Microsoft word - res update - dec 2007

NVA RESEARCH UPDATE NEWSLETTER
December 2007
www.nva.org
This newsletter has been supported, in part, through a grant from the Enterprise Rent-A-Car Foundation.
This newsletter is quarterly and contains abstracts from medical journals published between September and December 2007 (abstracts presented at scientific meetings may also be included). Please direct any comments regarding this newsletter to chris@nva.org.
Vulvodynia / Pain
Multilevel local anesthetic nerve blockade for the treatment of vulvar vestibulitis syndrome.
Rapkin AJ, McDonald JS, Morgan, M
Am J Obstet Gynecol.2007 Oct 11; [Epub ahead of print]
OBJECTIVE: Vulvar vestibulitis syndrome is a major cause of dyspareunia. This pilot study was designed
to evaluate a novel treatment approach. STUDY DESIGN: This is a prospective study of 27 women with
vulvar vestibulitis. The protocol included 5 treatment sessions with caudal epidural, pudendal nerve block,
and vestibular infiltration of local anesthetic agents. RESULTS: There were significant improvements in
vestibular pain as determined by the vulvalgesiometer, McGill pain questionnaire, self-report, and the
Female Sexual Functioning Inventory. CONCLUSION: Serial multilevel nerve blocks administered for the
treatment of vulvar vestibulitis is a conceptually neurophysiologically based modality that may be effective
and merits a placebo-controlled study.
Improvement in vulvar vestibulitis with montelukast.
Kamdar N, Fisher L, MacNeill C
J Reprod Med. 2007 Oct;52(10):912-6.
OBJECTIVE: To determine if montelukast treatment improves symptoms in patients with vulvar
vestibulitis. STUDY DESIGN: We administered montelukast to a series of patients with vestibulitis seen at
the Pennsylvania State University Vulvodynia Clinic over a period of 2.5 years. We reviewed outcomes
using a scoring scheme to quantify signs and symptoms, before and after treatment, in 29 montelukast-
treated subjects and 18 subjects in a comparison group treated with standard therapies. RESULTS:
Subjects treated with montelukast showed an average of 52% in improvement in symptoms as compared
to a 15% improvement in the controls (p < 0.0001). CONCLUSION: Montelukast is a viable treatment
option for women with vulvar vestibulitis. This finding implies that leukotrienes have a role in the
pathophysiology of vulvar vestibulitis.
Surgery combined with muscle therapy for dyspareunia from vulvar vestibulitis: an observational
study.
Goetsch MF
J Reprod Med.2007 Jul;52(7):597-603.
OBJECTIVE: To explore the dual importance of treating vestibule allodynia and pelvic floor myalgia in
correcting dyspareunia associated with severe vulvar vestibulitis. STUDY DESIGN: In this observational
study, 111 women were treated by modified superficial vestibulectomy and were evaluated for referral to
physical therapists for pelvic floor myalgia. They were followed with interval repeat examinations. Later
cohort assessment was by patient questionnaire surveys. Data from pelvic floor muscle examinations and
physical therapy referrals were added by retrospective chart review. Primary outcomes were swab touch
sensitivity and dyspareunia. RESULTS: Eighty-five percent of subjects ultimately had nontender vestibule
examinations postoperatively. Fewer, numbering 64%, reported resolution of dyspareunia, 24% had less
dyspareunia, 9% were no better, and 3% reported they were worse. Fifty percent of those with continued
dyspareunia had no remaining vestibulitis, but had tight or tender pelvic muscles. Failure of surgery and
physical therapy to correct dyspareunia related significantly to length of symptoms before therapy (p =
0.02). Follow-up averaged 3.7 years, with a range of 0.25-14. CONCLUSION: Superficial surgery can
correct vulvar vestibulitis, but without treatment for pelvic floor myalgia, women may continue to have
dyspareunia. Physical therapy is an important adjunct to achieve comfort.
Novel bioadhesive patch-type system for photodynamic vulvodynia therapy after delivery of 5-
aminolevulinic acid: preliminary evaluation.
Zawislak AA, McCarron PA, McCluggage WG, Donnelly RF, Price JH, McClelland HR, Woolfson AD
J Reprod Med.2007 Jul;52(7):645-53.
