Granuloma fissuratum of the posterior fourchette is hallmarked by recurrent splitting of the skin and severe pain with vaginal penetration during events such as intercourse, tampon insertion, and vaginal examination (Fig. 1). We believe this lesion is similar to one first described by Sutton1 in 1932, occurring at the labioalveolar fold, which he termed granuloma fissuratum plicae labio-alveolaris, or granuloma fissuratum for short. Others subsequently reported similar lesions occurring on the ear and nose.2–6 Although granuloma fissuratum of the posterior fourchette is not uncommon, there is scarce reference to this condition in the literature. Anecdotal evidence suggests that most gynecologists have encountered patients with granuloma fissuratum.
Barbero described dyspareunia and vulvar pain caused by a membranous hypertrophy of the posterior fourchette in 1994.7 Associated fissuring of the posterior fourchette was noted. Likewise, Barbero's clinical and histopathological description of nonspecific chronic inflammation is similar to the previous reports of granuloma fissuratum.1–7 Additional descriptions of vulvar lesions with a similar appearance to those we describe have been identified as vulvodynia secondary to posterior band with fissuring, or fissuring of the posterior vulva.8–10
The aim of this retrospective study was to describe the characteristics of women who experience chronic fissuring of the posterior fourchette and the outcome of the treatments.
SUBJECTS AND METHODS
Subjects for this nonrandomized retrospective chart review were patients with granuloma fissuratum evaluated by a single practitioner in a vulvar vaginal disease specialty clinic from January 1, 1995, through December 31, 2003, with follow-up abstracted to the last vulvar clinic visit before data abstraction on March 31, 2004. Multiple sources were used to identify the subjects diagnosed with granuloma fissuratum, including pathology records and operative lists (surgical patients), International Classification of Diseases-9th Revision codes, personal documents, and an ongoing chart review (patients who did not undergo surgical repair). The University of Iowa Institutional Review Board approved the study.
Data abstracted included age, use of hormones, parity, mode of delivery, history of candidiasis, codiagnoses, vulvar symptoms (including dyspareunia, pain, burning, and itching), treatment (medical versus surgical), and outcome (diagnoses and symptom scores). The Vulvar Disease Clinic uses a standardized assessment tool for each patient encounter to track patient symptoms and outcomes. Symptom scores for dyspareunia, pain, burning, and itching are graded on a Likert scale from 0 to 10 (0 = no pain, 10 = most severe pain). Diagnosis of granuloma fissuratum was made by the presence of a fissure noted at the posterior fourchette in conjuncture with the patient's description of repetitive fissuring of the posterior fourchette with attempted vaginal penetration. The time of granuloma fissuratum diagnosis and the coexisting symptoms were recorded for the first visit to the vulvar clinic where the diagnosis of granuloma fissuratum was noted in the chart. Symptoms from the first visit were compared with symptoms at the time of the final visit before completion of data abstraction on March 31, 2004.
Demographic characteristics of women with granuloma fissuratum were analyzed with t tests, χ2, or Fisher exact tests, as appropriate. The denominator was corrected to adjust for missing data, if needed, for each variable (that is, we did not impute missing data values). Vulvar symptom scores pre- and posttreatment were compared by using SAS 9.0 (SAS Institute Inc, Cary, NC) with the Wilcoxon signed rank test, with P = .05 considered significant.
Medical treatment varied depending on the vulvovaginal diagnoses. There were more than 10 concomitant vulvovaginal conditions identified on record review. All women were instructed to avoid contact irritants (including spermicides) and to resist self-treatment for perceived infections (ie, discontinue over-the-counter yeast treatments). Sitz baths and topical steroid ointments were frequently used as an initial measure to reduce inflammation associated with contact irritants. Surgery was offered only if treating all coexisting conditions medically resulted in insufficient improvement.
The method of surgical repair is detailed as follows:
- After administration of adequate anesthesia, the patient is placed in the dorsal lithotomy position using candy cane stirrups. An examination is performed, and tension is placed on the posterior fourchette to reproduce the fissure. The extent of the fissure must be realized for complete excision of the lesion, as noted in Figure 1.
