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Gynaecology > 12. Vulvo- Vaginal Disease > Flashcards

12. Vulvo- Vaginal Disease Flashcards

1
Q

Why do women commonly seek gynaecological care related to vaginal discharge?

A

Vaginal discharge is one of the most frequent reasons for women to seek gynaecological care, often due to infections or other causes.

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2
Q

What are some common organisms involved in vaginal discharge?

A

Common organisms include
- Trichomonas vaginalis,
- Candida albicans,
- Gardnerella vaginalis, -
- and other anaerobic bacteria.

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3
Q

Can vaginal discharge always be attributed to infections?

A

No, some women may have vaginal discharge for reasons unrelated to infections. Normal or physiological discharge is typically non-offensive, white in color, viscous, and acidic.

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4
Q

What other conditions may result in excessive vaginal discharge?

A

Conditions include:
- Foreign bodies (e.g., tampons)
- Allergic reactions (e.g., latex condom allergy)
- Oestrogen-containing contraceptives (e.g., combined oral contraceptives)
- Malignancies (e.g., cervical or endometrial carcinoma)

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5
Q

How is vaginal discharge managed?

A

Management depends on the underlying cause of the discharge, with treatment targeting the specific condition.

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6
Q

What causes bacterial vaginosis (BV)?

A

BV arises due to the absence of Lactobacilli, which normally keep the vagina acidic by converting glycogen to lactic acid. This reduction in acidity allows for the overgrowth of anaerobic bacteria.

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7
Q

Which common anaerobes are involved in bacterial vaginosis?

A

Common anaerobes include:
- Gardnerella vaginalis
- Bacteroides spp
- Mobilincus spp
- Mycoplasma hominis

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8
Q

How is bacterial vaginosis diagnosed?

A

The diagnosis is made using the Amsel criteria, which include:
1. Vaginal pH > 4.5
2. Release of a fishy smell upon addition of 10% KOH (Positive Whiff test)
3. Characteristic greyish discharge
4. Presence of clue cells on microscopy

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9
Q

What is the treatment for bacterial vaginosis?

A

Treatment options include:

Metronidazole 400mg, 8 hourly for 7 days, or a 2g stat dose.

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10
Q

What risks are associated with bacterial vaginosis?

A

Women with BV are at an increased risk of second-trimester miscarriages and preterm delivery.

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11
Q

What are the symptoms of trichomoniasis?

A

Trichomoniasis causes vulvo-vaginitis that may present with severe symptoms, including:
- Purulent, frothy, greenish-yellow, offensive vaginal discharge
- Itching and burning sensation
- Classically, a “strawberry-like” appearance of the cervix

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12
Q

How is trichomoniasis diagnosed?

A

Microscopy: Vaginal secretions mixed with normal saline can detect about 60% of the microorganisms.

Culture: Although culture is the gold standard for diagnosis, it is usually not required as the diagnosis can often be made clinically.

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13
Q

What is the treatment for trichomoniasis?

A

Metronidazole 2g stat, or

Metronidazole 400mg, 8 hourly for 7 days.

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14
Q

What are the symptoms of candidiasis?

A

Classic symptom: Severe vaginal itch

Vaginal discharge: White, resembling curdles of milk

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15
Q

How is candidiasis diagnosed?

A

Microscopy: 10% KOH wet smear to confirm the presence of yeasts and hyphae.

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16
Q

What are the predisposing factors for candidiasis?

A
  • Immune suppression states: pregnancy, diabetes, HIV/AIDS
  • Use of long-term steroids
  • May follow antibiotic treatment due to alteration of vaginal flora
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17
Q

What is the treatment for candidiasis?

A

Uncomplicated cases: Single dose of vaginal clotrimazole 500mg

General advice: Shower instead of bathing, avoid tight clothing, wear cotton underwear, etc.

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18
Q

What should be done for patients with repeated attacks of candidiasis?

