Disorders of the Vulva

Question 1

What is the Vulva

Answer 1

The external Vagina

Question 2

what is the anterior border of the vagina

Answer 2

bladder/urethra

Question 3

what is the posterior border of the vagina

Answer 3

upper 1/3, pouch of douglas (retrouterine pouch)

lower 2/3 rectum

Question 4

what are the most common symptoms of vulval pathology

Answer 4

pruitis
soreness
burning
superficial dyspareunia

Question 5

what are some causes of pruitis vulvae

Answer 5

candidiasis
vulval warts 
pubic lice
psoriasis
eczema
contact dermatitis 
lichen planus
lichen simplex
lichen sclerosis 
carcinoma 
premalignant disease (VIN)

Question 6

what is another name for lichen simplex infection of the vulva

Answer 6

chronic vulval dermatitis

Question 7

who commonly gets lichen simplex

Answer 7

contact dermatitis patients
patients with eczema
patients with sensitive skin

Question 8

what part of the vulva is most affected by vulval lichen simplex

Answer 8

labia majora

Question 9

what is the common feature of vulval lichen simplex

Answer 9

severe intractible pruitis - worse at night

Question 10

what systemic conditions are associated with vulval lichen simplex

Answer 10

low iron

stress

Question 11

how do you treat vulval lichen SIMPLEX

Answer 11

emmolients + moderate potency steroids + antihistamines

if diagnosis in doubt biopsy

Question 12

what does lichen planus infection look like

Answer 12

purple patches/plaques with hypopigmented scaling

Question 13

what are features of vulval lichen planus

Answer 13

pruitis +/- pain

Question 14

how do you treat vulval lichen planus

Answer 14

high potency steroids

Question 15

what does lichen sclerosis look like

Answer 15

pink-white papules, sometimes linking to form hypopigmented patches of skin with fissures

Question 16

what are features of lichen sclerosis

Answer 16

severe pruitis - especially at night

sometimes adhesions may develop

Question 17

what do 40% of women with lichen sclerosis also have `

Answer 17

another autoimmune condition

Question 18

what is the risk of cancer progression from lichen sclerosus

Answer 18

5%

Question 19

what is the treatment for lichen sclerosus

Answer 19

ultra potent topical steroids

Question 20

what are examples of vulval pain syndromes

Answer 20

vulvar dysthaesia/vulvodynia

Question 21

what are vulval pain syndromes associated with

Answer 21

contraceptive use
burning vulvar pain
superficial dyspareunia

Question 22

how do you treat vulval pain syndromes

Answer 22

gabapentin/amitryptalline

Question 23

what infections commonly affect the vulva

Answer 23

herpes simplex
vulval warts
syphilis
donovanosis

Question 24

what is vulval candidiasis more common in

Answer 24

diabetes
immunosuppression
antibiotic use
pregnancy

Question 25

how do you treat vulval candidiasis

Answer 25

Topical Itraconazole

Question 26

what is a bartholins cyst

Answer 26

blockage of the serous gland used for vaginal lubrication

Question 27

what can happen with bartholins cyst’s if they go untreated

Answer 27

infection by e-coli/staph causing an abscess

Question 28

how do you treat a bartholins abscess

Answer 28

incision and drainage

marsupialisation may also be done (suturing open so it doesnt block again

Question 29

what are features of vaginal cysts

Answer 29

congenital asymptomatic lesions, appear smooth and white

Question 30

what is vaginal adenosis

Answer 30

columnar epithelium in the vagina

Question 31

what medication is commonly associated with vaginal adenosis

Answer 31

diethylstilboestrol in pregnancy (type of oestrogen)

Question 32

what is the natural progression of vaginal adenosis

Answer 32

normally spontaneously resolve but very ocasionally may turn malignant (clear cell cancer)

Question 33

what % of all genital cancers do vulval carcinomas account for

Answer 33

5%

Question 34

what is the most common age range for vulval carcinoma

Answer 34

> 60

Question 35

what are the vast majority (95%) of vulval carcinomas

Answer 35

SCCs

Question 36

what are risk factors for vulval carcinoma development

Answer 36

lichen sclerosis
immunosuppression
smoking
pagets disease of the vulva

Question 37

what is the presentation for vulval carcinomas

Answer 37

pruitis
bleeding
discharge

Question 38

what stage do 50% of patients with vulval carcinoma present at

Answer 38

1

Question 39

how is vulval carcinoma staged

Answer 39

Stage 1 tends to be whether it is contained in the perieum or not, there is a 1a and 1b referring to size and degree of stromal invasion , lymph nodes have to be negative 

Stage 2 Is any local spread outside the perineum with negative lymph nods 

Stage 3 is a tumour of any size with positive nodes 

Stage 4a is any invasion into urethra/bone/bladder/rectum 

Stage 4b is distant metastases 

Question 40

how do you treat vulval carcinoma

Answer 40

Stage 1
Wide local excision without a lympadenectomy

Other stages

If <4cm or no clinical suspicion of lymph node spread = Sentinel node biopsy

If SNB is -ve inguinofemoral lymphadenectomy is considered

If SNB is +ve or not indicated a wide local excision with groin lymphadenectomy is done (e.g. triple incision radical vulvectomy)

Question 41

what are the complications of a radical vulvectomy

Answer 41

wound breakdown
infection
sexual and body image issues 
lymphedema of the leg 
lymphoblast formation

Question 42

what is the prognosis of a radical vulvectomy (5 year survival)

Answer 42

5 year survival stage 1: >90%

3-4 = 40%