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3608_title 7/6/06 9:52 AM Page 1 Anatomy,The Physiology, Vulva and Pathology Edited by MirandaThe Procter & Gamble A. CompanyFarage Cincinnati, Ohio, U.S.A. HowardUniversity of California I. Maibach School of Medicine San Francisco, California, U.S.A. New York London Informa Healthcare USA, Inc. 270 Madison Avenue New York, NY 10016 © 2006 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business No claim to original U.S. Government works Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number-10: 0-8493-3608-2 (Hardcover) International Standard Book Number-13: 978-0-8493-3608-9 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the conse- quences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopy- ing, microfilming, and recording, or in any information storage or retrieval system, without writ- ten permission from the publishers. For permission to photocopy or use material electronically from this work, please access www. copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organiza- tion that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data The vulva : anatomy, physiology, and pathology / edited by Miranda A. Farage, Howard I. Maibach. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8493-3608-9 (hardcover : alk. paper) ISBN-10: 0-8493-3608-2 (hardcover : alk. paper) 1. Vulva--Diseases. 2. Vulva--Pathophysiology. 3. Vulva--Anatomy. I. Farage, Miranda A. II. Maibach, Howard I. [DNLM: 1. Vulva. 2. Vulvar Diseases. WP 200 V9913 2006] RG261.V86 2006 618.1’6--dc22 2006044473 Visit the Informa Web site at www.informa.com and the Informa Healthcare Web site at www.informahealthcare.com 3608_Discl.indd 1 7/6/06 11:27:52 AM To my adored Mother and Father: your countless sacrifices have formed my world and given me the gift of purpose and strength of will to succeed. Wherever you are, I am nourished and guided by your never-ending love. M.A.F. Foreword This is a much needed book for the patient with vulvovaginal symptomatology too often faces the prospect of an incomplete evaluation and misdirected thera- pies. There are many reasons for this. Physicians with practice time constraints magnified by an office full of waiting patients too often begin their physical examination with the introduction of the vaginal speculum, bypassing the vulva. In addition, the record of diagnostic accuracy of vaginal infections by physicians shows a high error rate and inaccurate diagnoses lead to inappropriate therapeutic interventions, which only prolong and sometimes intensify patient’s symptomatology. Finally, to a large extent, the care of patients with vulvovaginal problems requires dermatologic insights that are too often lacking for many practitioners. The editors of this book, Miranda A. Farage and Howard I. Maibach, attempt to address these shortcomings and I applaud their efforts. They have selected experts who have both the knowledge and the ability to organize their prose that captures reader attention and accomplishes reader understanding. The underlying philosophy of this book is to provide an in-depth expose´ of the anatomy and physiology: a basis for the understanding of the pathophysiology and one that sets a goal to achieve with appropriate therapy. This is followed by an exposition of the myriad presentations of patients with vulvovaginal disease, and current scientifically accepted treatment regimens. There is an excellent analysis of the menstrual cycle and the range of health care products that are now available to women. Since medicine is not practiced in a vacuum, the influences of race and societal norms on women are provided in detail. Finally, there is a fascinating section that provides an in-depth review of newer investigational techniques that will influence the future care of women. This is a book for all readers. For me, it is a cover-to-cover joy to read. For others, it will be a valuable office reference to be opened every day to address v vi Foreword problems of individual patient care. My congratulations to both the editors and the authors. Obviously, it is a labor of love that hits the mark. William J. Ledger, M.D. Professor and Chairman Emeritus Department of Obstetrics and Gynecology New York Presbyterian Hospital-Cornell Medical Center New York, New York, U.S.A. Preface Few books are devoted exclusively to the vulva. The assumption that vulva skin is like the skin of external body surfaces is wrong. Vulvar tissue has many unique physiological properties and characteristics that differentiate it from the skin and tissue of other body sites. Researchers studying the vulva and clinicians treating patients with vulvar conditions know that there is a paucity of information about the vulva in the medical literature. Consequently, the unique physiology of the vulva, its normal and diseased states, pertinent cultural and hygiene practices that affect vulvar health, and the direction of current investigative research are not widely recognized. This insufficient body of information is responsible for the existing deficiencies in knowledge of the vulva, education and training of physicians about vulvar conditions, and appropriate diagnosis and treatment of vulvar pathology. We attempt to redress these deficiencies with this new volume, The Vulva, a compilation of up-to-date clinical and research information collected in one comprehensive work. The Vulva was written primarily for medical and scientific audiences to underscore unique aspects of vulvar physiology, to highlight possible ethnic differences, to review vulvar diseases, to alert researchers and clinicians to cultural and hygiene practices that affect vulvar health, and to share the latest techniques in investigative research on vulvar tissue. The Vulva includes chapters on vulvar anatomy, physiology, microbiology, age-related changes, ethnicity, diseases, global cultural and hygiene practices, personal products used on the vulva, and toxicological and bioengineering research methods applied to vulvar research. The information included in this book presents the current knowledge and understanding of vulvology. Although this work attempts to be a comprehensive and up-to-date resource, we acknowledge that research on the vulva lags behind other fields. Researchers and clinicians who have contributed to this volume hope to promote a better understanding of the unique physiology of the vulva and to encourage needed research. vii viii Preface This book is intended to increase awareness of the unique health concerns of the vulva and to be a valuable resource on the vulva region for the medical and scientific communities. ACKNOWLEDGMENTS Many appreciations and thanks are gratefully owed to the many people who contributed knowingly and indirectly to this book. The following readers generously offered their time and expertise to peer-review relevant chapters: Drs. Kenneth W. Miller, Bruce E. Jones, Mr. John Blevins, Ms. Lisa Lennon, Drs. Tom Osborn, Brian Gray, Ray Warren, Mr. Ron Visscher and Mr. Kevin Johnson. In addition, Ms. Jan Tremaine, Drs. D. A. Hutchins, and T. L. Nusair have assisted with the review of this book. Their collective recommendations have vastly improved the texts assembled here. Many thanks go to the efforts and help of all the contributors of this book. This book represents the fruits of a jointly conceived and executed venture and has benefited from partners. Many thanks and appreciations go to Drs. Sharon Mitchell and Bruce E. Jones who encouraged and supported the idea for this book from the start. My thanks go to Ms. Lisa Lennon for her help and support of this book. No praise is excessive for her efforts for which she has my heartfelt gratitude. My deepest and most sincere debt is owed to an exceptional person who shepherded the book from start to finish, Dr. Kenneth W. Miller without whose belief, support, help, encouragement, guidance and understanding, this book would not have seen the light of day. Above all, my everlasting gratitude, thanks and love go to my family, husband and children who supported, helped and encouraged me all the way with their incredible patience. Your continuous care, unconditional love and sacrifice made all this possible, and easier to achieve. Miranda A. Farage Howard I. Maibach Contents Foreword William J. Ledger .............................. v Preface . ........................................... vii Contributors . ........................................... xv PART I. ANATOMY AND PHYSIOLOGY 1. Anatomy of the Vulva . ................................ 1 Aikaterini Deliveliotou and George