Chapter 25: Vulval Conditions Flashcards
You are a trainee intern in a gynaecology clinic with Anne, a 60 year old para 3 NZ European woman. She has had pruritus vulvae for five years, with some relief when topical steroids were applied. She attended the clinic a week ago and a biopsy was taken from an abnormal area on the vulva. On examination, there is whitening of the vulval skin in a ‘figure-of-8 pattern including peri anal and phimosis of the clitoral prepuce.
vulval whitening
From the following options what is the most likely pathology?
Malignant Melanoma of the Vulva
Vulval Intraepithelial Neoplasia
Squamous cell carcinoma of the vulva
Lichen Sclerosis
Vitiligo
Lichen Sclerosis
You are a trainee intern in a family planning clinic seeing Laveni, a 25 year old nulliparous Pacifica woman. Laveni presents with a 10 day history of intense vulval pruritis for 10 days. It is associated with a green, frothy vaginal discharge. Laveni has recently broken up with her boyfriend. She is on the combined oral contraceptive pill. When performing a pelvic examination you note vulval erythema and a green frothy discharge at the introitus. A speculum examination shows a strawberry red cervix and the same green frothy discharge. You take a swab of the discharge. Of the following options, what is the most effective treatment for Laveni’s symptoms while you are awaiting swab results?
Ciprofloxacin 500g stat PO
Metronidazole 2g PO stat
Doxycycline 100mg bd for 10 days
Benzathine penicillin 2.4 million units IM stat
Azithromycin 1g PO stat
Metronidazole 2g PO stat
Trichomoniasis
You are a trainee intern in a gynaecology ward admitting Julie, a 22 year old nulliparous Pākehā woman. Julie is in urinary retention. She also has vulval ulcers and vesicles that have been present for 3 days and are exquisitely painful. She also has had dysuria, paraesthesia and soreness in the vulval area. Julie is taking paracetamol 1gm every four hours and last took a dose two hours ago. She looks distressed and has a fever of 37.6. Her bladder is palpable up to the umbilicus. The vulva is reddened, very tender, and there are several small shallow ulcers on both labia minora. It is too tender to undertake a speculum examination. There is inguinal lymphadenopathy. From the following options, what action will give the most IMMEDIATE relief of her symptoms?
Give further paracetamol orally
Insert an indwelling urinary catheter
Prescribe oral valaciclovir 500mg bd
Prescribe topical anaesthetic gel
Advise a salt water bath (Sitz bath)
Arrange an epidural or general anaesthetic
Insert an indwelling urinary catheter
You are a trainee intern in a general practice seeing Li, a 22 year old Chinese woman. Li presents with a 3 day history of vulval pain, dysuria, and she has noticed ulcers on her vulva. She is still able to pass urine. On examination she has a fever of 37.6. Her abdomen is soft but there is bilateral inguinal lymphadenopathy. The labia are swollen and reddened, with small shallow ulcers on the labia minora. Li finds your attempts at a speculum examination too painful. You conclude her symptoms are due to a specific infection. From the following options, what is the MOST LIKELY cause of the infection?
Candida albicans
Gardnerella vaginalis
Syphilis
Trichomonas vaginalis
Herpes simplex
Human Papilloma Virus
Herpes simplex
You are a trainee intern in a general practice seeing Alice, a 22 year old Pākehā woman. Alice presents with a 3 day history of vulval pain, dysuria, and she has noticed ulcers on her vulva. She is still able to pass urine. On examination she has a fever of 37.6. Her abdomen is soft but there is bilateral inguinal lymphadenopathy. The labia are swollen and reddened, with small shallow ulcers on the labia minora. Alice finds your attempts at a speculum examination too painful. From the following options, what is your most immediate investigation?
A swab from the base of an ulcer for M, C & S
A virology swab from the base of a vulval ulcer
Blood for HSV serology typing
A cervical smear
An MSU
A virology swab from the base of a vulval ulcer
You are a trainee intern in a sexual health clinic seeing Cherry, an 18 year old Pākehā woman. Cherry presents with vulval itch and lesions that have been present for 2 weeks. She has no current sexual partner and has had 3 previous sexual partners. Cherry had swabs and blood tests for an STI screen 2 months ago and has not had sex since then. On examination there are a large number of moderate sized genital warts on both labia, but none within the vagina or on the cervix. Cherry asks what she could have done to prevent these warts. Of the following options, which strategy would have given her the best protection against developing genital warts?
Being immunised with Gardasil before she had any sexual contact
Having more regular STI checks
Always using condoms when having sex
Nothing would have prevented development of these warts
Not having oral sex
Being immunised with Gardasil before she had any sexual contact
Spreads with any skin to skin, so condoms only slightly reduce risk
You are a trainee intern in General Practice seeing Aroha, a 19 year old Māori woman who is 10 weeks pregnant. Aroha presents with an itchy vulva for 2 weeks. On examination there are a large number of moderate sized (2-3cms) genital warts on both labia, but none within the vagina or on the cervix. From the following options, which is the preferred treatment for Aroha’s genital warts?
