weeks, and then 3×/week until weeks 12-14; dosage was then increased to 5×/week for non-responders. Vulvovaginal symptoms and pH were assessed at 4 time points (baseline [T1]; 4-6 weeks [T2]; 12-14 weeks [T3]; 22-24 weeks [T4]) with clinical evaluation, the Vaginal Assessment Scale (VAS), Vulvar Assessment Scale (VuAS), Female Sexual Function Index (FSFI), and Menopausal Symptom Checklist (MSCL)., Results: Of 43 patients, mean age was 59 years (range, 38-78); 54% (23/43) were partnered; and 49% (21/43) were sexually active. VAS, VuAS, MSCL, and SAQ (Sexual Activity Questionnaire) scores significantly improved from baseline to each assessment point (all p < .002). FSFI total mean scores significantly increased from T1 to T2 (p < .05) and from T1 to T4 (p < .03). At T1, 41% (16/39) felt confident about future sexual activity compared to 68% (17/25) at T4 (p = .096). Severely elevated vaginal pH (>6.5) decreased from 30% (13/43) at T1 to 19% (5/26) at T4 (p = .41)., Conclusion: The HLA-based gel improved vulvovaginal health and sexual function of endometrial cancer survivors in perceived symptoms and clinical exam outcomes. HLA administration 1-2×/week is recommended for women in natural menopause; a 3-5×/week schedule appears more effective for symptom relief in cancer survivors., Competing Interests: Declaration of competing interest Outside the submitted work, Dr. Jewell reports personal fees from Covidien/Medtronic. All other authors have no conflicts of interest to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Sexual difficulties and vulvovaginal changes are common for women undergoing, and following, cancer treatments. These changes have significant impacts on quality of life and significant relationships. The current study aimed to (1) evaluate women's interest and attendance in a group-based educational workshop to address changes in vulvovaginal health and sexuality after cancer, and (2) describe participant characteristics and presenting concerns., Methods: Two hundred eighteen women with a history of cancer expressed interest in receiving information about the workshop and completed phone screening. Interested women (n = 156) completed an online questionnaire package examining vulvovaginal health and sexual function prior to attending the workshop., Results: Approximately 75% of the women who completed screening attended the workshop. Clinically significant sexual distress was reported by 91% of participants, and 97% of sexually active participants exceeded the threshold for sexual dysfunction (per FSFI). Women within 1-2 years of diagnosis tended to report less sexual distress, less severe vulvovaginal symptoms, and less impact from these symptoms compared to women farther out from diagnosis. While the majority of women reported vaginal dryness and pain during intercourse, only a minority reported engaging in health promotion strategies sufficient to expect symptom improvement., Conclusions: The current study suggests that group-based educational workshops for vulvovaginal and sexual concerns are utilized by patients and should be offered to women well into disease survivorship. Workshops targeting vulvovaginal symptoms and sexual concerns may be a cost-effective method of reducing sexual distress and improving patients' sexual function and quality of life.

Objective: Genital hiatus (Gh) and perineal body (Pb) are part of the Pelvic Organ Prolapse Quantification assessment system, but it is unclear whether measurements should be taken at rest or on Valsalva. This study was designed to assess the predictive value of Gh and Pb measurements obtained at rest and on Valsalva for signs and symptoms of pelvic organ prolapse (POP)., Methods: This is a retrospective study involving 416 women who presented to a tertiary urogynecology unit with symptoms of pelvic floor dysfunction. Genital hiatus and Pb were measured at rest and on maximal Valsalva. The strength of association between binary markers of POP and measurements of Gh/Pb was estimated using logistic regression analysis. Receiver operator characteristic statistics were used to compare predictive values of Gh and Pb measurements obtained at rest and on Valsalva., Results: A total of 451 women were seen during the study period. Thirty-five were excluded owing to missing data, leaving 416. Fifty-four percent (n = 223) complained of POP symptoms. On examination, 80% (n = 332) had significant POP (stage 2+ in anterior or posterior compartments or stage 1+ in the central compartment). On imaging, significant POP was diagnosed in 66% (n = 275). Mean hiatal area was 22 cm (SD, 7; range, 5-49 cm) at rest and 30 cm (SD, 10; range, 11-69 cm) on Valsalva. Genital hiatus and Pb measured on Valsalva were consistently stronger predictors of prolapse symptoms and objective prolapse (by clinician examination and by ultrasound) than at Gh and Pb measured at rest. The corresponding area under the curve values were significantly larger for Gh/Pb measures on Valsalva after adjusting for multiple confounders., Conclusions: Genital hiatus/Pb measured on maximal Valsalva is a superior predictor of symptoms and signs of POP compared with Gh/Pb at rest.

Trichomonas vaginalis is an extracellular parasite that colonizes the human urogenital tract leading to trichomoniasis, the most common sexually-transmitted non-viral disease worldwide. The immune response plays a critical role in the host defense against this parasite. Trichomonas' DNA contains unmethylated CpG motifs (CpGDNA) that in other microorganisms act as modulators of the immune response. However, the molecular mechanisms responsible for CpGDNA immune modulation are still unclear. As macrophages participate in the first line of defense against infection, we investigated the type of immune response of murine macrophages to T. vaginalis DNA (TvDNA). We observed high expression of the proinflammatory cytokines IL-6 and IL-12p40 in macrophages stimulated with TvDNA. In contrast, the anti-inflammatory response, assessed by IL-10 and IL-13 mRNA expression was delayed. This suggests that the immune response induced by TvDNA is modulated through cytokine production, mediated partly by NADPH-oxidase activity, as TvDNA induced reactive species of oxygen production and a rounded morphology in macrophages indicative of an M1 phenotype. Furthermore, infected mice pretreated with TvDNA displayed persistent vulvar inflammation and decreased parasite viability consistent with higher proinflammatory cytokine levels during infection compared to untreated mice. Overall, our findings suggest that TvDNA pretreatment modulates the immune response favouring parasite elimination.

Cancer treatment may result in loss of ovarian function through surgical removal of the ovaries, chemotherapy or radiation. While menopausal symptoms, such as hot flushes, night sweats, sleep disturbance, memory concerns and mood issues can be extremely bothersome to some women going through menopause naturally, women who undergo an induced menopause usually experience more sudden and severe symptoms. Pain and vaginal dryness can occur whether a woman has a sexual partner or not. In women with breast cancer, the aetiology of impaired sexual functioning, and lowered sexual desire, is often multifactorial, and may be related to physical and/or psychological reasons. Pain and vaginal dryness in women without a history of breast cancer can usually be safely treated with vaginal estrogens, in the form of a cream, pessary or ring, and simple lubricants or vaginal moisturisers. Safe usage of vaginal estrogen replacement therapy in breast cancer patients has not been studied within randomised clinical trials of long duration; the guidelines below reflect a clinical consensus.

