Table Of Content3608_title 7/6/06 9:52 AM Page 1
The Vulva
Anatomy, Physiology,
and Pathology
Edited by
Miranda A. Farage
The Procter & Gamble Company
Cincinnati, Ohio, U.S.A.
Howard I. Maibach
University of California School of Medicine
San Francisco, California, U.S.A.
New York London
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© 2006 by Informa Healthcare USA, Inc.
Informa Healthcare is an Informa business
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Printed in the United States of America on acid-free paper
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International Standard Book Number-10: 0-8493-3608-2 (Hardcover)
International Standard Book Number-13: 978-0-8493-3608-9 (Hardcover)
This book contains information obtained from authentic and highly regarded sources. Reprinted
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Library of Congress Cataloging-in-Publication Data
The vulva : anatomy, physiology, and pathology / edited by Miranda A. Farage,
Howard I. Maibach.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8493-3608-9 (hardcover : alk. paper)
ISBN-10: 0-8493-3608-2 (hardcover : alk. paper)
1. Vulva--Diseases. 2. Vulva--Pathophysiology. 3. Vulva--Anatomy. I. Farage,
Miranda A. II. Maibach, Howard I.
[DNLM: 1. Vulva. 2. Vulvar Diseases. WP 200 V9913 2006]
RG261.V86 2006
618.1’6--dc22
2006044473
Visit the Informa Web site at
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3608_Discl.indd 1 7/6/06 11:27:52 AM
To my adored Mother and Father: your countless sacrifices have formed my
world and given me the gift of purpose and strength of will to succeed.
Wherever you are, I am nourished and guided by your never-ending love.
M.A.F.
Foreword
This is a much needed book for the patient with vulvovaginal symptomatology
too often faces the prospect of an incomplete evaluation and misdirected thera-
pies. There are many reasons for this. Physicians with practice time constraints
magnified by an office full of waiting patients too often begin their physical
examination with the introduction of the vaginal speculum, bypassing the
vulva. In addition, the record of diagnostic accuracy of vaginal infections by
physicians shows a high error rate and inaccurate diagnoses lead to inappropriate
therapeutic interventions, which only prolong and sometimes intensify patient’s
symptomatology. Finally, to a large extent, the care of patients with vulvovaginal
problems requires dermatologic insights that are too often lacking for many
practitioners.
The editors of this book, Miranda A. Farage and Howard I. Maibach,
attempt to address these shortcomings and I applaud their efforts. They have
selected experts who have both the knowledge and the ability to organize
their prose that captures reader attention and accomplishes reader understanding.
The underlying philosophy of this book is to provide an in-depth expose´ of the
anatomy and physiology: a basis for the understanding of the pathophysiology
and one that sets a goal to achieve with appropriate therapy. This is followed
by an exposition of the myriad presentations of patients with vulvovaginal
disease, and current scientifically accepted treatment regimens. There is
an excellent analysis of the menstrual cycle and the range of health care
products that are now available to women. Since medicine is not practiced
in a vacuum, the influences of race and societal norms on women are
provided in detail. Finally, there is a fascinating section that provides an
in-depth review of newer investigational techniques that will influence the
future care of women.
This is a book for all readers. For me, it is a cover-to-cover joy to read. For
others, it will be a valuable office reference to be opened every day to address
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vi Foreword
problems of individual patient care. My congratulations to both the editors
and the authors. Obviously, it is a labor of love that hits the mark.
William J. Ledger, M.D.
Professor and Chairman Emeritus
Department of Obstetrics and Gynecology
New York Presbyterian Hospital-Cornell Medical Center
New York, New York, U.S.A.
Preface
Few books are devoted exclusively to the vulva. The assumption that vulva
skin is like the skin of external body surfaces is wrong. Vulvar tissue has
many unique physiological properties and characteristics that differentiate it
from the skin and tissue of other body sites. Researchers studying the vulva
and clinicians treating patients with vulvar conditions know that there is a
paucity of information about the vulva in the medical literature. Consequently,
the unique physiology of the vulva, its normal and diseased states, pertinent
cultural and hygiene practices that affect vulvar health, and the direction of
current investigative research are not widely recognized. This insufficient body
of information is responsible for the existing deficiencies in knowledge of
the vulva, education and training of physicians about vulvar conditions, and
appropriate diagnosis and treatment of vulvar pathology.
