Subclinical manifestations of vulvar human papillomavirus infection

Androgen insensitivity syndrome

Androgen insensitivity syndrome (AIS) is a disorder caused by a mutation of the gene encoding the androgen receptor (AR; Xq11-q12). The prevalence of AIS has been estimated to be one case in every 20,000 to 64,000 newborn males for the complete syndrome (CAIS), and the prevalence is unknown for the partial syndrome (PAIS). The symptoms range from phenotypically normal males with impaired spermatogenesis to phenotypically normal women with primary amenorrhea. Various forms of ambiguous genitalia have been observed at birth. The diagnosis is confirmed by determining the exact mutation in the AR gene. PAIS individuals require precise diagnosis as early as possible so that the sex can be assigned, treatment can be recommended, and they can receive proper genetic counseling. After birth, differential diagnosis should be performed using other forms of abnormal sexual differentiation of primary amenorrhea. The treatment of AIS is based on reinforcement sexual identity, gonadectomy planning, and hormone replacement therapy. The prognosis for CAIS is good if the testicular tissue is removed at the appropriate time. For PAIS, the prognosis depends on the ambiguity of the genitalia and physical and psychosocial adjustment to the assigned sex.

Inflammatory dermatoses of the vulva

Inflammatory, non-neoplastic epidermal alterations of the vulva can be correctly diagnosed using classification schemes applied to skin elsewhere on the body. A wide range of inflammatory disorders may occur on the vulva, and they may have a similar clinical presentation to HPV lesions. However, HPV is incurable and often is treated surgically. Accordingly, as inflammatory dermatoses commonly occur on the vulva and are often curable with topical therapy, an awareness of these entities and an ability to distinguish them from HPV are imperative.

Symptoms and HPV infection of the vulva: clinical manifestations or mere coincidence?

Two hundred women with abnormal Pap smears and/or vulvar symptoms and 30 with normal Pap smears were investigated to determine the association between symptoms and (i) human papilloma virus infection of the vulva, and (ii) a spongiotic tissue reaction or a spongiotic dermatitis of the vulva. All had vulvar colposcopy and biopsy Human papilloma virus infection was diagnosed by histopathology and in situ hybridisation technique. HPV infection was present in biopsies of 48% of asymptomatic women and 33% with symptoms (p = 0.13) and HPV DNA in 37% of asymptomatic women and 31% with symptoms (p = 0.72). Spongiotic tissue reaction was diagnosed in 53.5% of asymptomatic women compared to 74% of symptomatic women (p = 0.007). This study suggests that vulvar symptoms are not clinical manifestations of HPV infection, but may be caused by dermatitis rather than HPV infection per se.

Normal findings in vulvar examination and vulvoscopy

OBJECTIVE

To determine the normal vulvar findings by naked eye examination and by vulvoscopy in healthy women without vulvar complaints.

DESIGN

Observational study.

POPULATION

Forty healthy volunteers without vulvar complaints recruited via a newspaper advertisement.

METHODS

Vulvar examination, human papillomavirus (HPV) polymerase chain reaction of vulvar and cervical swabs, saline and KOH smears and vulvoscopy before and after the application of 5% acetic acid.

MAIN OUTCOME MEASURES

Prevalence of vestibular erythema, vestibular papillomatosis, HPV infection on the vulva and in the cervix and vulvoscopic findings.

RESULTS

The mean age of the women was 37.8 years (median 38.0, range 21-56). Nine women were current smokers and 21 had previously smoked. Naked eye vulvar examination showed vestibular papillomatosis in 13 women (33%) and vestibular erythema in 17 women (43%). The touch test was positive in 9 of the 17 women (53%) with vestibular erythema. Vulvoscopy after the application of acetic acid 5% showed an acetowhite vestibule in all women. Twelve women (30%) had acetowhite lesions outside the vestibule. Six women (15%) were positive for HPV DNA. The presence of HPV DNA did not correlate with vestibular erythema or vestibular papillomatosis. There was a weak association between HPV DNA and acetowhite lesions outside the vestibule (P = 0.055, Fisher's exact test). In this group the younger women significantly more often had vestibular papillomatosis (t-statistic = 3.07; P = 0.003) and women who smoke more often had a genital HPV infection (P = 0.016, Fisher's exact test).

CONCLUSIONS

Vestibular erythema, vestibular papillomatosis, and acetowhite lesions are common in this group of healthy women without vulvar complaints.