A

Search for predisposing causes: diabetes, use of COC, HIV

Prophylactic antifungals:
- Fluconazole 150mg orally, or
- Treat during attacks

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19
Q

What are the common causes of vulval pruritus?

A

Infections:
- Fungal: Candida, Tinea cruris
- Protozoal: Trichomonas
- Parasitic: Scabies, threadworm
- Viral: HPV/Warts

Skin disorders:
- Allergic or irritant dermatitis
- Psoriasis
- Lichen sclerosus
- Squamous cell hyperplasia

Atrophy: Especially in post-menopausal women

Pre-malignant conditions: Vulval intraepithelial neoplasia (VIN)

Malignancies:
- Squamous carcinoma
- Melanoma

Miscellaneous:
- Trauma (scratching –
- Lichen simplex chronicus)
- Foreign body
- Psychological

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20
Q

What is the approach to managing vulval pruritus?

A

Detailed history:

  • Duration of symptoms
  • Associated symptoms such as discharge and pain
  • What treatments have been used, including home remedies
  • Use of lotions, soaps, bath salts etc
  • Are symptoms stress-related?
  • Any systemic illnesses eg: HIV, diabetes, renal transplant, auto-immune diseases

Examination:

Good light, do a thorough systematic examination of the genitalia and the peri-anal area

Investigations:

It is of utmost importance when a vulval lesion is present that the area should be biopsied to make the correct diagnosis, as naked eye diagnosis is very difficult.

Pigmented lesions, persistently eroded lesions or indurated areas should be particular cause for concern.
Biopsies should be taken from the edge of ulcerated or abnormal areas and include some normal skin.

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21
Q

What are the treatment options for vulval pruritus?

A

Strict hygiene:
- Avoid scented products

Low threshold for biopsies

Treatment based on cause: Address underlying cause (e.g., infection, dermatitis, malignancy)

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22
Q

What should be kept in mind regarding the diagnosis of vulval candidiasis in post-menopausal women?

A

Be cautious of diagnosing vulval candidiasis unless the woman is diabetic or on HRT.

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23
Q

What is Lichen Sclerosus (LS)?

A

LS is a chronic inflammatory dermatosis with an unknown aetiology, possibly of autoimmune origin. It causes severe vulval pruritus and dyspareunia and can affect women of all ages, though it is most common in post-menopausal women and prepubertal girls.

24
Q

What are the classic characteristics of Lichen Sclerosus lesions?

A

The classic lesion is ivory-white and atrophic, with a “figure of 8” distribution involving the vulval and perianal skin. The underlying inflammation causes fibrosis and sclerosis, leading to anatomical resorption of the vulva, introital stenosis, and dyspareunia.

25
Q

What are the potential complications of Lichen Sclerosus?

A
  • Introital stenosis
  • Inability to pass urine
  • Dyspareunia
  • Risk of malignant transformation (about 4%), which is higher if associated with differentiated (non-HPV-related) Vulvar Intraepithelial Neoplasia (VIN)
26
Q

How is Lichen Sclerosus treated?

A
  • Potent topical steroids, such as Clobetasol (Dermovate)
  • Topical emollients and moderately-potent steroids for maintenance therapy
  • Glycerine during intercourse for vaginal dryness and dyspareunia
  • Surgery for introital stenosis (historically used)
  • Experimental treatment: Injection of adipose-derived stem cells to regenerate vulval skin
27
Q

What is the prognosis for patients with Lichen Sclerosus?

A

The condition can be treated but rarely cured. Regular follow-up by a vulval disease specialist is essential for early detection of any suspicious areas.

28
Q

What is the role of surgery in treating Lichen Sclerosus?

A

Surgery was historically used to release introital stenosis but is less common now with experimental treatments involving stem cell injections.

29
Q

What is Vulval Intraepithelial Neoplasia (VIN)?

