Biitish Journal of ObArernc\ a i d Gyicrecology December 1990, Vol. 97, pp 1148-1150
Carbon dioxide laser treatment for vulval papillomatosis (vulvodynia) M. I. SHAFI, C. FINN, D. M. LUESLEY, J . A. JORDAN, T. P. ROLLASON Summary. Genital papillomatosis accompanied by distrcssing vulval symptoms is often termed vulvodynia. Common prcsenting symptoins are vulvar burning, pruritus and dyspareunia. Sixtecn patients with vulval papillomatosis (vulvodynia) have been treated by carbon dioxide laser therapy over a 4-year period. Initial rcsponses at 6 weeks appeared encouraging but with follow-up it became apparent that the relapse rate was high, with a mean symptom-free interval of 4.6 months. Of t h e 16 patients treated, only thrce remain symptom free. In view of o u r findings, we recommend that laser therapy should not be offered as a primary procedure, if a t all, for patients with vulval papillomatosis.
Vulva1 disease is common but the actiology of many vulval conditions is poorly understood and trcatment is, o f necessity, mostly empirical. Symptoms can be distressing and embarrassing and help may be sought only reluctantly. The discovery of the significanceof koilocytosis and the increased ability to detect human papillomavirus (HPVj has allowed the aetiology of many conditions to be attributed to this virus. There has been an increase in macroscopic genital papillomatosis which has bccn parallclcd by an increase in subclinical papillomatosis accompanied by distressing vulval symptoms, often termed vulvodynia. Univer4ty of Birmingham Department of Ohtetrics and Gynaecology, Dudley Road Hmpital, Birmingham M 1 SHAI-I Research Fellow C F l N N Research Eellow D M LU6SLk.Y Seizror Lecturer Department of Obstetrics and Gynaecology, Birmingham and Midland Hospital for Women, Sparkhill, Birmingham J A JORDAN Con~ultunt Department of Pathology, UniverGty of Birmingham 1 P ROLLASON Senrur Lecturer Correspondencc M I Shaft
1148
Many patients attending our clinic complaining of vulval burning havc marked accto-while epithelium on vulvoscopy and koilocytosis alone on histological examination of biopsy specimens. Although at present the significance of these features is unclear. it is possible that they may represent an atypical reaction to the presence of HPV. Since the carbon dioxide laser was introduced into gynaecological practice i n the mid-l970s, it has been increasingly used to treat a variety of vulval conditions. We havc becn using laser therapy for patients with vulvodynia, to provide a nonmutilating treatment for this distrcssing condition. Patients and methods
During a 4-year period, 16 paticnts havc been diagnosed as having vulval papillomatosis (vulvodyniaj and have been treated with the carbon dioxidc laser at the Birmingham and Midland Hospital for Women. Other causes for their symptoms, such as chronic candidiasis, cyclic vulvitis and vestibulitis were excluded by detailed interview and examination. The pathological specimens have been reported by one of us (T.P.R.). Patient details have been transcribed from the case notes. All the patients were initially seen in thc colposcopy clinic and
CO, laser for vidvodynia no patient has bccn lost to follow-up. Kelapsed disease has been classified as symptomatic if the patient’s original symptoms recurred following lascr therapy. Results The mean age of the 16 patients was 36 year5 (range 19-66), with a peak prevalcncc in the fourth decade. Twelve women were premenopausal, one was postmenopausal and three had had hysterectomies. Vulval pain was thc commonest symptom (11 patients, 69%). Other common symptoms were vulval pruritus in nine (56%) and dyspareunia and postcoital pain in nine (56%). Infrequent symptoms were vaginal discharge in two patients, vulval swelling and abnormal vaginal bleeding in one patient each. Patients often had two or more symptoms. The mean duration of symptoms was 41 months (range 6 9 6 months). All patients wcrc assesscd colposcopically with full examination of the lower genital tract. Various appearances were noted. Ten patients had acetowhitcning; 13 had evidence of warts (macroscopic in six and microvilli in seven); two had erythematous and one had hypertrophic changes. The lesions were multifocal in nine patients; confluent in five and unifocal in only two. Six patients had previously