| Peer-Reviewed

Acetic Acid Test Performed by Vulvoscopy Had Revealed an "O Sign" in the Inner Vulvar Ring of Patients with Vulvodynia

Received: 11 June 2023     Accepted: 29 June 2023     Published: 8 July 2023
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Abstract

This study examined the distribution and characteristics of acetowhite staining (AWS) in three vulvar rings in women with chronic vulvar discomfort. AWS was monitored as a secondary outcome measure in the study DATRIV (Diagnostic Accuracy of Three Rings Vulvoscopy). The study included 328 consecutive participants, divided into four groups based on their medical history, results from the vulvodynia questionnaire designed by the International Society for the Study of Vulvovaginal Disease, and clinical examination. Asymptomatic participants were classified into a normal vulva group (N = 82) and an impaired vulvar skin group (N = 82). Patients with chronic vulvar discomfort were divided into primary vulvar distress/vulvodynia (N = 82) and secondary discomfort caused by vulvar dermatosis (N = 82). The clinical data collected from the three rings vulvoscopy (TRIV) were analyzed using statistical software such as StatSoft (Dell, Austin, TX, USA), Statistica 12 (TIBCO®, Palo Alto, CA, USA), and SPSS 20 (IBM, Armonk, NY, USA). The study was conducted with the approval of the Institutional Review Board of Polyclinic Harni, and all participants provided written informed consent. The study's findings support the notion that AWS patterns can vary across different histological areas of the vulva and can indicate specific conditions. The higher incidence of AWS in the outer vulvar ring among patients with vulvar dermatosis (45.1%) suggests a widespread involvement in this area. In contrast, the study found that patients with vulvodynia (96.3%) and impaired vulvar skin (78.0%) exhibited a higher AWS frequency and a distinct pattern called the "O sign" in the inner vulvar ring. AWS in the middle vulvar ring was observed in all participants. However, there were noticeable differences between patients with vulvodynia and vulvar dermatosis, highlighting the potential diagnostic value of AWS distribution in this area. The faster onset of AWS in patients with vulvodynia (mean 51.6 seconds), a significantly higher frequency of sharp demarcation of AWS (49.4%), nontransparent AWS (16%), the "O sign" (81.7%) and provoked erythema (11.1%) supports the role of a potential inflammatory component in this condition in response to AWS. This specific pattern suggests that AWS combined with the TRIV approach can enhance the clinical recognizability of vulvodynia. The similarity in the distribution and characteristics of AWS in patients with vulvodynia and impaired vulvar skin suggests a potential connection between the two conditions and the progression or evolution of vulvodynia in the presence of impaired vulvar skin over time.

Published in Journal of Gynecology and Obstetrics (Volume 11, Issue 3)
DOI 10.11648/j.jgo.20231103.12
Page(s) 61-72
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2023. Published by Science Publishing Group

Keywords

Acetic Acid Test, Acetowhite Staining, O Sign, Three Rings Vulvoscopy, Chronic Vulvar Discomfort, Vulvodynia, Vulvar Dermatosis

