Clinical Recommendation: Pediatric Lichen Sclerosus

Lichen sclerosus is a chronic inflammatory condition affecting the anogenital region that may present in the prepubertal or adolescent patient. Clinical presentations include significant pruritus, labial adhesions, and loss of pigmentation. Treatment includes topical anti-inflammatory agents and long-term follow-up as there is a high risk of recurrence and an increased risk of vulvar cancer in adult women with history of lichen sclerosus. These recommendations are intended for pediatricians, gynecologists, nurse practitioners and others who care for pediatric/adolescent girls in order to facilitate diagnosis and treatment.     

Prevalence of vulvodynia and risk factors for the condition in Portugal

Objective

To investigate the prevalence of vulvodynia in Portugal and factors associated with this condition.

Methods

In a cross-sectional study, an online survey was distributed by email and posted on a website and social networks. Women aged at least 18 years who were living in Portugal were eligible to complete the survey between June 1 and November 30, 2013. Participants had to have had symptoms for at least 6 months to be deemed to have vulvodynia.

Results

Overall, 1229 questionnaires were included in analyses. A total of 80 (6.5%) women had vulvodynia at the time of the survey, and 117 (9.5%) had had it previously; lifetime prevalence was 16.0%. Pregnancy and type of delivery were not associated with vulvodynia. Women who had ever taken oral contraceptives were significantly more likely to have ever had vulvodynia (P < 0.010). Candidiasis, genital herpes, urinary tract infections, depression, and premenstrual syndrome were associated with ever having had vulvodynia (P < 0.01). Pain syndromes were associated with ever having had vulvodynia, especially fibromyalgia and bladder pain syndrome (P < 0.001). Scoliosis and hysterectomy were also significantly associated (P < 0.01).

Conclusion

The prevalence of vulvodynia in Portugal is similar to that elsewhere. Three main groups of factors might lead to vulvodynia: local inflammatory factors, general pain susceptibility, and pelvic nerve interference.     

Borderline Ovarian Tumor in the Pediatric and Adolescent Population: A Case Series and Literature Review

Study Objective

To determine the diagnosis, management, and outcome for children and adolescents with borderline ovarian tumor (BOT), and to provide a review of the literature on BOT in children and adolescents.

应用宫腔镜诊治幼女和少女妇科疾病

幼女和少女妇科疾病的诊治在以往是一个比较棘手的问题。由于其生理和解剖特点,加上受到传统观念的影响,在必须进行经阴道检查和手术时,处女膜就成为了妇科医生诊断和治疗的障碍。近年来妇科内镜技术的发展使宫腔镜成为诊治幼女和少女妇科疾病的重要手段。宫腔镜进入时无需使用拉钩过度牵拉阴道,可在不损伤处女膜的前提下通过尚未发育成熟的相对狭窄的阴道,帮助确立诊断并可进行治疗,因而可替代大部分传统的需用阴道窥器的经阴道检查和手术,其全程均在可视下操作所以更加安全。近年来,应用宫腔镜在不损伤处女膜的情况下诊治幼女和少女的妇科疾病已经成为一种趋势,但大多数相关报道还仅局限于个案报道和含有少量病例的临床研究。对评估应用宫腔镜进行阴道内镜和（或）宫腔镜检查或手术来诊治幼女和少女妇科疾病的可行性和有效性进行综述。     

Recommendations for the Study of Vulvar Pain in Women,Part 1: Review of Assessment Tools

