Diagnostic Accuracy of Three Rings Vulvoscopy for Detection of Vulvar Dermatosis

The distribution of patients with and without vulvar dermatosis diagnosed by vulvoscopy (N-S-P Scheme) and histopathology. According to the specificity of lesions, vulvoscopy results were classified as normal N (absence of any lesion), suspect S (non-specific lesions) and pathologic P results (lesion specific to dermatosis); and each of the three vulvar rings is represented by a single result. The final vulvoscopy result is presented in the form of a three-letter formula, where the first letter indicates the vulvoscopy result in the Outer Vulvar Ring, the mean initial indicates the vulvoscopy result of the Middle Vulvar Ring and the last letter denotes the vulvoscopy result of the Inner Vulvar Ring. N-S-P Scheme divides the results of the vulvoscopy into three groups: Normal Vulvoscopy, Suspect Vulvoscopy and Pathological Vulvoscopy. Diagnosis of vulvar dermatosis was established if one or more vulvar rings showed pathological results (Pathological Vulvoscopy).

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Histopathology distinguishes two groups of patients with and without vulvar dermatosis. Therefore the accuracy of the N-S-P Scheme had been estimated according to these two groups of patients.

The table shows the distribution of patients with and without vulvar dermatosis diagnosed by Three Rings Vulvoscopy (TRIV) using the Vulvoscopy Index and histopathology as a reference test. The Vulvoscopy Index as an outcome measure of TRIV is designed as a quantitative test based on five characteristics: vulvar complaints, Marinoff index, Cotton-Swab test, vulvar lesions according to the three vulvar rings and specificity of lesions; with following results: Normal Vulva (0-2 points), Impaired Vulvar Skin (3-11 points), Vulvodynia (12-18 points), and Vulvar Dermatosis (19-32 points). Since histopathology distinguishes only patients with and without vulvar dermatosis, the clinical value the Vulvoscopy Index had been estimated according to these two groups of patients. Patients with vulvoscopy diagnoses: Normal Vulva, Impaired Vulvar Skin and Vulvodynia were classified into the group Absent Vulvar Dermatosis.

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Vulvar dermatosis was diagnosed in 82 patients by vulvoscopy and 72 patients by histopathology. Absent vulvar dermatosis was found in 246 patients by vulvoscopy and 256 patients by histopathology. The likelihood of vulvar dermatosis was higher as the value of the Vulvoscopy index was higher.

The table shows the distribution of patients with Absent Vulvar Dermatosis diagnosed by Three Rings Vulvoscopy (patients with vulvoscopical diagnoses Normal Vulva, Impaired Vulvar Skin and Vulvodynia) and histopathology, according to single categories of the Vulvoscopy Index. The five categories within the Vulvoscopy Index are: 1. Vulvar complaints (present vs. absent), 2. Marinoff index (positive vs. negative), 3. Cotton-Swab test (positive vs. negative), 4. Vulvar lesions according to the vulvar rings (Outer, Middle, and Inner Vulvar Ring Lesion) and 5. Specificity of lesions (Non-specific and Specific Lesions).

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Absent Vulvar Dermatosis was diagnosed in 246 patients by vulvoscopy and 256 patients by histopathology. The likelihood of absent vulvar dermatosis was higher as the value of the Vulvoscopy index was lower.

The table shows the distribution of patients with Vulvar Dermatosis diagnosed by Three Rings Vulvoscopy and histopathology according to single categories of the Vulvoscopy Index. We described five categories within the Vulvoscopy Index: 1. Vulvar complaints (present vs. absent), 2. Marinoff index (positive vs. negative), 3. Cotton-Swab test (positive vs. negative), 4. Vulvar lesions according to the vulvar rings (Outer, Middle, and Inner Vulvar Ring Lesion) and 5. Specificity of lesions (Non-specific and Specific Lesions).

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Vulvar dermatosis was diagnosed in 82 patients by vulvoscopy and 72 patients by histopathology. The likelihood of vulvar dermatosis was higher as the value of the Vulvoscopy index was higher.

