Disorders of the Vulva and Vagina Flashcards
What components make up the vulva? 5
Occasionally contains what?
- Keratinized squamous epithelium,
- hair follicles,
- sebaceous glands,
- sweat glands,
- apocrine glands
- Occasionally contains breast tissue – may swell and become tender after delivery
- What kind of tissue makes up the vagina?
- Vaginal pH os what?
- Vaginal flora is made up of what? 3
- Nonkeratinized squamous epithelium
- Vaginal pH is 4.0- 4.5 in premenopausal women
- Vaginal flora –
- lactobacillus and other
- aerobic and
- anaerobic bacteria
Symptoms of vaginitis?
8
- A change in the volume, color, or odor of vaginal discharge
- Pruritus
- Burning
- Dyspareunia
- Dysuria
- Spotting
- Erythema
- Pelvic discomfort
Vaginitis
1. What is it important to document about veginitis?
- One CANNOT determine etiology from _________ alone and may mistreat the condition
- etiology of the vaginitis
2. history and PE
Careful external examination of the vulva:
1. In bacterial vaginitis the vulva appears how?
- What may suggest a dermatitis of the vulva? 3
- In bacterial vaginitis the vulva appears normal
- Erythema,
- lesions or
- fissures may suggest a dermatitis of the vulva
What things should we do in the exam for vaginitis?
5
- May detect a foreign body
- Note characteristics of vaginal discharge even though classic examples are not always the case
- Check the cervix for erythema and discharge
- Check for vaginal trauma
- Bimanual exam to check for cervical motion tenderness and uterine tenderness
- swab with a pH swab or dry swab the ______ of the vagina, not pooled secretions
- Use __________ pH paper or swab
- Premenopausal women—pH = ?
- Trichomoniasis—pH = ?
- Bacterial vaginosis—pH = ?
- Candidial infection—pH = ?
- In pregnant women amniotic fluid ______ the pH
- What is not helpful?
- WALL
- narrow range
- 3.5– 4.5
- 5.0-6.0
- > 4.5
- 4.0 – 4.5
- raises
- Bacterial cultures
What are some of the microscopy associated with vaginitis Dx?
4
- saline wet mount
- KOH prep
- rapid antigen
- Nucleic acid tests
What will you find on the following:
- saline wet mount 3
- KOH prep 3
What are the following tests used to dx?
3. Rapid antigen and Nucleic acid tests
- Saline wet mount: (evaluate within 20 min.)
- Clue cells—bacterial vaginosis (BV)
- Trichomonads
- Increased PMNs—cervicitis - KOH prep:
- Destroys cells
- Reveals hyphae & budding of yeast
- Amine test—smelling the slide immediately after adding KOH for the “fishy” smell of (BV or trich) - BV and rich
What is the most common cause of discharge of women of childbearing age?
Bacterial Vaginosis
Bacterial Vaginosis
- Abnormality of the normal vaginal flora? 2
- Findings on exam? 3
- Abnormality of the normal vaginal flora:
- Decrease in hydrogen-peroxidase lactobacilli
- Increase in primarily gram negative rods - Findings on exam:
- Fishy odor
- Clue cells
- Thin, white/gray, fishy smelling discharge
BV alone does not cause what? 5
What is usually the complaint?
BV alone does not cause what
- Dysuria
- Dyspareunia
- Pruritis
- Burning
- Vaginal inflammation
- Usual complaint is that of a malodorous or copious discharge
- Up to 75% of infections may be asymptomatic
Amsel criteria for diagnosis of BV
4
At least 3 of the 4 criteria:
- Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
- Vaginal pH > 4.5
- Positive whiff-amine test
- Clue cells on saline wet mount, comprising at least 20% of epithelial cells
BV treatment:
- First line?
- Alternate?
- Preferred: Metronidazole:
- Oral 500mg BID for 7 days (no alcohol)
- Intravaginal (gel) 5g q day for 5 days - Clindamycin:
- Oral 300mg po BID for 7 days
- Intravaginal
2% cream 5g q day for 7 days
Ovules 100mg intravaginal X 3 days
Clindesse 2%, single intravaginal dose of 5g
- _________ as an adjunctive therapy may be helpful
2. Do sexual partners need to be treated?
- Probiotics as an adjunctive therapy may be helpful
2. Sexual partners do not need to be treated
- Describe reoccurence rates?
- Women who have 3 or more documented cases of BV in 12 months be offered what?
- What do we not do for this?
