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Study Objective: To determine the subtypes of labial adhesion (LA) and arrange treatment options accordingly., Design and Setting: Patients who presented to our clinic with LA between July 2016 and February 2018 were divided into 4 groups. Location of the adhesion area, thickness of the adhesive tissue, and response to topical steroid (betamethasone valerate 0.1% ointment) therapy were identified as common features., Participants: Seventy-five prepubertal girls., Interventions and Main Outcome Measures: To determine the subtypes of the LA and evaluate the treatment response of patients in each subtype group., Results: LA was divided into 4 subtypes according to their common characteristics. For patients with type I, 2 weeks of topical steroid treatment resulted in complete recovery (100%). For those with type II, 12 (80%) patients had complete response to topical steroid treatment for an average of 3 weeks. Type III and IV patients were completely unresponsive to topical steroid treatment., Conclusion: Classification of LA patients into subtypes and determination of treatment on the basis of this classification make a major contribution in planning the treatment of patients, not by trial-and-error, but using a predetermined strategy., (Copyright © 2020 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: No consensus on the management of symptomatic cysts or abscesses of the Bartholin's gland exists., Objectives: To assess the effectiveness and safety of surgical interventions for a symptomatic Bartholin's cyst or abscess., Search Strategy: We searched bibliographical databases from inception to April 2019., Selection Criteria: Randomised trials evaluating a surgical intervention for the treatment of a symptomatic Bartholin's cyst or abscess., Data Collection and Analysis: Eight trials, reporting data from 699 women, were included. Study characteristics and methodological quality were recorded for each trial. Summary estimates were calculated using random-effects methods., Main Results: When considering the recurrence of a symptomatic Bartholin's cyst or abscess, the evidence was consistent with notable effects in either direction (risk ratio [RR] 0.76; 95% confidence interval [CI] 0.41-1.40) when comparing marsupialisation with incision, drainage and insertion of a Word catheter. Limited inference could be made when comparing marsupialisation with incision, drainage and silver nitrate insertion (RR 1.00; 95% CI 0.57-1.75), and incision, drainage and cavity closure (RR 0.25; 95% CI 0.01-4.89). There was limited reporting of secondary outcomes, including haematoma, infectious morbidity and persistent dyspareunia., Conclusions: Current randomised trial evidence does not support the use of any single surgical intervention for the treatment of a symptomatic cyst or abscess of the Bartholin's gland., Prospective Registration: PROSPERO: International Prospective Register of Systematic Reviews; CRD42018088553., Tweetable Abstract: Further research is needed to identify an effective treatment for #Bartholin's cyst or abscess. @jamesmnduffy., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Objectives: Three types of lichen planus (LP) occur on the vulva: erosive, classic, and hypertrophic. The latter 2 occur on keratinized skin and little is known about their clinicopathologic appearance., Materials and Methods: Vulvar biopsies of keratinized skin reported as LP or "lichenoid" between 2011 and 2017 were reviewed. Inclusion required age of older than 18 years, a lichenoid tissue reaction, and insufficient abnormal dermal collagen to diagnose lichen sclerosus. Clinical and histopathologic data were collected and cases were categorized as hypertrophic, classic, or nonspecific lichenoid dermatosis. Descriptive statistics were performed and groups were compared with the Fisher exact test., Results: Sixty-three cases met criteria for inclusion. Twenty-nine (46%) cases were categorized as hypertrophic LP, 21 (33%) as classic LP, and 13 (21%) as nonspecific lichenoid dermatosis. There were no significant differences in age, primary symptom, biopsy location, or duration of disease between the 3 groups. When compared with classic and nonspecific disease, hypertrophic LP was less likely to have comorbid dermatoses and more likely to be red, diffuse, have scale crust, and contain plasma cells in the infiltrate. Nonspecific disease had similar clinical features to classic LP but was less likely than the other 2 categories to have a dense lymphocytic infiltrate and exocytosis., Conclusions: Vulvar LP on keratinized skin has a diversity of appearances and presents a clinicopathologic challenge. Further research is required to understand the natural history of hypertrophic LP and the underlying diagnosis of nonspecific lichenoid cases.

