Curr Treat Options Oncol. 2006 Mar;7(2):85-91.
Sentinel node dissection in vulvar cancer.
Hakim AA, Terada KY.
Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Department of Obstetrics and Gynecology, Suite 420, 333 East Superior Street, Chicago, IL 60611, USA. amy-hakim@northwestern.edu

Vulvar cancer is an uncommon but devastating disease. In addition to radical vulvectomy, most patients require inguinofemoral lymphadenectomy, which often results in wound infection, wound breakdown, and chronic lymphedema. In the past, the gold standard for early lesions was radical vulvectomy with complete bilateral inguinal-femoral lymphadenectomy. This resulted in a low rate of recurrence but devastating disfigurement and high complication rates. Because only approximately 20% of patients with vulvar cancer have positive lymph nodes upon presentation, the traditional approach of inguinal-femoral lymphadenectomy for all patients resulted in many patients undergoing a morbid procedure without any real benefit. Sentinel node dissection, by removing only the nodes with the highest risk of containing metastases, offers a much less morbid alternative. In addition, because only one or two lymph nodes are removed, these can be subjected to a more thorough histopathologic analysis than conventional complete lymphadenectomy. This involves serial sectioning and immunohistochemical staining for cytokeratin antigen. Very small metastases, termed micrometastases, can be detected in this fashion. Therefore, sentinel node dissection with serial sectioning and immunohistochemical staining potentially offers a more accurate assessment of the regional nodes with less morbidity. Patients with positive sentinel nodes may then undergo additional therapy. Patients with negative sentinel nodes are theoretically at very low risk for metastases and should not require any additional treatment.

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Obstet Gynecol. 2006 Mar;107(3):617-624.
Vulvodynia: characteristics and associations with comorbidities and quality of life.
Arnold LD, Bachmann GA, Rosen R, Kelly S, Rhoads GG.
Women's Health Institute, UMDNJ-Robert Wood Johnson Medical School; Department of Psychiatry, UMDNJ-Robert Wood Johnson Medical School; and Department of Epidemiology, UMDNJ-School of Public Health, New Brunswick, New Jersey.

OBJECTIVE: This case-control survey compared health history and health care use of women with vulvodynia with a control group reporting absence of gynecologic pain. METHODS: Women with a clinically assessed diagnosis of vulvodynia and asymptomatic controls were matched for age and mailed a confidential survey that evaluated demographics, health history, use of the health care system, and history of vulvodynia. Participants were all current or former ambulatory patients within a university health care system. RESULTS: Of the 512 questionnaires mailed to valid addresses, 70% (n = 91) of cases and 72% (n = 275) of controls responded, with 77 cases and 208 controls meeting eligibility criteria. Women with vulvodynia reported a substantial negative impact on quality of life, with 42% feeling out of control of their lives and 60% feeling out of control of their bodies. Forty-one percent indicated a severe impact on their sexual lives. When comorbidities were evaluated individually and adjusted for age, fibromyalgia (odds ratio 3.84, 95% confidence interval 1.54-9.55) and irritable bowel syndrome (odds ratio 3.11, 95% confidence interval 1.60-6.05) were significantly associated with vulvodynia. On a multivariate level, vulvodynia was correlated with a history of chronic yeast vaginitis and urinary tract infections. CONCLUSION: This survey highlights the psychological distress associated with vulvodynia and underscores the need for prospective studies to investigate the relationship between chronic bladder and vaginal infections as etiologies for this condition. As well, the association of vulvodynia with other comorbid conditions, such as fibromyalgia and irritable bowel syndrome, needs to be further evaluated. LEVEL OF EVIDENCE: II-2.

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Am J Obstet Gynecol. 2006 Feb;194(2):377-80.
Preliminary results of 5% imiquimod cream in the primary treatment of vulva intraepithelial neoplasia grade 2/3.
Le T, Hicks W, Menard C, Hopkins L, Fung MF.
Division of Gynecologic Oncology, University of Ottawa, Ottawa, Ontario, Canada.

OBJECTIVE: This study was undertaken to study the tolerability and efficacy of 5% imiquimod cream in the primary treatment of vulva intraepithelial neoplasia (VIN) grade 2/3. STUDY DESIGN: VIN grade 2/3 patients were recruited from regional colposcopy units. Imiquimod cream was applied over the abnormal area by the patient using an escalating dose regime for total treatment duration of 16 weeks. At the end of study, repeat colposcopy and biopsy of the target lesion were performed to assess for response. RESULTS: Twenty-three patients participated. Twenty patients (87%) had VIN grade 3. Nine patients (39%) had multifocal disease on colposcopy. Therapy was well tolerated with the most commonly observed side effects being irritation at the application site. Responses were evaluable in 17 patients. Complete responses were observed in 9 patients with partial responses in another 5 (relative risk 82%). The median time to response was 7 weeks. CONCLUSION: Imiquimod cream can induce histologic regression of high-grade VIN lesions and is well tolerated using a slow dose-escalating regime.

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Expert Rev Anti Infect Ther. 2006 Feb;4(1):125-35.
Trichomoniasis and its treatment.
Nanda N, Michel RG, Kurdgelashvili G, Wendel KA.
Department of Medicine, Oklahoma University Health Science Center, Oklahoma City, OK, USA.

Trichomonas vaginalis has long been recognized as a cause of infectious vaginitis in women. More recently, studies have demonstrated a significant burden of disease in men with urethritis or men at high risk for sexually transmitted diseases. There is increasing interest in this pathogen as more data accumulates linking it to HIV transmission and perinatal morbidity. New diagnostic methods have emerged that may increase sensitivity of diagnosis or improve point-of-care access to testing. Nitroimidazoles remain the mainstay of therapy. Metronidazole and tinidazole are highly effective as single-dose therapy. Unfortunately, despite the link between T. vaginalis infection and perinatal morbidity, nitroimidazole therapy during pregnancy remains controversial. Although metronidazole resistance is currently uncommon, pharmacological features and nitroimidazole resistance patterns suggest that tinidazole may be more effective in treating patients with metronidazole treatment failure. Alternatives to nitroimidazole therapy are few, and most have limited efficacy and significant toxicity.

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Int J Gynecol Cancer. 2006 Jan-Feb;16(1):283-7.
Unilateral groin and pelvic irradiation for unilaterally node-positive women with vulval carcinoma.
Jackson KS, Fankam EF, Das N, Naik R, Lopes AD, Godfrey KA, Hatem MH, Branson AN, Taylor WT.
Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, United Kingdom. suzijackson@doctors.org.uk

It is essential that any patient with resected vulval cancer and significant nodal disease receive optimal adjuvant treatment with radiation. Adequate radiotherapy for such patients with unilateral positive groin nodes has not been defined. Whether both groins and pelvic sidewalls should be irradiated or only the affected (node positive) side remains unclear. From our registry, we identified all patients with primary, previously untreated squamous cell carcinoma of the vulva undergoing bilateral inguinofemoral lymphadenectomy (superficial and deep nodes) and having unilaterally positive groin nodes treated with unilateral groin and pelvic radiotherapy (44 Gy in 22 fractions). Clinical and pathologic records were reviewed to identify the anatomical site and timing of recurrences in these patients and determine whether unilateral groin and pelvic irradiation was sufficient for disease control on the node-negative side. From 1983 to 2002, 20 patients with unilateral positive nodes treated with unilateral groin and pelvic irradiation were identified. Nineteen patients were classed as having FIGO stage III disease and one as FIGO stage IV due to involvement of the rectal mucosa. There were nine patients with disease recurrences in this group (45%). The disease-free interval ranged from 4 to 31 months (median time to recurrence, 9 months). All nine patients had local or regional failures, the most common site being the ipsilateral groin (six of nine patients). One patient was also found to have distant metastases. There were no recurrences noted in the contralateral (nonirradiated) groin or pelvic sidewall. Recurrence was generally fatal. Eight of the nine patients subsequently died of their disease. The ninth patient died of another cause. There was a high incidence of regional failure after unilateral groin and pelvic radiotherapy, but there were no recurrences on the nonirradiated, node-negative side. Although a small series, we speculate that there is no apparent disadvantage to administering unilateral adjuvant radiotherapy for unilaterally positive groin nodes and encourage further studies in order to more confidently determine whether the tendency observed in our center holds true.

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Infect Dis Obstet Gynecol. 2005 Dec;13(4):197-206.
An evaluation of butoconazole nitrate 2% site release vaginal cream (Gynazole-1) compared to fluconazole 150 mg tablets (Diflucan) in the time to relief of symptoms in patients with vulvovaginal candidiasis.
Seidman LS, Skokos CK.
Philadelphia Women's Research, Philadelphia, PA 19114, USA. seidmanlb@aol.com

BACKGROUND: It is estimated that as many as 13 million cases of vulvovaginal infection occur in the United States annually, the majority of which are the result of Candida albicans infection. The symptoms of vulvovaginal infections are often painful and distressing to the patient. The objective of this study was to compare the time to symptomatic relief of vulvovaginal candidiasis (VVC) with butoconazole nitrate 2% Site Release vaginal cream (Gynazole-1) and oral fluconazole 150 mg tablets (Diflucan). METHODS: This randomized, open-label, parallel study evaluated 181 female patients with moderate to severe symptoms of VVC. Patients were randomized to single-dose therapy with either butoconazole nitrate 2% Site Release vaginal cream or fluconazole. The primary outcome measure was the time to onset of first relief of symptoms. Secondary measures included the time to overall relief of symptoms and the reinfection rate over the first 30 days following treatment. The overall safety of both products was investigated through the collection of adverse event reports. RESULTS: The median time to first relief of symptoms occurred at 17.5 h for butoconazole patients as compared to 22.9 h for fluconazole patients (p < 0.001). The time at which 75% of patients experienced first relief of symptoms was 24.5 h versus 46.3 h for butoconazole and fluconazole, respectively (p < 0.001). By 12- and 24-h post-treatment, 44.4% and 72.8% of patients in the butoconazole treatment group reported first relief of symptoms versus 29.1% and 55.7% of patients in the fluconazole group (p = 0.044 and p = 0.024 respectively). In patients experiencing first relief of symptoms within 48 h of dosing, the median time to first relief of symptoms in the butoconazole treatment group was significantly shorter at 12.9 h compared to 20.7 h for the fluconazole treatment group (p = 0.048). There were no significant differences between the two groups with respect to time to total relief of symptoms or reoccurrence of infection within 30 days of treatment. Butoconazole therapy was shown to have fewer reported adverse events, including drug-related adverse events, than fluconazole therapy. Vulvovaginal pruritis and vulvovaginal burning were the most common drug-related adverse events attributed to butoconazole. Headache, diarrhea, nausea, upset stomach and skin sensitivity were the most common drug-related adverse events attributable to fluconazole. CONCLUSIONS: Single-dose butoconazole nitrate 2% Site Release vaginal cream provides statistically significant improvement in time to first relief of symptoms in the treatment of VVC compared to fluconazole. There is no difference between these two treatments with respect to total relief of symptoms or reinfection rate. Although there was no significant difference in the incidence of adverse events judged by the investigator to be treatment-related, butoconazole treatment did result in fewer patients experiencing adverse events than fluconazole.