had abnormal cytology. Two of these had been treated for cervical intracpithelial neoplasia, onc had HPV changes on cervical biopsy and onc had ccrvical carcinoma. All patients underwent diagnostic biopsy: ten of these were performed under local anaesthcsia using a Keyes punch biopsy knife and six had biopsies under general anaesthesia. Single biopsy was performed i n 12 patients and multiplc biopsy in four. All specimens showed koilocytosis and some also showed other fcatures of I-IPV infection, for example papilloniatosis and hyperkeratosis, with no other pathological proccsscs. All 16 patients have been treated with superficial laser therapy by experienced personnel using a carbon dioxide laser in superpulse or chopped mode, down to the second surgical plane (Reid 1985a). Paraffin gauze dressings were applied postoperatively and removed within 24 h. ‘The treated area was irrigated with normal saline, dried with a hairdrier and silver sulphadiazine creani was applied at least twice
1149
daily. Two patients developed labial adhcsions which required division under general anaesthesia. Another patient, surprisingly, conceived within 6 weeks postoperatively! Patients were followed in the colposcopy clinic. Ten patients (63%) reported symptomatic relief at the 6-week Collow-up examination. The relief was shortlived in most of them, only thrce (19%) remain symptom free at the censor date 71,7 and 40 months after laser therapy. The mean symptom-free interval was 4.6 months. Discussion In the western world. we are experiencing an epidemic of sexually transmitted HPV infections (Department of Health. 1989). Most affected patients devclop condylomas after an incubation period. Many of these lesions regress spontaneously or with simple therapy (Reid 1Y85h). In some women the lesions become chronic and refractory to conventional therapy. Vulval papillomatosis (vulvodynia) is increasingly being diagnosed by the advent of vulvoscopy and directed biopsy. Differential diagnosis includes cyclic vulvitis and vestibulilis, with which it may overlap or coexist (McKay 1989). Vulval papilloniatosis is symptomatic. commonly prescnting with vulval pain, pruritus and dyspareunia. Various treatments havc becn describcd , all characterized by a poor response o r mutilation ol’ the vulval structure and function. There have been favourable reports on the use of laser therapy in such patients (Baggish 1980). Before treatment with lascr a biopsy is essential to confirm the diagnosis and exclude malignancy or vulval intracpithelial neoplasia. The affected areas are treated under colposcopic guidancc in ordcr to minimize the area lasered and to assess the depth of destruction. The initial response at 6 weeks appeared encouraging but with follow-up it became apparent that the relapse rate was high, with a incan duration lo relapse of 4.6 months. Of the 16 patients treated only thrcc remain symptom free. In view of our findings we recommend that laser should not be offered as a primary procedure, if at all. for patients with vulval papillomatosis. If the operation is offered, surgeons must counsel the patient and her partner adequately and be certain that the extent and severity of the condition justify contemplation of this operation. l t must not be assumed that the technical sophistication of laser treatment
1150
M . I . Shuji el al.
guarantees a successful outcome. The symptoms are distressing to the patient and it remainq important to continue assessment of new treatments that preserve vulval structure and function hut eradicate symptomatology associated with vulval papillomatosis. References Haggish M . S. (1980) Carbon dioxide lascr trcatment for condylorna acuminata vcncral infections. Obsiet Gynecol55, 711-715. Department of Health. (1989) New cases seen at genitourinary medicine clinics 1987. Summary information from Form SBH 60: 1987. DOHLondon.
McKay M. (1989) Vulvodynia. Arclz Derrnntol 125, 256-262. Reid R. (19851) Superficial laser vulvectomy, I . The efficacy of cxtended epidermal ablation for refraclory and very extensive condylomas. A m .I Obsret C ; ! i n e ~151, ~ l 1047-1052. Reid R. (19856) Superficial laser vulvectumy, 111. A new surgical technique for appendagr-conserving ablation of rcfractol-y condylomas and vulvar intraepithelial ncoplasia. Am J Obstet Gynecol 152, 501-509.
