Interpretation of Nondiagnostic Vulvar Biopsies

The aim of the study was to assess clinical and histopathologic characteristics of symptomatic women who underwent a nondiagnostic biopsy of the inner vulva.

Consecutive nondiagnostic biopsies from medial labia minora, posterior fourchette, and vestibule obtained from symptomatic women between 2011 and 2015 were reviewed for this retrospective histopathologic case series. Histopathologic assessment included site, basal layer appearance, lymphocytic infiltrate, and presence of fibrosis or sclerosis. Examination findings, treatment, initial impression, and final clinical diagnosis were recorded. Descriptive statistics were performed; clinical and histopathologic characteristics were compared with Fisher exact test.

There were 85 cases; mean age was 53 years. Most women presented with painful erythema and underwent biopsy to confirm (30, 35%) or exclude (43, 51%) lichen planus. After clinical follow-up and histopathologic review, most cases had persistent diagnostic discordance. Final clinical diagnoses were available in 70 women: lichen planus in 27 (38%), vulvodynia in 15 (21%), and the other 28 (40%) had LS (8), plasma cell vulvitis (5), psoriasis (4), dermatitis (4), candidosis (3), estrogen deficiency (3), and aphthosis (1). Histopathologic review highlighted the difficulty in distinguishing mucosa-associated lymphoid tissue from an inflammatory infiltrate in 23 (27%) of cases. Compared with other sites, biopsies from the mucocutaneous junction were more likely to be associated with a positive culture for Candida albicans.

Nondiagnostic biopsies from the inner vulva should prompt thoughtful multidisciplinary review, but more research is required to resolve the problem of clinicopathologic discordance through better understanding of vulvar histology and pathophysiology.