3/21 Vuvular Flashcards
Vulvar function: 3 items?
- Protects urinary and sexual opening from trauma and infection
- For sexual arousal
- To accommodate childbirth
Structures?
Left arrow: prepuce/clitoral hood
R: clitoris
structure?
hymen
impt features of a physical exam when concerned about vulvar issues?
- examine external genitalia
- specular exam and microscopic examination of secretions (yeast infections etc)
- rest of SKIN, esp MOUTH
Condition?
Lichen Planus
Erosive, note the “missing bits” (clitoris, labia)
skin is eroded, raw
A few things about biopsy:
locations?
anesthetic?
type?
post-biopsy care?
- biopsy in a few locations
- topical anesthetic
- use a punch biopsy or scissor biopsy (cut off a little flap)
- stop bleeding with presure + (a few agents I doubt we need to know) - rarely need suture
- use petroleum daily until healed
Condition?
Normal variant: Ectopic Sebaceous Glands
Condition?
Normal varient: vulvar papillomatosis
Looks like warts but soft, harmless
describe the hymen?
normal crescentic hymen
describe the hymen?
septate hymen (normal)
what can be causes of atrophic vulvovaginitis?
- estrogen deficiency (menopause, possibly menarche, postpartum breastfeeding, OCPs)
- inflammation due to irritation (soap, creams, urine, feces, friction)
condition?
(itchy, burns, fissures, thin tissue)
some atrophy. causes dryness, thin tissue, fissures
condition?
atrophic vulvovaginitis
-Very dry, withered. Thin, no wrinkles, no hair, Sore, uretha gets red.
Fix w estrogen
Wth time and estrogen, redness will go away tissues will be more moist and supple.
Flattening and scarring won’t go awa. Slightly larger clitoris due to androgen imbalance (too much androgen).
What is the commonest cause of vulvar erosions/ulcers?
HSV
HSV.
usually spread from a symptomatic or asx partner?
what is the recurrence rate for HSV I? HSV II?
Are women typically aware of their infection?
Primary HSV v recurrent HSV - prevalance of each?
- Usually spread from an asymptomatic partner
- Women are asymptomatic carriers of HSV, usually unaware of their infection
- Recurrence rate for HSV I= 45%; HSV II= 89%
- Prevalence: she says that ‘primary HSV is uncommon’ & women often present with recurrent HSV with no primary HSV history
Condition?
would this present with any systemic sx?
how long would this last?
Primary HSV. (description: groups of blisters/pustules)
Systemic Sx: fever, malaise, pain, dysuria
Duration: 2 weeks
Condition?
any systemic symptoms?
duration?
Recurrent HSV (description: small blisters, fissures, or ulcers)
(there is a prodromal itch, tingling)
systemic sx: mild malaise
Duration: a few days.
Condition?
Primary HSV
Primary can get necrotic as in lower left
Contrast with Recurrent HSV (Upper Right and Lower Right)
Condition?
Recurrent HSV
Recurrent usually just results in erosions as in lower right
Contrast with Primary (left pics)
Condition?
First episode of non-primary HSV
(The pustules help you identify this)
What are the 4 types of common anatomical variants?
(this is an objective)
- Sebaceous gland hyperplasia (numerous, small 1-2 mm yellowish papules along the inner aspects of the labia minora. These are harmless but slightly oversized, normal, ectopic sebaceous glands.)
- Vulvar papillomatosis (look like warts, but they are soft rather than hard)
- Hymen types (crescentic v. microperforated v. imperforate)
- Labial hypertrophy (defined as width greater than 4cm). Reduction surgery if required.
how would we diagnose this?
Diagnosis: Culture, PCR testing and HSV I and II serology
Condition?
symptoms?
HSV in immunosuppressed patient
Chronic ulcers extending at periphery.
may become necrotic
Main cause of vulvar ulcers?
Herpes simplex in the immunosuppressed
Yes, she said earlier it was just HSV (no mention of the immunosuppressed).
Genital HSV infection info:
Viral shedding pattern?
Do antiviral drugs stop all shedding?
A new primary genital infection in a young woman is more likely to be HSV 1 or HSV 2?
-HSV viral shedding occurs 1 day in 5 throughout life
-Antiviral drugs do not stop all shedding
- HSV-1 is increasing in all age groups
- New primary genital infections in young women are more likely HSV1 than HSV2
- HSV-1 does not protect from HSV-2 (duh)
HPV causes what (name 2 general pathologies)?
What strains most commonly cause warts?
- HPV causes genital warts and cancer (genital intra-epithelial neoplasia, squamous cell carcinoma)
- Warts commonly caused by strains 6 and 11 (non-oncogenic)
HPV in young women: general course of the infection?
What happens with infections that persist?
infections are temporary, have little long-term significance.
Most infections clear (90% within 2 yrs)
If infection persists, there is a high risk of developing pre-cancer of the cervix. Can progress to invasive cervical cancer in 15-20 y
Condition?
Is there a cure?
what are symptom?
HPV
No cure
varying degree of irritation, itching, soreness
condition?
50% of patients who have this also have what?
some children who have this have a history of what?
