This article describes the outcome of a behavioral approach with or without preceding surgical intervention in 48 women with the vulvar vestibulitis syndrome. In the first part of the study, 14 women with the vulvar vestibulitis syndrome were randomly assigned to one of two treatment programs: either a behavioral approach or a behavioral approach preceded by surgery. In the second part of the study, 34 women and their partners were given a choice of treatment. Follow-up data were gathered a mean of 3 and 2 1/2 years after treatment, respectively. In the randomized patient population, the intervention had a positive effect on all of them: the complaints disappeared, diminished or did not change but formed less of a problem. The difference in outcome between the two different treatments, a behavioral approach with or without preceding surgery, was not statistically significant. In the second non-randomized part of the study, 28 out of the 34 women (82%) chose the behavioral approach without preceding surgery. The difference in outcome between the two treatments was not statistically significant. Two out of the 28 women who chose behavioral treatment without preceding surgery had to be referred for psychiatric consultation because of serious psycho-sexual problems. In one woman, psychiatric treatment was successful. Three other women, whose behavioral treatment failed, underwent additional surgery, which clearly helped them to overcome the deadlock in the behavioral approach. The behavioral approach should be the first choice of treatment for the vulvar vestibulitis syndrome. Surgical intervention should be considered as an additional form of treatment in some cases with the vulvar vestibulitis syndrome to facilitate breaking the vicious circle of irritation, pelvic floor muscle hypertonia and sexual maladaptive behavior.
History. A 64-year-oId patient was referred to us with persistent abnormalities ofthe glans penis. In 1974 he had been circumcised for a longstanding phimosis with local fusion ofthe prepuce. After this operation, painful, itchy crusts and small fissures were reported to have developed on the glans penis. At the same time the external urethral orifice became stenosed necessitating dilatation. Different local treatments produced no improvement.Examination. Thick white-yellow adherent crusts and scales were seen on the glans penis. The skin had a dry, cracked appearance and some erythematous erosions were present. The general impression was that of an 'armour' surrounding the glans penis.Histology, (glans penis) The epidermis showed extensive areas of local hyperkeratosis and parakeratosis. The keratinocytes showed large hyperchromatic and polymorphic nuclei with mitoses. The dermis contained an infiltrate of lymphocytes, plasma cells and histiocytes.Therapy. Patient is currently being treated with 5-fiuorouracil cream.Comment. Pseudoepitheliomatous, keratotic and micaceous balanitis was first described by Lortat-Jacob and Civatte in I96i.''^ This skin affection occurs in males who have developed phimosis at a later age. After circumcision the typical clinical features develop. Histopathological FIGURE 1. l^seudoepkheiinmatous, keratotic and micaceous balanitis of Lortat-Jacob and Civatte.
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