OBJECTIVE: To assess the applicability of photodynamic therapy (PDT) in the management of
vulvodynia whereby a novel, patch-type system, loaded with 5-aminolevulinic acid (ALA), was used to
administer PDT to vulvar regions displaying the characteristics of vulvodynia. STUDY DESIGN: Eleven
patients underwent PDT using a bioadhesive patch to deliver ALA over 4 hours. A nonlaser light source
delivered 100 J cm(-2) to the target area using red light of 630 nm. Fluorescence of protoporphyrin IX was
observed under ultraviolet light illumination, with no significant difference found between that produced
after the first and second applications of the patch. RESULTS: There was a significant reduction (p=
0.0077) in overall symptoms after completion of treatment. No significant alleviation (p = 0.1088) in pain
during intercourse was observed following treatment. Eight patients experienced a symptomatic
response, while 3 exhibited no improvements in symptoms. No adverse reactions or worsening of
reported symptoms was reported. CONCLUSION: The results suggest that PDT is of value in the
management of vulvodynia, most probably as a viable option to conventional approaches. Further studies
involving larger numbers of patients are required to confirm the efficacy of PDT in the management of
vulvodynia.
The vulvalgesiometer as a device to measure genital pressure-pain threshold.
Pukall CF, Young RA, Roberts MJ, Sutton KS, Smith KB
Physiol. Meas. 28 (2007) 1543–1550

The construction and application of the vulvalgesiometer are described. This manually-applied device
allows for the quantifiable measurement of pressure-pain thresholds in the external female genital region.
A set of five vulvalgesiometers exerting pressures from 3 to 950 g was used in two studies. The goal of
the first study was to examine the ability of the vulvalgesiometers to discriminate between women with
and without provoked vestibulodynia (PVD). In a matched sample of affected and non-affected women,
women with PVD exhibited significantly lower vestibular pressure-pain thresholds as compared to control
women. As well, approximately half the sample of women with PVD described the sensation elicited at
pressure-pain threshold as similar to the pain experienced during sexual intercourse. The goal of the
second study was to investigate the inter-rater reliability of the vulvalgesiometers. In this separate
sample of women with and without PVD, each participant was tested for pressure-pain threshold by two
different investigators at different times. Results demonstrated high levels of inter-rater reliability,
indicating that the vulvalgesiometers can be consistently used by different investigators. Further, results
indicated significant negative correlations between pressure pain thresholds and pain intensity ratings
recorded during the cotton-swab test, suggesting that the lower the threshold, the higher the pain ratings
during vestibular palpation. The vulvalgesiometers can be utilized for several purposes, including
treatment outcome studies and measuring the degree of PVD severity.
Vulvodynia: new thoughts on a devastating condition.
Gunter J
Obstet Gynecol Surv. 2007 Dec;62(12):812-9.
Vulvodynia affects 3% to 15% of women; many suffer through years of misdiagnosis and for those who
receive care cures are uncommon. Little is known about the etiology and a wide range of therapeutic
options are available. With treatment approximately 50% of women will report sustained improvement in
pain scores of 50% or more, however, reasons for varied response rates are yet unknown. This article will
explore 3 factors that may contribute to inconsistent results with therapy; the hypothesis that vulvodynia is
a systemic disorder; the idea that failure to address the psychological or emotional aspect or chronic pain
may affect outcome; and the concept that chronic vulvar pain, like headache, is not a single condition but
is a diverse group of disorders that produce the same symptom. Target Audience: Obstetricians &
Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should
be able to state that vulvodynia is a complex disorder, explain that no one treatment is superior, relate
that pathophysiology is important, and recall that psychological aspects of chronic pain must be
appreciated.

Provoked vestibulodynia.
Pukall CF, Smith KB, Chamberlain SM
Women’s Health. 2007; 3(5):583-92.
Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Affected women report
negative impacts in terms of sexual functioning, relationship adjustment, psychological well-being and
overall quality of life. Although the etiology of vulvodynia is not well understood, it appears as if different
levels of pathophysiology are implicated. Accordingly, therapeutic options are targeted at a variety of
mechanisms. Unfortunately, few randomized, controlled trials exist, and few combination therapies have
been examined; however, the quality and breadth of the treatment literature is improving. Further studies
are needed to more fully investigate the mechanisms involved in the development and maintenance of
vulvodynia, and more research in the area of treatment outcome is needed.