- Recurrence rates are high
- May retreat with same or different regimen - Women who have 3 or more documented cases of BV in 12 months be offered maintenance therapy—metronidazole gel for 7-10 days then twice weekly dosing for 4-6 months
- NOT clindamycin because of toxicity
Vulvovaginal Candidiasis
Second most common cause of vaginitis symptoms and accounts for 1/3 of vaginitis cases—not an STI
1. Primary etiologic agent? 2
2. Pathogenesis? 3
- Candida albicans,
- C. glabrata accounts for the remainder
- Organism migrates from the anus to the vagina and colonizes there
- Less common sexual or relapse from reservoir in vagina
- Infection occurs when there is overgrowth of candida
Risk factors for Candidiasis
4
- DM
- Increased estrogen levels (e.g. OCP, pregnancy)
- Immunosuppression
- Antibiotic use (up to 1/3 of women develop it)
Diagnosis for Candidiasis:
3
- On speculum exam
- KOH wet mount slide (up to 50% negative)
- In rare cases cultures for candida are indicated:
What would you find on the spectulum exam for candiasis? 3
- Thick, white, sometimes “cottage cheese”, discharge
- In severe cases a gray membrane
- pH = 4.0-4.5
Wen would you get a culture for candida?
2
- In multiple recurrent or persistent cases not responsive to treatment (may have resistant pathogen)
- Women with normal pH, no visible pathogen on wet mount
Vulvovaginal Candidiasis
Prevention/Education
5
- Keep the external genital area clean and dry.
- Avoid irritating soaps (including bubble bath), vaginal sprays and douches
- Change tampons and sanitary napkins frequently
- Wear loose cotton (rather than nylon) underwear that doesn’t trap moisture
- Take antibiotics only when prescribed and never take them for longer then necessary
Treatment for candidiasis:
Uncomplicated infection (Mild to moderate signs/symptoms, Probable infection with C. albicans, Healthy, nonpregnant)?
2
- Many OTC intravaginal treatments available and highly effective
Women may prefer oral treatment—
2. Fluconazole (Diflucan) 150 mg x 1 dose prescription and can interact with many drugs stays in vaginal secretions 72 hours
What would make a candida infection complicated?
7
- Severe signs/symptoms
- Infection with other than C. albicans, usually C. glabrata
- Pregnancy,
- DM,
- immunosuppression,
- debilitation
- History of verified (> 4 infections yr.) vaginal candidiasis
Treatment of complicated candida?
4
- Fluconazole 150 mg 2-3 doses 72 hrs apart
- Topical therapy w/ clotrimazole/miconazole/terconazole for 7 – 14 days
- Intravaginal boric acid tablets for 2 weeks (FATAL IF SWALLOWED)
- Flucytosine cream intavaginally qHS for 2 wks
What is the most common STI in the world?
Trichomonas Vaginitis
What is Trichomonas caused by?
Flagellated protozoan—Trichomonas vaginalis—causative organism
Trichomonas Vaginitis
- How can the symptoms from this range in women? 2
- How is the disease transmitted? 3
- Females infections range from
-asymptomatic (50%) to
-acute, severe, inflammatory disease
(Males are generally asymptomatic & the infection resolves spontaneously 90% of the time—the remainder get typical urethritis symptoms) - Women can acquire the infection from men or
- other infected women;
- men do not acquire it from other men
Trichomonas Vaginitis
Presentation?
4
- Malodorous, thin, green/yellow vaginal discharge (70%)
- Burning, dysuria, frequency (urethra commonly involved also)
- Pruritus, dyspareunia, pelvic discomfort
- Post-coital bleeding
Trichomonas Dx?
5
- On speculum exam MAY see green, malodorous, frothy discharge (
What is a sign that occurs in 2% of trichomonas infection?
“Strawberry” Cervix
Who should we treat for trich?
2
- All women even if asymptomatic should be treated if there is evidence of infection
- All partners involved need to be treated and MUST abstain from sex until finishing antibiotic and asymptomatic
- Non-pregnant females & men with trich should be treated for what? 2
- Pregnant females?
- Nursing females?
- HIV positive pts?
- Recurrent infections:
- what is it usually due to?
- May treat with what?
- If the above fails?
- If still refractory?
- -Tinadazole (Tindamax) or
-metronidazole (Flagyl)
1 time dose of 2 grams (4-500mg pills) - Pregnant females: 2 g dose of metronidazole
- Nursing females: 2 g dose of Flagyl but pump breast milk and discard for 24 hours after taking
- HIV positive patients: 7 day course of either med BID
- Recurrent infections:
- Usually due to return to sexual activity too soon and reinfection
- May treat with Metronidazole 2g dose again or use 7 day course of 500mg BID of either drug
- If the above fails can treat with 2 g a day for 5 days
- If still refractory—culture to see if resistant strain
- Gentital herpes is caused by what?
