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Recognising Covert Disease in Women with Chronic Vulval Symptoms Attending an STD Clinic: Value of Detailed Examination Including Colposcopy

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Recognising Covert Disease in Women with Chronic Vulval Symptoms Attending an STD Clinic: Value of Detailed Examination Including Colposcopy Genitourin Med: first published as 10.1136/sti.65.1.46 on 1 January 1989. Downloaded from Genitourin Med 1989;65:46-49 Recognising covert disease in women with chronic vulval symptoms attending an STD clinic: value of detailed examination including colposcopy M A BYRNE,*t MM WALKER,$ J LEONARD,§ D PRYCE,* D TAYLOR-ROBINSON*t From the *Jefferiss Research Wing ofthe Praed Street Clinic, the Departments oftHistopathology and §Dermatology, St Mary's Hospital, London, and the tDivision ofSexually Transmitted Diseases, Clinical Research Centre, Harrow, Middlesex SUMMARY A vulval colposcopy clinic was established in the sexually transmitted diseases (STD) clinic of St Mary's Hospital, London, to investigate patients with chronic symptoms (mean duration 3j years). Fifty patients with a mean age of33 were studied for 12 months, and a specific diagnosis was established for many of them. Forty complained of pruritus vulvae, 33 of dyspareunia, and 30 of vulvodynia. One or more macroscopic abnormality was seen in 29 of the women, the most common being erythema, papules, plaques, and fissures. Colposcopic abnormalities, however, were identified in 45 ofthe women, the most common being acetowhite epithelium in a flat, papillary, or cobblestone pattern. Biopsy specimens were obtained from 33 of the patients, and all had abnormal histological features. Those ofhuman papillomavirus (HPV) infection were the most common, and were found in 27 specimens; evidence ofvulval intraepithelial neoplasia was seen in seven and that ofdermatoses in 10. Further work is required, however, before concluding that HPV was necessarily responsible for the chronic symptoms. In many sexually transmitted diseases (STD) clinics vulvodynia. Vulvodynia was defined, according to the http://sti.bmj.com/ there is a subset of patients with chronic, often recommendation of the International Society for the longstanding, vulval symptoms for which no clear Study ofVulvar Disease, as chronic vulval discomfort cause can be found by routine investigation. These especially characterised by burning.' This was women usually attend a clinic on multiple occasions differentiated from pruritus vulvae, which is and are seen by many different doctors in their quest associated with chronic scratching. Dyspareunia was for reliefoftheir symptoms. A range ofdiagnoses from superficial rather than deep in character, and ranged chronic non-specific irritation to psychosomatic dis- from occasional mild discomfort to complete pre- on September 28, 2021 by guest. Protected copyright. ease is often put forward. To ascertain whether an clusion ofsexual intercourse. We saw 50 patients (aged underlying physical cause exists in such women we 19 to 56 (mean 33) years) in 12 months. Each was investigated a group in detail, undertaking colpo- allotted a one hour appointment. scopic examination of the vulva. We report our Assessment of each patient included taking a observations here. detailed medical history and making a general physical examination. In particular, the external genitalia were Patients and methods inspected carefully and then the entire lower genital tract was examined using a Zeiss colposcope. The A specific clinic, the vulval colposcopy clinic, was vulva and cervix were evaluated both before and two instigated to investigate women referred from the to four minutes after the application of5% acetic acid. general STD clinic because they had one or more ofthe All abnormalities identified in this way were docu- following symptoms: pruritus vulvae, dyspareunia, or mented diagrammatically. Punch biopsy specimens 4 mm in diameter were obtained from abnormal areas in a proportion of patients only, as some were unwilling Address for reprints: Dr D Taylor-Robinson, Division of Sexually Transmitted Diseases, Clinical Research Centre, Watford Road, to undergo biopsy. Specimens were placed in 10% Harrow, Middlesex HAl 3UJ formol saline, fixed overnight, processed routinely, and stained with haematoxylin and eosin at three Accepted for publication 22 August 1988 levels before being examined by light microscopy. 