We attempt to redress these deficiencies with this new volume, The Vulva,
a compilation of up-to-date clinical and research information collected in one
comprehensive work. The Vulva was written primarily for medical and scientific
audiences to underscore unique aspects of vulvar physiology, to highlight
possible ethnic differences, to review vulvar diseases, to alert researchers and
clinicians to cultural and hygiene practices that affect vulvar health, and to
share the latest techniques in investigative research on vulvar tissue. The Vulva
includes chapters on vulvar anatomy, physiology, microbiology, age-related
changes, ethnicity, diseases, global cultural and hygiene practices, personal
products used on the vulva, and toxicological and bioengineering research
methods applied to vulvar research.
The information included in this book presents the current knowledge and
understanding of vulvology. Although this work attempts to be a comprehensive
and up-to-date resource, we acknowledge that research on the vulva lags behind
other fields. Researchers and clinicians who have contributed to this volume hope
to promote a better understanding of the unique physiology of the vulva and to
encourage needed research.
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viii Preface
This book is intended to increase awareness of the unique health concerns
of the vulva and to be a valuable resource on the vulva region for the medical
and scientific communities.
ACKNOWLEDGMENTS
Many appreciations and thanks are gratefully owed to the many people
who contributed knowingly and indirectly to this book.
The following readers generously offered their time and expertise to
peer-review relevant chapters: Drs. Kenneth W. Miller, Bruce E. Jones, Mr.
John Blevins, Ms. Lisa Lennon, Drs. Tom Osborn, Brian Gray, Ray Warren,
Mr. Ron Visscher and Mr. Kevin Johnson. In addition, Ms. Jan Tremaine, Drs.
D. A. Hutchins, and T. L. Nusair have assisted with the review of this book.
Their collective recommendations have vastly improved the texts assembled
here. Many thanks go to the efforts and help of all the contributors of this book.
This book represents the fruits of a jointly conceived and executed
venture and has benefited from partners. Many thanks and appreciations go to
Drs. Sharon Mitchell and Bruce E. Jones who encouraged and supported the
idea for this book from the start. My thanks go to Ms. Lisa Lennon for her
help and support of this book. No praise is excessive for her efforts for which
she has my heartfelt gratitude. My deepest and most sincere debt is owed to an
exceptional person who shepherded the book from start to finish, Dr. Kenneth
W. Miller without whose belief, support, help, encouragement, guidance and
understanding, this book would not have seen the light of day.
Above all, my everlasting gratitude, thanks and love go to my family,
husband and children who supported, helped and encouraged me all the way
with their incredible patience. Your continuous care, unconditional love and
sacrifice made all this possible, and easier to achieve.
Miranda A. Farage
Howard I. Maibach
Contents
Foreword William J. Ledger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
PART I. ANATOMY AND PHYSIOLOGY
1. Anatomy of the Vulva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Aikaterini Deliveliotou and George Creatsas
Introduction . . . . 1
Embryology of Vulva . . . . 1
Anatomy of the Vulva . . . . 2
Conclusion . . . . 7
References . . . . 7
2. Tissue Structure and Physiology of the Vulva . . . . . . . . . . . . . . . . . 9
Miranda A. Farage and Howard I. Maibach
Introduction . . . . 9
Variations in Epithelial Structure . . . . 12
Blood Flow and Innervation . . . . 14
Hormonal Responsiveness . . . . 16
Immune Cell Populations . . . . 16
Tissue Hydration and Barrier Function . . . . 17
Permeability . . . . 18
Skin Irritation . . . . 19
Microbiology . . . . 20
Conclusion . . . . 22
References . . . . 22
ix