Vulvovaginal atrophy is a condition that affects women, although it is mainly associated with the onset of menopause mainly due to hormonal changes vulvovaginal laxity and mucosal atrophy can also affect women at different life stages such as after pregnancy or for cancer patients who have undergone chemo or endocrine therapy. This condition negatively influence quality of life, sexual desire, and self-confidence. Many therapies have been considered mainly with inconclusive or transient results in terms of benefit factor. Recently, a new non-invasive product, containing hyaluronic acid, oligopeptides, and antioxidants was introduced to the market. Its name is "Primavera," by Renaissance, Italy. The aim of this product is to allow a vulvo-vaginal biostimulation and considered simple, safe, and satisfactory., (© 2018 Wiley Periodicals, Inc.)

The study aimed to assess the effects of ospemifene on vulvar vestibule in postmenopausal women with vulvar pain and dyspareunia. Fifty-five postmenopausal women used oral ospemifene 60 mg/d for 60 d. Symptoms of dryness, burning, and dyspareunia were evaluated on a 10 cm visual analog scale. Visual examination of the vulvar vestibule was also conducted. Patients also underwent current perception threshold (CPT) testing obtained from the vulvar vestibule. Fifty-five patients (94.6%) completed the treatment. Hot flashes were the most frequent adverse effects, but this led to a discontinuation of therapy in three patients (5.4%). After therapy, there was a statistically significant decrease from the baseline in the mean scores for dryness, burning, and dyspareunia and reduction of vestibular trophic score (baseline value of 11.2-4.2 after the therapy, p ≤ 002) and cotton swab test scores (2.81 compared with 1.25, p = .001). There was a difference in CPT values for all nerve fibers and more consistent for C fibers (-38% of sensitivity). These results confirm the efficacy of ospemifene on postmenopausal vestibular symptoms and signs; moreover, the drug was effective in normalizing vestibular innervation sensitivity.

The aim of the study was to verify the efficacy of vulvar Visnadine spray in premenopausal women affected by female sexual arousal disorder (FSAD). Thirty-eight women aged 25-40 years affected by FSAD were enrolled in the randomized crossover study, by two possible sequences: on-demand, washout, daily (A sequence); and daily, washout, on-demand (B sequence). The Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale (FSDS) were used to assess sexual function and sexual distress, respectively. Color Doppler ultrasonography was used to measure clitoral blood flow. The study had two follow-ups at 30 (T1) and 60 days (T2). Thirty-one women completed the study. Mean (SD) sexual activity and vulvar Visnadine spray usage was 1 ± 0.9 weekly during on-demand administration for both the sequences (Vs T0, p = NS). The mean sexual activity during daily usage was 2 ± 0.9 (Vs T0, p < .004) and 2 ± 0.8 (Vs T0, p < .001) for A and B sequences, respectively. FSFI total score, particularly genital arousal, improved more during the daily than during on-demand phases of both sequences (p < .001). Finally, clitoral blood flow improved significantly during daily usage of both the sequences (p < .001). Our study suggests that vulvar Visnadine spray could improve sexual performance of women affected by FSAD, producing changes in subjective and objective sexual aspects.

Background: Vulvodynia is a frequently missed pathology, often confused with vaginismus. The Q-tip test (QTT) is fundamental for the diagnosis; however, there is lack of data about its performance in asymptomatic women., Objective: This study intended to evaluate the QTT for painful vestibular spots in asymptomatic women., Methods: Q-tips were gently pressed at different areas of the vulvar vestibule to obtain a 0-10 score representing the pain felt. This was performed in 267 consecutive patients presenting to the gynecology outpatient clinic for reasons other than vulvovaginal complaints. A questionnaire was done to evaluate the possibility of unrecognized vulvodynia., Results: Out of the 267 women, 18 (6.7%) fitted the diagnosis of vulvodynia and were excluded from the analysis. Of the remaining 249, 41 (16.5%) had a positive QTT. We could not find differences in the sexual activity rate between women with and without a positive QTT. No demographic differences could be found between the two groups. Only depression was more common in women with a positive QTT [31.7% (13/41) versus 10.8% (21/208), p=.001)., Conclusions: Asymptomatic women can have painful vestibular spots in the absence of vulvodynia. A positive QTT cannot be considered equivalent to vulvodynia, highlighting the need for extensive workup of these women before that diagnosis can be assumed.

Background and Objective: Vaginal childbirth, natural process of aging, congenital factors, and surgical interventions are considered the main causes of vulvo-vaginal laxity driven by changes in collagen and elastin fibers. This causes a loss of strength and flexibility within the vaginal wall. As a result, women may experience lack of sensation and stress urinary incontinence (SUI)-the condition of involuntary loss of urine associated with activities that cause an increase in intra-abdominal pressure (eg, sneezing, coughing, and lifting). Both vaginal laxity and urinary incontinence significantly affect patients' quality of life (QoL). The aim of this study was to evaluate efficacy and safety of a noninvasive radiofrequency device when used to treat SUI and vulvo-vaginal laxity through its heating effect which stimulates collagen and elastin fibers., Methods: Twenty-seven women (average age 44.78±10.04 years) with indications of mild/moderate SUI as well as vulvo-vaginal laxity were treated with a monopolar radiofrequency device. The treatment course consisted of three once-a-week sessions. Each session included intravaginal treatment followed by treatment of labia majora and the perineum. Improvement in the SUI condition was evaluated by applying the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-UI SF). Data were collected at the baseline, after the last treatment and at 1-month follow-up visit. Vaginal laxity was assessed by subjective vulvo-vaginal laxity questionnaire (VVLQ). Data were collected before the 1st treatment and during the 1-month follow-up visit. Patient's satisfaction was recorded using a satisfaction questionnaire. Data were collected after the last treatment and at the 1-month follow-up visit. Any adverse events related to the treatments were monitored., Results: On a scale of 0 to 5, the average frequency of urine leak improved from "2-3 times a week" (2.15±1.03 points prior to treatment) to "once a week" (1.00±0.78 points post-treatment), and on to "never" (0.44±0.51 points at the 1-month follow-up visit). Sixteen subjects (59.3%) reported decrease in the amount of leakage, with 15 women (55.6%) becoming completely leak-free at the 1-month follow-up. At the 1-month follow-up visit, 24 subjects (88.9%) expressed their condition's interference with everyday life decreased and 17 patients (62.9%) said the condition did not interfere with their everyday life at all as a result of the treatment. All results are statistically significant (P<.05). No adverse events were recorded. All subjects reported improvement in vaginal laxity, from average perception of "very loose" (2.19±1.08 points prior to treatment) to "moderately tight" (5.74±0.76 points at the 1-month follow-up visit). During the follow-up visit, 89% of the patients "agreed" or "strongly agreed" that their SUI condition improved, and 93% of the patients "agreed" or "strongly agreed" that their gratification during intercourse improved. None of the subjects reported dissatisfaction., Conclusion: The study confirmed the monopolar radiofrequency method as an effective and safe treatment of SUI and vulvo-vaginal laxity. The treatments were well tolerated by all subjects with no adverse effects., (© The Authors. Journal of Cosmetic Dermatology Published by Wiley Periodicals, Inc.)