Vulvovaginal cysts are a common problem for women, causing significant pain, discomfort and impact on quality of life. For clinicians, classifying and differentiating these cysts from each other and selecting appropriate management can be challenging, yet there is no integrated classification system and little literature that broadly summarises a clinical approach. We aimed to create a useful tool for clinicians by providing a detailed summary of various vulvovaginal cysts and abscesses with a clear novel classification system and hierarchy for diagnosis and management, to aid clinicians in this process., (© 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Introduction: In 2014, the executive council of the International Society for the Study of Vulvovaginal Disease, the boards of directors of the International Society for the Study of Women's Sexual Health, and the International Pelvic Pain Society acknowledged the need to revise the current terminology of vulvar pain, on the basis of the significant increase in high-quality etiologic studies published in the last decade., Materials and Methods: The new terminology was achieved in the following 4 steps. The first involved a terminology consensus conference with representatives of the 3 societies, held in April 2015. Then, an analysis of the relevant published studies was used to establish a level of evidence for each factor associated with vulvodynia. The terminology was amended on the basis of feedback from members of the societies. Finally, each society's board accepted the new terminology., Results and Conclusions: In 2015,the International Society for the Study of Vulvovaginal Disease, International Society for the Study of Women's Sexual Health, and International Pelvic Pain Society adopted a new vulvar pain and vulvodynia terminology that acknowledges the complexity of the clinical presentation and pathophysiology involved in vulvar pain and vulvodynia, and incorporates new information derived from evidence-based studies conducted since the last terminology published in 2003.

Labia minora hypertrophy of unknown and under-reported incidence in the general population is considered a variant of normal anatomy. Its origin is multi-factorial including genetic, hormonal, and infectious factors, and voluntary elongation of the labiae minorae in some cultures. Consults with patients bothered by this condition have been increasing with patients complaining of poor aesthetics and symptoms such as difficulty with vaginal secretions, vulvovaginitis, chronic irritation, and superficial dyspareunia, all of which can have a negative effect on these patients' sexuality and self esteem. Surgical management of labial hypertrophy is an option for women with these physical complaints or aesthetic issues. Labia minora hypertrophy can consist of multiple components, including the clitoral hood, lateral prepuce, frenulum, and the body of the labia minora. To date, there is not a consensus in the literature with respect to the classification and definition of varying grades of hypertrophy, aside from measurement of the length in centimeters. In order to offer patients the most appropriate surgical technique, an objective and understandable classification that can be used as part of the preoperative evaluation is necessary. Such a classification should have the aim of offering patients the best cosmetic and functional results with the fewest complications.

Background: Vulvar dermatoses are often difficult to classify due to histopathologic overlap. We aimed to report our experience at a single institution., Methods: A total of 183 non-neoplastic, non-infectious vulvar biopsies were reviewed. Associations between histopathologic features and specific diagnoses were analyzed by Chi-squared tests., Results: Twenty-two biopsies (12.0%) showed two concurrent processes. A limited differential rather than a definitive diagnosis was rendered in 15 cases (8.2%). The final diagnoses included lichen sclerosus (LS) (38.8%), lichen simplex chronicus (LSC) (29.0%), eczematous dermatitis (23.0%), Zoon vulvitis (8.2%), non-specific/resolved dermatitis (5.5%), hidradenitis suppurativa (2.7%), Behçet disease (2.2%), lichen planus (1.6%), ruptured cyst (1.6%), ulcer not-otherwise-specified (1.6%), psoriasis (1.1%), radiation dermatitis (1.1%), sebopsoriasis (1.1%), seborrheic dermatitis (1.1%), epidermolytic hyperkeratosis (0.5%) and granular parakeratosis (0.5%). Early LS and Zoon vulvitis were commonly included as part of a differential diagnosis. LS was associated with wiry collagen with lymphocyte entrapment (p = 0.0188). LSC was associated with zones of pale epithelium (p = 0.0084), and often displayed prominent fibroblasts (p = 0.0555). Zoon vulvitis was frequently misdiagnosed, and was associated with basal keratinocytic crowding (p < 0.0001)., Conclusions: Our study has determined the relative frequencies of a wide variety of vulvar dermatoses, and identified new diagnostic clues for early LS, LSC and Zoon vulvitis., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Vaginal labiaplasty has been described for the management of functional and aesthetic problems associated with protrusion of the labia minora. Despite increasing numbers of procedures performed, there is a paucity of data to guide treatment paradigms. This systematic review aims to establish a simple, unifying classification scheme for labial protrusion and summarize current labiaplasty techniques and practices., Methods: A systematic literature review was performed using the PubMed database. Additional articles were selected after reviewing references of identified articles., Results: The search returned 247 articles. After applying inclusion criteria to identify prospective and retrospective studies evaluating different techniques, outcomes, complications, and patient satisfaction, 19 articles were selected. Labiaplasty of the labia minora was described in 1949 patients. Seven different surgical techniques were used for labiaplasty, including deepithelialization, direct excision, W-shaped resection, wedge resection, composite reduction, Z-plasty, and laser excision. Patient satisfaction rates for each technique ranged from 94 to 100 percent. The most common postoperative complication for all techniques was wound dehiscence (4.7 percent). Key areas for perioperative patient management were defined., Conclusions: Labiaplasty is safe and carries a high satisfaction rate. However, current practices remain exceedingly diverse. The authors propose a simplified classification system based on the distance of the lateral edge of the labia minora from that of the labia majora, rather than from the introitus. Key areas for perioperative patient management include patient anesthesia, resection technique used, wound closure, and postoperative care. Further randomized studies using a standardized classification system are required to better compare different techniques and establish best practices.

