CH 39 Benign Disorders of the Vulva and Vagina

Question 1

Lichen Sclerosus, what is it

Answer 1

a benign, chronic inflammatory process; the most common vulvar dermatological disorder

Question 2

Possible causes of lichen sclerosus

Answer 2

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

Question 3

Signs and symptoms of lichen sclerosus

Answer 3

usually happens over 60 years old, pruritus, pain, dyspareunia, white lesions

Question 4

Progression of acute lichen sclerosus

Answer 4

1. 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

Question 5

Progression of chronic lichen sclerosus

Answer 5

1. 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

Question 6

Diagnosis of lichen sclerosus

Answer 6

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

Question 7

Differential diagnosis of lichen sclerosus

Answer 7

vitiligo, lichen simplex chronicus, psoriasis

Question 8

Complications of lichen sclerosus

Answer 8

high rate of squamous cell cancer in women with lichen sclerosus. Clobetasole is an effective tx

Question 9

Lichen sclerosus treatment (none medical)

Answer 9

stop itch scratch cycle, minimize dermal inflammation, avoid tight underwear, cleanse with mild soap, dry vulvar skin with hair dryer

Question 10

Medication for lichen sclerosus

Answer 10

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

Question 11

Herpes genitalis pathogenesis

Answer 11

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.

Question 12

Signs and symptoms of herpes genitalis

Answer 12

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

Question 13

Diagnosis of herpes genitalis

Answer 13

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

Question 14

Complications of herpes genitalis

Answer 14

stigmatization, apprehension of recurrent outbreaks

Question 15

Neonatal herpes

Answer 15

associated with 60% mortality rate, half of survivors have neuro/ocular sequelae, Ask pregant women if they’ve ever had outbreaks

Question 16

Herpes genitalis treatment

Answer 16

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

Question 17

Condyloma acuminatum (genital warts) pathogenesis

Answer 17

incubation can be from a few weeks to months or years. caused by HPV (mainly 6 and 11),

Question 18

Condyloma acuminatum prevention

Answer 18

Quadrivalent HPV vaccine before sex. can be given to women ages 9-45 and men ages 9-26.

Question 19

signs and symptoms of Condyloma acuminatum

Answer 19

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

Question 20

Complications of Condyloma acuminatum

Answer 20

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

Question 21

Condyloma acuminatum pretreatment

Answer 21

use colposcope and cytologic smear to examine lesions. Test for other STDs and biopsy to r/o neoplasia. abstain from sex or use condom

Question 22

Treatment done by provider for Condyloma acuminatum

Answer 22

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)

Question 23

Treatment done by patient for Condyloma acuminatum

Answer 23

Podofilox solution or gel, Imiquimod cream (active immune enhancer that stimulates production of interferon and other cytokines

Question 24

bartholin’s cyst clinical findings

Answer 24

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.

Question 25

Bartholin’s cyst treatment

Answer 25

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

Question 26

Hidradenitis suppurativa, what happens

Answer 26

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

Question 27

hidradenitis suppurativa treatment

Answer 27

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

Question 28

provoked vulvodynia (PVD) pathogenesis

Answer 28

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

Question 29

signs and symptoms of provoked vulvodynia

Answer 29

introital pain on vestibular or vaginal entry, vestibular tenderness/ pressure from cotton tipped applicator, vestibular erythema

Question 30

provoked vulvodynia tx

Answer 30

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.

Question 31

unprovoked vulvodynia

Answer 31

etiology unknown, usually 60 years old. vestibular pain or burning is usually constant with periods of relief or flareups.

Question 32

unproboked vulvodynia treatment

Answer 32

amitriptyline as well as topical local anesthetics, If unrelieved in 3 months, anticonvulsants (gabapentin)

Question 33

candidiasis pathogenesis

Answer 33

caused by candida albicans, dependent on considerable growth. associated with DM, HIV, obesity, pregnancy, anitbiotics, corticosteroids, oral contraceptives

Question 34

candidiasis signs and symptoms

Answer 34

intense vulvar itching, white cheesy vaginal discharge and vulvar erythema. Burning sensation may follow urination especially if there is excoriation

Question 35

wet prep eval of candidiasis

Answer 35

normal vaginal ph, pseudohypahe on wet prep. also do vaginal culture

Question 36

candidiasis treatment

Answer 36

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

Question 37

Bacterial vaginosis pathogenesis

Answer 37

most common cause of symptomatic bacterial infection in reproductive aged women. overgrowth of Gardnerella vaginalis

Question 38

Bacterial vaginosis signs and symptoms

Answer 38

fishy vaginal discharge (especially after sex), milky homogenous malodorous usually nonirritating discharge. clue cells on wet mount

Question 39

Bacterial vaginosis treatment

Answer 39

flagyl, clindamycin. Clindamycin (reduces effectiveness of condoms and diaphragms