Objective: The aim of this study was to review the preclinical data showing the role of both estrogens and androgens in the physiology of the vagina, and, most likely, in vulvovaginal atrophy of menopause., Methods: Mass spectrometry-based assays (validated according to the FDA guidelines) for the measurement of sex steroids, their precursors, and metabolites were used. In addition to fixation of the vagina for morphological examination, histomorphometry, immunocytochemistry, immunofluorescence, and quantitative reverse transcription polymerase chain reaction were performed., Results: The vaginal epithelium of the animals receiving dehydroepiandrosterone (DHEA) was made of large multilayered columnar mucous cells showing distended cytoplasmic vacuoles representative of an androgenic effect. DHEA also stimulates collagen fiber compactness of the lamina propria (second layer)-an effect essentially due to an androgenic effect, whereas stimulation by DHEA of the muscularis in the third vaginal layer is approximately 70% due to the androgenic conversion of DHEA. Stimulation of the surface area of the nerve endings, on the contrary, is exclusively androgenic. Vaginal weight stimulation by DHEA is about 50% androgenic and 50% estrogenic., Conclusions: Practically all studies on the influence of steroid hormones in the vagina have focused on luminal epithelial cells. Since all estrogens and androgens in postmenopausal women are made intracellularly and derive from the conversion of circulating DHEA, it is of interest to observe from these preclinical data that DHEA exerts both estrogenic and androgenic activity in the three layers of the vagina, the stimulatory effect on nerve density being 100% androgenic. Taking vaginal weight as a global parameter, the stimulatory effect of DHEA in the rat vagina is about equally estrogenic and androgenic, thus illustrating the importance of androgens in vaginal morphology and function, and the likely importance of androgens in vulvovaginal atrophy of menopause.

Although women with vulvodynia typically have increased vulvar sensitivity, data on characteristics associated with the degree of vulvar sensitivity are lacking. We measured vulvar sensitivity using cotton swab test and vulvodolorimeter among a subset of 335 women, aged younger than 70 years, in the longitudinal Woman to Woman Health Study. Comparing the vulvodynia screening results from their online/paper survey to that at the time of the examination, 42 women had ongoing vulvodynia, 66 had a recent remission, 22 control participants had a recent onset of vulvodynia, and 205 control participants remained asymptomatic. Vulvar sensitivity was greater in each vulvodynia group compared with the control group (P < .001), and was associated with younger age at first onset of pain (P = .025), pain after intercourse (P = .008), describing the pain as a "pressure," "burning," or "irritating" (P = .015, P = .005, and P = .006, respectively), with increased severity of pain ever (P = .012), and with subsequent persistent or relapsing vulvodynia (P < .001 for each). A score of >1 for the cotton swab summary score best differentiated case from control participants (sensitivity 71.9%; specificity 72.0%). Although 13.8% of women with vulvodynia had no increased sensitivity on cotton swab testing, they did not differ in most clinical characteristics or clinical course from those with increased vulvar sensitivity., Perspective: This study showed that women with vulvodynia have more vulvar sensitivity than control women, but the spectrum of sensitivity is broad. Furthermore, those with and without vulvar sensitivity did not differ in most vulvar pain characteristics or in prognosis, suggesting a positive swab test is not required to substantiate the diagnosis., (Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Health care professionals can play a pivotal role in promoting vulvovaginal health through assessment and appropriate intervention., Aim: To develop and validate brief clinical measurements to facilitate the identification of vulvovaginal symptoms in patients with and survivors of cancer., Methods: One hundred seventy-five women survivors of cancer attending a Female Sexual Medicine and Women's Health Program from September 26, 2012 through October 31, 2014 completed the Vaginal Assessment Scale (VAS) and the Vulvar Assessment Scale (VuAS)-a modified version of the VAS that targets vulvar symptoms. Pelvic examination results were recorded using a clinical examination checklist., Main Outcome Measures: Internal consistency of the two scales was assessed using Cronbach α, and the correlation between scales and other outcomes was reported., Results: The internal consistency measurements of the VAS and VuAS at the first visit were 0.70 and 0.68, which decreased to 0.53 and 0.66 at the last visit. The VAS composite and VuAS composite scores were moderately correlated with each other (0.42 and 0.45 at first and last visits, respectively). A strong correlation was observed between VAS pain with intercourse and Female Sexual Function Index (FSFI) pain with intercourse (-0.63 and -0.71 at the first and last visits, respectively). Worse pain with examination, worse functioning on the FSFI pain, lubrication, and total scores, and worse vulvar irritation were correlated with more severe symptoms on the VAS and VuAS., Conclusion: The VAS and VuAS are simple tools that can be used by clinicians to assess health concerns in women diagnosed with and treated for cancer. Validation is needed across diverse settings and groups of women., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Chronic pain may be perceived differently according to gender and race, which may affect physical health and psychological wellbeing. We evaluated daily pain ratings in black women as compared to white women with provoked vestibulodynia (PVD)., Methods: Seventy-one women (44 black, 27 white) rated pain severity with tampon insertion and sexual intercourse and recorded daily vulvar pain level on a visual analogue scale (0 = no pain to 10 = worst pain imaginable). In addition, they completed the Brief Pain Inventory (BPI) Interference Scale and Hamilton Anxiety Depression Scale (HADS). Multivariate analysis was performed to determine the effect of race on pain intensity after adjusting for functional impairment, affective distress and demographic characteristics., Results: Pain ratings from tampon insertion (6.37 ± 1.89 vs. 5.61 ± 1.98, p = .12) and sexual intercourse (6.28 ± 2.11 vs. 5.29 ± 2.50, p = 0.24) were similar, but daily vulvar pain (4.57 ± 2.27 vs 2.74 ± 2.43, p = <.01) was significantly higher in black women. BPI-interference scores were associated with small, but significant increases in tampon insertion pain (p = <.01, beta = .06 units) and daily pain (p < .01, beta = .10 units) and to a lesser degree with sexual intercourse pain when corrected for multiple comparisons (p = .05, beta = .06 units). Race had no effect on pain after adjusting for other variables., Conclusion: While race was associated with functional impairment, after accounting for this, race was not associated with level of vulvar pain with PVD.