IntroductionThe etiology and consequences of chronic vulvar pain are multidimensional, resulting in highly variable clinical presentations and no established treatment algorithm. Inconsistent use of measurement tools across studies is a significant barrier to drawing conclusions regarding etiology and treatment. In a companion paper, we review additional methodological challenges to the study of chronic vulvar pain and potential solutions.AimTo review and recommend assessment and measurement tools for vulvar pain and associated key outcomes.MethodsThe authors reviewed the scientific evidence related to measurement of vulvar pain and made decisions regarding recommendations via discussion and consensus.Main Outcome MeasureWe assessed measurement tools for vulvar pain and related outcomes and considered advantages and disadvantages of their use.ResultsEmpirically validated measurement tools are available and should be used uniformly across studies to support comparisons and pooling of results. There is, at times, a trade-off between advantages and disadvantages when selecting a particular tool, and researchers should be guided by their specific research aims, feasibility, and potential to gain further knowledge in the field. Researchers should incorporate a biopsychosocial assessment of vulvar pain and its consequences.Clinical ImplicationsThis review provides a comprehensive list of measurement tool recommendations for use in clinical research, and in some cases, clinical practice.Strengths & LimitationsThis expert review can guide study design and decision-making for those researching vulvar pain and its consequences. The review content and recommendations are based on expert knowledge of the literature rather than a formal systematic review.ConclusionA thorough consideration of vulvar pain assessment tools is essential for continued progress toward identifying factors involved in the development and maintenance of vulvar pain and developing empirically supported treatments.Rosen NO, Bergeron S, Pukall CF. Recommendations for the Study of Vulvar Pain in Women, Part 1: Review of Assessment Tools. J Sex Med 2020; 17:180–194.     

Treatment Approach and Prognosis of Pediatric and Adolescent Nonepithelial Malignant Ovarian Tumors: A Retrospective Prognosis Analysis

Study Objective

Nonepithelial malignant ovarian tumors are rare in the pediatric and adolescent population. The aim of this study was to observe the spectrum of pathology, presentation, outcome, and risk factors for survival of pediatric nonepithelial malignant ovarian tumors in a Chinese pediatric population.

Evolution in the Management of Pediatric and Adolescent Ovarian Torsion as a Result of Quality Improvement Measures

Study Objective

The aim of this study was to document the change in ovarian conservation rate after ovarian torsion as a result of continuous quality improvement (CQI) measures, and to determine factors that contribute to this outcome.

Unilateral Labial Edema in a Female Adolescent: A Gynecologic Presentation of Rhabdomyolysis

Background

Rhabdomyolysis can be the result of vigorous physical activity. Typical signs and symptoms at presentation are muscle pain, weakness, or dark colored urine. There is no scientific literature associating rhabdomyolysis with gynecologic signs and symptoms.

Surgical Management of Benign Adnexal Masses in the Pediatric/Adolescent Population: An 11-Year Review

Study Objective

The purpose of this study was to compare ovarian conservation rates and surgical approach in benign adnexal surgeries performed by surgeons vs gynecologists at a tertiary care institution.

Enhancing Postgraduate Training in Pediatric and Adolescent Gynecology: Evaluation of an Advanced Pelvic Simulation Session

Study ObjectiveTo describe and evaluate a Canadian simulation session designed to teach pediatric and adolescent gynecology (PAG) history taking, examination and operative skills, and an approach to the child and adolescent.DesignObstetrics and gynecology residents in a single academic center participated in a PAG simulation session and rated their gain in knowledge on 6 aspects of PAG care.SettingAcademic half-day at the University of Ottawa Skills and Simulation Centre.ParticipantsTwenty-four Obstetrics/Gynecology residents at the University of Ottawa.InterventionsParticipants completed 4 stations teaching PAG-appropriate history taking, genital examination, Tanner staging, vaginal sampling and flushing, hymenectomy, vaginoscopy, laparoscopic adnexal detorsion, and approach to the child/adolescent. Advanced pelvic models were used for procedure specific stations. Participants completed an anonymous evaluation form at the end of the session.Main Outcome MeasureSelf-perceived increase in knowledge and PAG specific skills after the simulation session.ResultsTwenty-four residents completed the simulation session and post-session evaluation. All residents (100%) agreed that they had gained knowledge in PAG history taking, examination techniques, office procedures, operative skills, approach to child, and approach to the adolescent. Qualitative feedback stressed the excellence of instruction, interaction, immediate feedback, and hands-on experience. All residents (100%) stated the PAG simulation session should continue.ConclusionsThis advanced PAG simulation session increased resident self-perceived knowledge. Other obstetrics/gynecology training programs should consider implementing advanced PAG simulation sessions to increase resident knowledge and confidence in delivering care to the pediatric/adolescent patient.     

