newer techniques such as reflectance confocal microscopy may be of some use [20].
Table 7.2 Main indications for imaging in vulval disease
| Examples | |
|---|---|
| Congenital abnormalities | Müllerian duct agenesis, Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome Vaginal septa Developmental cysts Cloacal exstrophy |
| Benign lesions | Cysts Fistulae |
| Inflammatory disease | Hidradenitis suppurativa Crohn’s disease |
| Malignant disease | Staging at diagnosis Recurrent disease Monitoring post treatment |
Vulvoscopy
The colposcope, giving a magnification of 8–10 times, is not helpful during examination of the vulva. It provides a very small field of examination and shows up little on keratinised skin. The use of the colposcope for the investigation of cervical and vaginal lesions cannot be extrapolated to the vulva [21]. There is no place for the routine use of toluidine blue and little for acetic acid, as the confusion caused by misplaced emphasis on acetowhite tissue has been considerable, and the light reflection effect produced is non‐specific. It has been shown that 30% of women without any vulval symptoms had acetowhite areas outside the vestibule [22].
Colposcopic examination of the vestibule, vagina, and cervix may, of course, be indicated at some time for certain patients.
References
1 4 Lewis, F.M., Agarwal, A., Neill, S.M. et al. The spectrum of histopathologic patterns secondary to the topical application of EMLA® on vulvar epithelium: clinicopathological correlation in three cases. J Cutan Pathol. 2013; 40(8): 708–713.
2 11 Vieira‐Baptista, P., Grincevičienė, S., Oliveira, C. et al. The International Society for the Study of Vulvovaginal Disease Vaginal Wet Mount Microscopy Guidelines: How to perform, applications, and interpretation. J Lower Gen Tract Dis. 2021; 25: 172–180.
3 12 Klatte, J.L., van der Beek, N. and Kemperman, P.M. 100 years of Wood's lamp revised. J Eur Acad Dermatol Venereol. 2015; 29(5): 842–847.
4 13 Griffin, N., Grant, L.A. and Sala, E. Magnetic resonance imaging of vaginal and vulval pathology. Eur Radiol. 2008 Jun; 18(6): 1269–1280.
5 14 Matos, J., Orazi, C., Sertorio, F. et al. Imaging of diseases of the vagina and external genitalia in children. Pediatr Radiol. 2019 May; 49(6): 827–834.
6 15 Lin, G., Chen, C.Y., Liu, F.Y. et al. Computed tomography, magnetic resonance imaging and FDG positron emission tomography in the management of vulvar malignancies. Eur Radiol. 2015 May; 25(5): 1267–1278.
7 18 Vaccaro, CM. The use of magnetic resonance imaging for studying female sexual function: A review. Clin Anat. 2015 Apr; 28(3): 324–330.
8 21 Micheletti, L., Bogliatto, F. and Lynch, P.J. Vulvoscopy: Review of a diagnostic approach requiring clarification. J Reprod Med. 2008 Mar; 53(3): 179–182.
8 Topical and Non‐Surgical Treatments
Fiona M. Lewis
CHAPTER MENU
Types of preparation Emollients Barriers Topical steroids Adverse effects Calcineurin inhibitors Adverse effects Imiquimod Adverse effects Potassium permanganate Lubricants
Non-surgical treatments Phototherapy and photochemotherapy Photodynamic therapy (PDT) Adverse effects
Topical treatments
Topical treatment used for vulval disease may need to be modified from that used to treat the same disease at another site. For example, strong tar preparations or Vitamin D analogues used to treat psoriasis on the scalp or limbs may be very irritant in the anogenital area. This chapter looks at the general principles of topical and non‐surgical treatments and their potential adverse effects.
General vulval hygiene
It is important to ask about hygiene practices as these can vary with cultural influences and personal preference [1]. Many women feel the need to clean the vulva several times a day as they are often worried that a lack of hygiene on their part may have contributed to their vulval symptoms. Transepidermal water loss from the thinner vulval skin is greater than that from the forearm and is therefore more susceptible to the irritant effects of any application.
Simple washing once daily is required to wash away secretions and sweat. Soap removes the natural lipids produced by epithelial cells that have an important role in the integrity of the skin barrier, and so using an emollient as a soap substitute is encouraged. A bland ointment‐based emollient such as emulsifying ointment is preferred because of the low allergenic potential with this substance. Creams and lotions often contain preservatives which can be irritant and may sting if the skin is fissured. Several over‐the‐counter products can affect L. crispatus counts, which will alter the normal microbiome and increase the likelihood of inflammation [2]. The use of these products is widespread, with over 50% of post‐menopausal women questioned reporting use of at least one product [3].
Types of preparation