Receirwi 9 March 1990 Accepted h June I990
Carbon dioxide laser treatment for vulval papillomatosis (vulvodynia) M. I. SHAFI, C. FINN, D. M. LUESLEY, J . A. JORDAN, T. P. ROLLASON Summary. Genital papillomatosis accompanied by distrcssing vulval symptoms is often termed vulvodynia. Common prcsenting symptoins are vulvar burning, pruritus and dyspareunia. Sixtecn patients with vulval papillomatosis (vulvodynia) have been treated by carbon dioxide laser therapy over a 4-year period. Initial rcsponses at 6 weeks appeared encouraging but with follow-up it became apparent that the relapse rate was high, with a mean symptom-free interval of 4.6 months. Of t h e 16 patients treated, only thrce remain symptom free. In view of o u r findings, we recommend that laser therapy should not be offered as a primary procedure, if a t all, for patients with vulval papillomatosis.
Vulva1 disease is common but the actiology of many vulval conditions is poorly understood and trcatment is, o f necessity, mostly empirical. Symptoms can be distressing and embarrassing and help may be sought only reluctantly. The discovery of the significanceof koilocytosis and the increased ability to detect human papillomavirus (HPVj has allowed the aetiology of many conditions to be attributed to this virus. There has been an increase in macroscopic genital papillomatosis which has bccn parallclcd by an increase in subclinical papillomatosis accompanied by distressing vulval symptoms, often termed vulvodynia. Univer4ty of Birmingham Department of Ohtetrics and Gynaecology, Dudley Road Hmpital, Birmingham M 1 SHAI-I Research Fellow C F l N N Research Eellow D M LU6SLk.Y Seizror Lecturer Department of Obstetrics and Gynaecology, Birmingham and Midland Hospital for Women, Sparkhill, Birmingham J A JORDAN Con~ultunt Department of Pathology, UniverGty of Birmingham 1 P ROLLASON Senrur Lecturer Correspondencc M I Shaft
1148
Many patients attending our clinic complaining of vulval burning havc marked accto-while epithelium on vulvoscopy and koilocytosis alone on histological examination of biopsy specimens. Although at present the significance of these features is unclear. it is possible that they may represent an atypical reaction to the presence of HPV. Since the carbon dioxide laser was introduced into gynaecological practice i n the mid-l970s, it has been increasingly used to treat a variety of vulval conditions. We havc becn using laser therapy for patients with vulvodynia, to provide a nonmutilating treatment for this distrcssing condition. Patients and methods
During a 4-year period, 16 paticnts havc been diagnosed as having vulval papillomatosis (vulvodyniaj and have been treated with the carbon dioxidc laser at the Birmingham and Midland Hospital for Women. Other causes for their symptoms, such as chronic candidiasis, cyclic vulvitis and vestibulitis were excluded by detailed interview and examination. The pathological specimens have been reported by one of us (T.P.R.). Patient details have been transcribed from the case notes. All the patients were initially seen in thc colposcopy clinic and
CO, laser for vidvodynia no patient has bccn lost to follow-up. Kelapsed disease has been classified as symptomatic if the patient’s original symptoms recurred following lascr therapy. Results The mean age of the 16 patients was 36 year5 (range 19-66), with a peak prevalcncc in the fourth decade. Twelve women were premenopausal, one was postmenopausal and three had had hysterectomies. Vulval pain was thc commonest symptom (11 patients, 69%). Other common symptoms were vulval pruritus in nine (56%) and dyspareunia and postcoital pain in nine (56%). Infrequent symptoms were vaginal discharge in two patients, vulval swelling and abnormal vaginal bleeding in one patient each. Patients often had two or more symptoms. The mean duration of symptoms was 41 months (range 6 9 6 months). All patients wcrc assesscd colposcopically with full examination of the lower genital tract. Various appearances were noted. Ten patients had acetowhitcning; 13 had evidence of warts (macroscopic in six and microvilli in seven); two had erythematous and one had hypertrophic changes. The lesions were multifocal in nine patients; confluent in five and unifocal in only two. Six patients had previously had abnormal cytology. Two of these had been