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Obstet Gynecol. 2006 Jan;107(1):136-143.
Effects of Long-Term Use of Nonoxynol-9 on VaginalFlora.
Schreiber CA, Meyn LA, Creinin MD, Barnhart KT, Hillier SL.
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine and Magee-Womens Research Institute, Pittsburgh, Pennsylvania; and Penn Fertility Care and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Medical Center, Penn Fertility Care, Philadelphia, Pennsylvania.

OBJECTIVE: Products containing nonoxynol-9 have been used as spermicidal contraceptives for many years, but limited data have been published describing the long-term effects of nonoxynol-9 use on the vaginal microbial ecosystem. This longitudinal study was conducted to examine the effects of nonoxynol-9 on the vaginal ecology. METHODS: Vaginal swabs were obtained from 235 women enrolled in a randomized clinical trial before initiation of use of 1 of 5 different formulations of nonoxynol-9 for contraception, and up to 3 more samples were gathered over 7 months of use. The swab samples were evaluated in a single laboratory. The prevalence of several constituents of the normal vaginal flora was evaluated. The associations between nonoxynol-9 dosage, formulation, average product use per week, and number of sex acts per week were calculated. RESULTS: The changes in prevalence of vaginal microbes after nonoxynol-9 use were minimal for each of the different nonoxynol-9 formulations. However, when both nonoxynol-9 concentration and number of product uses are taken into account, nonoxynol-9 did have dose-dependant effects on the increased prevalence of anaerobic gram-negative rods (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.1-5.3), H(2)O(2)-negative lactobacilli (OR 2.0, 95% CI 1.0-4.1), and bacterial vaginosis (OR 2.3, 95% CI 1.1-4.7). CONCLUSION: This study demonstrated that most nonoxynol-9 users experienced minimal disruptions in their vaginal ecology. There were no differences between the different formulations evaluated with respect to changes in vaginal microflora. However, independent of the nonoxynol-9 formulation, there was a dose-dependent effect with increased exposure to nonoxynol-9 on the risk of bacterial vaginosis and its associated flora. LEVEL OF EVIDENCE: II-2.

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Arch Gynecol Obstet. 2006 Jan;273(4):232-5. Epub 2005 Oct 25.
Comparative efficacy of two regimens in syndromic management of lower genital infections.
Sharma JB, Mittal S, Raina U, Chanana C.
Department of Obstetrics & Gynecology, All India Institute of Medical Sciences & Lok Nayak Hospital, New Delhi, India, jbsharma@eth.net.

Aim: The aim of this study was to compare the efficacy and safety of two combination regimens in the syndromic management of lower genital infection. Seventy-two non-pregnant women presenting with symptoms of lower genital infection diagnosed as vaginitis on clinical examination and lacking obvious upper genital infection were enrolled to one of the two treatment regimens as a syndromic treatment. No investigations were performed to cut the cost and to avoid the loss of patients on follow-up. Thirty-seven women (group I) were prescribed a course of clotrimazole (Imidil, Lyka) 100 mg vaginal pessaries for 6 days. Along with their partners they were prescribed 2 gm secnidazole (Secnil forte) and 150 mg fluconazole (Syscan) as a single therapy. Thirty-five women (group II) were prescribed vaginal clotrimazole as mentioned above. A combination kit containing 150 mg fluconazole, 2 gm secnidazole and 1 gm azithromycin (FAS-3 kit, Lyka) was also prescribed to both partners with the advice to take azithromycin on empty stomach, and the other three tablets after food. Results: All women in both groups were seen after 1 week for relief of symptoms and after 1 month for any recurrence. Mean parity was 2.7 and 3.0, respectively. The total symptomatic relief was observed in 67.6 and 94.3% cases, partial relief in 27 and 5.7% cases and no relief was observed in 5.4% and nil cases, respectively, in the two groups. Recurrence was seen in two and nil cases, respectively, in the two groups. Most women tolerated both the treatments well with no major side effect in any case. Treatment cost was higher in group II (Rupees 120) than in group I (Rupees 65). Conclusions: Both combination kits with local clotrimazole were reasonably effective and safe in the syndromic approach for lower genital infections. The combination kit with azithromycin, secnidazole and fluconazole was more effective with better symptomatic relief and less recurrence rate and may be routinely recommended in all cases of lower genital infection as a cost effective, safe and effective strategy.

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Curr Infect Dis Rep. 2005 Nov;7(6):445-52.
Her choice: dealing with lactobacilli, vaginitis, and antibiotics.
Pirotta MV, Garland SM.
Department of General Practice, University of Melbourne, 200 Berkeley Street, Carlton, 3053, Victoria, Australia. m.pirotta@unimelb.edu.au.

Vulvovaginal candidiasis is a common problem for women, yet there are many gaps in knowledge about candida's pathogenesis, immunity, and its reputed association with antibiotic use. Women often self-diagnose and self-manage the problem, yet one of the most common folk remedies used, the probiotic lactobacillus, has no biologically plausible mechanism to explain any beneficial actions and no rigorous evidence to support its effectiveness. This paper explores these issues and summaries potential areas for further research.

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Int J STD AIDS. 2005 Nov;16(11):736-8.
Recurrent bacterial vaginosis: the use of maintenance acidic vaginal gel following treatment.
Wilson JD, Shann SM, Brady SK, Mammen-Tobin AG, Evans AL, Lee RA.
Department of Genitourinary Medicine, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK. janet_d.wilson.nhs.uk

Bacterial vaginosis (BV) frequently recurs after treatment. One option in the management of recurrences is to keep the vaginal pH at 4.5 or less, in order to prevent overgrowth of bacteria, until the normal lactobacilli are re-established. We report the outcome of using maintenance acetic acid vaginal gel, after treatment of BV, in a sample of 49 women with frequent recurrences. Half of the women had no further recurrences, and in those who did there was a significant increase in time to first recurrence (4.8 months) after commencing the gel compared with the previous recurrence (2.1 months). Prior to using acidic gel, the mean recurrence rate in 49 women was 4.4 per woman/year, and this was reduced to 0.6 recurrences per woman/year. As there are few effective therapies for women with recurrent BV, we feel this offers an option that can currently be used in clinical practice.

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Am J Obstet Gynecol. 2005 Oct;193(4):1404-9.
Insight into the treatment of vulvar pain: a survey of clinicians.
Updike GM, Wiesenfeld HC.
Department of Obstetrics, Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. gupdike@mail.magee.edu

OBJECTIVE: The purpose of this investigation was to determine practice patterns among clinicians who frequently treat patients with vulvar pain syndromes. STUDY DESIGN: A cross-sectional survey was distributed to providers in the United States whose names were on a referral list of clinicians that care for women with vulvar pain (National Vulvodynia Association, Silver Springs, MD). The survey included 2 clinical vignettes. Clinicians were asked to report what treatments they would use to treat women with generalized vulvodynia and localized vulvodynia. Data were analyzed with descriptive statistics. A comparison of categoric data was accomplished with the Fisher's exact test. RESULTS: Surveys were mailed to 327 providers; 167 completed surveys were returned, for an overall response rate of 51%. The most commonly used treatment for vulvodynia was tricyclic antidepressants. There was no difference in the use of physical therapy, estrogens, injected or topical steroids, interferon, or laser therapy to treat generalized and localized vulvodynia. Respondents were more likely to use tricyclic antidepressants (P < .001), gabapentin (P < .001), and psychiatric care (P < .001) and less likely to use local anesthesia (P < .001) and vestibulectomy (P = .007) for the clinical scenario that represented generalized vulvodynia than they were for the scenario that represented localized vulvodynia. Most clinicians reported screening for vaginal infections, and many clinicians perform colposcopy and/or vulvar biopsy. Respondents recommend a variety of lifestyle modifications in the treatment of vulvodynia. CONCLUSION: Clinicians use a wide variety of treatments for vulvar pain and use different therapies for variants of vulvodynia.

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Can J Microbiol. 2005 Sep;51(9):777-81.
Vaginal microbial diversity among postmenopausal women with and without hormone replacement therapy.
Heinemann C, Reid G.

Urogenital infections in postmenopausal women remain problematic. The use of estrogen replacement therapy has been shown to lower these infection rates, corresponding to increasing colonization by Lactobacillus species. Despite the gut's 500 microbial species and the proximity of the anus to the vagina, only a relatively few microbial strains appear to be able to colonize the urogenital area. In the present study, the sparsity of microbes in the vagina was confirmed by denaturing gradient gel electrophoresis analysis of swabs taken at time zero and monthly for 3 months from 40 postmenopausal subjects receiving Premarin (conjugated equine estrogen in combination with progesterone) hormone replacement therapy (HRT) and 20 who were not on HRT. Lactobacilli were recovered from the vagina of 95% or more women in both groups, but in the HRT group, Lactobacillus were more often the dominant and only colonizers and significantly fewer bacteria with pathogenic potential were found. The incidence of bacterial vaginosis was significantly lower in the HRT group than in the non-HRT-treated women (5.6% versus 31%). The use of HRTs has recently come under criticism. The ability of drugs such as Premarin to help recover the lactobacilli vaginal microbiota appears to be at least one benefit of HRT use. In women not using HRTs, use of probiotics may be the only way to restore a nonpathogen-dominated flora.