Vulvar vestibulitis syndrome and estrogen dose of oral contraceptive pills.
Greenstein A, Ben-Aroya Z, Fass O, Militscher I, Roslik Y, Chen J, Abramov L
J Sex Med. 2007 Nov;4(6):1679-83.
Introduction. Vulvar vestibulitis syndrome (VVS) is a diverse, multifactorial phenomenon. Its precise
etiology is unknown. Aim. To define the association between oral contraceptive (OC) estrogen dosage
and VVS. Methods. Women diagnosed as having VVS participated in the study. Main Outcome
Measures. Data on type and usage of oral contraceptive pills (OC) were obtained by a questionnaire, and
they were compared for the data on OC usage in the general population. Results. Available commercial
data on Israeli women taking OC showed that 51% of them use low-dose estrogen (</=20 microg) OC
and 49% use higher-dose estrogen (30-35 microg) OC. Of the 132 women in the study, 86 (65%) used
OC: 68 (79%) used low-dose estrogen OC (P < 0.002 compared to the general population), while only 18
(21%) used high-dose estrogen OC (P < 0.002 compared to the general population). Conclusion.
Significantly more patients who are treated in our clinic for VVS use low-dose estrogen than those who
use high-dose estrogen OC.

Painful bladder syndrome/interstitial cystitis and vulvodynia: a clinical correlation.
Peters K, Girdler B, Carrico D, Ibrahim I, Diokno A
Int Urogynecol J Pelvic Floor Dysfunct. 2007 Nov 24; [Epub ahead of print]
Vulvodynia affects 25% of women with painful bladder syndrome/interstitial cystitis (PBS/IC). The
objective of our study was to clinically evaluate the association of PBS/IC and vulvodynia and possible
contributing factors. To our knowledge, this has not been reported. Seventy women with PBS/IC were
evaluated from December 2005 to December 2006 with a comprehensive history and exam. Two groups
were formed-those with vulvodynia and those without vulvodynia for comparison. Of the women, 51.4%
had vulvodynia and 48.6% did not have vulvodynia using our operative definition. Average levator pain
levels were significantly greater in those with vulvodynia. There was no significant difference in the total
number of lifetime pelvic surgeries, history of sexually transmitted infections (STIs), vaginitis, or abuse
history between groups. The correlation of vulvodynia and PBS/IC may have been underestimated.
Research needs to explore the link between precipitating factors, symptoms, and effective treatment
options for PBS/IC and vulvodynia.
"If sex hurts, am I still a woman?" The subjective experience of vulvodynia in hetero-sexual
women.
Ayling K, Ussher JM
Arch Sex Behav. 2007 Sep 18; [Epub ahead of print]
Vulvodynia has recently been recognized as a significant health problem among women, with a
considerable proportion experiencing psychological distress and sexual dysfunction for many years. This
study used a material-discursive framework and a qualitative methodology to investigate women's
subjective experience of vulvodynia within the context of a hetero-sexual relationship, and their
negotiation of coitus, commonly associated with vulvar pain. Seven women, who had experienced
vulvodynia between 2 and 10 years, took part in in-depth interviews. Thematic decomposition drawing on
a Foucauldian framework for interpretation identified that six of the seven women took up subject
positions of "inadequate woman" and "inadequate partner," positioning themselves as failures for
experiencing pain during coitus, which they interpreted as affecting their ability to satisfy their partners
sexually, resulting in feelings of shame, guilt, and a decreased desire for sexual contact. This was
interpreted in relation to dominant discourses of femininity and hetero-sexuality, which conflate a woman's
sexuality with her need to be romantically attached to a man, position men as having a driven need for
sex, and uphold coitus as the organizing feature of hetero-sex. Only one woman positioned herself as an
"adequate woman/partner," associated with having renegotiated the coital imperative and the male sex
drive discourse within her relationship. These positions, along with women's agentic attempts to resist
them, were discussed in relation to their impact on hetero-sexual women's negotiation of vulvodynia.
Implications for future research and vulvodynia treatment regimes are also raised.