2. Which episode will be the worst?
- caused by the herpes simplex virus
- HSV-1 and HSV-2 - The primary outbreak is the worst episode and recurrent outbreaks are generally less severe
Symptoms of genital herpes?
4
- Painful genital ulcers and itching
- Dysuria
- Tender inguinal lymphadenopathy
- May have systemic symptoms like headache and fever
- Genital herpes: Physical exam? 4
2. Dx should be confirmed by what? 2
- Physical exam:
- Multiple vesicles on an
- erythematous base are noted,
- vulvar swelling,
- lymphadenopathy - Diagnosis should be confirmed by
- viral cell culture or
- PCR (polymerase chain reaction)
Herpes Simplex - Management
- Treatment for PRIMARY infection needs to be started within __ hours—length _____ days
- What is the treatment? 3
- Recurrent disease treatment? 3
- Suppressive therapy? 3
- 72, 7-10
- Acyclovir (Zovirax): 400 mg TID or 200 mg 5 x a day
- Famcyclovir (Famvir): 250 mg TID
- Valocyclovir (Valtrex): 1000 mg BID
- Acylovir: 800 mg BID x 3 days
- Famcyclovir: 1000 mg BID x 1 day
- Valocyclovir: 500 mg BID x 3 days
- Acyclovir: 400 mg BID
- Famcyclovir: 250 mg BID
- Valocylovir: 500 mg 1 x a day
MOST common viral sexually transmitted disease in the U.S.?
Codylomata acuminata (anogenital warts)
Codylomata acuminata (anogenital warts)
- Etiologic agent?
- Clinical manifesation? 7
- HPV serotypes 16 and 18
- Pruritus,
- burning,
- pain
- Bleeding,
- vaginal discharge
- May have no symptoms
- When very large can interfere with defecation & coitus
Treatment for Genital Warts
Education? 3
- Must inform patient that prolonged treatment with frequent follow-up is necessary
- Clearance of warts is 35 – 100% but latent HPV can still exist and 20-30% have recurrence
- Spontaneous regression occurs up to 40% of cases
Treatment for Genital Warts
Indication for treatment? 4
- Alleviation of bothersome symptoms
- Cosmetic
- Because of obstruction, dyspareunia or psychological distress
- To decrease risk of transmission
Genital Warts: Reccommend a biopsy if what?
4
- Diagnosis is uncertain
- Lesion has suspicious features (irregular or unusual pigmentation)
- Patient is postmenopausal or immunocompromised
- Lesion is refractory to medical therapy
What are the types of treatment for genital warts? 3
- Chemical destruction
- Immunologic
- Surgery
Describe the different treatment options that are in each of the following categories:
- Chemical destruction? 3
- Immunologic? 2
- Surgery? 3
- Chemical destruction:
- Podophyllin—MUST NOT be used in pregnancy
- Trichloroacetic acid—highly caustic, can be used during pregnancy
- 5-fluorouracil gel—injected into the lesions - Immunologic:
- Imiquimod (Aldara) —externally applied cream
- Interferon alpha—systemic therapy - Surgery:
- Cryotherapy—liquid nitrogen, or probe cooled with nitrous oxide
- Laser therapy—done in operating room with anesthesia
- Excisional—knife or scissors, requires anesthesia
- Vertical transmission can occur:
HPV can manifest in young children as what?
3 - What is the most severe manifestation of Vertical transmission from genital warts?
- Mucosal,
- conjunctival or
- laryngeal disease
- Juvenile-onset respiratory papillomatosis (JRP) is the most severe although rare
Vulvar Disease-Mulloscum Contagiosum
- What does it look like? 6
- What might it contain?
- Can be transmitted how?
- Treatment? 3
- Multiple,
- 1-2 mm
- raised,
- painless lesions
- Dome-shaped with
- central dimple
- Contain cheesy-white material
- Can be sexually transmitted
- Treatment:
- cryosurgery,
- bichloracetic acid,
- dermal curette.