Vulvar and vaginal atrophy (VVA) is a common and progressive medical condition in postmenopausal women. The REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey assessed knowledge about VVA and its impact in 3,046 postmenopausal U.S. women, and recorded women's attitudes about their interactions with health care providers and about available treatments. REVIVE identified poor disease awareness and understanding among women, failure of health care professionals to evaluate women for VVA signs and symptoms, low treatment rates and concerns about the safety and efficacy of available therapies. Strategies to address these needs include proactive screening, education for women and clinicians about VVA and recommendations for treatment and follow-up., (© 2015 AWHONN.)

Vulvar pain and discomfort (vulvodynia) are common conditions that can have a significant impact on a patient's quality of life. Vulvodynia is a difficult condition to evaluate and treat. This article gives the primary gynecologist a basic framework with which to identify, diagnose, and begin treatment for these patients and refer if necessary. Initial evaluation and physical examination are discussed in detail. Treatments ranging from self-management strategies to nonpharmacologic and pharmacologic therapies will be explored. Because vulvodynia is a chronic pain disorder, diagnosis is the key to beginning treatment and support for this patient population., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Gene duplication and divergence has emerged as an important aspect of developmental evolution. The genomes of Caenorhabditis nematodes encode an ancient family of PUF RNA-binding proteins. Most have been implicated in germline development, and are often redundant with paralogs of the same sub-family. An exception is Cbr-puf-2 (one of three Caenorhabditis briggsae PUF-2 sub-family paralogs), which is required for development past the second larval stage. Here, we provide a detailed functional characterization of Cbr-puf-2. The larval arrest of Cbr-puf-2 mutant animals is caused by inefficient breakdown of bacterial food, which leads to starvation. Cbr-puf-2 is required for the normal grinding cycle of the muscular terminal bulb during early larval stages, and is transiently expressed in this tissue. In addition, rescue of larval arrest reveals that Cbr-puf-2 also promotes normal vulval development. It is expressed in the anchor cell (which induces vulval fate) and vulval muscles, but not in the vulva precursor cells (VPCs) themselves. This contrasts with the VPC-autonomous repression of vulval development described for the Caenorhabditis elegans homologs fbf-1/2. These different roles for PUF proteins occur even as the vulva and pharynx maintain highly conserved anatomies across Caenorhabditis, indicating pervasive developmental system drift (DSD). Because Cbr-PUF-2 shares RNA-binding specificity with its paralogs and with C. elegans FBF, we suggest that functional novelty of RNA-binding proteins evolves through changes in the site of their expression, perhaps in concert with cis-regulatory evolution in target mRNAs., (© 2013 Wiley Periodicals, Inc.)

Background: Labiaplasty is an increasingly popular surgical intervention but little is known about the characteristics and motivation of women who seek the procedure or the psychosexual outcome., Method: A total of 55 women seeking labiaplasty were compared with 70 women who did not desire labiaplasty. Various general measures of psychopathology as well as specific measures (Genital Appearance Satisfaction; Cosmetic Procedure Screening for labiaplasty) were used. Labia measurements of the women seeking labiaplasty were also obtained., Results: Women seeking labiaplasty did not differ from controls on measures of depression or anxiety. They did, however, express increased dissatisfaction towards the appearance of their genitalia, with lower overall sexual satisfaction and a poorer quality of life in terms of body image. Women seeking labiaplasty reported a significantly greater frequency of avoidance behaviours on all the domains assessed, and greater frequency of safety-seeking behaviours for most of the domains. Key motivations reported for labiaplasty were categorized as cosmetic, functional or sexual. Of the 55 women seeking labiaplasty, 10 met diagnostic criteria for body dysmorphic disorder., Conclusions: This is the first controlled study to describe some of the characteristics and motivations of women seeking labiaplasty. We identified a wide range of avoidance and safety-seeking behaviours, which occurred more frequently in the labiaplasty group than the control group. These could be used clinically as part of a psychological intervention for women seeking labiaplasty.

Purpose: We assessed external genitalia sensitivity and sexual function in adults with congenital adrenal hyperplasia who had undergone Passerini-Glazel feminizing genitoplasty as children, and compared them to a control group of healthy counterparts., Materials and Methods: Inclusion criteria were congenital adrenal hyperplasia, Passerini-Glazel feminizing genitoplasty, adult age and penetrative vaginal intercourse. Thermal and vibratory sensitivity of the clitoris, vagina and labia minora were analyzed using the Genito Sensory Analyzer (Medoc Ltd., Minnetonka, Minnesota). Psychosexual outcome was assessed with the Beck Depression Inventory, Zung Self-Rating Anxiety Scale, Female Sexual Distress Scale and Female Sexual Function Index. Matched analyses were performed to compare outcomes in patients to controls (healthy medical students). All statistical tests were performed using SPSS®, version 18.0 RESULTS: A total of 12 patients (10%) entered the study. Thermal and vibratory clitoral sensitivity was significantly decreased in all patients compared to healthy controls (p <0.01). There was no difference in thermal or vibratory vaginal sensitivity between patients and controls. On the Female Sexual Distress Scale 11 patients (91.6%) and 11 controls (91.6%) described a stable satisfactory relationship. All patients reported active sexual desire, good arousal, adequate lubrication and orgasm. No significant difference in Female Sexual Function Index global score or single domain scores was observed between patients and controls., Conclusions: Although clitoral sensitivity in sexually active patients with congenital adrenal hyperplasia treated with Passerini-Glazel feminizing genitoplasty is significantly reduced compared to controls, sexual function in those patients is not statistically or clinically significantly different from their healthy counterparts. Finally, 1-stage Passerini-Glazel feminizing genitoplasty seems to allow normal adult sexual function., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Numerous cutaneous lesions are located in the region of the female genital organs, occasionally presenting a diagnostic and therapeutic challenge. The most common cases include: eczema vulvae, lichen simplex chronius, lichen sclerosus et atrophicus or lichen planus. Clinical presentation of these lesions is not always characteristic for certain dermatoses. Thus, it is important to conduct proper tests, including histopathological or contact allergy examination. Only thorough diagnostics allows to implement correct therapy. This paper shows a detailed description of dermal lesions located in the region of the female genital organs of the allergic and lichenoid origin, together with the literature review on diagnosis and treatment.

