Disorders of the vulva and vagina

Question 1

Anatomy of vulva and vagina

Answer 1

vulva = everything in labia major, mons pubis and perineum
vagina = 7-10cm long, lined by squamous epithelium

most lymph drainage -> inguinal lymph nodes -> femoral -> external iliac nodes of pelvis (route of spread of vulvar carcinoma)

Question 2

Vulval symptoms

Answer 2

pruritus
soreness
burning
superficial dyspareunia (pain on sexual penetration)

causes = infection, dermatological disease, malignant and premalignant disease, vulval pain syndromes

systemic disease ay predispose to certain vulval conditions (e.g. candidiasis with DM)

Question 3

Lichen simplex (or chronic vulval dermatitis)

Answer 3

from sensitive skin/dermatitis/eczema → chronic inflammatory skin condition

sx:

• severe pruritus (especially at night)
• labia majora = inflamed, thickened with hyper/hypopigmentation
• exacerbated by chemical/contact dermatitis, stress, low body iron stores
• soap irritant

Ix: vulval biopsy if diagnosis is in doubt

Tx: emollients, moderately potent steroid creams and antihistamines to break tech-scratch cycle

Question 4

Lichen Planus

Answer 4

Mucosal surfaces of mouth and genital region

flat, papular, purplish lesions

erosive

pain than pruritus

tx: high potency steroid creams, surgery avoided

Question 5

Lichen sclerosus

2nd line = tacrolimus (done in specialist clinics)

Answer 5

vulval epithelium collagen loss

postmenopausal women

autoimmune, thyroid disease, vitiligo

pink-white papule → coalesce to form parchment-like skin with fissures

pruritus worse at night → trauma with bleeding, skin splitting → discomfort, pain, dyspareunia

ix: biopsy to exclude carcinoma
tx: ultra-potent topical steroids

Question 6

Vulvar dysaesthesia (vulvodynia) or the vulval pain syndromes

Answer 6

of exclusion, no organic causes

associated with = hx of genital tract infections, former use of oral contraceptives, psychosexual disorders

• spontaneous generalised = burning pain commonly in older patients
• vestibule = superificial dyspareunia, pain using tampons, more common in younger women

tx: amitriptyline or gabapentin (antidepressant or anticonvulsant)

Question 7

Infections of the vulva and vestibule (candidiasis example)

Answer 7

HSV, vulvar warts (condylomata acuminata), syphilis, donovanosis

candidiasis = if prolonged exposure to moisture, more common in diabetics/obese/pregnancy/abx/immunosuppressed

• irritation and soreness of vulva and anus rather than discharge
• tx: prolonged topical or oral anti fungal therapy

Question 8

vulvar candidiasis (acute mx) CKS

Answer 8

vulvar candidiasis (recurrent mx)

Question 9

Pruritus Vulvae (mx guide)

Answer 9

Question 10

Bartholin’s gland cyst and abscess

Answer 10

2 glands behind labia minor secrete lubricating mucus for coitus

blockage of duct → cyst formation

infection = Staph or E. coli → abscess

sx: acutely painful, large tender red swelling
tx: incision nd drainage, marsupialisation

Question 11

vulvovaginal candidiasis: mx guide

Answer 11

Question 12

Premalignant disease of the vulva: vulval intraepithelial neoplasia (VIN)

Answer 12

Usual type

• most VIN, 35-55 y/o
• associated with HPV (16) + CIN, cigarette smoking, chronic immunosuppression
• appearance varies
• usually warty/basaloid SCC

Differentiated type

• rarer
• associated with lichen sclerosis
• older women
• higher risk of progression to cancer

Pruritus/pain common in VIN

tx = emollients, mild topical steroids

GOLD STANDARD = local surgical excision to relieve sx’s, confirm histology and exclude invasive disease

Question 13

Vulvar carcinoma: epidemiology and pathology

Answer 13

most common over 60 y/o

95% SCC’s

Question 14

Vulvar carcinoma: aetiology

Answer 14

de novo

associated with lichen sclerosis, immunosupression, smoking and Paget’s disease of the vulva

Question 15

vulvar carcinoma: clinical features

Answer 15

History: pruritus, bleeding/discharge, may find mass, malignancy often presents late

Examination: ulcer/mass most commonly on labia major or clitoris, inguinal lymph nodes may be enlarged, hard and immobile

Question 16

vulvar carcinoma: spread and staging

Answer 16

50% stage 1

local spread to lymph drainage of vulva (superficial to deep inguinal nodes to external iliac nodes)

staging is surgical and histological (i.e. after surgery)

Question 17

Vulvar carcinoma: Ix

Answer 17

biopsy for diagnosis and histological type

CXR, ECG, FBC, U+E for fitness for surgery

Question 18

Vulvar carcinoma: treatment (mc guide)

Answer 18

stage 1a: local excision w/o inguinal lymphadenopathy

other stages: sentinel lymph node biopsy, complete inguinofemoral lymphadenopathy

Question 19

carcinoma of the vulva at a glance

Answer 19