Currently, urogenital complaints are among the most common problems encountered by family practitioners, gynecologists, and dermatologists. In response to the intricacy of vulvar disorders, the International Society for the Study of Vulvovaginal Disease was created to facilitate the exchange between clinicians and pathologists involved in the care of these patients. Recent classifications for inflammatory disorders and intraepithelial neoplasm have been proposed. In addition, vulvar skin biopsies are the most common source of intradepartmental consultation during dermatopathology sign-out. The purpose of this article is to review the various inflammatory dermatoses of the vulva and to update readers with new advances regarding these entities.

Background: Information on genital wart incidence in adolescents and young adults before human papillomavirus (HPV) vaccination is important for understanding the impact of the vaccine on the epidemiology of this early outcome of HPV infection., Methods: The study population included 11- to 29-year-old enrollees of Northern California Kaiser Permanente between July 1, 2000, and July 1, 2005, before the availability of the HPV vaccine. We identified genital warts with an algorithm combining genital wart-specific International Classification of Diseases, Ninth Revision, Clinical Modification codes (078.10, 078.11, and 078.19) with physician-recorded anatomic locations. We calculated sex- and age-specific incidence rates of genital warts and described the specific anatomic location of presentation, as well as recurrences of genital warts., Results: We identified 1,682 cases of genital warts among 181,264 individuals. The incidence rate was highest among women (6.3/1000 person-years) and men (2.9/1000 person-years) aged 20 to 24 years old. Among women (n = 96,792), 63.4% of the 1240 incident genital wart cases occurred on the vulva and 21.1% on the cervix. Among men (n = 84,472), 91.6% of the 442 incident genital wart cases did not have a specific anatomic location recorded. Most people with an incident genital wart diagnosis (87.2%) did not have a recurrence during the observation period., Conclusions: Our study found that the incidence of genital warts was highest among persons aged 20 to 24 years using a unique method to identify the location of the wart. Information on incidence of genital warts before vaccine use provides baseline data that can be used to measure HPV vaccine impact.

Objective: The study aimed to formulate an easy clinical approach that may be used by clinicians of all backgrounds to diagnose vulvar dermatological disorders., Materials and Methods: The International Society for the Study of Vulvovaginal Disease appointed a committee with multinational members from the fields of dermatology, gynecology, and pathology and charged the committee to formulate a clinically based terminology and classification of vulvar dermatological disorders. The committee carried out its work by way of multiple rounds of e-mails extending over almost 2 year's time., Results: The committee was able to formulate a consensus report containing terminology, classification, and a step-wise approach to clinical diagnosis of vulvar dermatological disorders. This report was presented and approved by the International Society for the Study of Vulvovaginal Disease at the XXI International Congress held in Paris, France, on September 3 to 8, 2011., Conclusions: The authors believe that the approach to terminology and classification as well as clinical diagnosis contained in this article allows clinicians to make highly accurate diagnoses of vulvar dermatological disorders within the clinical setting. This, in turn, will reduce the need for referrals and will improve the care for women with most vulvar disorders.