Atrophic Vaginitis
1. Can occur in women of any age who experience a decrease in what?
- Estrogen stimulation function? 6
- estrogenic stimulation of urogenital tissue
- Maintains a well-epithelialized vaginal vault
- It acts on receptors in the vagina, vulva, urethra & trigone of the bladder
- Maintains the collagen content of epithelium
- Keeps epithelial surfaces moist
- Maintains optimal genital blood flow
- Maintains acidic vaginal pH (without estrogen pH > 5)
Atrophic Vaginitis—Risk factors
8
- Natural menopause
- Bilateral oophorectomy
- Spontaneous premature ovarian failure
- Ovarian failure due to radiation, chemo or surgery
- Premenopausal meds with anti-estrogenic effect
- Post-partum reduction in estrogen production during lactation
- Prolactin elevation
- Amenorrhea secondary to suppression of the hypothalamic-pituitary axis because of chronic treatment with glucocorticoids
Atrophic Vaginitis- Clinical Manifestations
7
- Vaginal dryness, burning or itching
- Decreased lubrication during sex
- Dsypareunia
- Vulvar or vaginal bleeding (postcoital bleeding)
- Vaginal discharge
- Pelvic pressure or vaginal bulge
- Urinary tract symptoms—frequency, dysuria, hematuria
PE findings for atrophic vaginitis?
8
- Pale, smooth or shiny vaginal epithelium
- Loss of elasticity
- Sparsity of pubic hair
- Introital narrowing
- Lack of moisture
- Fusion or resorption of the labia minora
- Friable, unrugated epithelium of the vagina
- Shorten, narrowed, and poorly distensible vaginal vault
Atrophy: The clinical picture
6
- 2 years since natural menopause
- Loss of labial and vulvar fullness
- Pallor of urethral and vaginal epithelium
- Narrow introitus
- Minial vaginal moisture
- Loss of urethral meatal turgor
Treatment for atrophic vaginitis:
- Who is it indicated for?
- Rx for vaginal dryness? 3
- What is the most effective therapy?
- Treatment is indicated if the symptoms are causing a women distress
- Vaginal dryness:
- Vaginal moisturizers—Replens, Vagisil, and K-Y: to be used one or more times a week
- Vaginal lubricants are used at the time of coitus
- Sexual activity itself may improve vaginal function - vaginal estrogen therapy
Vaginal estrogen therapy:
- Contraindications?
- Advantage?
- Ways to administer this?
- SE? 3
- Some women need what kind of therapy?
- Contraindications: a woman with estrogen-dependent tumor
- Associated with urinary tract benefits
- Usually start with vaginal estrogen therapy:
- Cream,
- tablet or
- ring - SE:
- vaginal irritation,
- bleeding or
- breast tenderness - Systemic therapy
- What is the systemic estrogen therapy option for atrophic vaginitis?
- WHat drug?
- SE? 3
- Selective estrogen receptor modulator (SERM)
- Ospemifene (Osphena)
- SE:
- hot flushes,
- thromboembolism,
- endometrial cancer
Lichen Sclerosis
- Etology may be linked to what? 2
- PP?
- Two peaks of incidence?
- Dx?
- Symptoms? (whats the hallmark?) 5
- Etiology may be linked to genetics or autoimmune
- Pathophysiology: Intense inflammatory reaction
- Two peaks—prepubertal girls & postmenopausal women
- Diagnosis—biopsy
4% risk of cancer occurring - Symptoms
- Vulvar pruritus is the hallmark and may be so intense as to interfere with sleep
- Pruritus ani,
- painful defecation,
- anal fissures,
- dyspareunia
Lichen sclerosis exam
Exam findings?
6
- Chronic inflammation
- Well-demarcated white,
- finely wrinkled,
- atrophic patches
- Labia minora often shrink &
- adhesions of the labia majora may cover the clitoris
Treatment for lichen sclerosis
2
- clobetasol propionate 0.05% cream for 6-12 weeks (topical steroids)
- Then for maintenance therapy apply 1-3 times per week
What is the most common large cyst of the vulva?
Bartholin Duct Cyst
-average 1-3 cm size
Bartholin Glands Disorders
1. 2-3% of women develop what of the Bartholin glands? 2
- What are rare? 2
- Many what mimic Bartholin gland disorders—good differential diagnosis? 2
- cysts or abscesses
- Carcinoma and benign tumors
- vaginal and vulvar lesions
Bartholin Duct Cyst
- Most present how?
- How should we treat in women under 40?
- Over 40?
- If the cyst is large and not resolving then it can be treated with what?
- Treatment not necessary in women less than 40 unless infected or symptomatic
- In women older than 40, biopsy & drainage is performed to exclude carcinoma
- If the cyst is large and not resolving then it can be treated with the techniques described for treating an abscess
Bartholin Duct Abscess
- Clinical manifestations? 4
- Infection is usually what?