Clinical characteristics and psychopathological profile of patients with vulvodynia: an
observational and descriptive study.
Tribo MJ, Andion O, Ros S, Gilaberte M, Gallardo F, Toll A, Ferran M, Bulbena A, Pujol RM, Banos JE
Dermatology. 2008;216(1):24-30.
Background: Vulvodynia is a fairly common dermatological symptom that often interferes with the
personal, social and working activities of affected women and results in a significant loss of their quality of
life. It is a persistent and tedious clinical disorder which is often resistant to conventional treatments.
Objectives: The aim of this study is to evaluate the main clinical signs, associated psychopathological
disorders and outcome after antidepressant treatment of patients with vulvodynia. Methods: Eighty
patients were included. Clinical characteristics and psychopathological profiles were determined by
appropriate instruments. The improvement of clinical symptoms after combined antidepressant drug
therapy was also evaluated. Results: Pain (70%), burning (63.7%), dyspareunia (57.5%) and stinging
(56.2%) were the most commonly reported symptoms. Most patients (56.5%) showed anxiety, and 52.2%
of them were reported as having a depression disorder. When evaluated by psychometric tools, 81.4% of
patients scored >150 on the Life Event Scale, which means a risk >50% of suffering an illness in the near
future, and patients' scores in the Dermatology Life Quality Index showed higher values than the mean of
the Spanish validation group. After 6 months of combined treatment with escitalopram (10-20 mg/day),
perfenazine (2-4 mg/day) and amytriptiline (10 mg/day), a complete remission of the clinical symptoms
was achieved in 41% of patients. In contrast, only 12% of patients who did not follow drug treatment
reported a complete resolution of the clinical symptoms. Conclusions: Our results seem to confirm that
vulvodynia is associated with psychiatric co-morbidity such as stress and depression. The study highlights
that the psychiatric treatment may be a useful option to improve clinical symptoms. Whether these
patients should be evaluated for depression or be referred to a psychiatrist, remains to be investigated.
Vulvovaginal chronic graft-versus-host disease with allogeneic hematopoietic stem cell
transplantation.
Stratton P, Turner ML, Childs R, Barrett J, Bishop M, Wayne AS, Pavletic S
Obstet Gynecol. 2007 Nov;110(5):1041-9.
OBJECTIVE: To describe the diagnosis and management of female genital chronic graft-versus-host
(GVH) disease, a complication of hematopoietic stem cell transplantation. METHODS: From 1999 to
2006, 33 women with vulvar symptoms or undergoing systematic evaluation for chronic GVH disease
were referred 267 (median, range 29-6,117) days after transplantation for gynecologic evaluation.
Pertinent histories, laboratory tests, and skin and genital area-directed examinations were performed.
Vulvar disease was treated with superpotent topical glucocorticoids and topical estrogen. Sexually active,
menopausal women used vaginal dilators, topical glucocorticoids and estrogen, and estrogen vaginal
rings for vaginal synechiae. RESULTS: At presentation, most patients complained of vulvar pain during
urination and pain that prevented sexual intercourse. Twenty-nine of 33 presenting with vulvovaginal
chronic GVH disease had vulvar erythema, with additional signs including vulvar vestibulitis syndrome
(n=9), vulvar erosions (n=12), vulvar scarring (n=2), and vaginal scarring (n=6); over time, eight additional
patients developed vaginal scarring. Topical glucocorticoids improved vulvar symptoms, and estrogen
decreased vulvar mucosal friability. Eleven of 12 patients, who wanted to resume having intercourse,
responded to nonsurgical treatment for vaginal synechiae. CONCLUSION: A combination of topical
superpotent glucocorticoids and estrogen was effective in the treatment of vulvovaginal chronic GVH
disease. In those with vaginal scarring, use of a vaginal dilator and estrogen ring was helpful. Early
identification and treatment of vulvovaginal chronic GVH disease ameliorates vulvar pain by healing
eroded vulvar mucosa and may prevent the need for surgery for hematocolpos. LEVEL OF EVIDENCE:
III.
Neurosurgical treatment of perineal neuralgias.
