Monomorphic Papillae on Inner Labia and Vulvar Vestibule.

A 26-year-old female patient had noticed “small growths” on vulva since 1 year of her marriage. She had also experienced burning sensation, irritation, and pain in vulva on many occasions over the past 1 year. She was anxious and depressed because these symptoms interfered with her work and sexual activity. Her husband likened the appearance of her vulval lesions to a “broccoli.” She was in a monogamous relationship and with no history of sexual contacts. Examination revealed multiple, small, uniformly arranged, soft, smooth-surfaced, monomorphic papillae covering the inner aspect of labia minora and the vestibule [Figure 1a and b]. Color of the lesions was the same as that of adjacent mucosa. Lesions were tender. On vulval biopsy, we could see finger-like protrusions of loosely arranged subdermal tissue covered with normal mucosal epithelium [Figure 2]. No atypical koilocytes were identified. Polymerase chain reaction (PCR) for human papillomavirus (HPV) DNA was negative.

Figure 1

Uniformly arranged papillae in clusters on inner labia and vulval vestibule

Figure 2

Finger-like projections of loosely arranged subdermal tissue covered with normal mucosal epithelium (H and E, ×20)

Question

What is your diagnosis?

Answer

Diagnosis – Vulvar vestibular papillomatosis (VP) with vulvar vestibulitis syndrome (VVS).

Discussion

VP is considered a normal flexibility in topography and morphology of the vulvar epithelium. Prevalence reported in various studies has ranged between 1% and 33%.[123] In the past, papillary projections of the inner labia have been overdiagnosed as due to HPV infection. Careful identification of clinical parameters of VP – clusters of pink, soft, uniformly arranged tubular papillae on inner labia, hymen, or periurethral area with round tips, separate bases, and lack of circumscribed whitening on 5% acetic acid application – is diagnostic.[4] On the other hand, genital warts are skin-colored or pigmented, randomly arranged, firm, acuminate papules – individual papillary projections fuse at the base – with prominent whitening on 5% acetic acid application.[4] VP being distinct from genital warts has also been well established by PCR and in situ hybridization studies.

VP is asymptomatic in majority of affected females; however, vulvar pruritus, pain or burning, and dyspareunia may accompany in some patients.[5] Coexisting, VVS has also been reported – defined as severe pain on vestibular touch or vaginal entry, tenderness located within the vulvar vestibule.[6] The feeling of irritation and burning can persist for hours or days following sexual activity, engendering a sense of hopelessness and depression in the patient.[6]

A female with VP may be referred to a dermatologist for treatment of suspected genital warts. Therefore, it is imperative that dermatologists are familiar with this condition to avoid unnecessary treatment. However, there has been a scarcity of literature about this rare entity in Indian dermatological scenario; this is only the third case reported after Wollina and Verma[2] and Mehta et al.,[7] highlighting an apparent disregard for this potentially misdiagnosed entity.

Learning points

VP is a normal anatomic variation of vulvar mucosa

Careful identification of clinical appearance – smooth, soft, uniform-sized, small, monomorphic papules on inner labia and vestibule – is diagnostic of VP, further aided by acetowhitening test

It can be an added source of anxiety for a patient with coexisting pain, burning sensation, and VVS

A firm understanding about this condition spares the patient from any unnecessary investigation and treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.