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Infect Dis Obstet Gynecol. 2005 Sep;13(3):155-60.
The efficacy and safety of a single dose of Clindesse vaginal cream versus a seven-dose regimen of Cleocin vaginal cream in patients with bacterial vaginosis.
Faro S, Skokos CK; Clindesse Investigators Group.
The Woman's Hospital of Texas, Houston, Texas 77054, USA.

OBJECTIVE: To determine whether a single dose of Clindesse vaginal cream is comparable in efficacy and safety to Cleocin vaginal cream administered once daily for 7 days in the treatment of bacterial vaginosis. STUDY DESIGN: This multicenter, randomized, single-blind, parallel-group study enrolled 540 patients with BV infections. Treatment consisted of either a single intravaginal dose of Clindesse or 7 daily doses of Cleocin. Efficacy and safety were assessed 21-30 days after the start of treatment. The efficacy endpoints were Investigator Cure, Clinical Cure (a composite of all 4 Amsel's criteria and Investigator Cure), Nugent Cure (Nugent score < 4), and Therapeutic Cure (a composite of Clinical Cure and Nugent Cure). Resolution of individual Amsel's criteria was also evaluated. Treatment-emergent adverse events were monitored throughout the study. RESULTS: There were no significant differences in cure rates between the Clindesse and Cleocin treatment groups in Investigator Cure (P=0.702), Clinical Cure (P=0.945), Nugent Cure (P=0.788), or Therapeutic Cure (P=0.572). Results were also similar for 3 of 4 and 2 of 4 Amsel's criteria and for each individual Amsel's criterion (all P-values >0.200). Ninety-five percent confidence intervals for each endpoint were consistent with equivalence between the 2 products. There was no significant difference between the treatment groups in the incidence of treatment-emergent adverse events (P=0.386). CONCLUSIONS: A single dose of Clindesse vaginal cream is equivalent in safety and efficacy to a 7-dose regimen of Cleocin vaginal cream in the treatment of bacterial vaginosis. This represents a significant advance in the treatment of bacterial vaginosis.

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Altern Ther Health Med. 2005 Sep-Oct;11(5):38-43.
Alternative therapies for bacterial vaginosis: a literature review and acceptability survey.
Boskey ER.
Department of Preventative Medicine and Community Health, State University of New York Health Science Center, Brooklyn, NY, USA.

OBJECTIVE: This article reviews current research into non-antibiotic treatments for bacterial vaginosis and assesses interest in the use of alternative therapies for women's health in a non-representative sample of women. DESIGN: Literature review and online survey. SUBJECTS: A convenience sample of 192 women was selected from an online community devoted to the discussion of women's health. RESULTS: Data on alternative treatments for bacterial vaginosis are mixed. Studies have shown both positive and null effects for probiotic- and lactic acid-based treatments. The results of antiseptic studies were more uniformly positive, but the studies were generally not placebo-controlled. Women in the survey population were both interested in and experienced with alternative and complementary therapies for reproductive health problems--44% of them had used home or natural remedies to treat vaginal infections or menstrual problems, and only 20% indicated that antibiotics and antifungals would be their treatment of choice. CONCLUSIONS: Women are interested in alternative treatments for women's health problems such as yeast infections and bacterial vaginosis. Although such treatments have been investigated, further research--particularly in the form of high-quality, randomized, controlled trials--is strongly indicated.

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J Womens Health (Larchmt). 2005 Sep;14(7):627-33.
Perceived life stress and bacterial vaginosis.
Harville EW, Hatch MC, Zhang J.
Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina.

Background: Bacterial vaginosis (BV) is a common vaginal condition produced by overgrowth of anaerobic bacteria. Consequences of the condition may include preterm birth and pelvic inflammatory disease (PID). Because stress can suppress immune function, increased stress might increase the risk of BV. Our objective was to determine whether life stress was associated with risk of bacterial vaginosis in a cohort of nonpregnant women. Methods: A total of 411 African American women receiving routine gynecological care were recruited from two New York City hospitals. They were asked to rate the pressure they felt over the last week as a result of change, relationships, sickness, and finances using the Global Assessment of Recent Stress scale. An overall measure of stress was created by summing the responses over the categories. Stress was categorized into low, intermediate, and high tertiles. BV was diagnosed by gram stain score. Results: In almost all domains of life stress, women with high stress were more likely to have BV than those with low stress; however, none of the differences reached statistical significance. Thirty-four percent of women with BV had high overall stress as opposed to 26% of women without BV, giving an adjusted relative risk (RR) of 1.4 (95% confidence interval, 0.95, 2.1). Conclusions: In a cohort of African American women in New York City, perceived life stress showed no clear association with BV. Because of the prevalence of both the exposure and the disease, further study is warranted.

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J Sex Marital Ther. 2005 Jul-Sep;31(4):329-40.
Physiotherapy treatment of sexual pain disorders.
Rosenbaum TY.
The Clinic for Sexual Treatment and Rehabilitation, Tel Aviv, Israel. tallir@netvision.net.il

Physiotherapists provide treatment to restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of patients suffering from injuries or disease. Women with vulvar pain, dyspareunia, or vaginismus have limited ability to function sexually and often present with musculoskeletal and neurological findings appropriately addressed by a trained physiotherapist. Although pelvic floor surface electromyography (sEMG) biofeedback has been studied, the inclusion of physiotherapy in the team approach to treating women with sexual pain disorders is a relatively recent advancement, and its exact role is not widely understood by doctors, mental health professionals, or laypersons. This article will examine the supportive and often primary role of the physiotherapist in the overlapping conditions of vaginismus and dyspareunia.

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Curr Opin Pediatr. 2005 Aug;17(4):473-9.
Bacterial vaginosis: many questions—any answers?
O'Brien RF.
Division of General Pediatrics and Adolescent Medicine, The Floating Hospital for Children at Tufts-New England Medical Center, and Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts 02111, USA. robrien@tufts-nemc.org

PURPOSE OF REVIEW: Bacterial vaginosis, a common disorder among young women, is associated with adverse reproductive health outcomes. This review summarizes our current understanding of bacterial vaginosis and where future research should be focused. Recommendations for prevention, diagnosis, and treatment in both nonpregnant and pregnant populations are discussed. RECENT FINDINGS: Little progress has been made in understanding the causal factors. The results of several large prospective studies have shown that racial differences persist for rates of bacterial vaginosis even when other known risk factors are controlled for. Studies of the gene-environment interaction that examine the genetic aspects of immune response may explain racial differences and why some but not all women with bacterial vaginosis experience complications. Trials to prevent preterm birth by the treatment of bacterial vaginosis in pregnancy are disappointing. Resistance to clindamycin by bacterial vaginosis-associated anaerobic organisms has also been documented. New technology to provide rapid point-of-care diagnostic testing for bacterial vaginosis has emerged. SUMMARY: To understand the vaginal ecosystem and its role in reproductive health and disease, we will need to study not only the microflora but also the host-immune response. Currently recommended treatment options for bacterial vaginosis are associated with high rates of recurrence. A new concern is the development of macrolide resistance to vaginal anaerobic flora when clindamycin is used as treatment. Further studies are still needed to determine whether prevention or control of bacterial vaginosis, particularly approaches that rely not on antibiotic treatment but on the maintenance of a healthy vaginal ecosystem, can reduce adverse health outcomes.

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Maturitas. 2005 Aug 31; [Epub ahead of print]
Management of post-menopausal vaginal atrophy and atrophic vaginitis.
Castelo-Branco C, Cancelo MJ, Villero J, Nohales F, Julia MD.
Institut Clinic de Ginecologia, Obstetricia i Neonatologia, Hospital Clinic, Facultad de Medicina, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain.

The involution of the female genital tract seems to reflect a built-in biological life expectancy, inter-related with the hypothalamic-hypophyseal-ovarian axis. Lower levels of oestradiol have a number of adverse effects, including on the lower urinary tract. The major universal change is vaginal atrophy. The vaginal mucosa becomes thinner and dry, which can produce vaginal discomfort, dryness, burning, itching, and dyspareunia. The vaginal epithelium may become inflamed, contributing to urinary symptoms such as frequency, urgency, dysuria, incontinence, and/or recurrent infections. Moreover, it has been suggested that reduced oestrogen levels may affect periurethral tissues and contribute to pelvic laxity and stress incontinence. In association with hypoestrogenemia, changes in vaginal pH and vaginal flora may predispose post-menopausal women to urinary tract infection. Treatment to date has been based on local hormonal therapy, in the form of vaginal creams, tablets or suppositories. Other routes of hormone administration have also proved to be successful. Both local and systemic administration are both effective in maturation of the vaginal epithelium. However, despite the fact that the benefits of oestrogen replacement in preventing vaginal atrophy and reducing the incidence of related symptoms are well established, such therapy is contraindicated in some women and is not an acceptable option for others. Furthermore, the optimal HT administration route, the dosage regimen, and non-hormonal alternatives for improving symptoms and quality of life of the post-menopausal female population, have not been well studied. This review focuses on the changes involved in vaginal aging and efforts to present a synopsis of the pathophysiology and therapy of atrophic vaginitis and vaginal atrophy.

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Rev Med Liege. 2005 Jul-Aug;60(7-8):656-60.
[Vulvar lichen sclerosus]
[Article in French]
Gillard P, Vanhooteghem O, Richert B, de la Brassinne M.
Service de Dermatologie, CHU Sart Tilman, Liege.

Vulvar lichen sclerosus is a frequent mucocutaneous disease especially affecting 50 to 60 year-old women but with a possible onset at very young age. Symptoms are most disabling including pruritus and dyspareunia. Vulvar mucosa gradually becomes more white and atrophied. Degeneration into epidermoid carcinoma is possible. Treatment only consists of topical corticosteroids.