The table shows the distribution of lesions according to their specificity and vulvar rings in patients without vulvar dermatosis diagnosed by vulvoscopy (TRIV) and histopathology, as a reference test. According to the N-S-P scheme, we have set the diagnoses: Normal result (no lesion), Suspect result (non-specific lesion in any of the vulvar rings), and Pathological result (specific for dermatosis in any of the vulvar rings). Since histopathology can distinguish only patients with and without dermatosis, the distribution was estimated according to these two groups of patients. Hence, patients with normal and suspect vulvoscopic results were classified into one group called Absent Vulvar Dermatosis.

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Absent Vulvar Dermatosis was diagnosed in 246 patients by vulvoscopy and 256 patients by histopathology. The likelihood of absent vulvar dermatosis was higher as none of the vulvar rings were assessed as P.

The table shows the distribution of vulvoscopy lesions in relation to the vulvar rings and their specificity according to the N-S-P Scheme, in patients with vulvar dermatosis diagnosed by vulvoscopy (TRIV) and histopathology. Vulvoscopy findings of each of the three vulvar rings: Outer (first letter in the formula), Middle (second letter), and Inner Vulvar Ring (third letter) were evaluated as normal N (absence of any lesions), suspect S (non-specific lesions), or pathological P (lesions specific for dermatosis). Normal vulvoscopy indicated the absence of any lesion in all three vulvar rings (N-N-N). Suspect vulvoscopy was used to mark findings of non-specific lesions (S-#\*-#; S-S-#; S-S-S; S-N-S etc.). Pathological vulvoscopy spelled out the finding of lesions specific for dermatosis in any of the three vulvar rings (P-#-#; P-P-; P-P-P; P-N-S etc.). * is the label for any of the three possibilities: N or S or P.

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Vulvar dermatosis was diagnosed in 82 patients by vulvoscopy and 72 patients by histopathology. The likelihood of vulvar dermatosis was higher as one or more of the vulvar rings were assessed as P.

The table shows the results of Three Rings Vulvoscopy (TRIV) by single categories of the Vulvoscopy Index (mean± SD) in patients with Absent Vulvar Dermatosis diagnosed by TRIV and histopathology. According to the Vulvoscopy Index, we have set the diagnoses: Normal Vulva (0-2 points), Impaired Vulvar Skin (3-11 points), Vulvodynia (12-18 points), and Vulvar Dermatosis (19-32 points). Since histopathology can distinguish only patients with and without vulvar dermatosis, the distribution was estimated according to these two groups of patients. Hence, patients with vulvoscopical diagnoses Normal Vulva, Impaired Vulvar Skin and Vulvodynia were classified into the one group called Absent Vulvar Dermatosis. The likelihood of the diagnosis of Absent Vulvar Dermatosis was higher as the value of the Vulvoscopy index was lower.

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Absent Vulvar Dermatosis was diagnosed in 246 patients by vulvoscopy and 256 patients by histopathology.

The table shows the results of Three Rings Vulvoscopy (TRIV) by single categories of the Vulvoscopy Index (mean ± SD) in patients with Vulvar Dermatosis diagnosed by TRIV and histopathology. The Vulvoscopy Index is based on five characteristics: 1. Vulvar complaints (negative=0; positive=4 points), 2. Marinoff index (negative=0; positive=3 points), 3. Cotton-Swab test (negative=0; positive=2 points), 4. Vulvar lesions according to the vulvar rings (Outer Vulvar Ring Lesions=4 points; Middle Vulvar Ring Lesions=2 points and Inner Vulvar Ring Lesions=1 point) and 5. Specificity of lesions (Non-Specific Lesions=2 points; Specific Lesions=14 points). According to the Vulvoscopy Index, we have set the diagnoses: Normal Vulva (0-2 points), Impaired Vulvar Skin (3-11 points), Vulvodynia (12-18 points), and Vulvar Dermatosis (19-32 points). The likelihood of the diagnosis of Vulvar Dermatosis was higher as the value of the Vulvoscopy index was higher.

