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Common benign gynecological
disorders
Vulvar pain
Professor Jacob Bornstein
Western Galilee Hospital, Nahariya, Israel
Test for Vestibulitis
Vulvar Vestibulitis:
Friedrich’s criteria of diagnosis
1. Severe pain with vestibular touch
2. Sensitivity is limited to the vestibule
3. Erythema of various degrees (may be absent)
Outcome of surgery for Vulvar Vestibulitis
Age
17-80
Follow-up
in years
0.2-10
Outcome
CR
PR
CR+
PR
NR
Total
371
(57%)
103
(16%)
104
(16%)
68
(11%)
646
(100%)
Bornstein et al. Obstet Gynecol 1999;93:876-880
Vulvar pruritus
• Lichen Sclerosus
• How to do a vulvar biopsy
• Approach to chronic vulvar pruritus
Clinical characteristics of
Lichen Sclerosus:
1. Lichenification and vulvar +
perianal pruritus
5. Lichenification, including
thickening of the skin, a thick
keratin layer and emphasizing
the skin fissures
2. Second stage – Thinning of
the labia minora mucosa,
rendering it easy to become
lacerated
6. Fissure
3. The anterior parts of the labia
minora adhere to each other
and produce Phymosis
covering the clitoris
8. Stenosis of introitus –
“Kraurosis”
4. Ecchimoses – sign of
scrathing the skin
7. Involvement of the vulvar
and perianal area in the figure
of “8”
9. Rare prior to adolescence.
Spontaneously resolve after
puberty in 50%
10. Rarely extra-genital –
Forearm and breasts
Vulvar biopsy
Keye’s dermal punch
Principles of taking a vulvar biopsy
•Sterilization
•Topical anesthetic – Esracaine,
Emla
•Local anesthetic
•Sample the ulcer’s margin
•Take several biopsies from a large
lesion
•Do not compress the specimen
•Immerse in Formalin immediately
Side effects of local anesthetic - Lidocaine
•Dizziness
•Tinnitus
•Peri-oral itch
•Metal taste
•Tremor
•Convulsions
•Myocardial depression
Lichen Sclerosus
Histopathologic
diagnostic criteria:
1. Thin hyperkeratotic layer
2. Thinning of the epithelial
layer
3. Flatenning of the papillae
(Rete pegs)
4. Homogenization of the
stroma
5. Deep lymphocitic
infiltration
Lichen Sclerosus histopathologic diagnostic
criteria (Repeat):
1. Thin hyperkeratotic
layer
2. Thinning of the
epithelial layer
3. Flatenning of the
papillae (Rete pegs)
4. Homogenization of
the stroma
5. Deep lymphocytic
infiltration
Lichen Sclerosus: Etiology
• chronic
inflammation / atrophy
• autoimmune disease
• deficiency in dehydro-Testosterone
Treatments for Lichen sclerosus
Local steroids
Clobetasol
propionate 0.05%
Genital care
Symptomatic
treatment
Sitz baths
Anti-histamine (Otarex)
avoid strong soaps-
Emla 5%; Eurax 10%
-Avoid tight synthetic underwear
Dermovate (Clobetasol
Propionate 0.05%)
Cream or Ointment
Instruction for the use of Dermovate:
•Twice a day for two weeks
•Once a day for one month
•Twice a week for two months
•As needed
Follow up
•
•
•
•
3 month assesment
6 month follow-up
1 yearly follow-up
Every persistent ulceration or new growth
must be examined – risk of malignant
transformation: 3%-5%
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