- The skin is incised from the distal aspect of the hymen, ensuring a 1–2 mm margin beyond the fissure. The hymen is left intact unless the fissure extends into the hymen (Fig. 2).
- The lesion is then completely excised. The base of the fissure must be excised for optimal healing (Fig. 3).
- The distal vagina is then undermined to allow advancement and closure without tension (typically 2 cm). Hemostasis must be ensured at this point (we use electro-cautery and 4–0 Vicryl suture) (Fig. 4).
- The skin is approximated transversely, center-to-center, with 4–0 Vicryl to allow closure without tension (Figs. 5 and 6).
We identified 42 patients with granuloma fissuratum. Of those, 22 underwent perineoplasty and 20 were managed nonoperatively. A comparison of demographic characteristics by management (perineoplasty and nonoperative) is presented in Table 1.
The mean and median ages for the entire cohort at diagnosis of granuloma fissuratum were 44.5 and 42.5 years, respectively (range 26–78). Sixteen (38%) women were menopausal; of those 11 (69%) used systemic hormone therapy at the time of the initial granuloma fissuratum visit.
Thirty-two of 36 women (89%) reported being sexually active in terms of vaginal intercourse at the time of the first visit. Data about sexual activity were missing in the records of 6 women. Of the 32 sexually active women, 30 (94%) reported dyspareunia. The median duration of dyspareunia was 25 months (range 0–192 months). The 2 sexually active women without dyspareunia at the first visit presented with the chief complaint of pruritus and were treated nonoperatively: one for lichen sclerosis, the other for lichen planus. Both women had resolution of the granuloma fissuratum at the final visit.
Subjects who underwent perineoplasty had a longer duration of dyspareunia than those managed nonoperatively, with median durations of 41 and 17 months, respectively. Twenty-seven percent of women with dyspareunia noted this symptom for less than a 1-year duration.
Twenty-six percent (11 of 42) of the women were nulliparous, while 5 of the parous women delivered solely by cesarean delivery. Sixty-two percent (21 of 34) had a history of yeast infection (history of yeast infection was not recorded for 8 women).
At the initial evaluation within the Vulvar Vaginal Disease Clinic at our institution, most subjects were diagnosed with coexisting vulvovaginal conditions: 41 had 1, 40 had 2, and 26 had at least 3 coexisting diagnoses. The most frequent coexisting diagnoses were contact vulvitis (28 of 42) and yeast vulvovaginitis (19 of 42). Diagnoses and frequencies are noted in Table 2.
Patients who declined or were not offered perineoplasty had more coexisting vulvovaginal conditions than those who underwent perineoplasty. Following medical treatment alone, the fissure resolved in 13 (of 20) patients. This calls into question the etiology of the fissure in those 13 women. Treatment was aimed at the coexisting condition rather than targeting the fissure. Thus, patients with coexisting contact vulvitis or yeast vulvitis were treated for the contact vulvitis, with resolution of the fissure as well as the underlying dermatosis. In those 7 women in whom the fissure did not resolve, surgery was offered and declined by the patient (5), or the women continued to have symptom flares from a coexisting vulvovaginal condition, which precluded perineoplasty (2).
Overall, the fissure resolved in 13 of 20 women (65%) who were managed medically and in 21 of 22 women (95%) who underwent perineoplasty. The subject with the failed perineoplasty, as manifested by recurrent fissuring (and dyspareunia), had no codiagnoses at the final encounter. Her postoperative course was complicated by a small hematoma (1.5 cm). However, 6 of the 22 subjects who underwent perineoplasty were noted to have evidence of minor wound breakdown at the initial postoperative visit, which subsequently healed without incident. The fissure did not recur in the remaining patients who underwent perineoplasty during this time period. One patient underwent a previous office excision of the fissure, which failed (perineoplasty was performed and was successful).
