An observational cohort study of pelvic floor photobiomodulation for treatment of chronic pelvic pain

Aim: This research is the first to evaluate the effectiveness of trans-vaginal photobiomodulation therapy (TV-PBMT) for chronic pelvic pain. Materials & methods: Observational analysis of 128 women, undergoing TV-PBMT for chronic pelvic pain. Minimal Clinically Important Difference, defined as ≥2-point drop on a 0–10 numeric pain rating scale (NPRS), and effect size Cohen d coefficient, was calculated over nine treatments for overall pain, and pain with activities. Results: Compared with baseline, 64.5% of women showed improvement in overall pain, pain with bowel movement, intercourse, exercise, urination, sitting and vulvar pain (Minimal Clinically Important Difference = -2.4, -2.0, -2.4, -2.1, -2.1, -2.0, -3.1; d = 0.9, 0.7, 0.9, 0.7, 0.7, 0.7, 0.9) by treatment 9. Conclusion: In this cohort, TV-PBMT resulted in improvement of pelvic pain without serious adverse events.

Filiform projections of the vestibular mucosa: What’s your diagnosis?

29-year-old recently married woman was reffered by her gynecologist to our dermatology department for suspected vulvar condyloma acuminatum. She had no history of any extramarital sexual contacts and her partner was free of any clinical features of genital HPV infections. She was anxious about the origin of her lesions and the risk of her husband’s contamination. She reported burning sensation, irritation and vulvar pain. On clinical examination soft digitate mucous colored papules with a smooth surface were noted at the vulvar vestibule. These papillomatous projections were pearly, uniformly arranged and had separate bases (Fig. 1). Dermatoscopy demonstrated regular and linear pinkish projections arranged in a symmetric distribution. Irregular linear vascular channels were observed (Fig. 2). Figure 1: Clinical aspect: multiple skin-colored filiform and soft projections. Figure 2: Dermatoscopy showing regular and linear pinkish projections arranged in a symmetric distribution. WHAT’S YOUR DIAGNOSIS? ANSWER: Vestibular Papillomatosis Vestibular papillomatosis (VP) is a normal variant of the female genital mucosa [1,2]. It is first described in 1981 by Altemeyer and named pseudocondylomata of the vulva [3]. VP is frequently misdiagnosed as condyloma acuminatum and presents a source of anxiety in patients, aggressive investigations and inappropriate treatment [2]. This entity is most often asymptomatic, but it can be accompanied, as our case, by a feeling of burning, pain or dyspareunia. To avoid the misdiagnosis of VP as genital warts, Moyal-Barranco et al. had proposed five clinical parameters [4]. Unlike condyloma acuminatum, VP is formed by regular, soft and pink-colored papillae arising from a separate base. It is also characterized by the lack of circumscribed whitening on 5% acetic acid application. Dermoscopy can help to differentiate these two conditions by allowing a better identification of these clinical parameters. Linear vessels may sometimes be observed in the transparent core of the finger-like projections [5]. On the other hand, dermoscopy of condyloma acuminatum shows irregular whitish projections with tapering end that arise from a common base and comprise conglomerate vessel. Based on these clinical criteria and the dermoscopic aspect, biopsies will be unnecessary to confirm the diagnosis of VP.

Vulvodynia—It Is Time to Accept a New Understanding from a Neurobiological Perspective

Vulvodynia is one the most common causes of pain during sexual intercourse in premenopausal women. The burden of vulvodynia in a woman’s life can be devastating due to its consequences in the couple’s sexuality and intimacy, in activities of daily living, and psychological well-being. In recent decades, there has been considerable progress in the understanding of vulvar pain. The most significant change has been the differentiation of vulvar pain secondary to pathology or disease from vulvodynia. However, although it is currently proposed that vulvodynia should be considered as a primary chronic pain condition and, therefore, without an obvious identifiable cause, it is still believed that different inflammatory, genetic, hormonal, muscular factors, etc. may be involved in its development. Advances in pain neuroscience and the central sensitization paradigm have led to a new approach to vulvodynia from a neurobiological perspective. It is proposed that vulvodynia should be understood as complex pain without relevant nociception. Different clinical identifiers of vulvodynia are presented from a neurobiological and psychosocial perspective. In this case, strategies to modulate altered central pain processing is necessary, changing the patient’s erroneous cognitions about their pain, and also reducing fear avoidance-behaviors and the disability of the patient.

Localised childhood vulvar pemphigoid: a rare case study

In this case report we present a young patient with localised childhood vulvar pemphigoid. It is a rare variant of bullous pemphigoid with mostly a favourable prognosis and prompt response to potent topical corticosteroids. She presented with relapsing vulvar pain and lesions. Our case enlightens the recognition of this unusual subtype and the importance of performing a cutaneous biopsy.

P507 Vulvar Crohn’s disease: A challenging diagnosis

Background Crohn’s disease is an inflammatory bowel disorder with several well-known extraintestinal manifestations, such as erythema nodosum, uveitis, and arthritis. Less commonly observed are cutaneous, so-called metastatic lesions of the vulva, which represent a diagnostic and therapeutic dilemma and require a multidisciplinary approach. The objective of this study was to report a case series of patients with vulvar Crohn’s disease (VCD), describe its clinical features, histopathologic characteristics and therapeutic management. Methods In this retrospective study, we reviewed all cases of VCD seen in our department between 2008 and 2016. Data concerning age at diagnosis of VCD, vulval symptoms at presentation, histologic findings, and different treatment modalities were recorded. Only patients with both clinical features of VCD [knife-cut fissures, edema, ulceration] and histologic confirmation were included. A total of 3 cases were identified among 106 female patients with CD. Results Case 1: A 58-year-old patient, presented with a 4-year history of vulvar pain and itching. She had no bowel complaints. Clinical examination revealed hypertrophic exophytic lesions associated with linear ulcearations involving the vulva. A biopsy from the lesional skin showed non caseating gigantocellular granuloma. In view of the clinical and histopathological features, a diagnosis of Crohn’s disease of the vulva was made. Anti TNF treatment with adalimumab was started, resulting in a significant regression of the lesions. Case 2: A 47-year-old patient presented to our department with complaints of painful, persisting vulvar ulcers, and resulting dysperunia for 2 years. On clinical examination she had unilateral vulvar oedema with multiple “knife-cut” linear ulcers. A skin biopsy was done which revealed dense inflammatory lymphocytic infiltrate with non caseating granulomas. Treatment with adalimumab was initiated. An improvement of symptoms was noted. Case 3: A 16-year-old patient with no remarkable medical history, presented with a 2-year- history of persistent cheilitis and vulvar pain. Clinical examination of the external genitalia revealed ‘knife-cut’ vulvar fissures with important bilateral labial swelling and multiple papules on the surrounding skin. Histological analysis showed chronic inflammatory infiltrate with noncaseating tuberculoid granulomas. Anti-TNF treatment with infliximab was started with partial regression of lesions. Conclusion Our findings highlight the importance of keeping VCD on the differential diagnosis when faced with a range of vulvar symptoms. Anti-TNF agents seem to be an efficient treatment strategy for this particular localization.