Robert R, Labat JJ, Riant T, Khalfallah M, Hamel O
Adv Tech Stand Neurosurg. 2007;32:41-59
Perineal pain is the basis of presentation to different specialties. This pain is still rather unknown and
leads the different teams to inappropriate treatments which may fail. For more than twenty years, we have
seen these patients in a multidisciplinary consultation. Our anatomical works have provided a detailed
knowledge of the nervous supply of the perineum which allowed us to propose the description of an
entrapment syndrome of the pudendal nerve. Other disturbances of different origins were highlighted
helping colleagues to a better analysis of this enigmatic painful syndrome. Cadaveric studies have been
done to guide treatments by blocks and surgery if necessary according to well defined criteria. A
randomized prospective study validated the surgery. The retrospective study concluded that two thirds of
the patients improved after treatment. New anatomical concepts are leading us to enlarge the field of this
type of surgery, with the hope of improving the success rate.
Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria).
Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J
Neurourol Urodyn. 2007 Sep 7; [Epub ahead of print]
AIMS: The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially
clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the
diagnosis. We defined criteria that can help to the diagnosis. MATERIALS AND METHODS: A working
party has validated a set of simple diagnostic criteria (Nantes criteria). RESULTS: The five essentials
diagnostic criteria are: (1) Pain in the anatomical territory of the pudendal nerve. (2) Worsened by sitting.
(3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5)
Positive anesthetic pudendal nerve block. Other clinical criteria can provide additional arguments in favor
of the diagnosis of pudendal neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or
hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able
to explain the symptoms. CONCLUSION: The diagnosis of pudendal neuralgia by pudendal nerve
entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test
results of this disease. However, a combination of criteria can be suggestive of the diagnosis.
A prospective, single-blind, randomized crossover trial of sacral vs pudendal nerve stimulation for
interstitial cystitis.
Peters KM, Feber KM, Bennett RC
BJU Int. 2007 Oct;100(4):835-9
OBJECTIVE: To compare sacral nerve stimulation (SNS) with pudendal nerve stimulation (PNS) for
interstitial cystitis (IC). PATIENTS AND METHODS: Twenty-two patients with well-documented, refractory
IC had a tined lead placed at S3 and a second electrode implanted at the pudendal nerve via a posterior
approach. In a blinded, randomized design, each lead was tested for 7 days. The best lead was
implanted to a pulse generator and patients were followed at 1, 3 and 6 months. RESULTS: The time
required to place a sacral lead was 27.4 min, and a pudendal lead 19.6 min (P = 0.039). Of the 22
patients, 17 (77%) responded and had a permanent implant placed. PNS was chosen as the better lead
in 77% and SNS in 24%. The order in which the lead was stimulated had no effect on the final lead
implanted and there was no 'carry-over' effect. The overall reduction in symptoms was 59% for PNS and
44% for SNS (P = 0.05). At 6 months after implantation, voids improved by 41% (PNS) and 33% (SNS),
and mean voided volume increased 95% and 21%, respectively; validated IC questionnaires improved
markedly and complications were minimal. CONCLUSIONS: This is the first 'blinded' study of SNS vs
PNS for IC. A pudendal lead was implanted successfully in all patients, and most chose PNS as better
than SNS; the improvement was sustained over time.

Vulvar Dermatoses
Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics.
Jones RW, Scurry J, Neill S, Maclean AB
Am J Obstet Gynecol. 2007 Sep 29; [Epub ahead of print]
It is recommended that women with vulvar lichen sclerosus be followed in specialist clinics where difficulty
exists with symptom control or where there is clinical evidence of localized skin thickening. Follow-up is
also recommended for women who have previously been treated for squamous cell carcinoma of the
vulva (arising in lichen sclerosus or vulvar intraepithelial neoplasia) or where the pathologist expresses
concern and is unable to make a definitive diagnosis of differentiated vulvar intraepithelial neoplasia.
Unique dermatologic aspects of the postmenopausal vulva.
Summers PR, Hunn J
Clin Obstet Gynecol. 2007 Sep;50(3):745-51.
