Vulvitis

VULVITIS (vulvitis), an inflammatory process in one or another region of the external genitalia: on the labia majora and minora, in the folds between the thighs and the labia majora, on the pubis, perineum, clitoris, as well as in the vestibule of the vagina and in all glands and openings opening into the vestibule. In its histological structure, the vulva resembles the external skin with all its derivatives, and therefore inflammatory processes of the external genitalia are nothing other than the same processes that are observed on the skin, especially near and around the orifices opening outward, namely: the nose, mouth, and rectum. In addition, in inflammatory processes of the vulva, the following three factors should be taken into consideration: 1) anatomical features in the form of an abundance of folds, tenderness of the integument, and richness in blood vessels and nerves; 2) functional features in the form of constant moisture and wetting by secretions, elevated temperature compared to other external integuments, and variability of turgor depending on menstruation and sexual arousal; 3) richness and diversity of the microflora constantly inhabiting this area. The presence of these three factors is of great importance in all kinds of inflammatory processes (secretion is retained in the folds, promotes easy vulnerability, causes severe pain, irritation, etc.). Etiology. As on the external skin, the causes of inflammatory processes of the external genitalia are quite diverse. Mechanical, thermal, and chemical factors play a major role here. Masturbation, rough coitus, continuous wetting of the vulva by discharge from the urethra, Bartholin's glands, vagina, cervical canal, etc., and then irritation by urine with a high content of salts or sugar—all these factors can contribute to the development of inflammation of the vulva. The main role in the etiology of vulvitis is played, of course, by pyogenic microbes, gonococci, the diphtheria bacillus, thrush fungi, as well as tubercle bacilli, the pale spirochete (ulcus durum), and Ducrey's bacillus (ulcus molle). Vulvitis includes the following categories of diseases: I—vulvitis in the narrow sense of the word, II—vulvar dermatoses, III—infectious diseases, IV—severe forms of inflammation, and V—chronic ulcer. I. Vulvitis in the narrow sense of the word occurs in three forms: 1. Vulvitis vulgaris (vulvitis vulgaris s. simplex). 2. Gonorrheal vulvitis. 3. Infantile vulvovaginitis (vulvo-vaginitis infantum gonorrhoica). - 1. Vulvitis vulgaris. Pathogenesis: disruption of the superficial epithelial cover (sub coitu or during gynecological examination), maceration of the external cover by vaginal secretion, urine, etc., promote the reproduction and penetration of pyogenic microbes (streptococci, staphylococci, pneumococci, Escherichia coli). Clinically, vulvitis is divided into acute and chronic. In acute vulvitis, a burning sensation in the region of the external genitalia is observed, which especially increases during urination, and sometimes pain during movement. Later, the burning sensation gradually disappears, and a moderate or severe itching appears. The mucosa in vulvitis is intensely red, painful to the touch, sometimes smooth and edematous, sometimes with an uneven, rough surface, covered with a mucous or mucopurulent coating. In the chronic form of vulvitis, the main symptom is itching, and the main sign is the transition of the diffuse hyperemia of acute vulvitis into a patchy one. Spots are visible either on the inner surface of the labia minora or on the hymenal caruncles. Sometimes redness remains only around the external opening of the excretory duct of Bartholin's gland. The clitoris is edematous and hyperemic. An accumulation of secretion is visible in the area of the sulci clitoridis. On the inner surface of the labia minora, a peculiar roughness can often be seen: the mucosa seems to be speckled with tiny wart-like growths. They should not be confused with acuminated condylomas. Sometimes edema of the labia minora also appears. If one looks closely, one can notice tiny yellow nodules no larger than a pinhead. This is nothing other than hyperplastic sebaceous glands. The mucosa of the vaginal vestibule in chronic vulvitis is strongly hyperemic during menstruation and for several days after it. Sometimes hypertrophy of the labia minora is observed as a result of chronic vulvitis. 2. Gonorrheal vulvitis (vulvitis gonorrhoica) usually occurs only in children. Bumm managed to observe six cases of gonorrheal vulvitis in adult women, of which 2 were observed in very young subjects, 1 case in a woman in the climacteric period, and 3 cases in pregnant women (see Gonorrhea, gonorrhea of women). Gonorrheal vulvitis in adult women occurs only in the acute stage, after which recovery usually ensues. Chronic forms of gonorrheal vulvitis in adult women do not occur (Bumm). - 3. Infantile vulvovaginitis (vulvo-vaginitis infantum gonorrhoica), see Vulvovaginitis. II. Vulvar dermatoses are divided into three groups: dermatomycoses, pyodermas, bullous-ulcerative dermatoses. - 1. Dermatomycoses: a) Thrush (Soor) of the external genitalia occurs predominantly in pregnant women. Thrush of the vulva is always a secondary disease, with primary localization in the vagina. The vulvar mucosa remains almost without any changes. Only white epithelial scales are visible on its surface. The main symptom of the disease is the most severe itching in the region of the external genitalia. Diagnosis is made on the basis of microscopic examination of the coatings. Treatment should not be limited to the vulva alone. All films in the vagina and on the vulva are removed with a tampon moistened with a 20% solution of boric acid in glycerin. Then the woman is prescribed douches (2 times a day with a 4% solution of boric acid) and tampons with 20% boric acid in glycerin. After a few days, the thrush disappears. In stubborn cases, vaginal baths according to Menge using 2% silver nitrate give good results. The possibility of relapses should be kept in mind. b) Actinomycosis (actinomycosis vulvae) is a very rare disease. To date, only 3 cases have been described (Lieblein, Bongartz, Trapl), see Actinomycosis. - 2. Pyodermas: a) Folliculitis (folliculitis vulvae)—inflammation on the basis of staphylococcal infection of the hair follicle and sebaceous gland. According to Prochownik,