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Vulvar dermatosis was diagnosed in 82 patients by vulvoscopy and 72 patients by histopathology. The likelihood of vulvar dermatosis was higher as the value of the Vulvoscopy index was higher.

The table shows the results of Three Rings Vulvoscopy (TRIV) by single categories of the Vulvoscopy Index (median ± SD) in patients with Absent Vulvar Dermatosis diagnosed by TRIV (patients with vulvoscopical diagnoses Normal Vulva, Impaired Vulvar Skin and Vulvodynia) and histopathology. According to the Vulvoscopy Index, we have set the diagnoses: Normal Vulva (0-2 points), Impaired Vulvar Skin (3-11 points), Vulvodynia (12-18 points), and Vulvar Dermatosis (19-32 points). The likelihood of the diagnosis of Absent Vulvar Dermatosis was higher as the value of the Vulvoscopy index was lower.

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Absent Vulvar Dermatosis was diagnosed in 246 patients by vulvoscopy and 256 patients by histopathology.

The table shows the results of Three Rings Vulvoscopy (TRIV) by single categories of the Vulvoscopy Index (median ± SD) in patients with Vulvar Dermatosis diagnosed by TRIV and histopathology. The Vulvoscopy Index is based on five characteristics: 1. Vulvar complaints (negative=0; positive=4 points), 2. Marinoff index (negative=0; positive=3 points), 3. Cotton-Swab test (negative=0; positive=2 points), 4. Vulvar lesions according to the vulvar rings (Outer Vulvar Ring Lesions=4 points; Middle Vulvar Ring Lesions=2 points and Inner Vulvar Ring Lesions=1 point) and 5. Specificity of lesions (Non-specific Lesions=2 points; Specific Lesions=14 points). According to the Vulvoscopy Index, we have set the diagnoses: Normal Vulva (0-2 points), Impaired Vulvar Skin (3-11 points), Vulvodynia (12-18 points), and Vulvar Dermatosis (19-32 points). The likelihood of the diagnosis of Vulvar Dermatosis was higher as the value of the Vulvoscopy index was higher.

Time frame: ISSVD Questionnaire and TRIV, up to 75 minutes for each participant.

Population: Vulvar dermatosis was diagnosed in 82 patients by vulvoscopy and 72 patients by histopathology.

The table shows the presence, the quality, and the distribution of the aceto-whitening reaction after 5% acetic acid application (Aceto-Whitening Test), in relation to the three vulvar rings. The OUTER Vulvar Ring includes vulvar skin, the MIDDLE Vulvar Ring encompasses the modified mucosa, and the INNER Vulvar Ring is presented with glicogenized mucosa. Acetic acid is thought to cause swelling of the epithelial tissue through reversible coagulation or precipitation of the nuclear proteins and cytokeratins. Areas of pre-/malignant lesions turn densely white and opaque immediately after application of acetic acid, due to the presence of large numbers of dysplastic cells in the superficial layers of the epithelium. The acetowhite appearance is not unique to pre-/malignancy; it is also seen in other conditions with increased nuclear protein. The acetowhite reaction varies in intensity, within and between patients.

Time frame: Aceto-Whitening Test, up to 10 minutes for each participant.

Population: The Aceto-Whitening test was performed in 328 patients, classified into four groups based on anamnestic data and clinical examination. Localization and type, as well as the velocity of the AWR, were mapped into the TRIV Form Data. Aceto-Whitening of all structures of the Inner Vulvar Ring was named Ring sign.

The relationship between sexual vulvar discomfort and sexual intercourse (provocation and aggravation) in patients with vulvar dermatosis and vulvodynia, as recommended in the ISSVD Questionnaire.

Time frame: ISSVD Questionnaire, up to 30 minutes for each participant.

Population: Provocation and aggravation of vulvar discomfort depending on sexual intercourse were evaluated anamnestically by the ISSVD Vulvodynia Pattern Questionnaire.

The table shows the relationship among worsening of vulvar discomfort by using tampons, cycling, wearing tight clothes, menstruation, and urination in patients with vulvar dermatosis and vulvodynia.

Time frame: ISSVD Questionnaire, up to 30 minutes for each participant.