Aging and estrogen deficiency compromise the skin barrier's defense mechanisms, resulting in greater
microbial colonization of the skin. Susceptibility to mechanical injury and chemical irritation also
increases. Menopause blunts the cell-mediated immune response to microbes and allergens. Healing
after an insult is delayed. Skin disorders such as lichen sclerosus or allergic dermatitis may not be
clinically obvious. A biopsy interpreted by a dermatopathologist is often helpful. Some conditions require
long-term use of topical steroid ointments, and antimicrobial therapy. A compounding pharmacist may be
necessary to find a base for the topical cream that does not irritate.
Infectious Disease

Postmenopausal vaginitis.
Nyirjesy P
Curr Infect Dis Rep. 2007 Nov;9(6):480-4.
The importance of vaginitis in postmenopausal women will increase as the US population ages. With the
withdrawal of estrogen, the vaginal environment changes dramatically. Along with physical changes, an
overall decrease in the normal Lactobacillus-dominant flora and Candida colonization occurs.
Trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis still occur in menopausal women but
probably less commonly than in younger women. The effects of exogenous estrogen on these conditions
remain unknown. Less common conditions such as desquamative inflammatory vaginitis and lichen
sclerosus gain relative importance in this population.
Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated
vulvovaginal candidiasis (thrush).
Nurbhai M, Grimshaw J, Watson M, Bond C, Mollison J, Ludbrook A
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD002845
BACKGROUND: Anti-fungals are available for oral and intra-vaginal treatment of uncomplicated
vulvovaginal candidiasis (thrush). OBJECTIVES: The primary objective of this review was to assess the
relative effectiveness of oral versus intra-vaginal anti-fungals for the treatment of uncomplicated
vulvovaginal candidiasis. The secondary objectives of the review were to assess the cost-effectiveness,
safety and patient preference of oral versus intra-vaginal anti-fungals. SEARCH STRATEGY: The
following sources were searched for the original review: The Cochrane Library (Issue 4, 1999), MEDLINE
(January 1985 to May 2000), EMBASE (January 1980 to January 2000) and the Cochrane Sexually
Transmitted Disease (STD) Group Specialised Register of Controlled Trials. The manufacturers of anti-
fungals available in the UK were contacted. For the update, CENTRAL (January 2000 to August 2006),
PUBMED (January 2000 to August 2006), EMBASE (January 2000 to August 2006) and the Cochrane
STD Group Specialised Register were searched in August 2006. The reference lists of retrieved articles
were reviewed manually. SELECTION CRITERIA: Randomised controlled trials published in any
language. Trials had to compare at least one oral anti-fungal with one intra-vaginal anti-fungal. Women
(aged 16 years or over) with uncomplicated vulvovaginal candidiasis. The diagnosis of vulvovaginal
candidiasis to be made mycologically (i.e. a positive culture and / or microscopy for yeast). Trials were
excluded if they solely involved subjects who were HIV positive, immunocompromised, pregnant, breast
feeding or diabetic. The primary outcome measure was clinical cure. DATA COLLECTION AND
ANALYSIS: Two reviewers screened titles and abstracts of the electronic search results and full text of
potentially relevant papers. Independent duplicate abstraction was performed by two reviewers.
Disagreements regarding trial inclusion or data abstraction were resolved by discussion between the
reviewers. Odds ratios were pooled using the fixed effects models (except for two analyses when random
effects models were used because of potentially important heterogeneity). MAIN RESULTS: Two new
trials reporting three comparisons were found in the update. Nineteen trials are included in the review,
reporting 22 oral versus intra-vaginal anti-fungal comparisons. No statistically significant differences were
shown between oral and intra-vaginal anti-fungal treatment for clinical cure at short term (OR 0.94, 95%
CI, 0.75 to 1.17) and long term (OR 1.07, 95% CI, 0.82 to 1.41) follow-up. No statistically significant
differences for mycological cure were observed between oral and intra-vaginal treatment at short term
(OR 1.15, 95% CI, 0.94 to 1.42). There was a statistically significant difference for long term follow-up
(OR 1.29, 95% CI, 1.05 to 1.60) in favour of oral treatment, however the clinical significance of this result
is uncertain. Two trials each reported one withdrawal from treatment due to an adverse reaction.
Treatment preference data were poorly reported. AUTHORS' CONCLUSIONS: No statistically significant
differences were observed in clinical cure rates of anti-fungals administered by the oral and intra-vaginal
routes for the treatment of uncomplicated vaginal candidiasis. No definitive conclusion can be made
regarding the relative safety of oral and intra-vaginal anti-fungals for uncomplicated vaginal candidiasis.