Objective: To summarize current terminology and classification of vulvar disorders., Design: Review article., Setting: Gynecologic oncology center, Department of Gynecology and Obstetrics, General Faculty Hospital and 1st Medical School of Charles University, Prague., Methods and Results: Vulvar disorders include wide spectrum of different diagnoses. Multidisciplinary collaboration is frequently needed in diagnostical and therapeutical process. It is essential to use unified terminology using standard dermatological terms, and unified classification for comprehensible communication between different medical professions. Current classification, which is based on Clinical-pathological criteria, was established by International Society for the Study of Vulvovaginal Disease. Recently, there was introduced Clinical classification, which groups disorders according to main morphological finding., Conclusions: Adequate and unified classification and terminology are necessary for effective communication during the diagnostical process.

Objective: This study aimed to present the clinical and colposcopic terminology of the vulva (including the anus) of the International Federation of Cervical Pathology and Colposcopy., Materials and Methods: The terminology has been developed by the International Federation of Cervical Pathology and Colposcopy Nomenclature Committee during 2009-2011., Results: The terminology is part of a comprehensive terminology of the lower genital tract, allowing for standardization of nomenclature by colposcopists, clinicians, and researchers taking care of women with lesions in these areas. The terminology includes basic definitions and normal findings that are important for the clinician lacking experience with management of vulvar disease. This terminology introduces definitions for abnormal findings recently accepted by the International Society for the Study of Vulvovaginal Disease and includes patterns to identify malignancy., Conclusions: The terminology differs from past terminologies in that it includes colposcopic patterns and anal colposcopy. Nevertheless, the role of the colposcope in the management of vulvar disease is limited.

The vast majority of mastocytosis appear in childhood, urticaria pigmentosa (UP) and mastocytomas being the most common types. Terms such as "xanthelasmoid mastocytosis", "pseudoxanthomatous mastocytosis" or "nodular mastocytosis" have been introduced in the literature to describe the presence of yellowish papular or nodular lesions. We describe two children with cutaneous mastocytosis showing yellowish lesions in combination with other skin lesions. A 10-year-old girl presented with asymptomatic lesions in her vulva at birth, and developed brownish macules on her trunk years after. An eight-year-old boy presented with multiple yellowish papular lesions on his trunk, neck and limbs coexisting with a few clinically anetodermic lesions. No systemic involvement was found and the skin biopsy confirmed a cutaneous mastocytosis in both cases. The two patients are currently asymptomatic and are being periodically followed up. Mastocytoses may show a variety of clinical lesions, sometimes leading to misdiagnosis. Although there are previous reports, involvement of the mucosae and secondary anetoderma are not common findings in cutaneous mastocytoses. We consider that cutaneous manifestations of mastocytoses compose a clinical spectrum, thus explaining the coexistence of different clinical lesions and the development of uncommon presentations.

Perineal nodules occurring in male cyclists are reported in the literature, although the histologic features are not extensively documented. There has been little description of similar lesions in the female population. We describe 4 cases in which a vulval nodule or swelling developed in competitive female cyclists aged 15 to 45 years. The lesions were unilateral and occurred on the right or left labium majus (2 cases each). The histologic features were similar in all cases and consisted of a haphazard admixture of adipose tissue, variably cellular hyalinized tissue containing bland spindle-shaped fibroblasts, blood vessels, and nerve fibers. In some areas, thick cords of fibrous tissue imparted a keloid-like appearance. Other histologic features included plump mesenchymal cells with round or ovoid nuclei and abundant eosinophilic cytoplasm resulting in an epithelioid, plasmacytoid, or ganglion-like appearance (2 cases), a lymphocytic infiltrate around blood vessels (3 cases), foci of fat necrosis (1 case), and collections of elastic fibers (2 cases). One case recurred, the histologic features of the recurrent lesion being identical to the original. The overall morphologic appearances, especially in the cases with plump mesenchymal cells, bore some resemblance to proliferative fasciitis. Immunohistochemically, the cells were estrogen receptor positive and the plump mesenchymal cells were smooth muscle actin positive, in keeping with myofibroblasts. Desmin, S100, CD34, and HMGA2 were negative. Pathologists should be aware of this pseudoneoplastic lesion occurring on the vulva, which arises in a specific clinical setting and has the potential to be misdiagnosed as a variety of other mesenchymal lesions. We term this lesion as reactive fibroblastic and myofibroblastic proliferation of the vulva or "cyclist's nodule."