Population: Worsening of vulvar discomfort by the using of tampons, cycling, wearing tight clothes, menstruation and urination in symptomatic patients were evaluated anamnestically by the ISSVD Vulvodynia Pattern Questionnaire.

The table shows the age in four groups of patients with and without vulvar discomfort.

Time frame: ISSVD Questionnaire, up to 30 minutes for each participant.

Population: Baseline characteristics were assessed by anamnestic data (ISSVD Vulvodynia Pattern Questionnaire) and clinical examination.

The table shows the body mass index (Mean ± SD) in four groups of patients with and without vulvar discomfort.

Time frame: ISSVD Questionnaire, up to 30 minutes for each participant.

Population: Baseline characteristics were assessed by anamnestic data (ISSVD Vulvodynia Pattern Questionnaire) and clinical examination.

The table shows the height in four groups of patients with and without vulvar discomfort.

Time frame: ISSVD Questionnaire, up to 30 minutes for each participant.

Population: Baseline characteristics were assessed by anamnestic data (ISSVD Vulvodynia Pattern Questionnaire) and clinical examination.

The table shows the weight in four groups of patients with and without vulvar discomfort.

Time frame: ISSVD Questionnaire, up to 30 minutes for each participant.

Population: Baseline characteristics were assessed by anamnestic data (ISSVD Vulvodynia Pattern Questionnaire) and clinical examination.

The table shows the results of Cotton-Swab Test in four groups of patients. Cotton-Swab Test or Q-Tip Testing is part of a multidisciplinary approach to the assessment of sexual pain, especially, vulvodynia or vestibulodynia, in women. ISSVD recommended the Cotton-Swab test for the differential diagnosis of vulvodynia. The test consists of using a cotton-swab to palpate multiple vulvar and vestibular site while recording the woman's pain. We performed Cotton-Swab Test by touching the vulva at 6 points (each vulvar ring), organized into locations based on a clock face and marked like the hours on the clock: 2h, 4h, 6h, 8h, 10h, and 12 h.

Time frame: Cotton Swab Test, up to 10 minutes for each participant.

Population: Cotton-Swab test was evaluated by clinical examination of the Inner Vulvar Ring (TRIV Data Form).

The table shows demographic data - age: more or less than 65 years, reproductive age, menopause, domicile country as a country of birth, the degree of education (more and less than 12 years), marital status, births, abortions, and using of contraception among four groups of patient.

Time frame: ISSVD Questionnaire, up to 30 minutes for each participant.

Population: We assesses demographic data by ISSVD Vulvodynia Pattern Questionnaire (anamnestic).

The table shows the distribution of aceto-whitening reaction (AWR) after 5% acetic acid application (AWR - aceto-whitening reaction) in relation to the structures of the Inner Vulvar Ring. The INNER Vulvar Ring is presented with the following structures: the clitoris, Hart's line, the urethral sulcus, the urethral meatus, hymenal remnants, Bartholin's gland opening, and the vestibule. Acetic acid is thought to cause swelling of the epithelial tissue through reversible coagulation or precipitation of the nuclear proteins and cytokeratins. Areas of pre-/malignant lesions turn densely white and opaque immediately after application of acetic acid, due to the presence of large numbers of dysplastic cells in the superficial layers of the epithelium. The acetowhite appearance is not unique to pre-/malignancy; it is also seen in other conditions with increased nuclear protein. The acetowhite reaction varies in intensity, within and between patients.

Time frame: Aceto-Whitening Test, up to 10 minutes for each participant.

Population: We performed the aceto-whitening test with 5% acetic acid application in 328 patients, classified into four groups based on anamnestic data and clinical examination. Localization and type, as well as the velocity of the AWR, were mapped into the TRIV Form Data. Aceto-Whitening of all structures of the Inner vulvar ring was named Ring sign.

The distribution of aceto-whitening occurrence after 5% acetic acid application (AWR - aceto-whitening reaction) in relation to the structures of the Middle Vulvar Ring. The MIDDLE vulvar ring encompasses the following structures: the anterior commissure with the prepuce of the clitoris, interlabial sulci, labia minora, and the posterior commissure.