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J Reprod Med. 2005 Jul;50(7):513-23.
Chronic inflammation of the vagina: treatment and relationship to autoimmunity.
Thomson JC.
National Women's Hospital, Auckland, New Zealand. jthomson@world-net.co.nz

OBJECTIVE: To investigate noninfective, symptomatic, chronic inflammation (CI) of the vaginal mucosa to determine its prevalence and immunologic basis and to initiate an immunologic approach to treatment and assess the response. STUDY DESIGN: A prospective, observational, clinical study of 55 women with dyspareunia and/or discharge of vaginal mucosal origin. Vaginal biopsies and immune investigations were carried out. Treatment was instituted utilizing immune-modifying agents. RESULTS: The prevalence of CI of the vagina in symptom-free women was 0-4.3% and in the symptomatic group, 89%. Systemic immune activation was demonstrated in 43 of the 55, with 21 suffering from an autoimmune disease or a condition in which immune activation plays a part, including endometriosis in 20. Thirty-one were treated; intravaginal hydrocortisone acetate 10% foam was given in 24, giving full relief in 14 and inadequate relief in 10. Hydroxychloroquine, an immune-modifying, antirheumatic drug, was added and largely gave relief in these 10. Hydroxychloroquine alone was given in 4 and was effective in 3. Overall, immune-modifying drugs were successful in 97%. CONCLUSION: CI of the vaginal mucosa stems from local immune activation and is generally associated with evidence of other immune abnormalities, including autoimmune diseases and disorders in which immune activation play a part, including endometriosis. It can be successfully treated by immune modification.

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Eur J Obstet Gynecol Reprod Biol. 2005 Jun 1;120(2):202-5.
Successful treatment of bacterial vaginosis with a policarbophil-carbopol acidic vaginal gel: results from a randomised double-blind, placebo-controlled trial.
Fiorilli A, Molteni B, Milani M.
Obstetric Department, Ospedale Civile di Vimercate, Presidio di Carate, Milan, Italy.

OBJECTIVE: We evaluated the efficacy of a mucoadhesive vaginal gel (MVG, Miphil) with acidic-buffering properties in bacterial vaginosis (BV). STUDY DESIGN: Double-blind, placebo-controlled, 12-week trial. SUBJECTS: A total of 45 non-pregnant women with BV were enrolled in the trial. Patients were treated with MVG 2.5 g or the corresponding placebo (P) daily for the first week and then every 3 days for the following 5 weeks (treatment phase) in a 2:1 ratio. All patients were followed for an additional 6 weeks without treatments (follow-up phase). Clinical cure was defined as absence of vaginal discharge, vaginal pH <4.5, a negative fish odour test and a Nugent score <7. RESULTS: At week 6, 28 out of 30 women (93%) in the MVG group were clinically cured in comparison with only 1 out of 15 (6%) in the P group (P=0.0001). At week 12, 86% of MVG treated women remained cured in comparison with 8% in P group (P=0.0001). At baseline, the vaginal pH was 6.1+/-0.7 in the MVG and 5.5+/-0.7 in the P group. Vaginal pH significantly (P=0.003) decreased to 4.3+/-0.3 in the MVG group. In P group non-significant modifications of vaginal pH were observed (5.1+/-0.5). CONCLUSION: Our results demonstrated that this MVG is an effective treatment of BV.

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APMIS. 2005 May;113(5):305-16.
Bacterial vaginosis--a disturbed bacterial flora and treatment enigma.
Larsson PG, Forsum U.
Department of Molecular and Clinical Medicine, Linkoping University, and Department of Obstetrics and Gynaecology, Karnsjukhuset, Skovde, Sweden. p-g.larsson@vgregion.se

The syndrome bacterial vaginosis (BV) is characterized by a disturbed vaginal microflora in which the normally occurring lactobacilli yield quantitatively to an overgrowth of mainly anaerobic bacteria. As BV is a possible cause of obstetrics complications and gynaecological disease--as well as a nuisance to the affected women--there is a strong impetus to find a cure. In BV treatment studies, the diagnosis criteria for diagnosis of BV vary considerably and different methods are used for cure evaluation. The design of study protocols varies and there is no consensus respecting a suitable time for follow-up visits. For the purpose of this review, available data were recalculated for 4-week post treatment cure rates. For oral metronidazole the 4-week cure rate was found not to exceed 60-70%. Treatment regimens with topical clindamycin or topical metronidazole have the same cure rates. It can thus be said that no sound scientific basis exists for recommending any particular treatment. There is no evidence of beneficial effects on BV engendered by partner treatment, or by addition of probiotics or buffered gel. Long-term follow-up (longer than 4 weeks) shows a relapse rate of 70%. With a primary cure rate of 60-70%, and a similar relapse rate documented in the reviewed literature, clinicians simply do not have adequate data for determining treatment or designing clinical studies. This is unfortunate since--apart from the obvious patient benefits--clinical studies can often serve as a guide for more basic studies in the quest for underlying disease mechanisms. In the case of BV there is still a need for continued basic studies on the vaginal flora, local immunity to the flora and host-parasite interactions as an aid when designing informative clinical studies.

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Clin Exp Obstet Gynecol. 2005;32(2):111-3.
Local estrogen replacement therapy in postmenopausal atrophic vaginitis: efficacy and safety of low dose 17beta-estradiol vaginal tablets.
Mainini G, Scaffa C, Rotondi M, Messalli EM, Quirino L, Ragucci A.
Department of Gynaecologic Obstetric and Reproduction Sciences, Second University of Naples, Naples, Italy.

PURPOSE OF INVESTIGATION: To verify the effectiveness and safety of low-dose 17beta-estradiol vaginal tablets in the treatment of the postmenopausal atrophic vaginitis. PATIENTS AND METHODS: 325 postmenopausal women with atrophic vaginitis in estrogenic replacement therapy with 0.025 mg 17beta-estradiol vaginal tablets, one application each day for two weeks, and a single application two times a week for the following 22 weeks (total treatment period: 24 weeks). RESULTS: Most of the women reported an improvement of symptoms just after two weeks and minimal incidence of adverse reactions. No patients showed abnormal endometrial thickness and no one had to interrupt the treatment for abnormal uterine bleeding because of systemic absorption. CONCLUSION: Low-dose 17beta-estradiol vaginal tablets in the treatment of the postmenopausal atrophic vaginitis constitutes an extremely valid approach in terms of effectiveness and safety.

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Hautarzt. 2005 Jun;56(6):556-61.
[Vulvodynia.]
[Article in German]
Hengge UR, Runnebaum IB.
Klinik fur Dermatologie, Heinrich-Heine-Universitat, Dusseldorf.

Vulvodynia (vulvar dysesthesia) refers to vulvar pain (burning, irritation and rawness) of the external female genitalia for more than 3 months without other dermatological or gynecological causes. The term primary vulvodynia should be reserved for vulvar vestibulitis and essential (dysesthetic) vulvodynia. Vulvar vestibulitis is characterized by dyspareunia, allodynia and vulvar erythema. Most patients are Caucasian, premenopausal and sexually active. The prevalence is estimated as high as 15%. Damage to the sympathetic nerves with an increased pain sensitivity is the likely explanation for the burning sensation. Psychological impairment, which is common in many patients, rather seems to be the consequence of the chronic disease than a primary condition. Essential vulvodynia is characterized by vulvar burning, which is characteristically not limited to the vestibulum. The patients are generally older and dyspareunia is less severe. The prevalence of essential vulvodynia is 1-3%. Various interdisciplinary approaches to these two rather frequent genital diseases are discussed.

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Int J Gynaecol Obstet. 2005 Mar;88(3):281-5. Epub 2005 Jan 20.
Low-dose secnidazole in the treatment of bacterial vaginosis.
Nunez JT, Gomez G.
Faculty of Medicine, University of Zulia, Hospital Manuel Noruega Trigo, Maracaibo, Venezuela. jnunez@ncifcrf.gov

OBJECTIVE: To determine whether bacterial vaginosis could be cured with a single 1-g oral dose of secnidazole. MATERIAL AND METHODS: A total of 80 women were recruited at the outpatient gynecologic clinic of Manuel Noriega Hospital, Maracaibo, Venezuela. Diagnosis and patient enrollment were based on the Amsel criteria. The participants were randomized to 2 groups. In group 1 (n=44) participants received a single 1-g oral dose and in group 2 (n=32) participants received a single 2-g oral dose of secnidazole. Clinical cure was defined as the absence of the characteristic symptoms (a bad odor and a grossly abnormal discharge) and at least 2 of the following: vaginal pH less than 4.5, no fish odor on addition of KOH, and no Gardnerella vaginalis or clue cells on wet-mount examination. Cytologic cure was defined as an absence of G. vaginalis on a Papanicolaou (Pap) smear. RESULTS: Clinical cure was experienced by 95.5% of the women who received the 1-g oral dose and by 97.4% of the women who received the 2-g oral dose of secnidazole. There was no significant difference between the groups in the clinical resolution of bacterial vaginosis. Following treatment, results were negative for G. vaginalis in 94.7% of the women. In group 1, 41 women (93.2%), and in group 2, 31 women (96.9%) had cytologic cure. The Pap smear revealed G. vaginalis in 3 of the women in group 1 and 1 of the women in group 2 (P=0.47). Twenty-seven women (35.5%) reported mild side effects. More women had adverse effects in group 1 (n=16) than in group 2 (n=11) but this difference was not statistically significant. CONCLUSION: This clinical study showed that a single 1-g oral dose of secnidazole is effective to cure bacterial vaginosis associated with G. vaginalis.