Diagnosis of vulval inflammatory disease is difficult. In this study, we reviewed 31 vulval biopsies from 23 patients with clinical follow-up. We devised 2 scoring systems from recent publications to determine whether these could help to distinguish between lichen sclerosus (LS) and lichen planus (LP). We found that scoring systems could help in distinguishing LS from LP but that they were no better than using some select pathologic criteria, and were much more time-consuming. Most cases of LS had characteristic dermal sclerosis. LP cases had a characteristic band-like inflammatory infiltrate and did not always have features such as pointed rete ridges, wedge-shaped hypergranulosis and cytoid bodies as observed in nonvulval sites. Eczema was the third most common dermatosis in the study and had features that could also be observed in LS, such as acanthosis, abnormal collagen, and ectatic blood vessels. However, dermal sclerosus was not observed. Loss of dermal elastin fibers was observed in both LS and LP and thus did not help in discriminating between the 2 conditions. Oral LP elsewhere in the body was common and was observed in 20% of both the LS and LP group. A small proportion of patients did not fit into any category. We believed that it was important not to label patients as having a disease unless specific features were observed. It may be in their best interests to be called nonspecific rather than being put in the wrong disease category.

Objective: We evaluated a series of questions pertaining to vulvar pain symptoms to determine their association with a localized vulvodynia (vestibulodynia) diagnosis in women from the general population., Methods: A sample of 12,435 women completed a self-administered screening questionnaire for the presence of specific types and characteristics of vulvar pain lasting 3 months or longer. Sensitivity, specificity, and predictive values were calculated for each cross-classification of vulvar pain type and characteristic, using as the gold standard 121 subjects with a clinically confirmed vestibulodynia diagnosis., Results: Relative to women with clinically confirmed vestibulodynia, 83% reported >10 episodes of pain on contact at the time of tampon insertion, intercourse, or pelvic examination, and 83% also reported pain on contact that limited or prevented sexual intercourse. These strong associations with a vestibulodynia diagnosis were not observed with respect to women who reported vulvar pain symptoms of burning or knifelike pain, or vulvar pain characteristics of continuous versus intermittent pain, or provoked versus spontaneous pain., Conclusions: Our findings suggest that a small number of symptoms may be suitable for identifying a large proportion of women suffering from vestibulodynia which may be ideal for the development of an effective screening test in the future. However, we also recognize that a large proportion of women experiencing vulvar pain symptoms will not meet the diagnostic criteria for vestibulodynia. Thus, implementing such a screening procedure as part of a routine examination or testing would require a subsequent pelvic examination to confirm a vestibulodynia diagnosis and to rule out other known explanations for vulvar pain.

Introduction: Dermatologic diseases of the vulva may cause dyspareunia. These disorders may be overlooked by gynecologists and urologists because of lack of residency training experience. Dermatologists who are most familiar with these diseases are infrequently trained in vulvovaginal examination. As such, these disorders are often improperly diagnosed and treated., Aim: To describe the presentation and management of the major vulvar dermatoses including irritant and allergic contact dermatitis, lichen sclerosus, lichen simplex chronicus, and lichen planus., Main Outcome Measure: Data from a peer review literature search on the topic of vulvar dermatoses., Methods: The literature for this review article was obtained through a Medline search. Appropriate dermatology textbooks were utilized for additional information., Results: A comprehensive survey of the vulvar dermatoses., Conclusion: Vulvar dermatoses must be considered a part of the differential diagnosis of any woman with a sexual pain disorder. As such, healthcare providers who evaluate and treat women with dyspareunia must become familiar with the most common dermatologic disorders of the vulva.

Introduction: Vulvodynia is increasingly recognized as a cause of sexual pain. Aim. The goal of this Continuing Medical Education article was to provide a comprehensive review of vulvodynia including terminology, possible etiologies, and offer treatment options., Methods: A Medline search was conducted using several terms related to and including the terms vulvodynia, vulvar vestibulitis, vestibulodynia, and pudendal neuralgia., Results: A thorough review of vulvodynia., Conclusion: Vulvodynia most likely represents several disorders without an identifiable cause in many cases. The management of these patients requires a sensitive provider who can coordinate a multidisciplinary approach to their care. Despite the lack of large-scale, placebo-controlled trials, several new treatment options exist.

