Acute Vulvar Ulcer

Acute Vulvar Ulcer (Lipschütz ulcer) is a rare disease of non-venereal origin, localized exclusively on the genital organs, most commonly observed in girls aged 10-14 years. Acute vulvar ulcer usually begins with the appearance of itching, a sensation of heat, and severe pain in the area of the external genital organs, sometimes accompanied by elevated temperature, followed by the formation on the inner surface of the labia majora of extremely painful ulcers of an inflammatory character. According to Lipschütz, who first described this disease (1923), three clinical variants are distinguished: 1) The gangrenous form, which runs extremely violently, with chills and fever (up to 40°), clinically expressed as deep ulcers covered with dirty-yellow-green or black crusts or a fibrino-purulent coating and bordered by sharp edema and inflammatory redness and swelling of the surrounding area. The ulcers show an uncontrollable tendency to rapid peripheral growth and increase, and then after several days or 1-2 weeks the process completes as the temperature falls. 2) The ordinary form, which runs less acutely (without fever and such sharp subjective sensations) and is most common. The ulcers here are less deep and smaller in size, their base is soft, covered with a purulent secretion of grayish color, often with uneven undermined edges; they are also characterized by tenderness. Sometimes their course is prolonged due to peripheral enlargement. 3) The miliary form, also very painful, characterized by the appearance of numerous miliary ulcers the size of a pinhead without a tendency to peripheral growth. In very acute cases, the nearest regional lymph glands often become swollen. A tendency to recurrence is a characteristic feature of the course of acute vulvar ulcer. It often manifests after acute angina. In the ulcer discharge, a large quantity of easily cultivable Gram-positive thick straight rods with blunt rectangular ends can be found, which usually lie separately, sometimes arranged in chains. These bacilli, apparently identical with Döderlein's bacillus, Lipschütz named Bacillus crassus. He also found them on the mucous membranes of the genital organs not affected by ulcers, which may indicate the saprophytic nature of the microbes. Histologically, one finds: dilation of blood vessels, mainly of the superficial network, the walls of which appear edematous, infiltrated with leukocytes, with swollen endothelium, with hyperplasia of connective tissue cells of the inner membrane, strong leukocytic infiltration of the superficial layers of the skin with the formation of a fibrino-necrotic zone in the central part, where Bacillus crassus is usually found in sections. The diagnosis presents no particular difficulties: 1) the sudden appearance of the disease; 2) severe pain during urination and on touch; 3) non-sexual origin in girls; 4) localization on the genital organs; 5) the small size and depth of the ulcers; 6) the purulent-fibrinous nature of the discharge; 7) uneven undermined edges; 8) the presence of Bacillus crassus in the discharge; and 9) the short duration and benign course of the disease. By external appearance, acute vulvar ulcer can easily be confused with soft chancre ulcers and sometimes with vulvar diphtheritic ulcer. The prognosis is favorable, however, recurrences often occur. Treatment: washing with boric water or a weak solution of hydrogen peroxide, dusting with xeroform or dermatol, and in the gangrenous form with iodoform. Preventively, Lipschütz recommends specific vaccination or parenteral protein therapy.

M.; Per.