Figure 1. Ulcus vulvae acutum (after Schruder). (Prochownik), folliculitis can also occur via the hematogenous route (metastasis) in purulent disease of the appendages. b) Furunculosis, see Furuncle. - 3. Bullous-ulcerative dermatoses: a) Herpes vulvae, vesicular lichen (see Herpes). b) Ulcus vulvae acutum (Lipschütz; see Figure 1)—an acute disease, according to Scherber and Lipschütz, characterized by the appearance on the inner surface of the labia majora and minora of small, somewhat separate ulcers the size of a millet seed. The periphery of the ulcers is hyperemic and edematous. The edges are sharp, inflamed, and undermined; the surface of the ulcer is uneven, grayish or yellowish in color. Etiology—Bacillus crassus, a Gram-positive bacillus. The course of the disease is from 4 days to several weeks; it is accompanied by high temperature and pain. Treatment: sitz baths and dermatol dusting powders. The prognosis is favorable. III. Infectious diseases of the vulva.—Acute: a) Erysipelas (erysipelas vulvae) is a very rare disease occurring almost exclusively in the postpartum period (see Erysipelas). b) Diphtheria (diphtheria vulvae) occurs in children with simultaneous disease of the fauces and in women in the postpartum period in the form of ulcus puerperale (Bumm). Etiology—Loeffler's bacillus. Treatment with specific serum (see Diphtheria). c) Smallpox (variola vulvae). Ulcera dysenterica vulvae (dysenteric ulcers), ulcera typhosa (typhoid ulcers)—occur sometimes in dysentery and typhus. Other infectious diseases of the vulva: a) Tuberculosis (tbc vulvae)—quite a rare disease. To date, only a few dozen cases have been described..

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classifications Aню-. Figure 2. Esthiomene (after Meyer-Fa> (Aschoff), Ruegg).

Kroenig and Feit distinguish the following forms of tuberculosis of the vulva: 1) lupus vulvae - a very rare disease that affects both the skin and mucous membrane (see Tuberculous diseases of the skin); 2) tuberculosis cutis et mucosae miliaris ulcerosa (Jesionek) - see Tuberculous diseases of the skin; 3) elephantiasis form (see below). Tuberculous ulcers are usually located on the labia majora, on the perineum, or on the clitoris. Jesionek believes that tuberculosis easily develops on the basis of inflamed vulvar glands. The inguinal glands are enlarged, firm, and painless. According to Feit, the diagnosis can only be made when both giant cells and tuberculous bacilli are simultaneously found microscopically in the excised piece. Treatment - see Tuberculous diseases of the skin. b) Syphilitic ulcers on the external genitalia occur in all types and forms (see Gumma, etc.). c) Ulcus molle, see Soft chancre. IV. Severe forms of inflammation of the vulva. Abscess, phlegmon, and gangrene of the deep tissues of the external genitalia occur, mainly, in the postpartum period. The course is severe. The prognosis is serious. Treatment is surgical. V. Chronic ulcer. Ulcus vulvae chronicum, esthiomene (Hugier), lupus, lupus perforans et hypertrophicus, herpes excedens, ulcus chronicum elephantiasticum, elephantiasis vulvae lueticum, resp. postlueticum, posttuberculosum, postgonorrhoicum. - Esthiomene (see Figure 2) is an ulcer that usually begins in the area of fossa navicularis interlabialis, near the urethra, and gradually spreads over the entire vulva to the vagina, sometimes causing fistulas of adjacent organs (bladder, intestine). This condition occurs more often than is generally believed. Microscopically, esthiomene resembles tuberculous, luetic, or elephantiasis ulcers. Histologically, however, it usually represents a chronic inflammatory process. The etiology is not established. Observations at the State Venereal Institute in Moscow show that esthiomene occurs on the basis of gonorrhea, as well as in persons in whom syphilis and tuberculosis are found simultaneously with gonorrhea. Gougerot describes cases of esthiomene under the tongue and on the buccal mucosa. Diagnosis is sometimes very difficult and requires histological examination. Differential diagnosis of leukorrhea in various lesions of the vulva: 1) watery leukorrhea is usually not based on an inflammatory process; 2) purulent leukorrhea always indicates an inflammatory process; 3) tenacious, ointment-like, yellowish leukorrhea indicates hypersecretion of the sebaceous glands (masturbation); 4) an acute, unpleasant odor of leukorrhea occurs in unclean individuals or in condylomata acuminata; 5) a garlic odor indicates vulvitis diabetica; 6) an ammoniacal odor indicates cystitis, fistula, and urinary incontinence; 7) white plaques on the vulva indicate thrush or diphtheria; 8) a bloody character occurs in ulcers (esthiomene, etc.), or in condylomata acuminata, or as an admixture from higher organs. Lit.-see Vulva.

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