- ____ less likely but should be tested for in patients who are at a higher risk of STIs
- Rise in ______ as etiologic agent
- Clinical Manifestations:
- Swelling of the Bartholin gland with exquisite pain
- Occurs in 2% of women
- On exam it is erythematous, warm, tender and usually fluctuant
- There may be surrounding cellulitis
Infection:
- Usually polymicrobial
- STIs
- MRSA
Treatment of Cyst or Abscess
2
- I & D—lanced at or behind hymenal ring
2. Place a Word catheter into the cavity—left in place for at least 4 weeks
Treatment of Cyst or Abscess
- What is marsupialization?
- Reserved for who?
- Complications? 3
- Marsupialization is the surgical technique of cutting a slit into an abscess or cyst and suturing the edges of the slit to form a continuous surface from the exterior surface to the interior surface of the cyst or abscess.
- Done under local anesthesia
- Longer procedure - Reserved for patients who fail 1-2 placements of a Word catheter
- Complications:
- hematoma,
- scarring,
- dyspareunia
Cystocele:
- Aka?
- What is it?
- Occurs when?
- Causes?6
- AKA prolapsed bladder
- Bulging of the bladder into the vagina
- Occurs when the supportive tissues and muscles between the bladder and the vagina weaken and stretch…bladder bulges into vagina
- Causes:
- childbirth
- Repetitive straining for bowel movements
- Constipation
- Chronic or violent coughing
- Heavy lifting
- Obesity
Cystocele: Treatment?
4
- Watchful waiting, avoid heavy lifting or straining
- Pelvic floor (Kegel) exercises to strengthen pelvic muscles
- Pessary….silicone medical device placed in the vagina that supports the vaginal wall and hold the bladder in place
- Anterior vaginal wall repair (colporrhaphy)
- Whats Paget’s Disease?
- Extramammory dz may involve what? 3
- This may be indicative of what?
- Lesions look how? 4
- S/S? 3
- Intraepithelial adenocarcinoma
- Extramammary disease may involve
- genital,
- perianal and
- axillary areas - May be indication of underlying malignancy
- Lesions are
- brick red,
- scaly,
- velvety eczematoid plaque with
- sharp border - S/S:
- itching,
- burning,
- bleeding
Paget’s Disease
- Primary treatment?
- Recurrent disease may be treated with what? 5
- Reoccurrence?
- Primary treatment: excision with > 3 mm border from visible margin
- Recurrent disease may be treated with:
- Radiotherapy
- Laser
- Photodynamic therapy
- 5-FU
- Imiquimod - Local recurrence rate is 31-43%
Vulvar cancer:
Risk factors?
7
- HPV infection (60% )
- Cigarette smoking
- Lichen sclerosis
- Vulvar or cervical intraepithelial neoplasia
- Immunodefiency syndromes
- Prior history of cervical cancer
- Northern European ancestry
Vulvar cancer clinical manifestations?
6
- Unifocal vulvar plaque, ulcer or mass
- In 10% of cases the lesion is too extensive to determine the site of origin
- Lesions are multifocal in 5% of cases
- A second malignancy—usually cervical CA is found in up to 22% of patients with vulvar malignancy
- Pruritis is a common complaint
- Many patients are asymptomatic - NEED TO INSPECT
Histological Types of vulvar cancer?
5
- Squamous cell: over 90%
- Verrucous carcinoma—variant of squamous cell
- Melanoma—second most common vulvar CA
- Basal Cell carcinoma—2%
- Extramammary Paget disease- less than 1%
- Squamous cell vulvar cancer will have what histology?
2. How will it look?
- Keratinizing, differentiated or simplex type—more common
2. May have a warty appearance —predominately associated with oncongenic strains of HPV (found in younger women)
Vulavar CA—Mode of Spread
3
- Direct extension to adjacent structures
- Lymphatic embolization to regional lymph nodes—can occur early
- Hematogenous dissemination—occurs late in the disease
Vaginal Intraepithelial Neoplasia
- What reason to continue what after hysterectomy?
- Which strains of HPV associated with VAIN cases?
- Treatment? 4
VAIN (carcinoma)
- A reason to continue PAP smears after hysterectomy
- HPV (types 6 & 11) assoc with 80% of VAIN cases
- Treatment
- Laser ablation
- Local excision
- 5-fluorouracil intravaginal
- Vaginectomy and skin graft
Vaginal Intraepithelial Neoplasia
- MC histology type?
- Consistently associated with what?
- 50 to 90% of patients with VAIN had or currently have either? 2
- Vaginal squamous cell atypia without invasion
- VAIN is consistently associated with prior or concurrent neoplasia elsewhere in the lower genital tract
- intraepithelial neoplasia or carcinoma of the cervix or vulva