Gardasil vaccine
Local applications of Podophyllin resin
No treatment is necessary
Cryotherapy
Local applications of Imiquimod
Cryotherapy
Shes pregnant, imiquimod contraindicated.
You are a trainee intern in general practice seeing Kristina, a 22 year old New Zealander of Chinese ethnicity who presents with 24 hours of increasing soreness in the vulval area and pain in the vulva when passing urine. Kristina has no generalised symptoms but she has enlarged inguinal lymph nodes in the groin. Inspection of the labia and vestibule shows a number of shallow ulcers and some vesicles. You take a swab from the base of one of the vesicles. From the following options, what is the most appropriate management plan for her?
Prescribe lignocaine gel tds to the vulva
Prescribe valaciclovir 500mg bd initially for 7 days
Prescribe acyclovir cream three times daily to the vulva
Advise her that any sex in the next month must be with a condom
Wait for the results of the viral swab before commencing treatment
Feedback
Kristina likely has herpes. Treatment should start immediately, without waiting for the
Prescribe valaciclovir 500mg bd initially for 7 days
Oral better than cream
You are a trainee intern in a general practice seeing Te Aroha, a 34 year old para 3 Māori woman who works as a university lecturer. Te Aroha presents with a marble-sized lump on her left vulva that her husband noted several days ago. The lump is painless to touch and there is no history of injury. On examination, there is a fluctuant 1-2cm medially protruding lump at the inferior aspect of the left labia majora, at the 5 o’clock position and crossed by the labia minora. There is no skin discolouration or bleeding. Examination is otherwise normal. From the following options, what is the MOST LIKELY cause of her lump?
Vulval haematoma
Bartholin’s cyst
Vulval fibroma
Skene’s cyst
Squamous cancer of the vulva
Bartholin’s abscess
Bartholin’s cyst
You are a trainee intern in general practice seeing Anu, a 24 year old New Zealander of Indian ethnicity who is 5 months post-partum following a normal vaginal birth. Anu has had dyspareunia since her son was born. She feels dry and intercourse is uncomfortable. Her son is her first child. She did not have dyspareunia prior to her pregnancy. Anu is otherwise healthy. She is fully breast feeding her son. Her husband is supportive and she is safe at home. Her pregnancy and birth were uncomplicated and she had a small first degree tear that was sutured. Contraception is condoms. On examination the vaginal tissues look slightly atrophic. A speculum exam is uncomfortable for Anu. There are no scars, granulation tissue or lesions present. From the following options, what is the MOST APPROPRIATE management?
Tell Anu that her body is different after childbirth and she will need to adjust to the changes
Refer Anu and her husband for relationship counselling
Prescribe Ovestin (estrogen) cream vaginally
Put Anu on the combined oral contraceptive pill
Prescribe antibiotics as Anu likely has a latent infection
Prescribe Ovestin (estrogen) cream vaginally
You are a trainee intern in general practice reviewing Tūī, a 56 year old Māori woman who is para 4. Tūī presents with a 6 month history of vulval itch. Tūī is post-menopausal and stopped having periods five years ago. She has previously had a tubal ligation. She has no vaginal discharge and her symptoms have not responded to topical miconazole or ovestin. Dyspareunia is a significant problem and she is no longer able to have sex. On examination you see loss of labial architecture and diffuse whitening of the external genitalia in a figure of eight pattern affecting the perianal region. The vaginal tissues are normal. Of the following options, what is the MOST LIKELY diagnosis?
Vulval cancer
Vulval atrophy
Candida
Lichen sclerosis
HPV infection
Lichen sclerosis
You are a trainee intern in general practice seeing Lynne, a 66 year old Pākehā woman. Lynne presents with vulval discomfort and a lump. She has had longstanding vulval itch which has not responded to candida treatment. There is occasionally some bleeding. She smokes 10 cigarettes per day and has for the past 40 years. Lynne takes medication for hypertension and for asthma. On examination Lynne’s BMI is 26. Her general observations are stable. When you do a perineal examination, this is the appearance of Lynne’s vulva:
Looks real red, large ‘warty’? growth
Treat the cellulitis with antibiotics
Prescribe Imiquimod for genital warts
Refer to gynaecology clinic urgently for a vulval biopsy
Refer to sexual health for liquid nitrogen cryotherapy of the warts
Excise the lesion under local anaesthetic in general practice
Perform a swab of the lesion for MC&S and a full STI screen.
Refer to gynaecology clinic urgently for a vulval biopsy
Smoker
You are a trainee intern in colposcopy clinic sitting in with your supervising consultant. The next patient is Neve, a 35 year old para 3 Māori woman. Neve has been referred with a raised itchy area on the labia majora which has been present for 3 months. She is a smoker and has previously had a LLETZ biopsy for CIN3. On examination you see a 2 cm isolated raised plaque on the right labia majora which appears whiter than surrounding skin and has an uneven surface. A biopsy is taken. This is subsequently reported as usual type vulval intraepithelial neoplasia (uVIN). Of the following options, which is the most appropriate management?
Stop smoking
Imiquimod cream
HPV vaccine
Local excision
Observation only
Laser ablation
Local excision