Aim: The aim of this study was to extend the clinicohistological study to involve the whole normal and absent vagina for confirming the presence of the G-spot and its relation to the surrounding organs and sexuality and to identify certain precautions for its preservation during surgery., Material and Methods: This study was a descriptive randomized prospective study conducted at Kasr El Aini School of Medicine, Cairo University, Egypt. The G-spot was examined in 1500 women, 500 of them having vaginal and vulval surgery done for gynecological reasons. The G-spot was examined for its clinical and histological features and for determining the effect of surgery on its state and function., Results: The G-spot was found to be present in all women. It was a localized spot in 58% and diffuse in 42% of cases. Associated ejaculation was reported in all cases of the localized type and in 24.5% of the diffuse types. Clinical examination was found to be associated with certain local response in 52.7% of the local types. The G-spot was also found to be connected to the hymen in 100%, the urethra in 52.7%, the vulva in 82.2% and the cervix in 10.8% of cases. The mean of the sex scores and sexuality were significantly decreased in surgery involving the G-spot area. Recorded figures were 93.6 ± 3.4 and 88.2 ± 3.3 before and after surgery, respectively. The corresponding figures in the cases having a general spot were 86.4 ± 4.4 and 84.5 ± 2.4, respectively. The G-spot was found in cases of absent vagina to be localized in 59%, generalized in 28.2% and absent in 12.8% of cases., Conclusions: The G-spot is actually present in all women. It is originally related to the lower urinary tract and it is connected to different parts of the genital tract. It may be localized or generalized. Its integrity is essential for obtaining normal physiological sexuality. Surgery may affect the integrity of the G-spot, so surgical precautions must be carried out to maintain the integrity of this spot and the patient's sexuality., (© 2013 The Author. Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology.)

Introduction: Relatively little is known about the subjective reactions of women with lifelong vaginismus to erotic stimuli and genital arousal has never been investigated. Reports of maladaptive cognitions and fears regarding sexuality and intercourse suggest that anxiety may interfere with sexual arousal in women with vaginismus., Aims: To examine the genital and subjective responses to sexually explicit film stimuli of women with lifelong vaginismus compared with women with lifelong dyspareunia and women with no pain., Methods: Forty-five women (15 vaginismus, 15 dyspareunia, and 15 no pain) viewed two neutral and two erotic film sets, one depicting sexual activity without vaginal penetration and the other depicting intercourse, over two testing sessions., Main Outcome Measures: Vulvar temperature was recorded using an infrared camera. Participants completed a measure of subjective responses after viewing each film., Results: All groups experienced increased vulvar temperature during the erotic films regardless of activity depicted. In response to the erotic films, the vaginismus group reported less mental arousal than the no-pain group and a range of negative subjective responses, including threat and disgust. Overall, participants showed concordance between peak subjective sexual arousal and temperature change from baseline to peak arousal., Conclusion: Despite negative subjective responses, women with vaginismus responded with increased genital sexual arousal to erotic films. The resilience of genital arousal may have resulted from moderate levels of anxiety experienced in the laboratory setting facilitating sexual response regardless of subjective appraisal; however, anxiety experienced in a dyadic context may interfere more substantially., (© 2013 International Society for Sexual Medicine.)

Vulvar pain syndrome or vulvodynia is a common multifactorial, heterogeneous, and chronic gynecological disorder with an estimated prevalence of up to 16%. This disorder seriously impacts the quality of life of women in several ways. The etiology of this condition is complex and remains elusive and requires an extensive differential diagnosis. A standard therapeutic approach for the management of vulvar pain is still under investigation and must be multidisciplinary. This review outlines the anatomic and pathophysiologic aspects of vulvar pain., (Copyright © 2012 Wiley Periodicals, Inc.)

According to various statistics from 4.2 to 42% of women in reproductive age, complained of a mild or severe problems in sexual function. The study presents own data on treatment of vaginismus in 14 girls and young women aged 16 to 36 years who have turned from 2007 to 2012 to the Cabinet Children and adolescent gynaecology at the University Hospital "Maychin dom". A primary examination established a high and tenacious hymen in 7 (50%) patients. The patients demonstrated fear, but still allowed careful examination. At 3 girls (21.43%) a combined cause of complaints was found. They demonstrated fear of pain during coitus and reported bad memory of the first sexual attempts; they had high and tenacious hymen and were able to tolerate touching the vulva after much persusions. In 3 (21.43%) patients consequences of puritan education were registered. They did not allowed to touch the vulva despite the declaration that would allow such. In one patients (7.14%) a unstretchable vagina was found. She demonstrated dyspareunia (avoiding intercourse and having one failed marriage) but she tolerated penetration of her vagina of one phalanx. In all cases of vaginismus we performed educational lectures and artefitial defloration.

Introduction and Hypothesis: The purpose of this study was to determine pelvic floor muscle (PFM) function in hospitalized elderly women with urinary incontinence (UI)., Methods: A cross-sectional study was performed using data of 704 patients, routinely collected by means of a clinical UI assessment., Results: Only 25.5% of the patients were able to perform normal PFM contractions (Oxford grading scale score ≥3); 74.5% were unable to contract their PFM or showed weak PFM activity without circular contraction or elevation of the vagina. Vulvovaginal mucosal dystrophy was noted in 84% of the patients. A significant positive correlation of PFM function was found to cognitive status (MMSE score), mobility (Tinetti performance score), and history of previous PFM training; a negative correlation of PFM function was found to patients' age and vulvovaginal mucosal dystrophy, and no significant correlation to body mass index, parity, or history of hysterectomy., Conclusions: Targeted clinical UI assessment including digital vaginal palpation should be performed in all incontinent elderly women in order to detect PFM dysfunction and to optimize therapeutic measures.

Introduction: Provoked vestibulodynia (PVD) is the most common cause of dyspareunia in young women. The etiology is unclear, and there is little knowledge of how to predict treatment outcome., Aim: The aim of this study was to identify medical factors associated with treatment outcome and coital pain in women with PVD., Methods: Seventy women previously treated for PVD at a vulvar open care unit completed questionnaires and a quantitative sensory testing session., Main Outcome Measures: Concomitant bodily pain and treatment outcome were surveyed using a study specific questionnaire. Coital pain was rated on a visual analog scale (VAS), range 0-100. Psychometric screening was carried out using the Hospital Anxiety and Depression Scale. Pressure pain thresholds on the arm, leg, and in the vestibulum were measured using pressure algometers., Results: Major improvement/complete recovery was more likely in PVD patients with a maximum of one other concomitant pain disorder compared with patients with four or more (odds ratio = 7.8, confidence interval: 1.2-49.4, P = 0.03). In a multiple linear regression model, the number of other pain disorders (P < 0.01) and a diagnosis of primary PVD (P = 0.04) were positively associated with the coital VAS pain score. Women with secondary PVD reported major improvement/complete recovery to a higher extent than women with primary PVD (z = 2.11, P = 0.04)., Conclusion: A successful treatment outcome was more likely in PVD patients with fewer other concomitant pain conditions. The number of other bodily pain conditions was also associated to the intensity of the coital pain. Additionally, the results indicate higher incomplete response rates to treatment in women with primary PVD compared with secondary PVD., (© 2012 International Society for Sexual Medicine.)