Menstrual Suppression in Pediatric and Adolescent Patients with Disabilities Ranging from Developmental to Acquired Conditions: A Population Study in an Australian Quaternary Pediatric and Adolescent Gynecology Service from January 2005 to December 2015

Study ObjectiveThe aim of this study was to review the efficacy of different medical modalities for menstrual suppression in the cohort of patients with disabilities who presented to the Queensland Paediatric and Adolescent Gynaecology (PAG) Service between January 2005 and December 2015. Menstrual suppression in adolescents with disabilities is an important aspect of care to support the patient and their carers in managing the complexities of menstrual hygiene, pain, and other discomfort associated with menses. It is important for general practitioners, pediatricians, and gynecologists to establish the right modality of suppression for each individual adolescent.Design, Settings, Participants, Interventions, and Main Outcome MeasuresThe study was a retrospective case notes review of 68 adolescents who presented to the Queensland PAG Service, Brisbane, Australia with a request for menstrual suppression. The medical interventions included treatment with either combined oral hormonal contraceptive, oral medroxyprogesterone, depot medroxyprogesterone, or the levonorgestrel intrauterine system (Mirena, Bayer). The primary outcome measure was success of menstrual suppression from commencement of medical intervention to achievement of complete amenorrhea or very light bleeding described as spotting, for each medical modality. Secondary outcomes were length of time from first treatment to first observed menstrual suppression, and the number of outpatient appointments taken to achieve menstrual suppression.ResultsOf the 68 adolescents, 59/68 (86.8%) successfully achieved menstrual suppression, with 9/68 (13.2%) having ongoing treatment or loss to follow-up at the time of conclusion of the study; 39/68 (57.4%) were menstrually suppressed with their chosen medical modality after their initial appointment.ConclusionMedical modalities are highly effective in achieving menstrual suppression and no young women at this institution required a hysterectomy. Depot medroxyprogesterone was the most successful modality used to achieve menstrual suppression followed by the levonorgestrel intrauterine system. The combined oral hormonal contraceptive was the least successful medical treatment in achieving menstrual suppression.     

Ovarian-Sparing Surgery in Pediatric Benign Ovarian Tumors

Study ObjectiveTo evaluate outcomes of children after ovarian-sparing surgery (OSS) for non-neoplastic and benign neoplastic ovarian lesions.DesignRetrospective cohort study from January 2003 to January 2012.SettingSingle, high-volume, tertiary care hospital.ParticipantsChildren 18 years of age and younger.InterventionsNone.Main Outcome MeasuresPostoperative complications and tumor recurrence after OSS.ResultsOne hundred nine patients underwent OSS with a median age of 13.3 years (interquartile range [IQR], 11.4-15.1 years). Eighty-two patients were treated laparoscopically with 4 conversions to an open procedure. Postoperative complications included surgical site infections in 7 patients (6%). Pathology most commonly revealed functional ovarian cysts (n = 57) and mature teratomas (n = 37). Ninety-four patients (86%) were followed for a median of 10.4 months (IQR, 0.72-30.8 months). Fifty-five patients (60%) had subsequent imaging surveillance a median of 7.6 months postoperatively (IQR, 3.9-13 months). Ten patients (10%) developed a second ipsilateral lesion within a median time of 11 months (IQR, 7.7-24 months), of whom 5 girls had repeated surgery for mass enlargement or persistent abdominal pain at a median time of 10.5 months (IQR, 8.0-12.65 months). Fifty-eight patients (63%) began or resumed menses at their most recent follow-up. Three girls became pregnant after OSS at a median follow-up of 5 years (range, 2.4-6.7 years).ConclusionBenign ovarian lesions in children can be treated successfully with OSS with low recurrence and repeat surgery rates.     

A Rare Case of Vulvar Superficial Angiomyxoma in a Pediatric Patient

BackgroundSuperficial angiomyxoma (SAM) is a rare, benign cutaneous tumor. Originally described as a component of Carney complex, it is now recognized as a sporadic condition.CaseA 7-year-old girl was referred for management of a 2.5-cm mass arising from the right labia majora. Key pathologic features included lobules of spindle-shaped cells in a myxoid matrix and prominent neutrophilic infiltrate. The cells were positive for CD34 and negative for desmin, progesterone receptor, and estrogen receptor staining.Summary and ConclusionThis case is that of the youngest described patient with vulvar SAM. Patients should be carefully examined for manifestations of Carney complex to avoid potentially life-threatening complications. It is critical to distinguish SAM from aggressive angiomyxoma. The patient was referred to genetics and will be followed for local recurrence.