References
[1] Hinselmann H. Die Essigsäureprobe ein Bestandteil der erweiterten Kolposkopie. Deutsche medizinische Wochenschrif 1938; 40-42.
[2] Apgar BS, Brotzman GL, Spitzer M. Colposcopy principles and practice: an integrated textbook and atlas, 2nd Edition. Elsevier, Philadelphia, 2008.
[3] Prendiville W, Sankakaranyanan R. Colposcopy and treatment of cervical Precancer. IARC Technical Publication 2017; N°45, ISBN-13 978-92-832-2458-7 https:// publications.iarc.fr/555.
[4] Ferenczy A. Diagnostic procedure for lesions of the cervix. In: Pathology of the female genital tract. Edited by Ancel Blaustein, 2. Edition, Volume 1, Springer Science-Business Medical LLC, 1982; 178-83.
[5] Holtorff J. Kolposkopische Kriterien der atypischen Umwandlungszone. Geburtsh u Frauenheilk 1960; 20: 931.
[6] Kolstad P, Stafl A. Atlas der Kolposkopie. Nach der 3. Auflage übersetzt von Fritz Hübner. Ferdinand Enke Verlag Stuttgart, 1983.
[7] University of Zimbabwe and JHPIEGO Cervical Cancer Project. Visual inspection with acetic acid for cervical-cancer screening: test qualities in a primary-care setting. Lancet 1999; 353: 869-73.
[8] Belinson JL, Pretorius RG, Zhabg WH et al. Cervical cancer screening by simple visual inspection after acetic acid. Obstet Gynecol 2001; 98: 441-4.
[9] Ardahan, Melek PhD, RN; Temel, Ayla Bayik PhD, RN. Visual Inspection With Acetic Acid in Cervical Cancer Screening. Cancer Nursing 2011; 34 (2): p 158-163; DOI: 10.1097/NCC.0b013e3181efe69f.
[10] Jonsson M, Karlsson R, Evander M et al. Acetowhitening of the cervix and vulva as a predictor of subclinical human papillomavirus infection: sensitivity and specificity in a population-based study. Obstet Gynecol 1997; 90 (5): 744-7.
[11] Kesić, V.; Vieira-Baptista, P.; Stockdale, C. K. Early Diagnostics of Vulvar Intraepithelial Neoplasia. Cancers 2022; 14, 1822. https://doi.org/10.3390/cancers14071822.
[12] Apgar B. Differentiating normal and abnormal findings of the vulva. 1996; American Academy of Family Physicians 2023. Available at: https://indexarticles.com/reference/american-family-physician/differentiating-normal-and-abnormal-findings-of-the-vulva; Last accessed on 18. February 2023.
[13] González, M. G.-Y.; Muñoz Ledesma, A. M.; Monge, M. N.; Fontán, J. S. Colposcopy of the Vulva and Perineum Colposcopy of the Vulva and Perineum. Open Access Peer-Reviewed Chapter September. 2017. Available online: http://dx.doi.org/10.5772/intechopen.68768; Last accessed on February 19, 2023.
[14] Micheletti L, Preti M, La Monica F. La vulvoscopia, no debe ser destinada como el examen colposcopico de la vulva. Arch. Med. Actual Tracto Genit. Inf 2011; 3: 29-34.
[15] Reid R. Rational management of cervical and vulvar neoplasia. Contemp Ob Gyn 1993; 38: 92-112.
[16] Santoso J, Likes W. Colposcopic acetowhitening of vulvar lesion: a validity study. Arch Gynecol Obstet 2015; 292: 387-390: DOI 10.1007/s00404-015-3666-5.
[17] Harni V, Babic D, Barisic D. "Three Rings Vulvoscopy" – A New Approach to the Vulva. Gynaecol Perinatol 2015; 24: 37-45.
[18] Harni V, Babic D, Hadzavdic S, Barisic D. Diagnostic Accuracy of the Vulvoscopy Index for Detection of Vulvar Dermatosis (DATRIV Study, Part 1). Journal of Gynecology and Obstetrics 2022; 10 (1): 39-47. DOI: 10.11648.j.jgo.20221001.16.
[19] Harni V, Babic D, Hadzavdic S, Barisic D. Clinical Value of the N-S-P Scheme for Detection of Vulvar Dermatosis (DATRIV Study, Part 2). Journal of Gynecology and Obstetrics 2022; 10 (3): 159-166. DOI: 10.11648.j.jgo.20221003.11.
[20] Harni V, Babic D, Hadzavdic S, Barisic D. Nonspecific Lesions in Patients with Chronic Vulvar Discomfort Revealed Vulvodynia as Chronic Reflex Pain Syndrome (CRPS) Type I. Journal of Gynecology and Obstetrics 2022; 10 (6): 243-252. doi: 10.11648/j.jgo.20221006.12.
[21] ISSVD Vulvodynia Pattern Questionnaire. Available at: https://netforum.avectra.com/temp/ClientImages/ISSVD/3ef9c6ea-aac7-4d2b-a37f-058ef9f11a67.pdf; Last accessed on May 23, 2015.
[22] Byrne MA, Walker MM, Leonard J, Pryce D, Taylor-Robinson D. Recognising covert disease in women with chronic vulval symptoms attending an STD clinic: value of detailed examination including colposcopy. Genitourin Med 1989; 65: 46-9.
[23] Audisio T, Zarazaga J, Vainer O. A Classification of Vulvoscopic Findings for Clinical Diagnosis. J Lower Genit Tract Dis 1999; 3: 7-18.
[24] Bornstein J, Sideri M, Tatti S, Walker P, Prendiwille W, Haefner HK. 2011 Terminology of the Vulva of the International Federation for Cervical Pathology and Colposcopy. J Lower Genit Tract Dis 2012; 16: 290-5.
[25] Friedrich EG Jr. Vulvar vestibulitis syndrome. J Reprod Med 1987; 32: 110-4.
[26] Haefner H, Collins M, Davis GD, Edwards L, Foster D, Hartmann E, et al. The Vulvodynia Guideline. J Lower Genit Tract Dis 2005; 9: 40-51.
[27] Stockdale CK, Lawson HW. 2013 Vulvodynia Guideline Update. J Lower Genit Tract Dis 2014; 18: 93-100.
[28] van Beurden M, van der Vange N, de Craen AJM, Tjong-Ahung SP, ten Kate FJW, ter Schegget J, et al. Normal findings in vulvar examination and vulvoscopy. J Br Obstet Gynaecol 1997; 104: 320-4.
[29] Reid R, Greenberg MD, Daoud Y, Husain M, Selvaggi S, Wilkinson E. Colposcopic findings in women with vulvar pain syndromes. A preliminary report. J Reprod Med 1988; 33: 523-532.
[30] Kesic V. Colposcopy of the vulva, perineum, and anal canal. Chapter in Bosze P, Luesley DM. EACG Course Book on Colposcopy. Budapest, Primed-X-Press; 2003.
[31] Lifits–Podorozhansky, YM; Podorozhansky, Y; Hofstetter, S; Gavard, JA. Role of Vulvar Care Guidelines in the Initial Management of Vulvar Complaints. J Low Genit Tract Dis 2012; 16 (2): 88-91.
Cite This Article
  • APA Style