The term vulvar intraepithelial neoplasia (VIN) introduced in 1986 incorporates 3 grades of usual VIN (u-VIN I-III) and the differentiated VIN (d-VIN). Although u-VIN is etiologically associated with the human papillomavirus (HPV) infection, d-VIN represents an alternative HPV negative pathway of vulvar carcinogenesis. In 2004, the u-VIN I category was abandoned and u-VIN II and III were merged. Further, an alternative Bethesda-like terminology scheme presenting the term vulvar intraepithelial lesion was proposed recently. To analyze the impact of HPV profiles of vulvar precancerous lesions for their classification and to assess the presumable efficacy of the prophylactic HPV vaccination, 269 vulvar excisions representing lichen sclerosus, lichen simplex chronicus, condylomata acuminata, d-VIN, all grades of u-VIN and squamous cell carcinomas were subjected to the HPV typing by use of GP5+/6+ polymerase chain reaction and reverse line blot hybridization. The results showed different HPV profiles, and also differing frequency of multiple-type HPV infection and the age structure in patients with u-VIN II and III. The biologic heterogeneity within the u-VIN II category was also demonstrated. u-VIN I was distinguished as a rare disorder associated with high-risk HPV infection. We conclude that the original VIN terminology proposed in 1986 seems to be appropriate for the classification of vulvar squamous dysplastic lesions. The spectrum of HPV types found in vulvar squamous cell carcinomas indicates that the efficacy of HPV vaccination in preventing vulvar cancer might be diminished in the studied population, because the recently developed prophylactic vaccines are targeted against a limited number of HPV types.

The International Society for the Study of Vulvovaginal Disease (ISSVD) has, as one of its major societal goals, the development and promulgation of nomenclature and classification of vulvar disease. A committee of the ISSVD has developed new nomenclature and classification for the specific area of vulvar dermatoses. This classification was approved by the ISSVD members at the most recent international congress, held in New Zealand in February 2006.

Chronic pain anywhere on the body can be debilitating and demoralizing. When the pain is associated with sexuality, it can erode self-esteem and diminish relationships. Vestibulodynia (pain in the vulvar vestibule) is poorly understood and presents a clinical challenge to the provider. Although the etiology of vestibulodynia is unclear, and randomized controlled trials of therapies are lacking, the knowledge of current theories and treatments will assist providers in caring for women with this enigmatic problem.

Inflammatory, non-neoplastic epidermal alterations of the vulva can be correctly diagnosed using classification schemes applied to skin elsewhere on the body. A wide range of inflammatory disorders may occur on the vulva, and they may have a similar clinical presentation to HPV lesions. However, HPV is incurable and often is treated surgically. Accordingly, as inflammatory dermatoses commonly occur on the vulva and are often curable with topical therapy, an awareness of these entities and an ability to distinguish them from HPV are imperative.

Objective: To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia., Materials and Methods: Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition., Results: Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient., Conclusions: Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

Objective: This study aimed to test the reliability and validity of physician ratings in a broadly defined sample of women with vulvodynia and to examine the external validity of the vulvodynia subtypes., Design: Participants were 50 women who were independently diagnosed with vulvodynia by two study gynecologists. Physician ratings corresponding to Friedrich's three criteria for vulvar vestibulitis were taken at the two examinations. Each participant's diagnosis was subtyped as vulvar vestibulitis (VV) or dysesthetic vulvodynia (DV) based upon the physician ratings. Participants completed standardized measures of pain, sexual function, psychological function, and quality of life to examine the discriminant validity of the subtypes., Results: Test-retest reliability for the physician ratings of Friedrich's three criteria was stable for two of the three criteria (i.e., pain on attempted vaginal entry and tenderness to pressure localized within the vulvar vestibule). When these criteria were used to categorize participants as having VV or DV, the subtypes were not statistically different for measures used to examine the discriminant validity of the subtypes. While the distribution of patients changed when premenopausal state was added to the inclusion criteria for VV, the subtypes differed little on the outcome measures., Conclusions: Findings from the present study suggest that physician ratings for Friedrich's criteria can be operationalized and found to be reliable and valid in a wide range of women with vulvodynia. The absence of differences between subtypes on measures of pain, sexual function, psychological function, and quality of life challenge the clinical significance of these subtypes and support the theory that vulvodynia represents a continuum of chronic vulvar pain rather than two distinct entities.