Background: Midurethral slings successfully treat stress urinary incontinence through a minimally invasive vaginal approach. Postoperative pain related to sling placement can occur and poses both diagnostic and treatment dilemmas., Case: Four years after transobturator midurethral sling placement, the patient presented with complaints of left labial pain and dyspareunia since surgery. Using sensory mapping and a nerve stimulator, the problem was identified in the distribution of the genitofemoral nerve. Conservative therapy with a centrally acting neuromodulatory drug and nerve block relieved the pain., Conclusion: Postsling neuralgia diagnosis using sensory mapping and a nerve stimulator aids in indentifying the nerve involved and in successful conservative treatment with a nerve block.

Purpose: A significant proportion of mucosal melanomas contain alterations in KIT. The aim of this study was to characterize the pattern of KIT, NRAS, and BRAF mutations in mucosal melanomas at specific sites and to assess activation of the KIT downstream RAF/MEK/extracellular signal-regulated kinase (ERK) and phosphoinositide 3-kinase (PI3K)/AKT pathways in mucosal melanoma specimens., Experimental Design: Seventy-one primary mucosal melanomas from various sites were studied. Mutation analysis was done by DNA sequencing. Expression of KIT, phosphorylated (p)-ERK, and p-AKT was evaluated by immunohistochemistry., Results: KIT mutations were detected in 35% (8 of 23) of vulvar, 9% (2 of 22) of anorectal, 7% (1 of 14) of nasal cavity, and 20% (1 of 5) of penile melanomas. No KIT mutations were found in 7 vaginal melanomas. The difference in KIT mutation frequency between vulvar and nonvulvar cases was statistically significant (P = 0.014). The overall frequencies of NRAS and BRAF mutations were 10% and 6%, respectively. Notably, vaginal melanomas showed a NRAS mutation rate of 43%. KIT gene amplification (≥4 copies), as assessed by quantitative real-time PCR, was observed in 19% of cases. KIT expression was associated with KIT mutation status (P < 0.001) and was more common in vulvar than nonvulvar tumors (P = 0.016). Expression of p-ERK and p-AKT was observed in 42% and 59% of tumors, respectively, and occurred irrespective of KIT/NRAS/BRAF mutation status. NRAS mutation was associated with worse overall survival in univariate analysis., Conclusions: Results show that KIT mutations are more common in vulvar melanomas than other types of mucosal melanomas and that both the RAF/MEK/ERK and PI3K/AKT pathways are activated in mucosal melanoma specimens., (©2011 AACR.)

Introduction: Although it is highly recommended to use a multifaceted approach to treat provoked vestibulodynia (PVD), the large majority of treatment studies on PVD used a one-dimensional approach., Aim: To evaluate the long-term treatment outcome of a multifaceted approach to vulvar pain, sexual functioning, sexually related personal distress, and relational sexual satisfaction in women with PVD., Methods: Retrospective questionnaire survey 3-7 years after treatment., Main Outcome Measures: Sexual functioning, sexually related personal distress, and relational sexual satisfaction were measured using the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), and the Dutch Relationship Questionnaire (NRV), respectively. An additional questionnaire assessed socio-demographic variables, intercourse resumption, and the level to which the women would recommend the treatment to other women with PVD. Post-treatment vulvar pain scores were obtained using a visual analog scale (VAS). Pretreatment scores were reported in retrospect on a separate VAS., Results: The questionnaires were completed by 64 out of 70 women (91%). Mean follow-up was 5 years (range 3-7). Comparison of the mean pretreatment and post-treatment VAS scores showed a significant reduction in vulvar pain. Pain reduction was reported by 52 women (81%), whereas no change and pain increase were reported by 7 women (11%) and 5 women (8%), respectively. Post-treatment, 80% of the women had resumed intercourse. Only 5 women (8%) reported completely pain-free intercourse. Comparisons with age-related FSFI and FSDS Dutch norm data showed that scores for sexual functioning in the study group were significantly lower, while scores for sexually related personal distress were significantly higher. There were no significant differences in relational sexual satisfaction ratings between the study group and the NRV Dutch norm data., Conclusion: These retrospective data on long-term treatment outcome support the hypothesis that a multifaceted approach to PVD can lead to substantial improvements in vulvar pain and the resumption of intercourse., (© 2010 International Society for Sexual Medicine.)

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.

Introduction: Provoked vestibulodynia (PVD) is a distressing genital pain condition affecting 12% of women. Treatment modalities vary and although vestibulectomy has the highest efficacy rates, it is usually not a first-line option. Acupuncture has a long history in the traditional Chinese medicine (TCM) system and operates on the premise that pain results from the blockage or imbalance of important channels. The main principle of treatment is to move Qi and blood to cease genital pain., Aim: To explore effect sizes and feasibility in a pilot study of acupuncture for women with PVD., Methods: Eight women with PVD (mean age 30 years) underwent 10 1-hour acupuncture sessions. Specific placement of the needles depended on the woman's individual TCM diagnosis. TCM practitioners made qualitative notes on participants' feedback after each session. Main Outcome Measures. Self-reported pain (investigator-developed), pain-associated cognitions (Pain Catastrophizing Scale [PCS], Pain Vigilance and Awareness Questionnaire), and sexual response (Female Sexual Function Index) were measured before and after treatment sessions 5 and 10. Qualitative analyses of TCM practitioner notes were performed along with one in-depth case report on the experience of a participant., Results: A repeated measures analysis of variance revealed significant decreases in pain with manual genital stimulation and helplessness on the PCS. An examination of effect sizes also revealed strong (though nonsignificant) effects for improved ability to have intercourse and sexual desire. Qualitative analyses were overall more positive and revealed an improvement in perceived sexual health, reduced pain, and improved mental well-being in the majority of participants., Conclusions: Effect sizes and qualitative analyses of practitioner-initiated interviews showed overall positive effects of acupuncture, but there were statistically significant improvements only in pain with manual genital stimulation and helplessness. These findings require replication in a larger, controlled trial before any definitive conclusions on the efficacy of acupuncture for PVD can be made.

