CH 39 Benign Disorders of the Vulva and Vagina Flashcards
Lichen Sclerosus, what is it
a benign, chronic inflammatory process; the most common vulvar dermatological disorder
Possible causes of lichen sclerosus
vitamin A deficiency, autoimmune process, excess of enzyme elastase, decreased activity of 5 alpha reductase enzyme, which prevents conversion of testosterone to dihydrotestosterone and results in thinning of skin
Signs and symptoms of lichen sclerosus
usually happens over 60 years old, pruritus, pain, dyspareunia, white lesions
Progression of acute lichen sclerosus
- erythema and edema of vulvar skin 2. development of white plaques 3. uniting of white plaques 4. intense pruritus leading to scratch itch cycle 5. telangiectasis and subepithelial hemorrhage resulting from scratching 6. Erosions, fissures, ulcerations
Progression of chronic lichen sclerosus
- thin wrinkled and white skin with cigarette paper look, 2. agglutination of anterior parts of labia minora of both sides to cover clitoris and create phimosis, 3. contraction of vulvar structures with resultant introital stenosis (kraurosis), 4. involvement of the perianal region in the form of 8 around vulva and anus, 5. Devlopment in some women of islands of hyperplastic epithelia within atrophic lichen aclerosus epithelium
Diagnosis of lichen sclerosus
need 5 features in biopsy: 1. thin hyperkeratotic layer, 2. thinning of epithelial layer, 3. flattening of papillae, 4, Homogenization of the stroma, 5. Deep lymphocytic infiltration
Differential diagnosis of lichen sclerosus
vitiligo, lichen simplex chronicus, psoriasis
Complications of lichen sclerosus
high rate of squamous cell cancer in women with lichen sclerosus. Clobetasole is an effective tx
Lichen sclerosus treatment (none medical)
stop itch scratch cycle, minimize dermal inflammation, avoid tight underwear, cleanse with mild soap, dry vulvar skin with hair dryer
Medication for lichen sclerosus
oral antihistamine at bedtime. Give clobetasole diproprionate (dernovate) is a topical steroid that should be given at the beginning to obtain immediate relief of itching. If ineffective try tacrolimus cream, retinoid, antimlarial agents, photodynamic therapy. Only do surgery to prevent cancer
Herpes genitalis pathogenesis
infection occurs through intimate contact, mainly sex. Virus contaminates secretions and mucosal surfaces. The resulting erosion in skin allows port of entry for other STDs. There are periods of viral shedding without symptoms.
Signs and symptoms of herpes genitalis
tingling, burning, itching, flu like symptoms, right before presence of painful vesicular eruptions surrounded by red halos appearing in serpentine like fashion around vulva. may have urinary symptoms
Diagnosis of herpes genitalis
virus culture on fibroblast. Take specimen from vesicle fluid or scraping from erosion. polymerase chain reaction test may indicate previous outbreak rather than current one. Can use smear from Pap but is less sensitive. Cytologic characteristics: giant cells, multiple nuclei, molding of nuclei, ground glass appearance
Complications of herpes genitalis
stigmatization, apprehension of recurrent outbreaks
Neonatal herpes
associated with 60% mortality rate, half of survivors have neuro/ocular sequelae, Ask pregant women if they’ve ever had outbreaks
Herpes genitalis treatment
self limiting and heal spontaneously unless they get infected. Hospitalize if severe infection occurs with urinary retention, severe headache, or temp over 38.3 C/101 F. Treat with IV acyclovir in hospitalized pts and oral/topical antivirals for ambulatory pts. Also may give daily as suppressive therapy
Condyloma acuminatum (genital warts) pathogenesis
incubation can be from a few weeks to months or years. caused by HPV (mainly 6 and 11),
Condyloma acuminatum prevention
Quadrivalent HPV vaccine before sex. can be given to women ages 9-45 and men ages 9-26.