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Eur Urol. 2005 Mar;47(3):288-96.
The probiotic approach: an alternative treatment option in urology.
Hoesl CE, Altwein JE.
Department of Urology, Hospital Barmherzige Bruder, Technical University Munich, Krankenhaus Barmherzige Bruder, Romanstr. 93, 80639 Munchen, Germany. choesl2004@yahoo.com

OBJECTIVE: The prophylactic and therapeutic use of probiotic microorganisms is a wide and still controversial field. The review paper is aimed to summarize recent findings on the health-benefiting effects of probiotics in urological diseases. The use of certain beneficial strains against urogenital infections, bladder cancer recurrence and renal stone formation is discussed. METHODS: Literature search of PubMed documented publications and abstracts from meetings. RESULTS: Various clinical trials have now been performed which substantiate the beneficial effects of the probiotic strains L. rhamnosus GR-1, L. fermentum RC-14 and L. crispatus CTV-05 against urogenital infections, such as urinary tract infections and bacterial vaginosis. The potential of L. casei Shirota to reduce the recurrence rate of bladder cancer is one of the most intriguing examples for the use of probiotics in medical practice. The use of O. formigenes in the prevention of calcium oxalate stone disease was only recently suggested and needs to be further investigated. CONCLUSION: Clinical trials increasingly provide a profound scientific basis for the use of probiotics in medicinal practice including urology. Efforts to make probiotic products available which are validated according to the guidelines recommended by the WHO and FAO and produced according to Good Manufacturing Practice will contribute to the acceptance of probiotic therapy by both the physicians and the patients.

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Acta Derm Venereol. 2005;85(1):42-6.
A double-blind treatment study of bacterial vaginosis with normal vaginal lactobacilli after an open treatment with
vaginal clindamycin ovules.
Eriksson K, Carlsson B, Forsum U, Larsson PG.
Department of Obstetrics and Gynecology, Alands Centralsjukhus, Finland. katarina.eriksson@ahs.aland.fi

The expected 4-week cure rate after conventional treatment of bacterial vaginosis are only 65-70%. In an attempt to improve the cure rate by adding probiotic lactobacilli we performed a double-blind placebo-controlled study of adjuvant lactobacilli treatment after an open treatment with vaginal clindamycin ovules. Women with bacterial vaginosis as defined by Amsel's criteria were treated with clindamycin ovules. Vaginal smears were collected and analysed according to Nugent's criteria. During the following menstruation period the women used, as an adjuvant treatment, either lactobacilli-prepared tampons or placebo tampons. The lactobacilli tampons were loaded with a mixture of freeze-dried L. fermentum, L. casei var. rhamnosus and L. gasseri. The cure rate was recorded after the second menstruation period. There was no improvement in the cure rate after treatment with lactobacilli-containing tampons compared to placebo tampons; the cure rates as defined by Amsel's criteria were 56% and 62%, respectively, and 55% and 63%, as defined by Nugent's criteria. This is the first study to report cure rates for women with 'intermediate' wet smear ratings according to Nugent's classification and this group had an overall cure rate of 44%. The cure rate of treatment of bacterial vaginosis was not improved by using lactobacilli-prepared tampons for one menstruation.

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Ned Tijdschr Geneeskd. 2005 Feb 12;149(7):336-42.
[Surgical treatment of early-stage vulva carcinoma and the complications of the operation]
[Article in Dutch]
de Hullu JA, van der Zee AG.
Universitair Medisch Centrum St Radboud, afd. Gynaecologische Oncologie, huispost 415, Postbus 9101, 6500 HB Nijmegen. j.dehullu@obgyn.umcn.nl

The treatment of patients with early-stage squamous-cell carcinoma of the vulva (with a depth of invasion > 1 mm), i.e. stage T1 with a tumour diameter < or = 2 cm or T2 with a diameter > 2 cm without suspect groin nodes on palpation, has become less radical; in this way, the complications can be reduced without compromising the generally favourable prognosis. Wide local excision with tumour-free margins of 2 cm appears to be a safe option for the local treatment. Uni- or bilateral inguinofemoral lymphadenectomy with separate incisions is currently part of the standard treatment. The complications associated with this standard surgical treatment remain significant: there are frequent disorders of wound healing, wound infections, lymphoceles, lymphoedema and effects on psychosexual behaviour. The minimal invasive sentinel lymph-node procedure is a promising technique in patients with early-stage squamous-cell carcinoma of the vulva, but the safety of the procedure must still be proven.

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J Low Genit Tract Dis. 2005 Jan;9(1):40-51.
The vulvodynia guideline.
Haefner HK, Collins ME, Davis GD, Edwards L, Foster DC, Hartmann ED, Kaufman RH, Lynch PJ, Margesson LJ, Moyal-Barracco M, Piper CK, Reed BD, Stewart EG, Wilkinson EJ.
Department of Obstetrics and Gynecology, University of Michigan Hospitals, Ann Arbor, MI 48109, USA. haefner@umich.edu

OBJECTIVE: To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia. MATERIALS AND METHODS: Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition. RESULTS: Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient. CONCLUSIONS: Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

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Cochrane Database Syst Rev. 2005 Jan 25;(1):CD000262.
Antibiotics for treating bacterial vaginosis in pregnancy.
McDonald H, Brocklehurst P, Parsons J.
Microbiology and Infectious Diseases, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia, Australia, 5006. mcdonaldh@wch.sa.gov.au

BACKGROUND: Bacterial vaginosis is an imbalance of the normal vaginal flora with an overgrowth of anaerobic bacteria and a lack of the normal lactobacillary flora. Bacterial vaginosis during pregnancy has been associated with poor perinatal outcome and, in particular, preterm birth. Identification and treatment may reduce the risk of preterm birth and its consequences. OBJECTIVES: To assess the effects of antibiotic treatment of bacterial vaginosis in pregnancy. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (May 2004). SELECTION CRITERIA: Randomized trials comparing antibiotic treatment with placebo or no treatment, or comparing two or more antibiotic regimens in pregnant women with bacterial vaginosis or intermediate vaginal flora. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trials and extracted data independently. We contacted study authors for additional information. MAIN RESULTS: Thirteen trials involving 5300 women were included; all were of good quality. Antibiotic therapy was effective at eradicating bacterial vaginosis during pregnancy (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.19 to 0.24, nine trials of 3895 women). Treatment was not significant in reducing the risk of preterm birth before 37 weeks (OR 0.87, 95% CI 0.74 to 1.03, thirteen trials of 5300 women, and there was significant heterogeneity between trials, p-value 0.002), preterm birth before 34 weeks (OR 1.22, 95% CI 0.67 to 2.19, five trials of 851 women), preterm birth before 32 weeks (OR 1.14, 95% CI 0.76 to 1.70, four trials of 3565 women), or the risk of preterm prelabour rupture of membranes (OR 0.88, 95% CI 0.61 to 1.28, four trials of 2579 women). In women with a previous preterm birth, treatment did not affect the risk of subsequent preterm birth (OR 0.83, 95% CI 0.59 to 1.17, five trials of 622 women, with significant heterogeneity between these trials); however, it may decrease the risk of preterm prelabour rupture of membranes (OR 0.14, 95% CI 0.05 to 0.38, two trials of 114 women, and low birthweight (OR 0.31, 95% CI 0.13 to 0.75, two trials of 114 women). AUTHORS' CONCLUSIONS: Antibiotic treatment can eradicate bacterial vaginosis in pregnancy. However, this review provides little evidence that screening and treating all pregnant women with asymptomatic bacterial vaginosis will prevent preterm birth and its consequences. For women with a previous preterm birth, there is some suggestion that treatment of bacterial vaginosis may reduce the risk of preterm prelabour rupture of membranes and low birthweight.

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Akush Ginekol (Sofiia). 2004;43(6):23-6.
Polygynax in the treatment of fungal and non specific vaginitis.
Goran D, Vesna A, Adela S, Biljana TK, Snezana M.
Department of Gynecology and Obstetrics, Clinical Centre, Skopje.

BACKGROUND: Polygynax is a product commercialized in the form of vaginal capsule, associating bactericidal antibiotics: Neomycin, Polymyxin B and Nystatin--an antifungal agent which is fungicidal and fungistatic in vitro and in vivo. OBJECTIVE: The objectives of the study were to analyze the clinical and bacteriological efficacy of Polygynax in the treatment of bacterial vaginitis with one or more germs (mixed vaginitis) and Candida infections, and to investigate the correlation between the results of the initial clinical examination and bacteriological studies. MATERIAL AND METHODS: The study covered 88 patients diagnosed with mixed vaginitis during initial screening of vaginal flora (direct Gram stains and standard microbiology laboratory methods for cultivation of vagina/ cervix smears with antibiotic susceptibility testing). The patients were treated with Polygynax, applied in form of vaginal capsules (during 12 days, application before retiring). After at least 30 days following last day of therapy, the same diagnostic swabs were repeated. In this period, averaging 38.4 days, sexual abstinence was recommended. RESULTS: The results showed that total clearance of present germs was found in 83/88 patients (94.3% of the cases), according to the repeated cervico- vaginal smears. CONCLUSION: Polygynax is a treatment of preference against fungal infections, with added advantage of having wide antibacterial spectrum.

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Am Fam Physician. 2004 Dec 1;70(11):2125-32.
Management of vaginitis.
Owen MK, Clenney TL.
Emory University School of Medicine, Atlanta, Georgia, USA.

Common infectious forms of vaginitis include bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Vaginitis also can occur because of atrophic changes. Bacterial vaginosis is caused by proliferation of Gardnerella vaginalis, Mycoplasma hominis, and anaerobes. The diagnosis is based primarily on the Amsel criteria (milky discharge, pH greater than 4.5, positive whiff test, clue cells in a wet-mount preparation). The standard treatment is oral metronidazole in a dosage of 500 mg twice daily for seven days. Vulvovaginal candidiasis can be difficult to diagnose because characteristic signs and symptoms (thick, white discharge, dysuria, vulvovaginal pruritus and swelling) are not specific for the infection. Diagnosis should rely on microscopic examination of a sample from the lateral vaginal wall (10 to 20 percent potassium hydroxide preparation). Cultures are helpful in women with recurrent or complicated vulvovaginal candidiasis, because species other than Candida albicans (e.g., Candida glabrata, Candida tropicalis) may be present. Topical azole and oral fluconazole are equally efficacious in the management of uncomplicated vulvovaginal candidiasis, but a more extensive regimen may be required for complicated infections. Trichomoniasis may cause a foul-smelling, frothy discharge and, in most affected women, vaginal inflammatory changes. Culture and DNA probe testing are useful in diagnosing the infection; examinations of wet-mount preparations have a high false-negative rate. The standard treatment for trichomoniasis is a single 2-g oral dose of metronidazole. Atrophic vaginitis results from estrogen deficiency. Treatment with topical estrogen is effective.