Introduction: Dyspareunia remains under-investigated despite recent population-based studies indicating that its prevalence ranges from 12% to 21% in adult women. Although clinical data suggest that dyspareunia can begin during adolescence, a large-scale epidemiological study has yet to be conducted with this population., Aims: To determine the prevalence and characteristics of dyspareunia in a large-scale sample of adolescents, in addition to the characteristics of vulvo-vaginal insertion pain in nonsexual contexts., Methods: With written informed consent, data were obtained from 1,425 girls (12-19-year-olds), from seven metropolitan high schools during regular school hours using a self-report questionnaire., Main Outcome Measures: Dyspareunia prevalence was evaluated by asking sexually active participants whether or not they regularly (at least 75% of the time) experienced pain during intercourse. Pain duration, context of onset, location, intensity, and pain during tampon insertion and pelvic exams were evaluated., Results: Results revealed that 20% of sexually active girls (N = 251) reported having regular pain during intercourse for at least 6 months or more. A primary form of pain was reported by 67% of adolescents and significantly more girls with chronic dyspareunia identified the vaginal opening (39%; x=3.9/10) as being their most painful site compared with internal pain sites (18-29%; x=2.9-3.2/10) (P = 0.042). Chronic dyspareunia cases reported significantly more pain during first and usual tampon insertion (P = 0.003; P = 0.009) than pain-free controls, while no difference was found between groups regarding pelvic exams (P = 0.086). Experiencing severe pain at first tampon insertion was linked to a fourfold risk of reporting chronic dyspareunia (P = 0.001)., Conclusions: Results mirror prevalence estimates found in population-based studies with adult women and suggest that chronic dyspareunia is a significant sexual health problem in adolescent girls, with pain extending beyond intercourse to nonsexual contexts.

Background: Localised provoked vulvodynia (former vulvar vestibulitis syndrome) is the most common cause of superficial dyspareunia among young women. In a clinical setting, it is obvious that many women with localised provoked vulvodynia show signs of chronic stress. The objective of this study was to compare chronic stress in a group of women with localised provoked vulvodynia, referred to the vulvar unit at the Division of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden with control women of the same age and educational level, using two independent methods., Methods: Forty-three women with localised provoked vulvodynia and 35 healthy control women underwent a gynecological examination, filled in a health questionnaire, and self-collected saliva for analysis of cortisol at awakening and after 15, 30 and 45 min (morning awakening cortisol). Thirty-three patients and 28 controls completed a stress questionnaire., Results: Morning awakening cortisol was blunted in women with localised provoked vulvodynia (p < 0.05), indicating chronic stress. The stress questionnaire showed more signs of burnout (p < 0.005), and emotional (p < 0.05) and bodily symptoms of stress (p < 0.005) in women with localised provoked vulvodynia compared with control subjects (students t-test)., Conclusion: More women with localised provoked vulvodynia showed blunted morning awakening cortisol and reported more symptoms of stress compared with healthy control women of the same age.

Objectives: To compare a new procedure of reduction clitoro-labioplasty to clitoro-labiectomy in the management of adult onset clitoro-labiomegaly, and to show the disadvantages of the latter procedure that produces female genital mutilation and sexual dysfunction., Methods: This controlled, descriptive, comparative and prospective cohort study was performed at Kasr El-Aini School of Medicine, Cairo University, Egypt. 47 cases of clitoro-labiomegaly, 12 with known causes of intersex, were diagnosed and treated by reduction clitoro-labioplasty. In addition, a control group of 53 more cases, 6 with known causes of intersex, were followed after treatment by clitoro-labiectomy. Clitoro-labioplasty was performed by excision of the anterior part of the fused corpora after separation at the glans-corporal junction and a reduction in the size of the remaining part of the corpora to reform a normal clitoral size. The neurovascular bundles were essentially preserved during this procedure. The protruded parts of the labia minora are then excised to preserve their normal dimensions. The main outcome measures were the postoperative anatomical result, patient's satisfaction, the pre- and postoperative sex scoring, and sexuality., Results: Restoration of normal anatomy was successfully obtained after clitoro-labioplasty compared to partial or complete loss of these sensitive parts after clitoro-labiectomy. In addition, significant operative and postoperative complications were recorded in 27 cases with clitoro-labiectomy compared to none of the clitoro-labioplasty cases. The sex scores and sexuality improved significantly after the clitoro-labioplasty operation compared to clitoro-labiectomy (p < 0.005). Normalization of the sex scores and sexuality was found to be significantly related to preservation of critical clitoral length necessary for producing clitoral orientation and interest in sexuality., Conclusion: The new clitoro-labioplasty technique is able to preserve proper clitoral and labial anatomy and restore normal sexuality. Therefore it must be considered an essential line of treatment for clitoro-labiomegaly., (2009 S. Karger AG, Basel.)

Current treatment of neoplastic disease that involves the external female genitalia aims to achieve local disease control, but not to restore form and function of these organs. Despite a growing trend to reduce the extent of surgical resection, impaired quality of life after surgery due to severe sexual dysfunction and disturbed body image is common. We postulate that the integration of surgical techniques for vulvar and vaginal reconstruction into primary treatment would improve aesthetic and functional results and therefore quality of life. We systematically searched the literature for surgical procedures designed and validated for vulvovaginal reconstruction. Various skin flaps, both with random vascularisation and those based on vascular territories (ie, axial pattern, fasciocutaneous, musculocutaneous, and bowel flaps), can restore important parts of vulvovaginal form and function with acceptable morbidity at the donor and recipient sites. Appropriate vulvovaginal reconstruction cannot be achieved by doing a few standardised procedures; rather, it necessitates specialists who are familiar with general principles of reconstructive surgery to master many techniques to select the optimum procedure for the individual patient. Vulvovaginal reconstructive surgery has limitations, particularly achievement of functional restoration in irradiated tissue. Physicians who treat women with neoplastic disease of the external genitalia should be aware of the current state of vulvovaginal reconstructive surgery. Prospective controlled clinical trials are warranted to assess the effect of vulvovaginal reconstruction on morbidity and quality of life after treatment.