Time frame: Aceto-Whitening Test, up to 10 minutes for each participant.

Population: We performed the aceto-whitening test with 5% acetic acid application in 328 patients, classified into four groups based on anamnestic data and clinical examination. Localization and type, as well as the velocity of the AWR, were mapped into the TRIV Form Data.

The table shows the distribution of aceto-whitening occurrence (AWR) after 5% acetic acid application in relation to the structures of the Outer Vulvar Ring. The OUTER Vulvar Ring is presented with the following structures: Mons Pubis, Labia Majora, and the Perineum. Acetic acid is thought to cause swelling of the epithelial tissue through reversible coagulation or precipitation of the nuclear proteins and cytokeratins. Areas of pre-/malignant lesions turn densely white and opaque immediately after application of acetic acid, due to the presence of large numbers of dysplastic cells in the superficial layers of the epithelium. The acetowhite appearance is not unique to pre-/malignancy; it is also seen in other conditions with increased nuclear protein. The acetowhite reaction varies in intensity, within and between patients.

Time frame: Aceto-Whitening Test, up to 10 minutes for each participant.

Population: We performed the aceto-whitening test with 5% acetic acid application in 328 patients, classified into four groups based on anamnestic data and clinical examination. Localization and type, as well as the velocity of the AWR, were mapped into the TRIV Form Data.

The table shows the distribution of non-specific and specific lesions of the vulva in relation to the individual structures of the Inner vulvar ring according to the Three Rings Vulvoscopy. The INNER vulvar ring includes clitoris, Hart's line, urethral sulcus, urethral meatus, hymenal remnants, Bartholin's gland opening, and the vestibule. Non-Specific Lesions include non-specific erythema, punctuations, papillae, paleness and smoothness, fissures or sores in the absence of infection and pre/malignancy in any part of the vulva. Specific Lesions comprise eczematous inflammation with thickened, excoriated skin within chronic lichen simplex; hypopigmented or white lesions, fusion or resorption of the labia minora and clitoral hood, loss of vulvar architecture and sclerotic changes in lichen sclerosis; white reticular pattern to extensive erosion with agglutination or resorption of the labia within lichen planus and psoriatic erythematous papules with silver, scaly plaques.

Time frame: Three Rings Vulvoscopy, up to 45 minutes for each participant.

Population: Three Rings Vulvoscopy was performed in 328 patients, classified into four groups based on anamnestic data and clinical examination. Localization and specificity of the lesions were mapped into the TRIV Form Data. Vulvar lesions in patients with vulvodynia were not relevant for the diagnosis of vulvodynia which was made by Friedrich's criteria.

The table shows the distribution of non-specific and specific lesions of the vulva in relation to the individual structures of the Middle vulvar ring according to the Three Rings Vulvoscopy. The MIDDLE vulvar ring includes the anterior commissure with the prepuce of the clitoris, interlabial sulci, labia minora, and the posterior commissure. Non-Specific Lesions include non-specific erythema, punctuations, papillae, paleness and smoothness, fissures or sores in the absence of infection and pre/malignancy in any part of the vulva. Specific Lesions comprise eczematous inflammation with thickened, excoriated skin within chronic lichen simplex; hypopigmented or white lesions, fusion or resorption of the labia minora and clitoral hood, loss of vulvar architecture and sclerotic changes in lichen sclerosis; white reticular pattern to extensive erosion with agglutination or resorption of the labia within lichen planus and psoriatic erythematous papules with silver, scaly plaques.

Time frame: Three Rings Vulvoscopy, up to 45 minutes for each participant.

Population: Three Rings Vulvoscopy was performed in 328 patients, classified into four groups based on anamnestic data and clinical examination. Localization and specificity of the lesions were mapped into the TRIV Form Data. Vulvar lesions in patients with vulvodynia were not relevant for the diagnosis of vulvodynia which was made by Friedrich's criteria.