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Rev Iberoam Micol. 2004 Dec;21(4):177-81.
[Study of acute vulvovaginitis in sexually active adult women, with special reference to candidosis, in patients of the Francisco J. Muniz Infectious Diseases Hospital]
[Article in Spanish]
Buscemi L, Arechavala A, Negroni R.
Unidad Bacteriologia, Hospital de Infeccionsas Francisco Javier Muniz, Buenos Aires, Argentina.

The results of microbiological vaginal secretions samples obtained from 749 women (from July 2001 to July 2002) were studied in the Bacteriology Unit of the Francisco Javier Muniz Hospital from Buenos Aires. All patients suffered acute vulvovaginitis were child bearing and sexually active women, 334 of them were HIV-positive. The following are the results of the microbiological studies: Lactobacillus spp 50.6%, Gardnerella vaginalis 25.6%, Candida spp 17.4%, Trichomonas vaginalis 5.3%, Neisseria gonorrhoeae 0.3% and B group Streptococcus 0.8%. Candida vaginitis was significantly more frequent in HIV-positive patients, (21.6% vs 14%; p = 0.0086); meanwhile, trichomoniasis was less common although the difference was not statistically significant (3.6 vs 6.7%, p = 0.0810). The following Candida species were isolated in this study: Candida albicans 76.8%, Candida glabrata 15.6%, Candida parapsilosis 2.9%, Candida tropicalis 1.5% and Candida krusei 0.7%. Eight cases (6.2%) of vaginitis were produced by two Candida species (C. albicans and C. glabrata), and in three cases (2.17%) Saccharomyces cerevisiae were isolated. Five women suffering acute vaginitis with Candida spp presented another etiologic agent of vaginal infection, three cases T. vaginalis and two cases G. vaginalis. The following are some of the most important findings of this study: 1) Half of the patients presented a normal microbial biota; 2) Candida spp vaginitis was significantly more frequent among HIV-positive women; 3) we observed a high incidence of Candida glabrata infections (15.9%), 4) 6.2% of vaginal candidiasis were caused by more than one Candida species and, 5) the susceptibility pattern of C. albicans and C. glabrata isolates against fluconazole was similar to the one observed in other studies. The majority of C. albicans isolates were susceptible to fluconazole (MIC90 = 0.5 microg/ml) meanwhile C. glabrata strains were much less susceptible to this drug (MIC50 and MIC90 = 32 microg/ml).

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Am J Obstet Gynecol. 2004 Dec;191(6):1898-906.
Intravaginal metronidazole gel versus metronidazole plus nystatin ovules for bacterial vaginosis: a randomized controlled trial.
Sanchez S, Garcia PJ, Thomas KK, Catlin M, Holmes KK.
Hospital dos de Mayo, Lima, Peru.

OBJECTIVE: We compared metronidazole 0.75% gel (containing 37.5 mg metronidazole per dose) with ovules containing metronidazole 500 mg and nystatin 100,000 U, for intravaginal treatment of bacterial vaginosis (BV). STUDY DESIGN: In a single-blinded trial, symptomatic women with BV by both Amsel and Nugent criteria were randomly assigned to gel or ovules, once nightly for 5 nights, and asked to return 3 times after treatment. Analyses were intent-to-treat. RESULTS: Of 151 women with BV by both criteria at enrollment, 138 (91%) returned at least once. Product limit estimates for persistence or recurrence of BV at 14, 42, and 104 days were 20% (95% CI 10%-29%), 38% (95% CI 25%-48%), and 52% (95% CI 37%-63%) after gel treatment, and 4% (95% CI 0%-9%), 17% (95% CI 7%-26%), and 33% (95% CI 21%-46%) after ovule treatment ( P = .01). Among women without BV at first follow-up, subsequent intercourse without condoms independently predicted subsequent recurrence ( P </= .01). CONCLUSION: Metronidazole/nystatin ovules were significantly more effective than metronidazole gel. Unprotected sex predicted recurrence after initial improvement.

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Dermatol Ther. 2004;17(1):102-10.
The diagnosis and treatment of infectious vaginitis.
Edwards L.
Southeast Vulvar Clinic, Charlotte, North Carolina 28211, USA. ledwardsmd@aol.com

Inflammation of the vagina as a result of infectious agents is very common, both as an overgrowth of normal or common colonizers, or as a frank infection. The most common causes of infectious vaginitis are yeast, bacteria, protozoa, viruses, and parasites. Infections of the vagina produce an increase in vaginal secretion, vulvar symptoms of itching or irritation from contact with irritating vaginal fluid, and sometimes odor. A careful microscopic examination of vaginal secretions generally yields the correct diagnosis, but atypical or recalcitrant disease deserves a confirmatory culture, as noninfectious inflammatory processes can produce similar symptoms.

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MedGenMed. 2004 Nov 22;6(4):49.
Are vaginal symptoms ever normal? Review of the literature.
Anderson M, Karasz A, Friedland S.
Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York.

Purpose: Vaginal symptoms such as discharge, odor, and itch are among the most common presenting complaints in primary care. We undertook to determine if the symptoms associated with vaginitis (discharge, odor, irritation) occur in normal women. Methods: To answer this question, we performed a literature review. We conducted a Medline search using the following terms: "vagina," "vaginal discharge," "secretion," "odors," discharge," "pruritus," "normal," "irritation," "itch," "physical examination," "healthy," "asymptomatic," "quantity," and "physiology." To find additional references we reviewed textbooks in gynecology, primary care, and physical diagnosis and contacted authors. Results: There are few primary studies, and most are not of high quality. Existing data show that the quantity and quality of vaginal discharge in healthy women vary considerably both across individuals and in the same individual during the menstrual cycle. Most studies indicate that discharge is greatest at midcycle. Vaginal fluid contains malodorants, and one study of intact vaginal fluid found it to be malodorous. Two studies found that normal women reported irritative symptoms in the course of their menstrual cycle. Conclusions: The primary literature indicates that there is a wide variation in the normal vagina and that some of the symptoms associated with vaginal abnormality are found in well women. Both clinicians and their patients would benefit from a better understanding of the range of normal as well as what constitutes a meaningful departure from that range.

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Akush Ginekol (Sofiia). 2004;43(6):23-6.
Polygynax in the treatment of fungal and non specific vaginitis.
Goran D, Vesna A, Adela S, Biljana TK, Snezana M.
Department of Gynecology and Obstetrics, Clinical Centre, Skopje.

BACKGROUND: Polygynax is a product commercialized in the form of vaginal capsule, associating bactericidal antibiotics: Neomycin, Polymyxin B and Nystatin--an antifungal agent which is fungicidal and fungistatic in vitro and in vivo. OBJECTIVE: The objectives of the study were to analyze the clinical and bacteriological efficacy of Polygynax in the treatment of bacterial vaginitis with one or more germs (mixed vaginitis) and Candida infections, and to investigate the correlation between the results of the initial clinical examination and bacteriological studies. MATERIAL AND METHODS: The study covered 88 patients diagnosed with mixed vaginitis during initial screening of vaginal flora (direct Gram stains and standard microbiology laboratory methods for cultivation of vagina/ cervix smears with antibiotic susceptibility testing). The patients were treated with Polygynax, applied in form of vaginal capsules (during 12 days, application before retiring). After at least 30 days following last day of therapy, the same diagnostic swabs were repeated. In this period, averaging 38.4 days, sexual abstinence was recommended. RESULTS: The results showed that total clearance of present germs was found in 83/88 patients (94.3% of the cases), according to the repeated cervico- vaginal smears. CONCLUSION: Polygynax is a treatment of preference against fungal infections, with added advantage of having wide antibacterial spectrum.

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Eur J Obstet Gynecol Reprod Biol. 2004 Nov 10;117(1):70-5.
Efficacy and safety of vitamin C vaginal tablets in the treatment of non-specific vaginitis. A randomised, double blind,
placebo-controlled study.
Petersen EE, Magnani P.
Section of Gynaecological Infectiology, Gynaecological University Clinic, Hugstetter Strasse 55, Freiburg D-79106, Germany.

METHODS: This was a randomised, double-blind, placebo-controlled study to evaluate the efficacy and safety of Vitamin C vaginal tablets (250 mg) given once a day in patients suffering from non-specific vaginitis. The total length of the study was 20 days, including a treatment phase of 6 days. The primary end-point was the presence in the two groups of non-specific vaginitis 1 and 2 weeks after the end of treatment, as assessed by at least 3 out of the 4 characteristic symptoms: discharge, fishy odour, vaginal pH >/= 4.7, and presence of clue cells. Secondary end-points were the individual symptoms and signs, above reported, and pruritus, fever, superinfections, microscopic findings on vaginal smear, and colposcopy. PATIENTS: One hundred female patients aged 18 years or older and suffering from non-specific vaginitis were included in the study after giving their informed consent. Fifty were randomised to the active treatment and 50 to placebo. Seven patients, three in the Vitamin C group and four in the placebo group, were lost to follow-up and did not complete the treatment period. Two patients in the active group showed protocol deviations (age under 18 years and HIV-positive, respectively). The two groups resulted comparable for demographics, history and baseline clinical picture. RESULTS: A cluster analysis of the four main symptoms showed a statistically significant difference between the active group and the placebo group; significantly more patients were still affected by non-specific vaginitis after placebo (35.7%) compared to patients treated with Vitamin C tablets (14.0%). The meaningful secondary variable, referring to the microscopic examination of vaginal smear, supported the trend for efficacy in the Vitamin C treated group. The clue cells disappeared in 79% of patients treated with the drug and in 53% of patients on placebo. Similarly, bacteria disappeared in 77 and 54%, respectively, while lactobacilli reappeared in 79.1 and 53.3%, respectively. Vaginal pH values decreased significantly in both groups, but the frequency rate of subjects with pH >/= 4.7, as measured 1 week after the drug discontinuation, was significantly lesser in the Vitamin C group (16.3%) than in the placebo group (38.6%). Adverse events occurred in four patients, two on placebo (pruritus, cystitis) and two on Vitamin C (two candidiasis).