Objective: To determine the characteristics of vulvar pain as to location and provocation by touch and pressure in order to confirm that current International Society for the Study of Vulvovaginal Disease definitions of vulvar vestibulitis (provoked vestibulodynia) and vulvodynia (generalized vulvodynia) effectively describe and differentiate these 2 subsets., Study Design: The charts of all women diagnosed with vulvodynia at their initial clinic visit between November 2002 and June 2003 were reviewed for this study. Each patient was evaluated by questionnaire, interview in person and by physical examination to ascertain the location and provoked vs. spontaneous nature of the pain as primary criteria for the differentiation of provoked vestibulodyniafrom generalized vulvodynia., Results: Sixty patients were included in the analysis. Four (6.7%) described provoked pain only in the vestibule (vulvar vestibulitis, provoked vestibulodynia), and 5 women (8.3%) experienced only unprovoked pain that was not confined to the vestibule (dysesthetic vulvodynia, unprovoked generalized vulvodynia). Other patients fell into patterns not specifically recognized or identified by a name. Sixteen (26.7%) experienced both provoked and unprovoked pain always limited to the vestibule, and 21 (35.0%) described provoked and unprovoked pain that extended beyond the vestibule at least occasionally. Six (10.0%) patients described only provoked pain primarily but not limited to the vestibule, and 8 patients each described a unique pattern., Conclusion: This study suggests that the criteria of location and only provoked vs. only unprovoked pain alone do not describe 2 distinct subsets of vulvodynia; rather, there is overlap in provoked vs. unprovoked pain and location.

Objective: To compare the psychological and quality of life profiles of women with different subsets of vulvodynia and identify differential response patterns to a combined gynecologic-dermatologic treatment program., Study Design: Fifty-three women with vulvar dermatoses, dysesthetic vulvodynia and vulvar vestibulitis were recruited from a combined dermatologic and gynecologic vulvar clinic and completed instruments related to quality of life (QoL) and psychologic symptomatology. A repeated measurement design was employed. However, only 33 women could be assessed at the second point of measurement., Results: Women with different subsets of vulvodynia showed (1) distinct quality of life and psychological profiles, and (2) different response patterns to treatment. There were significant differences on most QoL scales, with patients with dysesthetic vulvodynia and with vulvar dermatoses showing greater impairment than patients with vestibulitis. However, patients with vestibulitis displayed a highly specific pattern of psychologic symptomatology. Patients with vulvar dermatoses had an improvement in problems related to intimacy than patients with vulvar pain syndromes., Conclusion: Treatment intervention studies seem to be indispensable in order to gain a better understanding of the complex interplay between different subsets of vulvodynia and psychological symptoms concurrently with differential treatment reactions.

Vulvodynia is a complex syndrome of chronic vulvar pain. It is divided into several subtypes: 1. cyclic vulvovaginitis (pain occurs after coitus), 2. vulvar vestibulitis syndrome (pain mainly with intercourse), 3. dysaesthetic vulvodynia (psychosomatic; diagnosis of exclusion), 4. vulvar dermatoses (e.g. pemphigus vulgaris, contact dermatitis). Additional causes have been described in single cases. Though vulvodynia is often accompanied by psychological distress, somatic causes have to be considered in each case.

Two types of tumefactions can be distinguished: diffuse, without an actually measurable tumour, and circumscribed, most often corresponding to benign tumours. Among diffuse tumefactions, the author diseases prolapse, inguinal hernias, hematomas, oedemas, vulvar varices, abcesses of the vulva and rare cases of elephantiasis. Each case is described and management is discussed. In a second section, where only large tumours can be termed tumescent, the author discusses cystic formations (serous, mucous and epidermal) and solid formations (fibromas, lipomas, acrochordons, neurofibromas, giant condylomas, voluminous endometriomas, and budding neoplastic mass). Excision of these tumours is always recommended as is pathologic surveillance.