HPV. cauliflower-like growths
50% of patients with this have cervical cancer
-30-40% of children with this have been abused
most common genital disease?
candidiasis
(c albicans = 75%)
Factors that promote candida?
Anything that will weaken your immunity:
antibiotics, immunodeficiency, diabetes, chemo, hormones, pregnancy, OCPs, steroids, HIV
condition?
vulvar candidiasis
condition?
candidiasis.
note cottage cheese discharge, pustules
but generally presentation is just redness and swelling.
condition?
candidiasis
define vulvar contact dermatitis
inflammation due to an exogenous agent that acts as irritant or allergen
what is generally the cause of vulvar contact dermatitis?
repeated exposure to an irritating agent:
generally it is from washing with a washcloth
COMMON, non-immunologic reaction
condition?
diaper dermatitis (type of contact dermatitis.)
below: same thing from adult incontinence (contact with urine and Depends)
condition?
how common?
possible etiology?
ALLERGIC contact dermatitis (type IV hypersensitivity rxn)
NOT common.
Could be caused by benzocaine, poison ivy, neomycin.
Name a few vulvar allergens.
Name a few vulvar irritants.
which is more frequent?
Allergens:
Benzocaine (Vasigil), preservatives, neomycin, latex, KY Jelly
Irritants:
Soaps/cleansers, sweat, uring, feces, creams
IRRITATIONS far more common than allergic rxns
condition?
HSV
What are the 3 “Lichens”?
What are features of each?
Lichen Sclerosis (Figure 8 pattern): Itchy, burns. Will scar. NOT in vagina
Lichen Planus (Lacy): itchy, burns. Will Scar. in VAG and MOUTH
Lichen Simplex Chronicus (thick hairless skin): CRAZY ITCH. No scarring. Not in vagina.
Condition?
symptoms?
how is it diagnosed?
LIchen simplex chronicus
Relentness Pruritis: years of itch
Dyspigmentation
Excoriations, crusts, lichenification, hair loss
Clinical diagnosis
condition?
What makes it worse?
Lichen Simplex Chronicus
Worse with heat, humidity, stress, irritants
condition?
what caused the lichenification?
LSC
Scratching caused lichenification
condition?
treatment?
LSC
Stop scratching! Sitz baths, soaks.
Reduce inflammation: steroids (topical, systemic if needed).
treat infections (yeast, bacteria)
LIchen Sclerosis: etiology?
causes what?
A chronic, autoimmune, mucocutaneous disease affecting the genital skin causing whiteness, tissue thinning and scarring
Condition?
Does it itch?
What does this condition cause 3-5% of the time?
LIchen sclerosis
Itches, burns
3-5% –> squamous cell carcinoma
Commonest cause of chronic vulvar disease?
LIchen sclerosis. (figure 8)
condition?
average age of onset?
Etiology?
Lichen sclerosis
avg onset: 35-40 yrs (perimenopausal)
genetic link, possibly autoimmune related
conditon?
Treatment?
LIchen sclerosis
Biopsy to confirm
Potent topical steroids (daily for 3 months, then 2/week forever)
condition?
Associated with SCC or not?
Lichen sclerosis
3-4% will progress to SCC
condition?
also affects what other body parts?
Lichen planus. note lacy pattern
also affects scalp, nails, skin, anus
condition?
etiology?
avg age of onset?
Lichen planus (in anus this time)
lacy pattern.
autoimmune disorder affecting mucosa. she also says it is due to irritants like drugs/chemicals or infections.
generally affects women 50-60 yrs.
condition?
Lichen Planus.
typical = lacy pattern, but can also cause erosion, loss of the ‘bits’
which two lichen diseases can cause SCC?
Lichen planus and lichen sclerosis.
NOT lichen simplex chronicus
condition?
LIchen planus
same lacy pattern that we see on the vulva
condition?
lichen planus
same lacy pattern on the hand as on the vulva
Condition?
Etiology?
Psoraisis
Hereditary, scaly rash
silver white scale on red plaques
conditoin?
Psoraisis
intraepithelial vulvar SCC: if multifocal, what may be the etiology?
if solitary, etiology?
- Multifocal: due to HPV 16, 18. Usually in younger women. looks like warts
- Solitary: lichen sclerosis. usually in older women.
condition?
related to what?
Vulvar intraepithelial multifocal SCC
usually related to HPV
condition?
vulvar intraepithelial neoplasia, multifocal (SCC)
related to HPV
condition?
related to what?
vulvar intraepitheleal neoplasia solitary type (at top of pic)
related to lichen sclerosis (also present)
causes of vulvodynia?
- infectious (candida)
- inflammatory (lichen planus)
- neoplastic (SCC)
- neurologic (herpetic neuralgia)
definition of LOCALIZED vulvodynia?
pain. sex hurts!
chronic condition, pain on touching the vulva or any penetration. (tampon, penis, etc)
COMMON
generalized vulvodynia: cause?
treatment?
neuralgia or regional pain syndrome
CONSTANT PAIN. uncommon
may do nerve blocks, tricylics, pelvic floor therapy