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BMC Surg. 2004 Oct 30;4(1):15.
Pudendal nerve decompression in perineology: a case series.
Beco J, Climov D, Bex M.
Gynaecology, CHU Sart-Tilman, University of Liege, B-4000 Liege, Belgium. jacques.beco@skynet.be

BACKGROUND: Perineodynia (vulvodynia, perineal pain, proctalgia), anal and urinary incontinence are the main symptoms of the pudendal canal syndrome (PCS) or entrapment of the pudendal nerve. The first aim of this study was to evaluate the effect of bilateral pudendal nerve decompression (PND) on the symptoms of the PCS, on three clinical signs (abnormal sensibility, painful Alcock's canal, painful "skin rolling test") and on two neurophysiological tests: electromyography (EMG) and pudendal nerve terminal motor latencies (PNTML). The second aim was to study the clinical value of the aforementioned clinical signs in the diagnosis of PCS. METHODS: In this retrospective analysis, the studied sample comprised 74 female patients who underwent a bilateral PND between 1995 and 2002. To accomplish the first aim, the patients sample was compared before and at least one year after surgery by means of descriptive statistics and hypothesis testing. The second aim was achieved by means of a statistical comparison between the patient's group before the operation and a control group of 82 women without any of the following signs: prolapse, anal incontinence, perineodynia, dyschesia and history of pelvi-perineal surgery. RESULTS: When bilateral PND was the only procedure done to treat the symptoms, the cure rates of perineodynia, anal incontinence and urinary incontinence were 8/14, 4/5 and 3/5, respectively. The frequency of the three clinical signs was significantly reduced. There was a significant reduction of anal and perineal PNTML and a significant increase of anal richness on EMG. The Odd Ratio of the three clinical signs in the diagnosis of PCS was 16,97 (95% CI = 4,68 - 61,51). CONCLUSION: This study suggests that bilateral PND can treat perineodynia, anal and urinary incontinence. The three clinical signs of PCS seem to be efficient to suspect this diagnosis. There is a need for further studies to confirm these preliminary results.

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Clin Exp Obstet Gynecol. 2004;31(3):175-8.
Infections of the lower female genital tract during childhood and adolescence.
Deligeoroglou E, Salakos N, Makrakis E, Chassiakos D, Hassan EA, Christopoulos P.
Division of Pediatric-Adolescent Gynecology and Reconstructive Surgery, University of Athens, Aretaieion Hospital, Athens (Greece).

PURPOSE: To review the pathogenesis, clinical presentation, diagnosis and treatment of lower female genital tract infections at a young age. METHODS: Review study. CONCLUSIONS: Lower female genital tract infections at a young age may involve the vulva, the vagina and, less frequently, the fallopian tubes. Good knowledge of the physiology and anatomy of the respective areas plays an important role in the diagnosis and treatment of vulvovaginitis. Candida albicans is the most frequent cause of infection, while Gardnerella vaginalis, Chlamydia trachomatis, Mycoplasma, and Trichomonas vaginalis are rarer ones. The clinical presentation includes a variety of symptoms and signs, with vaginal discharge being the prominent one. Treatment should be causative after careful investigation while preventive advice is mandatory.

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Mycoses. 2004 Oct;47(9-10):422-7.
Clinical and mycological efficacy of single-day oral treatment with itraconazole (400 mg) in acute vulvovaginal candidosis.
Urunsak M, Ilkit M, Evruke C, Urunsak I.
Department of Medical Microbiology, Faculty of Medicine, Cukurova University, Adana, Turkey.

This study aimed to investigate the effectiveness of single-day oral treatment with itraconazole in acute vulvovaginal candidosis (VVC). Vaginitis was demonstrated by both detection of yeast cells and pseudohyphae formation on microscopic examination of vaginal discharge and mycological culture as well as by the clinical signs and symptoms. Clinical and mycological examinations of the 52 patients were performed before, 1 week (short-term) and 4 weeks (long-term) after single-day oral treatment with itraconazole 200 mg b.i.d. The causative yeast fungi were: Candida albicans (76.9%), C. glabrata (9.6%), C. kefyr (9.6%) and C. krusei (3.9%), respectively. In short- and long-term examinations, clinical cure rates were found to be 61.5% and 90.4%, and mycological cure rates were 63.5% and 90.4%, respectively. Itraconazole was found to be 95.0% effective with C. albicans and 75.0% with other Candida species. It is concluded that treatment of acute VVC with itraconazole is safe and effective in the long-term.

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BMJ. 2004 Sep 4;329(7465):548. Epub 2004 Aug 27.
Effect of lactobacillus in preventing post-antibiotic vulvovaginal candidiasis: a randomised controlled trial.
Pirotta M, Gunn J, Chondros P, Grover S, O'Malley P, Hurley S, Garland S.
Department of General Practice, 200 Berkeley Street, Carlton, Victoria, Australia, 3053. m.pirotta@unimelb.edu.au

OBJECTIVE: To test whether oral or vaginal lactobacillus can prevent vulvovaginitis after antibiotic treatment. DESIGN: Randomised, placebo controlled, double blind, factorial 2x2 trial. SETTING: Fifty general practices and 16 pharmacies in Melbourne, Australia. PARTICIPANTS: Non-pregnant women aged 18-50 years who required a short course of oral antibiotics for a non-gynaecological infection: 278 were enrolled in the study, and results were available for 235. INTERVENTIONS: Lactobacillus preparations taken orally or vaginally, or both, from enrollment until four days after completion of their antibiotic course. MAIN OUTCOME MEASURES: Participants' reports of symptoms of post-antibiotic vulvovaginitis, with microbiological evidence of candidiasis provided by a self obtained vaginal swab. RESULTS: Overall, 55/235 (23% (95% confidence interval 18% to 29%)) women developed post-antibiotic vulvovaginitis. Compared with placebo, the odds ratio for developing post-antibiotic vulvovaginitis with oral lactobacillus was 1.06 (95% confidence interval 0.58 to 1.94) and with vaginal lactobacillus 1.38 (0.75 to 2.54). Compliance with antibiotics and interventions was high. The trial was terminated after the second interim analysis because of lack of effect of the interventions. Given the data at this time, the chances of detecting a significant reduction in vulvovaginitis with oral or vaginal lactobacillus treatment were less than 0.032 and 0.0006 respectively if the trial proceeded to full enrollment. CONCLUSIONS: The use of oral or vaginal forms of lactobacillus to prevent post-antibiotic vulvovaginitis is not supported by these results. Further research on this subject is unlikely to be fruitful, unless new understandings about the pathogenesis of post-antibiotic vulvovaginitis indicate a possible role for lactobacillus.

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ScientificWorldJournal. 2004 Aug 4;4:571-80.
Clinical holistic medicine: holistic sexology and treatment of vulvodynia through existential therapy and acceptance through touch.
Ventegodt S, Morad M, Hyam E, Merrick J.
The Quality of Life Research Center, Teglgardstraede 4-8, DK-1452 Copenhagen K, Denmark. ventegodt@livskvalitet.org

Sexual problems are found in four major forms: lack of libido, lack of arousal and potency, pain and discomfort during intercourse, and lack of orgasm. It is possible to work with a holistic approach to sexology in the clinic in order to find and repair the negative beliefs, repressions of love, and lack of purpose of life, which are the core to problems like arousal, potency, and pain with repression of gender and sexuality. It is important not to focus only on the gender and genitals in understanding the patient"s sexual problems. It is of equal importance not to neglect the body, its parts, and the feelings and emotions connected to them. Shame, guilt, helplessness, fear, disgust, anger, hatred, and other strong feelings are almost always an important part of a sexual problem and these feelings are often "held" by the tissue of the pelvis and sexual organs. The patient with sexual problems can be helped both by healing existence in general and by discharging old painful emotions from the tissues. The later process of local healing is often facilitated by a simple technique: accepting contact via touch. This is a very simple technique, where the self-acceptance of the patient is to be promoted, for example, asking the female patient to put her hand on her stomach (uterus) or vulva, after which the holistic physician puts his hand supportively around hers. When done with care and after obtaining the necessary trust of the patient, this aspect of holding often releases the old negative emotions of shame bound to the touched areas. Afterwards, the emotional problems become a subject for conversational therapy and further holistic processing. Primary vulvodynia seems to be one of the diseases that can be cured after only a few successful sessions of working with acceptance through touch. The technique can be used as an isolated procedure or as a part of a pelvic examination. When touching the genitals with the intention of sexual healing, a written therapeutic contract with the patient is highly recommended and a strict ethical code is necessary to avoid malpractice. As about one woman in three suffers from sexual problems, many of which seemingly can be efficiently alleviated by the simple holistic techniques of "holding and processing", it is very important that the holistic physician is also trained to work in the sexual sphere in order to be able to support his patients fully.

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Lancet. 2004 Mar 27;363(9414):1058-60.
Vulvodynia.
Lotery HE, McClure N, Galask RP.
Department of Dermatology, Royal South Hants Hospital, SouthamptonSO14 0YG, UK. hlotery@doctors.org.uk

CONTEXT: Vulvodynia is a term used to describe chronic burning and/or pain in the vulva without objective physical findings to explain the symptoms. The terminology and classification of vulvodynia continue to evolve, and much remains to be understood about the prevalence, pathogenesis, natural history, and management of this distressing condition. STARTING POINT: James Aikens and colleagues showed that chronic vulval pain (vulvodynia or vulvar dysaesthesia) is associated with worse depressive symptoms (Am J Obstet Gynecol 2003; 189: 462-66). However, the increased scores for depression in this case-control study were attributed to sexual disinterest and experience of chronic pain rather than to features of depressive disorder. These results lend weight to the increasing need for better understanding of the pathogenesis of vulval pain and how to manage it appropriately. WHERE NEXT? The aetiology of vulvodynia and effectiveness of treatments need further study. Appraising the available literature, we have formulated a useful approach to patients with chronic vulval pain. There is a pressing need for further case-control studies of potential causes of vulvodynia and for randomised trials of interventions.