    Vesna Harni, Damir Babic, Suzana Ljubojevic-Hadzavdic, Dubravko Barisic. (2023). Acetic Acid Test Performed by Vulvoscopy Had Revealed an "O Sign" in the Inner Vulvar Ring of Patients with Vulvodynia. Journal of Gynecology and Obstetrics, 11(3), 61-72. https://doi.org/10.11648/j.jgo.20231103.12

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    ACS Style

    Vesna Harni; Damir Babic; Suzana Ljubojevic-Hadzavdic; Dubravko Barisic. Acetic Acid Test Performed by Vulvoscopy Had Revealed an "O Sign" in the Inner Vulvar Ring of Patients with Vulvodynia. J. Gynecol. Obstet. 2023, 11(3), 61-72. doi: 10.11648/j.jgo.20231103.12

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    AMA Style

    Vesna Harni, Damir Babic, Suzana Ljubojevic-Hadzavdic, Dubravko Barisic. Acetic Acid Test Performed by Vulvoscopy Had Revealed an "O Sign" in the Inner Vulvar Ring of Patients with Vulvodynia. J Gynecol Obstet. 2023;11(3):61-72. doi: 10.11648/j.jgo.20231103.12

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  • @article{10.11648/j.jgo.20231103.12,
      author = {Vesna Harni and Damir Babic and Suzana Ljubojevic-Hadzavdic and Dubravko Barisic},
      title = {Acetic Acid Test Performed by Vulvoscopy Had Revealed an "O Sign" in the Inner Vulvar Ring of Patients with Vulvodynia},
      journal = {Journal of Gynecology and Obstetrics},
      volume = {11},
      number = {3},
      pages = {61-72},
      doi = {10.11648/j.jgo.20231103.12},
      url = {https://doi.org/10.11648/j.jgo.20231103.12},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.jgo.20231103.12},
      abstract = {This study examined the distribution and characteristics of acetowhite staining (AWS) in three vulvar rings in women with chronic vulvar discomfort. AWS was monitored as a secondary outcome measure in the study DATRIV (Diagnostic Accuracy of Three Rings Vulvoscopy). The study included 328 consecutive participants, divided into four groups based on their medical history, results from the vulvodynia questionnaire designed by the International Society for the Study of Vulvovaginal Disease, and clinical examination. Asymptomatic participants were classified into a normal vulva group (N = 82) and an impaired vulvar skin group (N = 82). Patients with chronic vulvar discomfort were divided into primary vulvar distress/vulvodynia (N = 82) and secondary discomfort caused by vulvar dermatosis (N = 82). The clinical data collected from the three rings vulvoscopy (TRIV) were analyzed using statistical software such as StatSoft (Dell, Austin, TX, USA), Statistica 12 (TIBCO®, Palo Alto, CA, USA), and SPSS 20 (IBM, Armonk, NY, USA). The study was conducted with the approval of the Institutional Review Board of Polyclinic Harni, and all participants provided written informed consent. The study's findings support the notion that AWS patterns can vary across different histological areas of the vulva and can indicate specific conditions. The higher incidence of AWS in the outer vulvar ring among patients with vulvar dermatosis (45.1%) suggests a widespread involvement in this area. In contrast, the study found that patients with vulvodynia (96.3%) and impaired vulvar skin (78.0%) exhibited a higher AWS frequency and a distinct pattern called the "O sign" in the inner vulvar ring. AWS in the middle vulvar ring was observed in all participants. However, there were noticeable differences between patients with vulvodynia and vulvar dermatosis, highlighting the potential diagnostic value of AWS distribution in this area. The faster onset of AWS in patients with vulvodynia (mean 51.6 seconds), a significantly higher frequency of sharp demarcation of AWS (49.4%), nontransparent AWS (16%), the "O sign" (81.7%) and provoked erythema (11.1%) supports the role of a potential inflammatory component in this condition in response to AWS. This specific pattern suggests that AWS combined with the TRIV approach can enhance the clinical recognizability of vulvodynia. The similarity in the distribution and characteristics of AWS in patients with vulvodynia and impaired vulvar skin suggests a potential connection between the two conditions and the progression or evolution of vulvodynia in the presence of impaired vulvar skin over time.},
     year = {2023}
    }
    

