What is the definition of vulvodynia?
Classification B
Vulvar pain of at least 3 months duration, without clear identifiable cause, which may have potential associated factors
What are possible causes of vulval pain
Classification A
Infection Inflammatory Neoplastic Neurological Trauma Iatrogenic Hormonal deficiencies
What forms the basis of treatment of vulvodynia
4 Ps
Patient education and reassurance - explain condition, give information. Skin care Pain modification - lignocaine ointment, Gabapentin cream, amitriptyline cream, avoid opioids, oral amitriptyline, gabapentin, pregabalin Physical therapy - physiotherapist - consideration of vaginal Diazepam, Botox Psychological and psychosexual therapy - involve partner - minimise stress - CBT, relaxation techniques - treat mental illness if present
What is localised provoked vestibulodynia?
Younger women 20-30
Superficial dyspareunia / inserting tampon / cycling
Pain may persist after SI
Pain free at other times
Develop hypertonicity in levator ani, secondary vaginismus
What is spontaneous generalised vulvodynia?
Involves large part of vulva Usually postmenopausal Chronic vulval discomfort Symptoms worsen during the day Intercourse doesn’t worsen symptoms
Lichen sclerosus epidemiology:
What is the peak age(s) of prevalence?
What is the prevalence of LS?
What is the associated incidence of vulvar SCC?
Peak:
- Prepuberty
- Peri and postmenopause
True prevalence unknown.
2-5% associated with vulvar SCC
What are the histopathological changes associated with lichen sclerosus?
· Epidermal atrophy/thinning
· Hyalinisation of the dermis (homogenous band of collagen in upper dermis) with underlying lymphocytic infiltrate.
Describe the examination findings associated with lichen sclerosus
- thin and crinkly with pearly white appearance but may be hyperkeratotic if there is concurrent squamous hyperplasia.
- Purpura, fissuring and erosions.
- Bilateral and symmetrical
- Figure of 8 encircling vulva and anus
- Shrinkage of introitus, loss or fusion of labia minora, clitoral hood sealed over.
- DOES NOT extend into vagina or anal canal
What are two differential diagnoses for lichen sclerosus and what distinguishing features help you tell them apart?
Lichen planus:
- Can occur together
- LP involves the vagina (inflammation and synechiae)
Lichen simplex chronicus:
- Hyperkeratotic
- Usually diagnosis of exclusion.
Outline management of lichen sclerosus
- If unsure confirm with vulval biopsy
- Swab and treat associated vulval infections
- Autoimmune investigations if clinically indicated.
- Ultra potent topical steroid e.g. clobetasol proprionate 0.05% 3 months then review
- Topical emollient
- Vaginal lubricant for dyspareunia
- Refer if not improving or if concern for VIN/SCC develops.
- Advise pt to report change e.g. lump, hardening of skin, pain etc.
What is the prognosis for LS?
Complete remission around 54%.
Prepubertal: often resolves spontaneously.
Over 70 years old; less likely to have complete remission.
Progression to SCC <5%.
Relapse common: 50% in 16 months, 84% in 4 years.
Other long term outcomes:
Sexual dysfunction
Dysaesthesia
Clitoral pseudocyst
What is the pathogenesis of lichen planus?
T-cell mediated autoimmune response against basal keratinocytes
What is the histopathology of lichen planus?
- Apoptotic keratinocytes in epidermis
- Upper dermis lymphocytic infiltration
- Basal cell liquefaction
- Increased granular layer
- Irregular sawtoothed acanthosis
What symptoms are associated with lichen planus?
- Itch
- Soreness
- Dyspareunia
- Urinary sx
- Vaginal discharge
- Sometimes postcoital bleeding
What examination findings are associated with lichen planus?
Classical:
- Papules on keratinised anogenital skin with or without striae on the inner aspect of vulva; hyperpigmentation often follows resolution.
Hypertrophic:
- Rare, mimics malignancy
- Thickened warty plaques which may become ulcerated, infect and painful; no vaginal lesions.
Erosive: most common type on vulva
- Mucosal erosions with Wickham’s striae
- Vaginal lesions can lead to scarring and complete stenosis’ friable telangiectasia and patchy erythema
How do you definitively diagnosis lichen planus?
4 mm vulval biopsy + immunofluorescence.
Biopsy may fail to detect classic histologic features of LP and cannot rule it out alone.
Immunofluorescence: may show shaggy staining of basement membrane zonedue to deposition of immunoglobulin.
List two differentials for LP
- Lichen sclerosus
- Pemphigoid
Outline management and prognosis of lichen planus
- 3% risk of malignant transformation; ask pt to report changes in skin apperance or symptoms.
- Ultrapotent topical steroid clobetasol proprionate and vaginal hydrocortisone/Colifoam.
- Only 9% will have resolution of signs of inflammation and 54% become symptom free; 75% have symptomatic improvement.
- Erosive type: refer for long term specialist follow-up.
- Treat any secondary infections with antibacterial and antifungals.
Condylomata accuminata (genital warts):
Which HPV types are implicated and what %?
HPV types 6, 11 implicated in 70-80%
What treatment options are available for genital warts?
Which ones are safe in pregnancy?
- Cryotherapy
- Ablative: diathermy, laser
- Surgical debulking
- Imiquimod 5% cream
- Trichloroacetic acid
Safe in pregnancy: cryotherapy, diathermy, laser, TCA.
What general measures are helpful for genital warts?
- Topical local anaesthetic gel prior to micturition and defecation
- Saltwater baths
- Treat associated candidiasis
- 1% silver sulphadiazine cream for large reaw areas.
What rare vertical transmission of genital warts/HPV can occur during vaginal delivery?
Recurrent respiratory papillomatosis: benign laryngeal tumours caused by HPV types 6 and 11.