At the final clinic visit, 14 women reported abstinence from sexual activity. The reason was generally not recorded in the medical record. As previously noted, in 6 women no information about sexual activity was recorded either before or after treatment. For the remaining 22 sexually active women, 13 had persistent dyspareunia. However, the median dyspareunia score for this cohort improved significantly, from 7.5 before treatment to 2.5 after treatment (P = .02) (data not shown). Among women that underwent perineoplasty, 11 were sexually active afterward; all had preoperative dyspareunia, and in 7 women (64%) this resolved after surgery. Among the 13 women managed nonsurgically who had resolution of the fissure, 7 were sexually active after treatment, and dyspareunia resolved in 2 (29%) of them. Although the fissure resolved in the majority of women, this was not accompanied by uniform relief of all vulvar symptoms, as noted in Table 3.
Of the 22 women who underwent perineoplasty, the median interval between the time of granuloma fissuratum diagnosis with us and surgery was 6.4 months. In those managed medically, the granuloma fissuratum resolved following treatment for the underlying dermatosis in 13 of 20 women. The median time of follow-up for the entire cohort was 10.5 months (range 0–84).
Histology revealed nonspecific chronic inflammation of the fissure for the majority of the subjects who underwent perineoplasty, including acanthosis, chronic inflammation, parakeratosis, and fibrosis. Additional findings were noted, which confirmed the codiagnoses noted during the evaluation (ie, lichen sclerosus and lichen planus). The women who were managed nonoperatively did not undergo a biopsy for evaluation of the fissure. Thus, there is no way to confirm fissure homogeneity between the treatment groups.
While the name “granuloma fissuratum” is, for the most part, a misnomer because the major histologic feature is not a granuloma, but rather epidermal hyperplasia with fibrosis and patchy chronic inflammatory cell infiltrate,3 the vulvar lesion we describe is both clinically and histologically similar to that of granuloma fissuratum initially reported occurring in the mouth, nose, and ears. Upon vulvar examination, a fissure is noted at the posterior fourchette. Histological findings of the lesions reveal a dense fibrous tissue with overlying stratified squamous epithelium and a chronic inflammatory infiltrate below the epithelium.
Subjects in Barbero's series7 differed from ours in that they were younger (mean 24.5 years), and all were nulliparous, with dyspareunia for longer than 1 year. Like Barbero, we found that a significant number of women with granuloma fissuratum report a history of yeast infection.
Most women had coexisting vulvar diagnoses, as has been noted in a previous review of vulvovaginal disorders.8 Thus, care must be taken to fully evaluate each patient's symptoms to make accurate diagnoses and to provide optimal care.
Median dyspareunia scores were significantly improved following treatment of the entire cohort, and dyspareunia was completely resolved in two thirds of sexually active women after perineorrhaphy. However, subjects endorsed no significant difference in score or presence of the other vulvar symptoms. Therefore, women should be counseled that management of the fissure may improve some, but not all, symptoms.
One of the subjects who underwent successful perineoplasty noted a previous unsuccessful office repair attempt. We have found that successful repair requires adequate excision (to include the full extent of the fissure, with undermining and mobilization of the distal vagina and reapproximation of healthy tissue), which is difficult to accomplish under local anesthesia in the office setting. Likewise, Woodruff and Friedrich11 have also described the repair of vulvar stricture or fissure related to other dermatoses and note that repair in the office under local anesthesia does not provide adequate relief. Others also describe excision and mobilization under general anesthesia to improve entry dyspareunia.7,10
One woman has persistent granuloma fissuratum following primary perineoplasty. Her postoperative course was complicated by a small hematoma and wound breakdown. However, 5 other subjects had similar wound breakdown and all subsequently healed without recurrent fissuring to date. Thus, the reason for persistent granuloma fissuratum after surgery is unclear.
Despite the paucity of literature regarding recurrent fissuring of the posterior fourchette, many gynecologists have encountered this problem. Although fissuring is common with some vulvar dermatoses such as lichen sclerosus and contact vulvitis and may resolve with the appropriate medical management, fissuring may also occur as a primary finding that may require perineoplasty in those patients who do not respond to medical therapy. Further research is needed to compare treatments and to improve other outcomes related to this condition.