46 Genitourin Med: first published as 10.1136/sti.65.1.46 on 1 January 1989. Downloaded from Recognising covert disease in women with chronic vulval symptoms attending an STD clinic 47 Table 1 Symptom complex at presentation ofSO women Table 3 Colposcopic appearances on examination ofSO with chronic vulval complaints women with chronic vulval complaints Symptom complex No ofpatients No ofpatients with Appearance oflesion indicated lesion* Pruritus vulvae only 9 Dyspareunia only I Aceto white epithelium 43 Vulvodynia only I Flat 40 Pruritus vulvae and dyspareunia 10 Papillary 22 Pruritus vulvae and vulvodynia 7 Cobblestone 12 Dyspareunia and vulvodynia 8 Fissuring 3 All three 14 Small warts 2 Ulceration I Erythema I Results *More than one lesion observed in some patients. SYMPTOMS the women. Table 3 shows that the most common The mean duration of symptoms was 3j years, but finding was acetowhite epithelium, which was ranged from two months to 27 years. Table 1 shows observed in 43. Many of these women had more than the symptom complex at presentation. Pruritus vulvae one of the following three distinct patterns of was a complaint of 40 patients, 33 had dyspareunia, epithelium: flat, which occurred on otherwise normal and 30 had vulvodynia. A combination oftwo or more non-raised skin, including mucosal and keratinised of these symptoms occurred in 39 of the women. surfaces; papillary, which comprised small multiple villous projections; and cobblestone, which comprised MACROSCOPIC APPEARANCES broader processes, possibly of fused papillae, raised Careful inspection showed one or more macroscopic above the surface and arranged in a cobblestone abnormality in 29 of the women. Table 2 shows that manner. The latter two types were confined to the the most common feature was erythema, which was mucous membrane of the vestibule, mainly at the noted in 14 women and in nine was confined to the fourchette (figure). posterolateral region ofthe vestibule. Thirteen women Colposcopy also showed other lesions in seven had papular or plaque like lesions that were associated patients (table 3). Genital herpes was diagnosed in one usually with lichenification or an eczematous patient after herpes simplex virus had been isolated appearance, and a proportion were pigmented. These from two small ulcers located on the inner aspect ofthe changes were located in the hair bearing areas of the labium minorum. In another patient, a small fissure http://sti.bmj.com/ vulva or perianally. Twelve ofthe women had fissures, was evident at the frenulum of the clitoris, the site of which were located on the mucosal surfaces of six and her soreness for one year. A pea sized nodule was in the remainder were associated with plaques. palpable, the excision of which resulted in Overall, 18 patients had easily visible changes located improvement of her symptoms. Histology showed in the hair bearing areas, and in two women these fibrous tissue. extended to include the labia minora. Eleven patients, however, had small fissures or erythema, or both, HISTOPATHOLOGICAL APPEARANCES on September 28, 2021 by guest. Protected copyright. which were confined solely to the mucosal surface, Thirty three patients willing to undergo biopsy had usually at the fourchette and could easily have been vulval skin taken from lesions seen macroscopically or overlooked without careful inspection in bright light. colposcopically; histological evaluation showed that all samples had abnormal features (table 4). Vulval COLPOSCOPIC APPEARANCES intraepithelial neoplasia (VIN) was identified in sam- Abnormalities were identified colposcopically in 45 of ples from seven patients, grade I in five cases and grade III in two; six of these seven lesions were visible to the Table 2 Macroscopic appearances on examination of50 naked eye. Koilocytosis was observed in samples from women with chronic vulval complaints 27 of the 33 patients. In 14 of them additional abnormalities were present as follows: seven had No ofpatients with associated VIN, five had inflammatory epithelial Appearance oflesion indicated lesion* hyperplasia (IEH), and two had non-specific inflam- Erythema 14 mation. Vulval dermatoses were identified in samples Papules or plaques 13 from 10 of the patients as follows: two had lichen Fissuring 12 sclerosis (LS) and eight had IEH. Six of the eight with Ulceration 4 Atrophic or white epithelium 2 IEH had koilocytes in the lesions, as mentioned previously, and one had associated non-specific *More than one lesion observed in some patients. inflammatory changes. Genitourin Med: first published as 10.1136/sti.65.1.46 on 1 January 1989. Downloaded from 48 8Byrne, Walker, Leonard, Pryce, Taylor-Robinson http://sti.bmj.com/ on September 28, 2021 by guest. Protected copyright. Figure Colpophotograph showing papillary and cobblestone patterns ofacetowhite epithelium at thefourchette. Cervical intraepithelial neoplasia (CIN) was detec- OTHER GENITAL TRACT INFECTIONS women, ofwhom had vulval koilocytosis. All women were screened and treated for STD before ted in six all had None of the women without such koilocytosis had their referral to the vulval clinic. Forty five had CIN. one or more infections previously. Fifteen of the 27 Genitourin Med: first published as 10.1136/sti.65.1.46 on 1 January 1989. Downloaded from Recognising covert disease in women with chronic vulval symptoms attending an STD clinic 49 Table 4 Histopathologicalfindings in 33 women with represent
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