A

VIN refers to the presence of abnormal or dysplastic cells in the vulval epithelium. It has two main types:

  • High-grade squamous intra-epithelial lesion (HSIL) of the vulva, associated with HPV infection (types 16 and 18).
  • Differentiated type, not associated with HPV.
30
Q

What is the difference between High-grade squamous intra-epithelial lesion (HSIL) and Differentiated VIN?

A

HSIL: Associated with HPV infection, seen in younger women, linked to HIV, smoking, and multiple anogenital site lesions. Can persist for long periods before progressing to squamous carcinoma

Differentiated VIN: Seen in older patients, not associated with HPV, lesions are more unifocal, and may arise near areas of Lichen Sclerosus.

31
Q

What is the association between Vulval HSIL and other health factors?

A

Vulval HSIL is associated with:

  • HIV infection
  • Cigarette smoking
  • Intra-epithelial neoplasia at multiple anogenital sites
32
Q

How is the extent of Vulval HSIL disease determined?

A

The extent of the disease can be determined by the application of acetic acid to the vulva. A biopsy is mandatory to exclude invasion.

33
Q

What are the medical treatments for Vulval HSIL?

A

Medical treatments include:

  • Imiquimod (Aldara) – most evidence, up to 78% success rate
  • Cidofovir
  • Topical chemotherapies (e.g., 5-Fluorouracil)
  • Photodynamic therapy
  • Therapeutic HPV vaccines (experimental)
  • Anti-viral therapies
  • Interferons
  • Indole-3-carbinol
34
Q

What are the surgical treatments for Vulval HSIL?

A

Surgical treatments include:

CO2 laser
Excision biopsy

35
Q

What is the recommended follow-up for patients with Vulval HSIL?

A

Careful follow-up is necessary because the disease tends to recur. Regular Pap smears are mandatory, as this is a multifocal disease and may be associated with cervical cancer precursors.

36
Q

What is the treatment approach for Differentiated VIN?

A

There is no place for conservative or medical therapy in differentiated VIN. Lesions should be excised with a wide margin and sent for histology, as areas of invasion are likely present, and the progression to malignancy is high with a high recurrence rate.

37
Q

What is the association of Differentiated VIN with other conditions?

A

Differentiated VIN occurs in older patients and is more likely to arise in areas adjacent to Lichen Sclerosus.

38
Q

What causes Vulval Warts (Condylomata Accuminata)?

A

Vulval warts are caused by infection with HPV types 6 and 11. They have reached epidemic proportions in South Africa due to widespread HIV infection

39
Q

How are small Vulval Warts treated in non-immunocompromised individuals?

A

Small condylomata in non-immunocompromised individuals may be treated medically with:

Trichloroacetic acid
Podophyllin
Imiquimod

40
Q

How are larger Vulval Warts treated?

A

Larger lesions are best treated surgically with:

CO2 laser (best cosmetic result)
Electrocautery
Excision

41
Q

What is a significant concern with repeated treatments for Vulval Warts and VHSIL in young women?

A

The severe psychosexual morbidity resulting from repeated treatments for vulval warts and vulval high-grade squamous intraepithelial lesions (VHSIL) in young women must not be underestimated.

42
Q

What are the common treatments for Vulval Dermatosis (Eczema, Psoriasis, Allergic Dermatitis)?

A

The treatment of vulval dermatosis (eczema, psoriasis, allergic dermatitis) is mainly with:

Steroid ointments (moderate to potent), as used on other parts of the body

43
Q

What is important to consider in the treatment of Allergic Dermatitis?

A

It is important to identify the cause of the allergy, and patch testing may be necessary.

44
Q

What is Lichen Simplex Chronicus and how is it treated?

A

Lichen Simplex Chronicus is caused by chronic scratching. The itch-scratch cycle needs to be broken, which is best done by:

  • Applying steroid cream
  • Removing the irritant, if possible.
45
Q

What is the most common cause of vulval ulcers in South Africa?

