Benign Vulvar Lesions Flashcards
Bartholin cyst and abscess
general and RF
Bartholin cyst
Obstruction of the excretory duct with retention of secretory fluid
Most common vulvar mass
Develop in ~2% of women of reproductive age
Risk factors:
Obesity
Poor hygiene
Shaving or waxing of pubic hair
Immunocompromisedindividuals
Pregnancy
Bartholin abscess
Results from fluid collection, or the gland itself, becoming infected
bartholin abcess
Etiology and pathogenesis
Nonspecific inflammationor trauma of the duct → duct occlusion → mucinous fluid accumulation within the gland = Bartholin cyst
Bartholinabscess:
Primary infection of the gland
Infection of a Bartholin cyst
Microbiology:
Usually polymicrobial, consisting of:
MRSA
Enteric gram-negative aerobes
Lower genital tract anaerobes that are found in women
Most common single pathogen:Escherichia coli
Less common, but also potentially due to STI (Neisseria gonorrhoeae,Chlamydia trachomatis)
bartholin abcess/cyst
General
Bartholin cysts:
Typically presents as a painless, unilateral, fluctuantmass
Appear near the posterior vaginal introitus
Often 1‒3 cm in size
Larger cysts may cause mild discomfort (especially during intercourse or movement)
Bartholin abscess:
Unilateral palpablemassnear the posterior vaginal introitus
May measure up to 4‒5 cm
Significantpain/tenderness in thevulva:
Acute onset
Often difficult to walk and sit due topain
Dyspareunia
Fever(possible, but uncommon)
Bartholin abscess/cyst
Dx and indication for biopsy
Both cysts and abscesses are diagnosed clinically
Culture any drainage
Indications for biopsy to rule out malignancy (rarely needed):
Individuals ≥ 40 years of age or postmenopausal women
If themasshas solid components
If themassis fixed to surrounding tissue
Screen for STI if the individual is at high risk
bartholin abscess/cyst
Tx
Incision and drainage:
Standard treatment
High risk of recurrence
To ↓ risk of recurrence, a word catheter is placed in the incision:
Allows continued drainage for up to 4 weeks
Allows the new tract to epithelialize and remain open, preventing reaccumulation of fluid
bartholin abscess/cyst
Abx indications and meds
Indications:
Culture-positive for MRSA
Surrounding cellulitis
Immunocompromised individuals
Signs of systemic infection
NOT indicated for:
Cysts
Uncomplicated abscesses that can be treated with incision and drainage
Regimens should cover anaerobes and MRSA
Recommended regimens include:
Trimethoprim-sulfamethoxazole +/-metronidazole
Trimethoprim-sulfamethoxazole +/- amoxicillin-clavulanate
Doxycycline +metronidazole
Lichen Sclerosus
general
Chronic, progressive, dermatologic condition of thevulvacharacterized byinflammationand epithelial thinning → scarring that can distort the anatomy
Benign condition, but is associated with an increased risk for vulvarsquamous cell carcinoma(SCC)
Long-term follow-up is recommended
Epidemiology
2 peaks (both low-estrogenstates):
Prepubertal girls
Perimenopausal or post-menopausal women (>50 years)
Lichen Sclerosus
patho
Etiology is unknown
Contributing factors likely include:
Genetic factors
Local factors (local irritation)
Hormonal factors (low estrogen)
Immunologic abnormalities
Chronic, progressive process
Inflammation and altered fibroblast function lead to:
Thinning of theepidermis
Areas of atrophy
Fibrosis in the upperdermis
Lichen sclerosus
clin man
Vulvar pruritus
Vulvar irritation or soreness
Dyspareunia
Anal discomfort:
Pruritus
Painfuldefecation
Porcelain-white, “parchment-like” plaques (classic finding)
Most common on the labia
“Figure of 8” pattern: white plaques around the labia, perineum, and anus
Lesions may also appear
Hemorrhagic or purpuric
Eroded or ulcerated
Hyperkeratotic
Excoriations, which may be associated with:
Mild lichenification (thickening of THE epidermis)
Edemaof thelabia minora
Scarring → leads to “loss-of-vulvar architecture”
Fusion of the labia
Fusion of the clitoral hood
Smaller introitus
Thevaginais generally not involved
lichen sclerosus
Dx
can be made clinically
biopsies are often preferred to confirm the diagnosis
Vulvar biopsy
Gold standard for diagnosis
Indications
Medical management fails
Exclude Malignancy
Clinical diagnosis is uncertain
lichen sclerosus
Tx
Good vulvar hygiene
Avoid harsh soaps, shampoos, and laundry detergents
Avoid excessive washing/scrubbing
Apply topicalemollients(Vaseline, Aquaphor) to serve as askinprotectant to ↓ irritation)
White cotton or silk underwear (thongs, lace, or synthetic materials to be avoided)
Avoid tight-fitting pants
1st-line treatment is medical management with high-potency topical corticosteroids
Clobetasol (topical):
Initial treatment: 6‒12 weeks
Maintenance treatment: may be lifelong
Treatment resistance
Intralesional Triamcinolone
Topicalcalcineurininhibitors:
Tacrolimus
Pimecrolimus
Rule outCandidainfection or bacterial superinfection
Biopsy, if not previously performed
Confirming the diagnosis
Ruling out malignancy
Lichen simplex chronicus
general
Benign vulvarskindisorder characterized by hyperkeratosis (thickening of theskin) that occurs secondary to chronic vulvar irritation
Typically occurs in mid-to-late adulthood (30‒50 years of age)
anything that leads to chronic rubbing or itching of the vulva can cause lichen simplex chronicus
Atopic dermatitis
Contact (irritant)dermatitis
Vulvareczema
Lichen simplex chronicus
clin man
Intense pruritus
Often worse at night
Usually intermittent
May be described as a burning sensation
Skin lesions
Well-demarcated, dry, plaques
Skin is thick, scaly, firm, and/or rough
Slightly erythematous
Accentuation of normalskinmarkings
Change inskinpigmentation (hyperpigmentation)
Excoriations
Lichen simplex chronicus
Dx
Primarily clinical
biopsy is frequently warranted to confirm the diagnosis and exclude malignancy
Vulvovaginitis should be excluded by:
Microscopy of vaginal fluid:
KOH prep
Wet mount (normal saline)
Fungal cultures
Point-of-care tests forbacterial vaginosis(BV)
Lichen simplex chronicus
Tx
Good vulvar hygiene
Medical management
Topical corticosteroids:
Clobetasol: for a shorter initial course
Lower potencysteroidsmay be used for a longer term as maintenance therapy
Topicalemollients
Antihistaminesfor symptomatic treatment ofpruritus
Diphenhydramine
Hydroxyzine