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Dermatol Ther. 2004;17(1):134-49.
Management of vulvar pain.
Fischer G.
Royal North Shore Hospital, Sydney, New South Wales, Australia. gaylef@chw.edu.au

Vulvodynia is a frequently used medical term that literally means "vulvar pain". Therefore, vulvodynia is a symptom, not a disease. The term itself indicates a variety of unpleasant chronic vulvar sensations, including burning, rawness, soreness, irritation, sensitivity, and formication. This may or may not include dyspareunia. Primary vulvodynia occurs when these sensory disturbances occur in the absence of observable dermatologic disease or vulvovaginal infection. There are several causes for this, including neuropathy, referred pain, and pelvic floor muscle dysfunction. For the purist, it is the patient in whom there is no observable reason for vulvar pain who represents the true case of vulvodynia. However, vulvodynia can also occur secondarily as a symptom of vulvar skin disease. Restricting the present paper to patients without objective signs leaves out all the important conditions which come into the differential diagnosis of vulvar pain which should be ruled out first. The first step in managing vulvodynia is making an accurate diagnosis of its cause. The present review summarizes the diagnosis and management of the chronic dermatologic diseases which may cause primary and secondary vulvodynia. The etiology of primary vulvodynia is much more poorly understood than secondary vulvodynia, and treatment of some aspects remains controversial.

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J Chemother. 2004 Apr;16(2):179-86.
Fenticonazole nitrate for treatment of vulvovaginitis: efficacy, safety, and tolerability of 1-gram ovules, administered as ultra-short 2-day regimen.
Fernandez-Alba J, Valle-Gay A, Dibildox M, Vargas JA, Gonzalez J, Garcia M, Lopez LH; Fentimex Mexican Study Group.
Escuela de Medicina de la Universidad Anahuac, Mexico. jufernan@anahuac.mx

Because of its potential as a low cost first-line monotherapy for the most common vulvovaginal infections, we evaluated fenticonazole nitrate in a prospective, open-label, multicenter pilot study with 101 sexually active women (per-protocol; 16 to 61 years of age) with vulvovaginitis involving single or mixed infections with Candida albicans, Trichomonas vaginalis, and/or Gardnerella vaginalis. Fenticonazole nitrate (1 g) was administered as vaginal ovules, once daily on days 1 and 3. Eradication (direct phase-contrast microscopy of vaginal swabs and/or microbiological culture) on day 8 was 90% (C. albicans, 26/29, p < 0.001), 70% (T. vaginalis, 7/10, p = 0.161), 67% (G. vaginalis, 22/33, p < 0.009), and 45% (mixed infection, 13/29, p = 0.001). After 28 days, relapse was 0% for candidiasis and trichomoniasis, 27% (6/22) for G. vaginalis, and 23% (3/13) for mixed infection. Overall, eradication of all offending pathogens was achieved in 67% of the total per-protocol population, with a relapse rate of only 16%. Score sums for symptoms improved from 7.0 (baseline) to 1.7 (day 8), and 0.71 (day 28), (p < 0.001). Treatment was safe and well tolerated. The results of our pilot study suggest that application of fenticonazole nitrate 1 g intravaginal ovules on 2 alternate days is a suitable first-line treatment of vulvovaginitis with acceptable broad-spectrum efficacy against the most commonly involved pathogens and with a low rate of early relapse, reserving antibiotics for patients with treatment failure or relapse of infection. Our results should encourage further examination of this approach in larger and well controlled clinical trials.

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Dermatol Ther. 2004;17(1):134-49.
Management of vulvar pain.
Fischer G.
Royal North Shore Hospital, Sydney, New South Wales, Australia. gaylef@chw.edu.au

Vulvodynia is a frequently used medical term that literally means "vulvar pain". Therefore, vulvodynia is a symptom, not a disease. The term itself indicates a variety of unpleasant chronic vulvar sensations, including burning, rawness, soreness, irritation, sensitivity, and formication. This may or may not include dyspareunia. Primary vulvodynia occurs when these sensory disturbances occur in the absence of observable dermatologic disease or vulvovaginal infection. There are several causes for this, including neuropathy, referred pain, and pelvic floor muscle dysfunction. For the purist, it is the patient in whom there is no observable reason for vulvar pain who represents the true case of vulvodynia. However, vulvodynia can also occur secondarily as a symptom of vulvar skin disease. Restricting the present paper to patients without objective signs leaves out all the important conditions which come into the differential diagnosis of vulvar pain which should be ruled out first. The first step in managing vulvodynia is making an accurate diagnosis of its cause. The present review summarizes the diagnosis and management of the chronic dermatologic diseases which may cause primary and secondary vulvodynia. The etiology of primary vulvodynia is much more poorly understood than secondary vulvodynia, and treatment of some aspects remains controversial.

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Curr Opin Obstet Gynecol. 2003 Dec;15(6):497-500.
Vulvodynia.
Smart OC, MacLean AB.

SUMMARY: PURPOSE OF REVIEW An increasing number of patients present with symptoms of vulvar pain, soreness, burning or irritation, which become chronic. Clinicians are often uncertain of the diagnosis. Terminology and an understanding of aetiology and therapy are evolving.RECENT FINDINGS Previous descriptions of vulvodynia have grouped patients according to whether pain is provoked by coitus (vulvar vestibulitis syndrome) or generalized and neuropathic pain (dysesthetic vulvodynia). Recent terminology debates have questioned whether 'vulvodynia' should be replaced by 'dysesthesia' and the term 'vestibulitis' avoided. Definitions of pain provocation, quality, duration, and distribution vary. Prevalence studies suggest one in six women may experience vulvodynia, although such a figure reflects clinic, patient or author reporting bias. Symptoms are as likely to be found in non-white as in white women. Although infection is often blamed, evidence for its role or that of inflammation is minimal. Immunohistochemistry has shown altered density of nerve endings and oestrogen receptors. There may be overlap with other pain syndromes. Several reviews have examined the many therapies available. Pharmacological alteration of nerve conduction (tricyclic antidepressants, gabapentin, local anaesthetics), biofeedback and sometimes surgery are helpful, but not always. Counselling and an understanding between patient and clinician/therapist are important for long-term results.SUMMARY Gynaecologists should be aware that they will encounter patients with vulvodynia who will need assessment and management. There are increasing numbers of clinics or clinicians with expertise to whom these patients can be referred.

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Curr Opin Obstet Gynecol. 2003 Dec;15(6):497-500.
Vulvodynia.
Smart OC, MacLean AB.

SUMMARY: PURPOSE OF REVIEW An increasing number of patients present with symptoms of vulvar pain, soreness, burning or irritation, which become chronic. Clinicians are often uncertain of the diagnosis. Terminology and an understanding of aetiology and therapy are evolving.RECENT FINDINGS Previous descriptions of vulvodynia have grouped patients according to whether pain is provoked by coitus (vulvar vestibulitis syndrome) or generalized and neuropathic pain (dysesthetic vulvodynia). Recent terminology debates have questioned whether 'vulvodynia' should be replaced by 'dysesthesia' and the term 'vestibulitis' avoided. Definitions of pain provocation, quality, duration, and distribution vary. Prevalence studies suggest one in six women may experience vulvodynia, although such a figure reflects clinic, patient or author reporting bias. Symptoms are as likely to be found in non-white as in white women. Although infection is often blamed, evidence for its role or that of inflammation is minimal. Immunohistochemistry has shown altered density of nerve endings and oestrogen receptors. There may be overlap with other pain syndromes. Several reviews have examined the many therapies available. Pharmacological alteration of nerve conduction (tricyclic antidepressants, gabapentin, local anaesthetics), biofeedback and sometimes surgery are helpful, but not always. Counselling and an understanding between patient and clinician/therapist are important for long-term results.SUMMARY Gynaecologists should be aware that they will encounter patients with vulvodynia who will need assessment and management. There are increasing numbers of clinics or clinicians with expertise to whom these patients can be referred.

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Gynecol Obstet Fertil. 2003 Nov;31(11):948-53.
[Psychosomatic approach of vulvodynia]
[Article in French]
Consoli SG.
pascale.van-vaeck@hop.egp.ap-hop-paris.fr

Vulvodynia is considered as a "somatoform disorder", i.e. as a somatic complaint not fully explained by a general medical condition. As any other somatoform disorder, it may reveal a depression, associated or not with anxiety. These patients always apply first to general practitioners or gynecologists and not to psychiatrists. It is, therefore, very important that these physicians could perform the diagnosis of depression, when this mood disorder is present, either by themselves or relying on the help of psychiatrists, and implement an appropriate treatment for depression. Vulvodynia is often associated with two pathological conditions: hysterical personality or hypochondriasis. It is fundamental that the doctors recognize these conditions in order to avoid the relational pitfalls, which would hinder the diagnostic and therapeutic approach.

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Am J Obstet Gynecol. 2003 Sep;189(3 Suppl):S24-30.
New concepts in vulvodynia.
Edwards L.
Southeast Vulvar Clinic, 401 S. Sharon Amity Road, Suite A, Charlotte, NC 28211, USA. ledwardsmd@aol.com

Vulvodynia is chronic vulvar burning/pain without clear medical findings. The etiology of vulvodynia is unknown and health care professionals should thoroughly rule out specific, treatable causes or factors such as dermatoses or group B Streptococcus infections. Vulvodynia is divided into 2 classes: vulvar vestibulitis syndrome is vestibule-restricted burning/pain and is elicited by touch; dysesthetic vulvodynia is burning/pain not limited to the vestibule and may occur without touch/press