A

The most common cause of vulval ulcers in South Africa is sexually transmitted diseases (STDs), especially herpes simplex infection. These ulcers have become more common due to the HIV epidemic and also increase the transmission of HIV due to mucosal interruption.

46
Q

What are some rare causes of vulval ulcers?

A

Other rare causes of vulval ulcers include:

  • Aphthous ulcers (especially in younger women)
  • Malignancy (especially in older women, which should always be excluded)
47
Q

Why should there be a low threshold for biopsy of vulval ulcers?

A

Vulval ulcers do not always have an appearance characteristic of their cause, so there should be a low threshold for biopsy of any abnormal skin to help determine the cause.

48
Q

What are the main classifications of vulval ulcers?

A

The main classifications of vulval ulcers are:

  • Aphthous: Minor, Complex aphthosis, Major, Behçet’s disease
  • Hormonal: Progesterone autoimmune dermatitis, Oestrogen hypersensitivity
  • Inflammatory Infective:
    • STDs: Herpes simplex, Syphilis, Chancroid, Lymphogranuloma venereum, Granuloma inguinale
      *Other: Epstein Barr virus, Cytomegalovirus, Tuberculosis
  • Non-infective: Crohn’s disease, Lichen Planus, Pemphigus, Pemphigoid
  • Neoplastic:
    • Benign
    • Malignant: Squamous carcinoma, Melanoma, Secondary
  • Traumatic: Abrasions
  • Iatrogenic: Fixed drug eruptions, Drug reactions
  • Idiopathic
49
Q

What is the cause of a Bartholin’s Cyst?

A

A Bartholin’s cyst occurs due to the occlusion of the Bartholin’s duct, leading to an accumulation of mucus.

50
Q

What happens when a Bartholin’s cyst becomes infected?

A

Infection of the Bartholin’s gland can result in a painful Bartholin’s abscess, which requires incision and drainage, followed by marsupialisation to prevent recurrent infection and swelling.

51
Q

When should recurrent Bartholin’s lesions be biopsied?

A

Recurrent lesions, especially in older women, should be biopsied to exclude the possibility of a Bartholin’s gland carcinoma.

52
Q

What are the categories of disorders causing Vulval Pain?

A

Vulval pain can be classified into two main categories:
a) Vulval pain related to a specific disorder:

  • Infectious: Candidiasis, Herpes
  • Inflammatory: Lichen planus
  • Neoplastic: Paget’s disease, Squamous carcinoma
  • Neurological: Herpes neuralgia, Spinal nerve compression

b) Vulvodynia:

Generalised:
-Provoked (sexual, non-sexual, or both)
-Unprovoked
– Mixed (provoked and unprovoked)

Localised (e.g., vestibulodynia, clitorodynia, hemivulvodynia):
- Provoked
- Unprovoked
- Mixed (provoked and unprovoked)

53
Q

What is vulvodynia?

A

Vulvodynia is defined as vulval discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable neurologic disorder.

54
Q

What is the known cause of vulvodynia?

A

The exact etiology of vulvodynia is not known, and it is considered multifactorial, making treatment difficult.

55
Q

What is important when treating a patient with vulvodynia?

A

It is important to listen to the patient, acknowledge the burning sensation despite the absence of visible lesions, and inquire about psycho-sexual problems.

56
Q

Which medications may help relieve discomfort in vulvodynia?

A

Increasing dosages of the following medications may help relieve discomfort:

  • Amitryptiline
  • Carbamazepine
  • Gabapentin
57
Q

What are some other effective treatments for vulvodynia?

A

Other treatments that may be effective include:

  • Vulval hygiene/care measures
  • Topical medications
  • Trigger-point injections
  • Biofeedback/physical therapy
  • Low oxalate diet with calcium + citrate supplementation
  • Cognitive behavioural therapy and sexual counselling

Gynaecology (25 decks)

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