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  • TY  - JOUR
    T1  - Acetic Acid Test Performed by Vulvoscopy Had Revealed an "O Sign" in the Inner Vulvar Ring of Patients with Vulvodynia
    AU  - Vesna Harni
    AU  - Damir Babic
    AU  - Suzana Ljubojevic-Hadzavdic
    AU  - Dubravko Barisic
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    PY  - 2023
    N1  - https://doi.org/10.11648/j.jgo.20231103.12
    DO  - 10.11648/j.jgo.20231103.12
    T2  - Journal of Gynecology and Obstetrics
    JF  - Journal of Gynecology and Obstetrics
    JO  - Journal of Gynecology and Obstetrics
    SP  - 61
    EP  - 72
    PB  - Science Publishing Group
    SN  - 2376-7820
    UR  - https://doi.org/10.11648/j.jgo.20231103.12
    AB  - This study examined the distribution and characteristics of acetowhite staining (AWS) in three vulvar rings in women with chronic vulvar discomfort. AWS was monitored as a secondary outcome measure in the study DATRIV (Diagnostic Accuracy of Three Rings Vulvoscopy). The study included 328 consecutive participants, divided into four groups based on their medical history, results from the vulvodynia questionnaire designed by the International Society for the Study of Vulvovaginal Disease, and clinical examination. Asymptomatic participants were classified into a normal vulva group (N = 82) and an impaired vulvar skin group (N = 82). Patients with chronic vulvar discomfort were divided into primary vulvar distress/vulvodynia (N = 82) and secondary discomfort caused by vulvar dermatosis (N = 82). The clinical data collected from the three rings vulvoscopy (TRIV) were analyzed using statistical software such as StatSoft (Dell, Austin, TX, USA), Statistica 12 (TIBCO®, Palo Alto, CA, USA), and SPSS 20 (IBM, Armonk, NY, USA). The study was conducted with the approval of the Institutional Review Board of Polyclinic Harni, and all participants provided written informed consent. The study's findings support the notion that AWS patterns can vary across different histological areas of the vulva and can indicate specific conditions. The higher incidence of AWS in the outer vulvar ring among patients with vulvar dermatosis (45.1%) suggests a widespread involvement in this area. In contrast, the study found that patients with vulvodynia (96.3%) and impaired vulvar skin (78.0%) exhibited a higher AWS frequency and a distinct pattern called the "O sign" in the inner vulvar ring. AWS in the middle vulvar ring was observed in all participants. However, there were noticeable differences between patients with vulvodynia and vulvar dermatosis, highlighting the potential diagnostic value of AWS distribution in this area. The faster onset of AWS in patients with vulvodynia (mean 51.6 seconds), a significantly higher frequency of sharp demarcation of AWS (49.4%), nontransparent AWS (16%), the "O sign" (81.7%) and provoked erythema (11.1%) supports the role of a potential inflammatory component in this condition in response to AWS. This specific pattern suggests that AWS combined with the TRIV approach can enhance the clinical recognizability of vulvodynia. The similarity in the distribution and characteristics of AWS in patients with vulvodynia and impaired vulvar skin suggests a potential connection between the two conditions and the progression or evolution of vulvodynia in the presence of impaired vulvar skin over time.
    VL  - 11
    IS  - 3
    ER  - 

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Author Information
  • Department of Obstetrics and Gynaecology, Polyclinic Harni, Zagreb, Croatia

  • Department of Pathology and Cytology, University Hospital Center, Zagreb, Croatia

  • Department of Dermatovenereology, University Hospital Center, Zagreb, Croatia

  • Department of Obstetrics and Gynaecology, Kardinal Schwarzenberg Klinikum GmbH, Schwarzach im Pongau, Austria

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