The decision to prescribe or recommend the purchase of an anti-fungal for oral or intra-vaginal
administration should take into consideration: safety, cost and treatment preference. Unless there is a
previous history of adverse reaction to one route of administration or contraindications, women who are
purchasing their own treatment should be given full information about the characteristics and costs of
treatment to make their own decision. If health services are paying the treatment cost, decision-makers
should consider whether the higher cost of some oral anti-fungals is worth the gain in convenience, if this
is the patient's preference.
Methylrosaniline chloride stained vaginal smears for the diagnosis of vulvovaginal candidiasis.
Liu XP, Fan SR
Int J Gynaecol Obstet. 2007 Nov;99(2):83-6. Epub 2007 Sep 29.
OBJECTIVE: To study the sensitivity and specificity of methylrosaniline chloride stained vaginal smears
for the diagnosis of vulvovaginal candidiasis (VVC). METHOD: Between September 2005 and February
2006, 214 cases of patients with VVC and 102 cases of controls were investigated at Peking University
Shenzhen Hospital. All strains were identified with the API Candida system. RESULTS: The average age
of the patients was 29.87 years. The sensitivity and specificity of methylrosaniline chloride stained vaginal
smears for the diagnosis of vulvovaginal candidiasis were 88.3% (189/214) and 96.1 (98/102). The
sensitivity of the vaginal smears for the diagnosis of recurrent vulvovaginal candidiasis, mild vulvovaginal
candidiasis and severe vulvovaginal candidiasis were 85.2% (46/54), 74.7% (71/95) and 99.2%
(118/119). CONCLUSION: Methylrosaniline chloride stained vaginal smears for the diagnosis of
vulvovaginal candidiasis are reliable and inexpensive.
Symptomatic candidiasis: Using self sampled vaginal smears to establish the presence of
Candida, lactobacilli, and Gardnerella vaginalis.
Engberts MK, Boon ME, van Haaften M, Heintz AP
Diagn Cytopathol. 2007 Oct;35(10):635-9.
In a prospective cohort study, 10 symptomatic women with recurrent vulvovaginal candidiasis were taught
how to prepare vaginal smears of their own vaginal fluids on days 7, 14, 21, and 28. The 40 smears were
stained with the PAS-method and examined by three different cytopathologists for presence of Candida.
Thereafter, the smears were restained with Giemsa-stain to determine presence of lactobacilli,
Gardnerella vaginalis ("clue cells") and neutrophils. All three cytopathologists unequivocally established
Candida blastospores and (pseudo)hyphae in 27 out of the 40 PAS-stained vaginal smears, whereas in
the remaining 13 smears Candida was not found. All 10 patients had Candida in their smears during the
second half of their menstrual cycle. Self sampled smears prove to be reliable for establishing the
presence of Candida in symptomatic patients with candidiasis. Candida is associated with a lactobacillus-
predominated vaginal flora, but with the absence of Gardnerella vaginalis. Further studies may be
directed towards the interaction between the various members of the vaginal flora. This study should
open molecular methodology for determining the possible interactions of lactobacilli and Candida.
Perceived stress in women with recurrent vulvovaginal candidiasis.
Ehrstrom S, Kornfeld D, Rylander E
J Psychosom Obstet Gynaecol. 2007 Sep;28(3):169-76.
OBJECTIVE: Recurrent vulvovaginal candidiasis (RVVC) has become very common. The aim of this
study was to evaluate if women with RVVC perceive more signs of chronic stress than healthy control
subjects. STUDY DESIGN: Thirty-three women with RVVC and 28 healthy control subjects completed a
questionnaire about perceived stress at work and in private life, and a health questionnaire. A comparison
of the results was performed with the one-way ANOVA test. RESULTS: More women with RVVC than
control subjects reported signs of burnout (p < 0.001), emotional symptoms of stress (p < 0.005),
impaired balance between work and leisure time (p = 0.01), bodily symptoms of stress (p < 0.05),
worrying factors at work (p < 0.05), and presented type D-personality (p < 0.05). CONCLUSIONS: The
results of this pilot study showed higher degree of perceived stress in women with RVVC compared with
healthy controls. These results are in line with our earlier findings of blunted morning rise cortisol and
lower mean levels of cortisol in women with RVVC compared with healthy controls.