The table shows the distribution of the non-specific and specific lesions of the vulva according to individual structures of the Outer Vulvar Ring according to the TRIV. The OUTER Vulvar Ring includes vulvar skin with the following structures: mons pubis, labia majora, and the perineum. Non-Specific Lesions include non-specific erythema, punctuations, papillae, paleness and smoothness, fissures or sores in the absence of infection and pre/malignancy in any part of the vulva. Specific Lesions (lesions specific for vulvar dermatosis) comprise eczematous inflammation with thickened, excoriated skin within chronic lichen simplex; hypopigmented or white lesions, fusion or resorption of the labia minora and clitoral hood, loss of vulvar architecture and sclerotic changes in lichen sclerosis; white reticular pattern to extensive erosion with agglutination or resorption of the labia within lichen planus and psoriatic erythematous papules with silver, scaly plaques.

Time frame: Three Rings Vulvoscopy, up to 45 minutes for each participant.

Population: Three Rings Vulvoscopy was performed in 328 patients, classified into four groups based on anamnestic data and clinical examination. Localization and specificity of the lesions were mapped into the TRIV Form Data. Vulvar lesions in patients with vulvodynia were not relevant for the diagnosis of vulvodynia which was made by Friedrich's criteria.

The table shows the distribution of non-specific and specific vulvar lesions in relation to the three vulvar rings (TRIV). The OUTER Vulvar Ring includes vulvar skin, the MIDDLE Vulvar Ring encompasses the modified mucosa, and the INNER Vulvar Ring is presented with glicogenized mucosa. Non-Specific Lesions include non-specific erythema, punctuations, papillae, paleness and smoothness, fissures or sores in the absence of infection and pre/malignancy in any part of the vulva. Specific Lesions comprise eczematous inflammation with thickened, excoriated skin within chronic lichen simplex; hypopigmented or white lesions, fusion or resorption of the labia minora and clitoral hood, loss of vulvar architecture and sclerotic changes in lichen sclerosis; white reticular pattern to extensive erosion with agglutination or resorption of the labia within lichen planus and psoriatic erythematous papules with silver, scaly plaques.

Time frame: Three Rings Vulvoscopy, up to 45 minutes for each participant.

Population: Three Rings Vulvoscopy was performed in 328 patients, classified into four groups based on anamnestic data and clinical examination. Localization and specificity of the lesions were mapped into the TRIV Form Data. Vulvar lesions in patients with vulvodynia were not relevant to the diagnosis of vulvodynia which was made by Friedrich's criteria.

The table shows the degree of dyspareunia in sexually active patients with and without vulvar discomfort. We used Marinoff Index as a measure of the degree of dyspareunia. Negative Marinoff Index (0) is a sign of the absence of dyspareunia. Four grades of Marionoff Index are: Marinoff Index 0 = no dyspareunia; Marinoff Index 1= discomfort/pain with intercourse that doesn't interfere with the frequency of sex; Marinoff Index 2= pain with intercourse which sometimes prevents intercourse and Marinoff Index 3= pain with intercourse preventing any intercourse.

Time frame: ISSVD Questionnaire, up to 30 minutes for each participant.

Population: Dyspareunia and Marinoff Index were evaluated anamnestically by the ISSVD Vulvodynia Pattern Questionnaire. We assessed the degree of dyspareunia only in sexually active patients.

The table shows the distribution of histopathological findings of vulvar epidermis among patients with and without vulvar discomfort, classified into four groups based on anamnestic data, clinical examination and Three Rings Vulvoscopy. Histopathological characteristics of vulvar epidermis included hyperkeratosis, parakeratosis, acanthosis, and epidermal atrophy. In the vulvar dermis, there were evaluated presence of inflammatory infiltrates (monocytes, lymphocytes, mastocytes), collagen fibers, hyalinization, hyperpigmentation, elongated dermal papillae, blood vessels, sebaceous glands, and nerve fibers.

Time frame: Histopathological Examination, up to 30 minutes for each vulvar sample.

Population: We performed a biopsy of the vulva in 164 symptomatic patients during the routine clinical care to histopathologically confirm or exclude a skin disorder. Vulvar specimens from 164 asymptomatic patients were granted from the women undergoing planned labiaplasty.