Vulvar dermatoses are the localizations to the vulva of a great variety of dermatoses. In genodermatoses, the expression of diseases on the vulva is a part of a complex syndrome. It is non indispensable for the diagnosis. In the immuno-allergic dermatoses or in dermatoses where the pathogenesis is not clearly understood, the vulvar disease is very important because the vulva is often the exclusive localization. The vulvar disease can be the first manifestation before the other expressions of the mucocutaneous disease. Sometimes, there is a risk of scars or transformation in epithelioma. So the diagnosis must be soon established. At least, hidradenitis suppurativa is disease where the choice of the must appropriate treatment is difficult.

Objective: To develop a classification system for the retrieval of stored material on various vulvar conditions., Study Design: The major subject areas of vulvar conditions and management were identified. They were further classified into categories and subcategories. A numbering system was chosen for coding. The information was formatted to allow retrieval from the Internet in a framework ready for label printing., Results: The classification system developed provides guidelines that are useful in making retrieval of stored material on various vulvar conditions more efficient. It can be expanded and personalized to fit the practitioner's needs and can be obtained from the Internet in the following manner by opening Netscape and entering the location: http:/(/)www.med.umich.edu/obgyn/vulva/ vulvalit.html. The filing system was formatted to allow standard, 5266, file-folder-sized label sheets to be inserted into the printer, allowing access to pretyped labels. A total of 464 labels will be printed., Conclusion: This system for retrieving vulvar information will be useful to many people, including clinicians, educators and researchers. The information is easily obtained from the Internet and printed in label form. It aids in the development of a system for life-long learning.

Recent developments in the surgical pathology of the vulva include updated classifications of non-neoplastic epithelial disorders and vulvar intraepithelial neoplasias. Several histologic variants of vulvar squamous cell carcinoma (SCC) with distinct clinicopathologic features have been described. The concept of superficially invasive vulvar SCC continues to be a complex issue. The use of standardized surgical pathology reports and checklists are recent developments in surgical pathology.

The aim of this paper is to update the physicians (gynecologists, dermatologists and pathologists) on the evolution of vulvar disease terminologies. In doing that the authors illustrate briefly the fundamental steps which led to present classifications of the International Society for the Study of Vulvar Disease (ISSVD). The classification of "non neoplastic epithelial disorders" together with that of "intraepithelial alterations" are illustrated and compared with the terminologies previously employed. The last ISSVD definition of "superficially invasive carcinoma" of the vulva is also presented and discussed. The authors concluded that even if all these ISSVD classifications represent an important effort for reaching a common language for a better international exchange of different experiences, nevertheless an improvement of these terminologies is still requested.

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

Lichen sclerosus et atrophicus is a disorder of the skin that can occur anywhere on the body and in all age groups but mainly affects middle-aged and elderly women in the vulvoperineal area. It consists of ivory or pink papules or macules that eventually coalesce into thin, gray, parchment-like areas. Clinically, the main symptoms are severe and intractable itching and vaginal soreness with dyspareunia. Although it has been described to be associated with an increased risk for epithelial malignancy this, in fact, very rarely occurs. The exact nature of LSA is still unknown. The accumulation of evidence does little to clarify its pathogenesis and etiology. The different reports indicate at least three general possibilities; autoimmune, metabolic, and more recently infectious etiology. The coexistence of such diverse findings in one disease entity may indicate one of the two; either we are facing a group of very similar conditions, which will be separated in the future into several closely related clinical entities, each with its own etiology, or that all findings represent a complex multi-step single pathogenetic mechanism. The latter possibility seems more probable because it has previously been suggested that B. burgdorferi, a recent prime suspect in the pathogenesis of LSA, may induce both metabolic and autoimmune abnormalities in the course of infection. New therapeutic options and attitudes emerge that dramatically improved the conservative treatment of this disease (Table 5).(ABSTRACT TRUNCATED AT 250 WORDS)

In this article, vulvar anatomy and histology are reviewed, and nonneoplastic and neoplastic epithelial disorders are presented. Included are lichen sclerosus, squamous cell hyperplasia, vulvar intraepithelial neoplasia, vulvar Paget's disease, and squamous cell carcinoma. Current terminology, tumor measurements, and staging for vulvar carcinoma are reviewed.