Anticandidal immunity and vaginitis: novel opportunities for immune intervention.
Cassone A, De Bernardis F, Santoni G
Infect Immun. 2007 Oct;75(10):4675-86. Epub 2007 Jun 11
[No abstract listed.]

Basic Science
Time course of neuroanatomical and functional recovery after bilateral pudendal nerve injury in
female rats.
Damaser MS, Samplaski MK, Parikh M, Lin DL, Rao S, Kerns JM
Am J Physiol Renal Physiol. 2007 Nov;293(5):F1614-21. Epub 2007 Aug 29
The pudendal nerve innervates the external urethral sphincter (EUS) and is among the tissues injured
during childbirth, which may lead to symptoms of stress urinary incontinence (SUI). To understand the
mechanisms of injury and repair, urethral leak-point pressure (LPP) was measured 4 days, 2 wk, or 6 wk
after bilateral pudendal nerve crush. Morphometric changes in the distal nerve and EUS were examined
by light and electron microscopy. To determine whether recovery resulted from pudendal
neuroregeneration, LPP was measured before and after pudendal nerve transection 2 wk after nerve
crush. LPP was significantly decreased 4 days after pudendal nerve crush compared with sham-injured
animals as well as 2 or 6 wk after nerve crush. LPP was not significantly different 2 or 6 wk after nerve
crush compared with sham-injured animals, suggesting that urethral function had returned to normal.
Four days after pudendal nerve crush, the EUS branch of the pudendal nerve distal to the injury site
showed evidence of nerve degeneration and the EUS appeared disrupted. Two weeks after nerve crush,
the distal nerve and EUS both showed evidence of both nerve degeneration and recovery. Two weeks
after nerve crush, LPP was significantly decreased after nerve transection. Six weeks after nerve injury,
evidence of neuroregeneration was observed in the pudendal nerve and the EUS. This study has
demonstrated that functional recovery and neuroregeneration are significant 2 wk after nerve crush,
although by anatomical assessment, recovery appears incomplete, suggesting that 2 wk represents an
early time point of initial neuroregeneration.
Intra-abdominal laparoscopic pudendal canal decompression - A feasibility study.
Loukas M, Jr RG, Tubbs RS, Wartmann C, Colborn GL
Surg Endosc. 2007 Nov 20; [Epub ahead of print]

BACKGROUND: Pudendal canal syndrome (PCS) is induced by the compression or the stretching of the
pudendal nerve within Alcock's canal. METHODS: Considering the difficulty and possible complications
involved in exposing the pudendal canal and nerve by either transperineal, transgluteal or
transischiorectal approaches, an intra-abdominal laparoscopic pudendal canal decompression (ILPCD)
was employed. For this technique, 30 male adult human cadavers were examined. RESULTS:
Measurements revealed an adequate working space in 16 (80%) of the 20 cadavers, while in four
specimens the ischiococcygeus muscle was too large to be mobilized sufficiently. The mean working
space was 24 mm with a range of 18 to 31 mm. It was considered that a working space of less than 20
mm would not be sufficient for manipulation of the instruments. With regards to pudendal nerve
compression, it was observed that 7 (35%) of the 20 cadavers exhibited anatomic signs of PCS. In five
(25%) specimens, the compression was observed between the sacrospinous and sacrotuberous
ligaments, while the other two (10%) exhibited a broader compression, by the falciform portion of the
sacrotuberous ligament. Under the guidance of a laparoscope, the peritoneum was cut laterally to the
bladder, and fascia pelvis was identified. The latter was split and the internal iliac vein was traced to the
opening of the pudendal canal allowing clear visualization of its contents. Subsequently, either the
sacrospinous or sacrotuberous ligament was cut. CONCLUSIONS: Considering that none of the surgical
procedures currently used are known to completely improve all the symptoms of PCS, ILPCD could
theoretically reduce stretching of the pudendal nerve.

Source: http://www.nva.org/pdf/Res%20Update%20-%20Dec%202007.pdf