Benign disorders of the lower genital tract

Question 1

what causes labial fusion?

Answer 1

excess androgens

Question 2

what can cause excess androgens?

Answer 2

excess androgen exposure, or enzyme def’y (21-hydroxylase def’y most common)

Question 3

CP of congenital adrenal hyperplasia

Answer 3

adrenal crisis - salt wasting, hypotension, hyperK+, hypoG

elevated 17-alpha-hydroxyprogesterone

Question 4

tx of CAH

Answer 4

cortisol (provides - fdbk to inh ACTH sec’n)

fludrocortisone to replace aldosterone

Question 5

CP of imperforate hymen:

Answer 5

primary amenorrhea w/cyclic pelvic pain
may have persistent pelvic pain due to accuml’n of menstrual flow behind hymen
increasing ab’l girth
hematocolpos (blood buildup behind hymen)

Question 6

tx of imperforate hymen

Answer 6

surg

Question 7

how does a transverse vaginal septum form?

Answer 7

mullerian tubercle doesn’t completely cannulize

Question 8

CP of transverse vaginal septum

Answer 8

same as imperforate hymen, but septum is deeper & thicker, and a normal hymen can be seen distal to it.

Question 9

tx of transverse vaginal septum

Answer 9

surgery

Question 10

what is vaginal atresia?

Answer 10

when UG sinus fails to form lower part of vagina, gets replaced w/fibrous tissue instead, no introitus seen. Same CP as imperforate hymen.

Question 11

what is vaginal agenesis?

Answer 11

seen in androgen insensitivity syndrome and Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.

Question 12

CP of MRKH pts

Answer 12

genetically female
normal ovarian fct
normal secondary sex char’ics
No proximal vagina, cervix, uterus, tubes

Question 13

CP of AI pts

Answer 13

genetically male, pht’lly female
no proximal vagina or uterus or tubes
undescended testis

Question 14

what is lichen sclerosis

Answer 14

atrophy of vulvar skin. maybe due to immunologic or hrm’l mech. Seen in post-menopausal women

Question 15

CP of lichen sclerosis

Answer 15

symmetric, white, thinned labial skin, may extend to perineum or anal sphincter. Pruritis. Dypareunia. Atrophy of labial epithelium.

Question 16

tx of lichen sclerosis

Answer 16

topical high-potency steroids

Question 17

what is squamous cell hyperplasia?

Answer 17

vulvar eczema/dermatitis. Thickened skin from edema. Chronic pruritis.

Question 18

tx of squamous cell hyperplasia

Answer 18

medium potency topical steroids

Question 19

what is lichen planus?

Answer 19

atrophic inflamm’y eruption of multiple shiny, flat, purple papules on inner aspects of labia minora, vagina, vestibule. C/b erosive. C/b drug-induced or spontaneous.

Question 20

tx of lichen planus?

Answer 20

hydrocortisone vag suppositories. May need surgical excision or vag dilators for vag adhesions. Vag estrogens for pts w/vaginal atrophy.

Question 21

what is lichen simplex chronicus

Answer 21

chronic inflam => scratching => thick white epith with scaling. Unilateral. Circumscribed. Pruritic.

Question 22

tx for lichen simplex chronicus?

Answer 22

medium-potency topical steroids

Question 23

what is vaginal adenosis?

Answer 23

red grandular spots & patches that are palpable on vaginal wall. Related to DES exposure. Epith contains multiple cell types (endocervix, endometrium, tubes). C/b premalignant so always bx it.

Question 24

dx’c approach to vulvar lesions?

Answer 24

all s/b bx’d b/c need histo’c dx. Esp if ulcerated or unifocal.

Question 25

approach to tx of vulvar lesions?

Answer 25

hygeine
avoid tight-fitting clothes/panties, bubble baths, douches, pwoders
clobetasol (high-potency steroid cream) for lichen planus or sclerosis
low-to-medium potency steroids for other dermatoses

Question 26

what is role of topical ES or TS in vaginal/vulvar lesions?

Answer 26

none!

Question 27

what is the most common tumor of the vulva?

Answer 27

epidermal inclusion cyst (occluded pilosebaceous duct or hair follicle)

Question 28

when to incise & drain a cyst?

Answer 28

if its infected or sx’c

Question 29

what is a skene’s gland cyst?

Answer 29

cyst in paraurethral glands

Question 30

what is a urethral caruncle?

Answer 30

small, red, fleshy tumors of distal urethral meatus, seen in post-menopausal women 2/2 vaginal atrophy

Question 31

mgt of urethral caruncle?

Answer 31

usually none needed. If spotting, short course of systemic or topical ES. Rarely, surgical excision.

Question 32

what are the most common benign solid tumors of vulva & vagina

Answer 32

lipoma
hemangioma
urethral caruncle

Question 33

mgt of Bartholin’s duct cysts:

Answer 33

if small and asx’c, nothing.
Sitz baths
if first presentation is in a pt over age 40, need to bx to r/o bartholin’s gland carcinoma.
If abscess forms, need to drain using Word catheter w/balloon tip or marsupialization.
if cx of drainage grows N. gonorrhoeae, or if concommittant cellulitis, give abx

Question 34

what is word catheter?

Answer 34

insert it into cyst, inflate balloon, leave it in for 4-6 weeks, allow it to re-epithelialize

Question 35

what is marsupialization

Answer 35

done for recurrent bartholin’s duct cysts or abscesses. Incise and sew open the gland

Question 36

what is a nabothian cyst?

Answer 36

dilated retention cyst on the cervix, 2/2 blockage of an endocervical gland. Usually asx’c

Question 37

what is a mesonephric cyst?

Answer 37

cyst forms in remnants of mesonephric (wolffian) duct. Lie on external surface of cervix, deep in cervical stroma

Question 38

char’ics of a cervical polyp:

Answer 38

pedunculated or broad-based (sessile)
post-coital spotting
intermenstrual spotting

Question 39

mgt of cervical polyps:

Answer 39

usually are benign and don’t need t/b removed, but are b/c there’s a chance they could be pedunculated endometrial polyps and :. premalignant

Question 40

mgt of cervical fibroids:

Answer 40

bx to r/o cervical cancer.

can excise if sx’c or if likely to cause problems in pg’y (obstruction)

Question 41

causes of cervical stenosis:

Answer 41

congenital
scarring s/p surgery or rad
obstruction w/cancer or polyp or fibroid

Question 42

mgt of cervical stenosis:

Answer 42

if asx’c, none.
if its blocking uterine outflow during menses, needs excision.
If stenosis is due to scarring, gentle dilation.