DOI: 10.12809/hkmj154536
PICTORIAL MEDICINE
Use of colposcopy in a patient with recurrent genital ulcers
Tomoko Matsuzono, MRCOG, FHKAM (Obstetrics and Gynaecology); WH Li, FHKCOG, FHKAM (Obstetrics and Gynaecology)
Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Jordan, Hong Kong
Corresponding author: Dr Tomoko Matsuzono (tomoko821@gmail.com)
 
 Full paper in PDF
 
Case
The patient was a 40-year-old female with a 5-month history of recurrent painful labial ulcers in December 2013. Investigations by a private physician revealed a negative VDRL (Venereal Disease Research Laboratory) test and vulval swab culture grew commensals only. The ulcers, however, failed to heal following treatment with antibiotics.
 
Vulval biopsy was performed at her first visit and histopathology report revealed only a non-specific ulcer with negative stains for fungus, bacteria, acid-fast bacilli, and herpes simplex virus. Papanicolaou smear showed atypical squamous cells of unknown significance (ASCUS).
 
In the absence of any obvious pathology for the non-healing ulcer, colposcopy was arranged: four ulcers were identified within the vagina, scattered over the right and left vaginal walls (Fig 1). A left lower vulval ulcer measuring 3 cm with slightly raised edges was also seen (Fig 2). Biopsies were taken over the cervix, vaginal, and vulval ulcers. Histopathology of these biopsies confirmed the presence of cervicitis and ulcers, with no evidence of malignancy.
 

Figure 1. An ulcer over (a) the right vaginal fornix and (b) the left vaginal wall
 

Figure 2. A 3-cm left lower vulval aphthous ulcer over the labia majora with well-demarcated border, and slightly raised edges; the surrounding skin is mildly erythematous and indurated
 
Upon systemic review, the patient revealed that she had been suffering from recurrent mouth ulcers and bruising over both shins. Subsequent examination revealed multiple aphthous mouth ulcers, as well as erythema nodosum over both shins.
 
Based on the clinical signs, a diagnosis of Behçet’s disease was made. The patient was commenced on prednisolone, and all ulcers had healed at subsequent follow-up.
 
Discussion
Behçet’s disease is a rare cause of genital ulceration. It is a multisystem vasculitic disorder and the diagnosis is based on clinical criteria.1 2 3 4 Our patient fulfilled the criteria of recurrent oral and genital ulcerations as well as a cutaneous manifestation.
 
Although there is little published evidence to support the value of colposcopy and biopsy in the diagnosis of Behçet’s disease, colposcopy enables a more detailed evaluation of the genital tract, and can be used to exclude the possibility of malignancy. Histopathological results in Behçet’s ulcer are typically non-specific with chronic active inflammation.
 
Papanicolaou smear in our patient showed ASCUS, but histopathology result for the cervix was normal. In a prospective study by Özdemir et al,2 abnormal cervical cytology, acetowhite epithelium, and iodine-negative epithelium on colposcopy were more common in Behçet’s patients. Nonetheless, the majority of ASCUS results revealed a normal finding for cervical histopathology. It was suggested that this was due to the benign inflammatory changes in the cervical epithelium.2
 
As in this case, diagnosis for recurrent genital ulcers can be difficult although when information about oral ulcers became available, a diagnosis of Behçet’s became more obvious. A complete history and physical examination that pays particular attention to signs or symptoms of an underlying associated systemic condition are essential when evaluating patients with recurrent genital ulcers.
 
References
1. Patel S, Prime K. Recurrent vulval ulceration: could it be Behçet’s disease? Int J STD AIDS 2012;23:683-4. CrossRef
2. Özdemir S, Özdemir M, Celik C, Balevi A, Toy H, Kamış U. Evaluation of patients with Behçet’s disease by cervical cytology and colposcopic examination. Arch Gynecol Obstet 2012;285:1363-8. CrossRef
3. Keogan MT. Clinical Immunology Review Series: an approach to the patient with recurrent orogenital ulceration, including Behçet’s syndrome. Clin Exp Immunol 2009;156:1-11. CrossRef
4. Bandow GD. Diagnosis and management of vulvar ulcers. Dermatol Clin 2010;28:753-63. CrossRef