Objective: To carry out a critical review of published studies concerning the treatment of provoked vestibulodynia., Methods: MEDLINE, PsycINFO, and Cochrane were used to identify treatment studies published between January 1996 and December 2006. All studies published in English that dealt specifically with the treatment of provoked vestibulodynia were included in the review regardless of their methodological quality. Thirty-eight treatment studies were thus examined in the present paper., Results: Since 1996, surgical treatment has received somewhat less empirical attention. Nevertheless, it still boasts the best success rates, which range from 61% to 94%. More studies have focused on medical treatments, yielding success rates varying between 13% and 67%. Behavioral treatments have been the least studied, although 35% to 83% of patients benefit from them. Despite these interesting results, only 5 of the 38 treatment studies reviewed are randomized clinical trials. Furthermore, the majority of studies have several methodological weaknesses, such as the absence of (1) control or placebo group, (2) double-blind evaluation, (3) pretreatment pain evaluation, and (4) validated measures of pain and sexual functioning., Discussion: On the basis of the results of the reviewed prospective studies and the randomized clinical trials, vestibulectomy is the most efficacious treatment to date. Though some medical treatments seem little effective, others appear promising and should be investigated further, as is the case with behavioral treatments. Additional randomized clinical trials are necessary to confirm the efficacy of surgery and validate nonsurgical treatments for provoked vestibulodynia.

The construction and application of the vulvalgesiometer are described. This manually-applied device allows for the quantifiable measurement of pressure-pain thresholds in the external female genital region. A set of five vulvalgesiometers exerting pressures from 3 to 950 g was used in two studies. The goal of the first study was to examine the ability of the vulvalgesiometers to discriminate between women with and without provoked vestibulodynia (PVD). In a matched sample of affected and non-affected women, women with PVD exhibited significantly lower vestibular pressure-pain thresholds as compared to control women. As well, approximately half the sample of women with PVD described the sensation elicited at pressure-pain threshold as similar to the pain experienced during sexual intercourse. The goal of the second study was to investigate the inter-rater reliability of the vulvalgesiometers. In this separate sample of women with and without PVD, each participant was tested for pressure-pain threshold by two different investigators at different times. Results demonstrated high levels of inter-rater reliability, indicating that the vulvalgesiometers can be consistently used by different investigators. Further, results indicated significant negative correlations between pressure-pain thresholds and pain intensity ratings recorded during the cotton-swab test, suggesting that the lower the threshold, the higher the pain ratings during vestibular palpation. The vulvalgesiometers can be utilized for several purposes, including treatment outcome studies and measuring the degree of PVD severity.

Objective: To assess the effect of order of sensitivity testing at the vulva and thumb on the sensitivity determined at the second site tested among women with and without vulvodynia., Study Design: We evaluated the stability of sensitivity measurements to pressure at the vulva and thumb when the order of testing was randomized to vulva first vs. thumb first; we repeated testing 1 week later in the opposite order., Results: Stability of results over time and the influence of the order of testing were determined among 13 women with vulvodynia and 20 asymptomatic control women. We found a strong correlation between results compared between the first and second visits as well as no order effect., Conclusion: The order of testing at vulvar and peripheral sites has little impact on the results of pressure-responsive sensitivity testing among women with and without vulvodynia.

Introduction: Vulvar vestibulitis syndrome (VVS) is a common cause of vulvar pain. Therapeutic options target different pain systems believed to be involved in its development and maintenance. Most treatments target the pain component with the assumption that sexual function will increase once the pain has decreased, yet this is not necessarily the case., Aims: Research has supported the effectiveness of hypnosis for many chronic pain disorders, and a case report demonstrated pain reduction and an increase in intercourse pleasure in a woman with VVS. This preliminary study examined the effectiveness of hypnosis on pain and psychosexual function in VVS. METHODS; Eight women suffering from VVS completed a hypnosis screening assessment, an interview, pain and psychosexual questionnaires, a gynecologic examination, vestibular pain threshold measurement, a psychosexual assessment, and six hypnotherapy sessions. The physical examinations, interview, and questionnaires were repeated at 1 and 6 months posttreatment., Main Outcome Measures: These included pain ratings during the gynecologic examination, vestibular pain thresholds, scores on the McGill Pain Questionnaire and Pain Catastrophizing Scale, and responses to questions on intercourse-related and nonintercourse-related pain. Measures of psychosexual function included the Female Sexual Function Index, State-Trait Anxiety Scale, Beck Depression Inventory-II, and the Brief Symptom Inventory., Results: Results indicated significant decreases in gynecologic examination pain and in several measures assessing intercourse pain, and nonsignificant increases in threshold. Some indices of noncoital vulvar pain decreased. Overall sexual function, particularly sexual satisfaction, increased at posttreatment. There were no differences on any psychological measure. Participants reported satisfaction with the treatment and rated their VVS pain reduction as average., Conclusions: Hypnotherapy appears to be a promising treatment for reducing intercourse pain and some aspects of noncoital vulvar pain, and for restoring sexual function in women with VVS. These results suggest that a large controlled trial should be considered.

Background: In recent years there has been increasing awareness of chronic vulvar pain, both in the medical and lay communities. The etiology of vulvar pain is largely unknown. Furthermore, there is no worldwide consensus regarding the terminology and classification of this condition, which makes it difficult to compare the results of different treatments. In 2003, following more than three decades of uncertainty, the terminology and classification of vulvar pain was re-established., Aim: To review the development of nomenclature for vulvar pain and the increasing understanding of its pathophysiology., Methods: A literature review was conducted of articles related to the nomenclature of vulvar pain and vulvar diseases, and a summary of the world congresses of the International Society for the Study of Vulvovaginal Disease (ISSVD) from 1976 until 2003., Results: In 1976, members of the ISSVD recognized vulvar pain as a unique entity, and called it burning vulva syndrome. In 1985, the ISSVD renamed this disorder "Vulvodynia" and classified it into two clinically distinctive subsets: dysesthetic vulvodynia and vestibulitis. However, recent studies failed to confirm an inflammatory pathogenesis, and the term vestibulitis was replaced by the term vestibulodynia at the 1999 ISSVD congress. In 2003, the ISSVD reviewed the terminology and used the term vulvodynia, which is further classified as either generalized or localized, and by the presence or absence of stimulus for pain., Conclusions: The re-establishment of the ISSVD terminology and classification in 2003 will help physicians and researchers improve the understanding of chronic idiopathic vulvar pain, and develop effective treatments.

This study assessed the association between pain perception and psychological variables in women with vulvar vestibulitis syndrome (VVS) by comparing 28 VVS women with 50 healthy women. We assessed non genital systemic pain perception with quantitative sensory testing by administering experimental pain stimuli to the forearm. The VVS women demonstrated a lower pain threshold and a higher magnitude estimation of pain, combined with a higher trait anxiety, increased somatization, and a lower body image. Among the VVS women, nonvaginal pain catastrophizing was significantly related to reported pain during coitus. A cluster analysis revealed four subtypes of VVS women, as characterized by levels of pain and personality variables. I suggest implications for the assessment and treatment of women suffering from painful coitus.