Benign and Malignant Vaginas

Question 1

Presentation of a patient with Bacterial Vaginosis (BV).

Answer 1

Gray/White thin vaginal discharge Fishy smell Usually no pruiritis, patients complain because of the odor and discharge

Question 2

What are the obstestric risks of BV?

Answer 2

PROM premature delivery chorioamnionitis W/ C-sections, increased risk of endometritis

Question 3

What is the GYN risk of BV?

Answer 3

cuff cellulitis (inflammation of the upper vagina) in post-hysterectomy patients

Question 4

How is BV diagnosed?

Answer 4

Vaginal pH greater than 5 Clue Cells on microscopy: vaginal epithelial cells that have irregular borders because of they are covered in bacteria Sniff/Whiff test: fishy smell of KOH prep

Question 5

Best treatment for BV.

Answer 5

Oral Metronidazole (flagyl) -500mg BID for 7 days (less effective is the 1-one 2 gram dose)

Question 6

What does a physician need to remind a patient to avoid while taking metronidazole.

Answer 6

No alcohol (disulfuram reaction makes patients sick)

Question 7

Should the patient’s partner be treated for BV as well?

Answer 7

Only if the patient is getting recurrent BV cases.

Question 8

How does a patient present with candidiasis?

Answer 8

Odorless “cottage cheese” vaginal discharge Vulvar irritation w/ burning on urination

Question 9

Most common cause of candidiasis.

Answer 9

Broad Spectrum antibiotic use

Question 10

How is candidiasis diagnosed?

Answer 10

KOH prep shows hyphae

Question 11

What is the treatment for Candidiasis?

Answer 11

Synthetic Imidazoles (all creams except for fluconazole, but fluconazole is only effective against 1 of the 3 strains)

Question 12

What are two special cases that influence treatment of Candidiasis?

Answer 12

Pregnancy: treatment requires longer regimen Diabetic Vulvitis: antifungals alone don’t fix the problem. Must also correct blood sugar levels

Question 13

Presentation of a patient with Trichomonas.

Answer 13

Yellow/gray frothy vaginal discharge Malodorous Strawberry cervix with vaginitis or cervicitis

Question 14

How is Trichomonas vaginalis diagnosed?

Answer 14

Wet mount shows flagellated protozoans

Question 15

What is the treatment for Trichomonas vaginalis?

Answer 15

Oral Metronidazole (all regimens equally effective) The partner should definitely be treated in this instance

Question 16

Number one cause of Pelvic Inflammatory Disease (PID) and why?

Answer 16

Chlamydia -very insidious onset, inflammation and damage to tissue occur before symptoms start.

Question 17

Treatment of choice for Chlamydia trachomatis

Answer 17

Azithromycin: 1g in 1 dose

Question 18

What are complications of Chlamydia infection?

Answer 18

Fitz-Hugh-Curtis Syndrome: the PID starts to ascend thru the peritoneal cavity and cause inflammation. The inflammation causes fibrosis and adhesions to abdominal cavity organs like the liver adhereing to parietal peritoneum.

Also can cause ectopic pregnancy due to uterine tube fibrosis.

Question 19

How do you treat newborns when the mother had a chlamydia infection?

Answer 19

Erythromycin ointment to newborn’s eyes

Question 20

Top two causes of prepubertal vaginitis.

Answer 20

1. Bubble Bath
2. Foreign Body

(if caused by infection, suspect sexual abuse)

Question 21

Most common cause of post-menopausal vaginitis.

Answer 21

Estrogen deficiency leading to atrophic vaginitis

Question 22

Treatment for atrophic vaginitis.

Answer 22

Local estrogen cream

Question 23

Presentation of a patient with Herpes Genitalis

Answer 23

with initial episode: Very painful urination, urethritis, urinary retention, patients are miserable. Labia may fuse from inflammation.

Question 24

Treatment for Herpes Genitalis

Answer 24

Valacyclovir (prodrug)

Acyclovir

(oral treament is better than topical)

Question 25

What is the management strategy in a patient that goes into labor with active Herpes lesions?

Answer 25

C-section to prevent infection of the newborn.

Question 26

Presentation of a patient with HPV

Answer 26

Condyloma Acuminata (genital warts)

If warts are seen, do a pap smear and culposcopy.

Question 27

Treatment for Condyloma Acuminata

Answer 27

Laser vaporization, cryotherapy, 5-FU ointment

Question 28

Treatment for any Bartholin gland pathology.

Answer 28

Incise and drain

Gland excision

Marsupialization (cutting into the abscess or cyst and stitching the ends together to create a continuous surface)

Question 29

Name the 3 types of vulvar neoplasia and how to distinguish each.

Answer 29

1. Vulvuar Dystrophy
2. Vulvar Intraepithelial Neoplasia (VIN)
3. Vulvar Squamous Cell Carcinoma

Must do a biopsy to differentiate

Question 30

Treatment for benign vulvar dysplasia.

Answer 30

Medium Strength Topical Corticosteroids

Question 31

What is Lichen Sclerosis?

Answer 31

Form of vulvar dysplasia that results in hyperkeratosis (patches of white thin parchment on the skin on and around the genitals)

Question 32

Treatment for Lichen Sclerosis

Answer 32

Potent Steroid Clobetasol

Question 33

What are the two forms of VIN?

Answer 33

Paget’s Disease: post menopausal, red/pink pathces of hyperplastic skin

Carcinoma in situ (CIS): any age, lots of color changes (red, pink, brown), pruritic

Question 34

What is the rule with the two types of VIN (and most other unusual vulvar growths)?

Answer 34

If it doesn’t go away, biopsy it

Question 35

Describe the five (0-4) stages of Vulvar Squamous Cell Carcinoma

Answer 35

0: carcinoma in situ
1: lessions less than 2cm
2: lesions greater than 2 cm
3. Involves anus, lower urethra, vagina, and/or unilateral inguinal nodes
4: involves upper urethra, bladder, rectal mucosa, bilateral inguinal nodes or distant sites

Question 36

Treatment for Vulvar Squamous Cell Carcinoma

Answer 36

Classical Radical Vulvectomy (or a modified version)