treated for cervical intracpithelial neoplasia, onc had HPV changes on cervical biopsy and onc had ccrvical carcinoma. All patients underwent diagnostic biopsy: ten of these were performed under local anaesthcsia using a Keyes punch biopsy knife and six had biopsies under general anaesthesia. Single biopsy was performed i n 12 patients and multiplc biopsy in four. All specimens showed koilocytosis and some also showed other fcatures of I-IPV infection, for example papilloniatosis and hyperkeratosis, with no other pathological proccsscs. All 16 patients have been treated with superficial laser therapy by experienced personnel using a carbon dioxide laser in superpulse or chopped mode, down to the second surgical plane (Reid 1985a). Paraffin gauze dressings were applied postoperatively and removed within 24 h. ‘The treated area was irrigated with normal saline, dried with a hairdrier and silver sulphadiazine creani was applied at least twice
1149
daily. Two patients developed labial adhcsions which required division under general anaesthesia. Another patient, surprisingly, conceived within 6 weeks postoperatively! Patients were followed in the colposcopy clinic. Ten patients (63%) reported symptomatic relief at the 6-week Collow-up examination. The relief was shortlived in most of them, only thrce (19%) remain symptom free at the censor date 71,7 and 40 months after laser therapy. The mean symptom-free interval was 4.6 months. Discussion In the western world. we are experiencing an epidemic of sexually transmitted HPV infections (Department of Health. 1989). Most affected patients devclop condylomas after an incubation period. Many of these lesions regress spontaneously or with simple therapy (Reid 1Y85h). In some women the lesions become chronic and refractory to conventional therapy. Vulval papillomatosis (vulvodynia) is increasingly being diagnosed by the advent of vulvoscopy and directed biopsy. Differential diagnosis includes cyclic vulvitis and vestibulilis, with which it may overlap or coexist (McKay 1989). Vulval papilloniatosis is symptomatic. commonly prescnting with vulval pain, pruritus and dyspareunia. Various treatments havc becn describcd , all characterized by a poor response o r mutilation ol’ the vulval structure and function. There have been favourable reports on the use of laser therapy in such patients (Baggish 1980). Before treatment with lascr a biopsy is essential to confirm the diagnosis and exclude malignancy or vulval intracpithelial neoplasia. The affected areas are treated under colposcopic guidancc in ordcr to minimize the area lasered and to assess the depth of destruction. The initial response at 6 weeks appeared encouraging but with follow-up it became apparent that the relapse rate was high, with a incan duration lo relapse of 4.6 months. Of the 16 patients treated only thrcc remain symptom free. In view of our findings we recommend that laser should not be offered as a primary procedure, if at all. for patients with vulval papillomatosis. If the operation is offered, surgeons must counsel the patient and her partner adequately and be certain that the extent and severity of the condition justify contemplation of this operation. l t must not be assumed that the technical sophistication of laser treatment
1150
M . I . Shuji el al.
guarantees a successful outcome. The symptoms are distressing to the patient and it remainq important to continue assessment of new treatments that preserve vulval structure and function hut eradicate symptomatology associated with vulval papillomatosis. References Haggish M . S. (1980) Carbon dioxide lascr trcatment for condylorna acuminata vcncral infections. Obsiet Gynecol55, 711-715. Department of Health. (1989) New cases seen at genitourinary medicine clinics 1987. Summary information from Form SBH 60: 1987. DOHLondon.
McKay M. (1989) Vulvodynia. Arclz Derrnntol 125, 256-262. Reid R. (19851) Superficial laser vulvectomy, I . The efficacy of cxtended epidermal ablation for refraclory and very extensive condylomas. A m .I Obsret C ; ! i n e ~151, ~ l 1047-1052. Reid R. (19856) Superficial laser vulvectumy, 111. A new surgical technique for appendagr-conserving ablation of rcfractol-y condylomas and vulvar intraepithelial ncoplasia. Am J Obstet Gynecol 152, 501-509.
Receirwi 9 March 1990 Accepted h June I990
