Benign Lower Genital Tract Disorders

Question 1

Congenital anomalies: labial fusion

Answer 1

2/2 exogenous androgens or Congenital Adrenal Hyperplasia (CAH) (21-hydroxylase deficiency) - check 17-OH progest

CAH, treat with cortisol (suppresses ACTH → inhibits adrenal activity → less androgens)
If salt- wasting, give mineralocorticoids back too (fludrocortisone). Surgery to reconstruct

Question 2

Vaginal atresia:

Answer 2

Lower vagina (from urogenital sinus) fails to develop. 
Primary amenorrhea, cyclic pelvic pain too - but no introitus (“vaginal dimple”) instead; confirm dx with U/S or MRI, then surgery (e.g. “vaginal pull-throguh”)

Question 3

Congenital anomalies: Imperforate hymen

Answer 3

Buildup of secretions (hydrocolpos / mucocolpos) in vagina, primary amenorrhea

+ cyclic pelvic pain at puberty. Surgery.

Question 4

Congenital anomalies: Transverse vaginal septum

Answer 4

2/2 incomplete canualization between mullerian upper vagina & urogenital sinus-derived lower vagina.
Can present like imperforate hymen, but exam shows short vagina with “blind
pouch” → U/S & MRI show upper vagina & uterus. Surgery.

Question 5

Congenital anomalies: vaginal agenesis

Answer 5

= mullerian agenesis = “mayer-rokitanksy-kuster-hauser” syndrome

Congenital absence of vagina as well as hypoplasia or absence of cervix, uterus, fallopian tubes.

Normal external genitalia & secondary sex characteristics (normal ovaries), 46,XX.

Primary amenorrhea in adolescence. Dx on U/S or MRI.

Can create neovagina with surgery (McIndoe - buttock skin graft reconstructed) or serial dilators (Frank/Ingram). Clearly, can’t carry pregnancy w/o uterus (but can use surrogate with her eggs)

Question 6

Epithelial disoders of vulva / vagina

Answer 6

Biopsy all vulvar lesions!
If vaginal, biopsy via colposcopy
For tx, avoid tight-fitting clothes, bubble baths, douching, etc.

Question 7

Lichen sclerosis physical findings:

Answer 7

Symmetric white, thinned skin on labia / perineum / perianal. 
Labia minora shrink, stick together. 
Does not involve vagina. 
Caucasian premenarchal girls and
postmenopausal women.

Question 8

Lichen sclerosis: symptoms

Answer 8

Usually asx; occ. pruritis/dyspareunia.

From itch/scratch cycle.

Question 9

Lichen sclerosis: treatment

Answer 9

High potency topical steroids (clobetasol) 1-2x/d x 6-12 wks

Question 10

Squamous cell hyperplasia: physical findings

Answer 10

Localized thickening of vulvar skin 2/2 edema

Raised white lesion on labia majora / clitoris

Question 11

Squamous cell hyperplasia: symptoms

Answer 11

Chronic pruritis, thickened skin

Question 12

Squamous cell hyperplasia: treatment

Answer 12

Medium potency topical steroids x 4-6 wks

Question 13

Lichen planus: physical findings

Answer 13

Shiny, flat, purple papules on inner labia majora, vagina, vestibule with lacy reticulated pattern; can erode, can have vaginal adhesions → stenosis. Also on hair-bearing skin/scalp (can → alopecia), oral
mucous membranes

Question 14

Lichen planus: treatment

Answer 14

Vaginal hydrocortisone suppositories; may need surgery / dilators for adhesions.
If postmenopausal, estrogen for atrophy.

Question 15

Lichen simplex chronicus: physical findings

Answer 15

Thickened white epithelium, unilateral usually, well circumscribed, excoriation,
lichenified

Question 16

Lichen simplex chronicus: treatment

Answer 16

Medium potency topical steroids
Antihistamines for itching
Get vulvar bx to r/o badness

Question 17

Vulvar psoriasis: physical findings

Answer 17

Red, moist lesions, sometimes scaly, a/w scalp / axilla / groin / trunk lesions

Question 18

Vulvar psoriasis: symptoms

Answer 18

Asx or occ. pruritis

Question 19

Vulvar psoriasis: treatment

Answer 19

UV light or topical steroids

Question 20

Vaginal adenosis: physical findings

Answer 20

Palpable red glandular spots, patches on upper 1⁄3 vagina on anterior wall

Question 21

Vaginal adenosis: treatment

Answer 21

A/w DES exposure in utero.
get Bx to r/o adenocarcinoma.
Follow (serial exams)

Question 22

Vulvar vestibulitis treatment

Answer 22

Tricyclic antidepressants to block sympathetic afferent pain loops
Pelvic floor rehabilitation, biofeedback, and topical anesthetics.
Surgery with vestibulectomy is recommended for patients who do not respond to standard therapies and are unable to tolerate intercourse.

Question 23

Epidermal inclusion cysts on vulva:

Answer 23

Usually go away, I&D if superinfected

Question 24

Sebacous cysts

Answer 24

Accumulating sebum

Usually go away, I&D if superinfected

Question 25

Apocrine sweat gland cysts

Answer 25

Can be occluded, abscesses → hidradenitis supperativa if multiple abscesses form Excise or I&D; give abx if cellulitis

Question 26

Skene’s gland cyst

Answer 26

Near urethral meatus

Question 27

Gartner’s duct cysts

Answer 27

Remnants of mesonephric ducts (Wolffian), which normally regress in females
Found on anterolateral aspect of upper vagina, usually asx but can p/w dyspareunia / pain with tampon use.
Can remove surgically if needed; can bleed (may need to use vasopressin)

Question 28

Benign solid tumors: Hemangiomas

Answer 28

Red, will regress, found in infants, can bleed 2/2 trauma.

Question 29

Benign cervical lesions: congenital

Answer 29

Can see double cervix = bicollis if 2 uteri or other anomalies 2/2 in utero DES exposure
(higher risk of clear cell adenocarcinoma of cervix / vagina).

Question 30

Cysts on cervix

Answer 30

Retention = nabothian from blockage of endocervical gland, usually asx, no tx needed
Mesonephric (from wolffian ducts), or endometrial implants too

Question 31

Cervical polyps

Answer 31

Pedunculated or broad based
Usually asx but can be a/w spotting.
Not premalignant, but remove - can mask irregular bleeding from other source!

Question 32

Cervical fibroids

Answer 32

Can cause intermenstrual bleeding, dyspareunia, bladder / rectal pressure, L&D
problems. Remove as possible.