The commonest causes of symptomatic vulvar disease: a dermatologist's perspective

A prospective study of 141 consecutive adult patients with chronic vulvar symptoms referred to a dermatologist was carried out to determine the commonest conditions seen. Eighty-nine per cent of patients underwent vulvar biopsy. The commonest cause of chronic vulvar symptoms in this group of patients was dermatitis, seen in 54% of patients. The other commonly seen conditions were lichen sclerosus (13%), chronic vulvovaginal candidiasis (10%), dysaesthetic vulvodynia (9%) and psoriasis (5%). Although 38% of patients had previously been diagnosed as suffering from human papillomavirus (HPV) vulvitis, histopathological evidence of HPV was seen in only 5%. All cases showing HPV also demonstrated spongiotic dermatitis on biopsy. In this study group, a majority (overall 72%) of patients with a chronic vulvar complaint had a corticosteroid responsive dermatosis rather than a gynaecological condition. The patients with HPV on biopsy also responded to topical corticosteroids, and it was concluded that their symptoms may have been due to dermatitis unrelated to the presence of HPV. In such patients, the assumption that 'subclinical HPV' is a cause of symptoms and the practice of focusing medical and particularly surgical treatment on eradication of the virus may be inappropriate. A review of the commonest vulvar conditions seen by the author is presented.

The chronically symptomatic vulva: aetiology and management

OBJECTIVE

To determine the causes and management of chronic vulval symptoms and to compare the findings in patients first presenting to a gynaecologist with those in patients first presenting to a dermatologist.

DESIGN

A prospective study of 144 patients, approximately half each being referred to a gynaecologist and a dermatologist. Diagnosis was based on clinical history, vulvoscopy, vulval biopsy and bacteriology. Biopsies were examined by a histopathologist experienced in dermatopathology and gynaecological pathology.

RESULTS

The two patient groups were similar in both range and frequency of conditions. The commonest cause of chronic vulval symptoms was dermatitis, which was found in 64% of our patients. Dermatitis occurred alone in 55% and was found in association with histological evidence of human papilloma virus (HPV) in a further 9%. These patients responded to simple dermatological methods, mainly topical corticosteroids. Histopathological evidence of HPV was encountered in only 23% of our patients, and of these 36% also demonstrated dermatitis on biopsy. Most responded to topical corticosteroids. Another 7% had lichen sclerosus, and all responded to potent topical corticosteroid. The remaining 15% demonstrated a range of diagnoses, including psoriasis, dysaesthetic vulvodynia, vulval intraepithelial neoplasia (VIN) and chronic candidiasis. The majority of patients had a corticosteroid responsive dermatosis rather than a gynaecological condition.

CONCLUSIONS

The majority of patients with a chronically symptomatic vulva who present to either a gynaecologist or a dermatologist have a dermatological condition that responds to simple dermatological treatments. We believe that the presence or absence of the human papilloma virus is not relevant to most patients with a chronically symptomatic vulva and treatments should not be aimed at eradicating this virus. Histopathologists and gynaecologists who have focused on gynaecological disorders have often missed simple dermatological conditions that are easily treatable.

Demonstration of Epstein-Barr virus DNA in acetowhite lesions of the vulva

Acetowhite lesions in the vulva disclosing koilocytosis have been related to infection by human papilloma virus (HPV). Because of the clinical resemblance of these lesions to oral hairy leukoplakia (OHL), and EBV-manifestation, 23 women with acetowhite koilocytotic lesions in the vulva were examined. The PCR-technique was used to detect EBV DNA as well as HPV DNA in 17% of 23 patients examined. In a control group of 19 patients EBV DNA was detected in 11% and HPV DNA in 42% of cell samples from normal vulvar mucosa. EBV DNA has not previously been demonstrated in the vulvar mucosa, and this virus might be related to subclinical acetowhite lesions.

The absence of genital human papillomavirus DNA in virginal women

Our aim was to determine the prevalence of human papillomavirus (HPV) infection in virginal women and to establish if other forms of sexual activity not involving penetration may contribute to the transmission of this infection. Female patients attending medical practitioners, and female high school students were recruited. Each participant answered an anonymous self answer questionnaire and collected a tampon specimen. Tampons were analysed for the presence of human papillomavirus by the polymerase chain reaction (L1 general primer and probe). Fifty-five female participants who were of a mean age of 18 years (range 13-41) were recruited. Twenty-three reported non-penetrative sexual activity. None of the 55 women had evidence of HPV infection (0%, upper 95% confidence interval 5.4%). Twelve tampons from sexually active women with normal Papanicolaou smears and a mean age of 26 years (range 19-44) attending a hospital clinic were analysed at the same time and four were found to be positive (P = 0.0006). We conclude that HPV infection prior to sexual intercourse, as determined by tampons specimens, is rare, even in those participating in other forms of sexual activity.