signs and symptoms of Condyloma acuminatum
condyloma is white, exophytic, or papillomatous growth. They are small at first and then form large cauliflower like masses and fingerlike projections and may proliferate profusely. Colposcope needed to see small lesions
Complications of Condyloma acuminatum
warts grow rapidly during pregnancy and may bleed during delivery predisposing the child to genital warts or recurrent respiratory papillomatosis (warts on vocal cords). C section should be done if lesions are present
Condyloma acuminatum pretreatment
use colposcope and cytologic smear to examine lesions. Test for other STDs and biopsy to r/o neoplasia. abstain from sex or use condom
Treatment done by provider for Condyloma acuminatum
bichloracetic acid or trichloroacetic solution, podophyllin in tincture with benzoin, cryosurgery, electrosurgery, simple surgical excision, laser valporization (sx options should be done at 32 weeks)
Treatment done by patient for Condyloma acuminatum
Podofilox solution or gel, Imiquimod cream (active immune enhancer that stimulates production of interferon and other cytokines
bartholin’s cyst clinical findings
obstruction of the bartholin gland results in retention of secretions and cystic dilatation causing infection, pain, tenderness, dyspareunia, and difficulty walking. Enlargement in postmenopausal patient may mean cancer.
Bartholin’s cyst treatment
drainage of infected cyst by marsupialization or insertion of Word catheter (inflatable balloon tipped catheter). Make incision in vestible, close to original orifice of Bartholin’s gland duct. Simple incision/drainage or aspiration would only be temporary. may need antibiotics. Excise in postmenopausal women
Hidradenitis suppurativa, what happens
refractory process of apocrine sweat glands, usually associated with staphylococci or streptococci. Insipissation of secretory material and secondary infection occlude ducts. Nodules appear and turn into abscess then rupture
hidradenitis suppurativa treatment
drainage and antibiotics based on organism sensitivity. Long term therapy with isotretinoin or antiandrogen therapy (cyproterone acetate or ethinyl estradiol). Surgical removal of skin needed if treatment doesn’t work
provoked vulvodynia (PVD) pathogenesis
nonkeratinized squamous epithelium og the vulva between labia minora. Hart line is perimeter. There is mast cell proliferation and degranulation, hyperinnervation, decreased natural killer cell activity, and enhanced heparanase activity
signs and symptoms of provoked vulvodynia
introital pain on vestibular or vaginal entry, vestibular tenderness/ pressure from cotton tipped applicator, vestibular erythema
provoked vulvodynia tx
1st 3 months: pelvic floor PT with biofeedback, topical lidocaine, topical estrogen, daily calcium citrate. If no success after 3 months: give tricyclic amitriptyline, lyrica, or gabapentin. IF still no relief: surgical therapy by vulvar vestibulectomy with vaginal advancement.
unprovoked vulvodynia
etiology unknown, usually 60 years old. vestibular pain or burning is usually constant with periods of relief or flareups.
unproboked vulvodynia treatment
amitriptyline as well as topical local anesthetics, If unrelieved in 3 months, anticonvulsants (gabapentin)
candidiasis pathogenesis
caused by candida albicans, dependent on considerable growth. associated with DM, HIV, obesity, pregnancy, anitbiotics, corticosteroids, oral contraceptives
candidiasis signs and symptoms
intense vulvar itching, white cheesy vaginal discharge and vulvar erythema. Burning sensation may follow urination especially if there is excoriation
wet prep eval of candidiasis
normal vaginal ph, pseudohypahe on wet prep. also do vaginal culture
candidiasis treatment
imidazoles, fungistatic agents that interfere with production of cell wall. topical steroid for itch and edema. may also give fluconazole or itraconazole. monitor liver function tests
Bacterial vaginosis pathogenesis
most common cause of symptomatic bacterial infection in reproductive aged women. overgrowth of Gardnerella vaginalis
Bacterial vaginosis signs and symptoms
fishy vaginal discharge (especially after sex), milky homogenous malodorous usually nonirritating discharge. clue cells on wet mount
Bacterial vaginosis treatment
flagyl, clindamycin. Clindamycin (reduces effectiveness of condoms and diaphragms
