Disorders of the Vulva and Vagina Flashcards
1
Q
What components make up the vulva? 5
Occasionally contains what?
A
- Keratinized squamous epithelium,
- hair follicles,
- sebaceous glands,
- sweat glands,
- apocrine glands
- Occasionally contains breast tissue – may swell and become tender after delivery
2
Q
- What kind of tissue makes up the vagina?
- Vaginal pH os what?
- Vaginal flora is made up of what? 3
A
- Nonkeratinized squamous epithelium
- Vaginal pH is 4.0- 4.5 in premenopausal women
- Vaginal flora –
- lactobacillus and other
- aerobic and
- anaerobic bacteria
3
Q
Symptoms of vaginitis?
8
A
- A change in the volume, color, or odor of vaginal discharge
- Pruritus
- Burning
- Dyspareunia
- Dysuria
- Spotting
- Erythema
- Pelvic discomfort
4
Q
Vaginitis
1. What is it important to document about veginitis?
- One CANNOT determine etiology from _________ alone and may mistreat the condition
A
- etiology of the vaginitis
2. history and PE
5
Q
Careful external examination of the vulva:
1. In bacterial vaginitis the vulva appears how?
- What may suggest a dermatitis of the vulva? 3
A
- In bacterial vaginitis the vulva appears normal
- Erythema,
- lesions or
- fissures may suggest a dermatitis of the vulva
6
Q
What things should we do in the exam for vaginitis?
5
A
- 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
7
Q
- 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?
A
- WALL
- narrow range
- 3.5– 4.5
- 5.0-6.0
- > 4.5
- 4.0 – 4.5
- raises
- Bacterial cultures
8
Q
What are some of the microscopy associated with vaginitis Dx?
4
A
- saline wet mount
- KOH prep
- rapid antigen
- Nucleic acid tests
9
Q
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
A
- 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
10
Q
What is the most common cause of discharge of women of childbearing age?
A
Bacterial Vaginosis
11
Q
Bacterial Vaginosis
- Abnormality of the normal vaginal flora? 2
- Findings on exam? 3
A
- 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
12
Q
BV alone does not cause what? 5
What is usually the complaint?
A
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
13
Q
Amsel criteria for diagnosis of BV
4
A
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
14
Q
BV treatment:
- First line?
- Alternate?
A
- 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
15
Q
- _________ as an adjunctive therapy may be helpful
2. Do sexual partners need to be treated?
A
- Probiotics as an adjunctive therapy may be helpful
2. Sexual partners do not need to be treated
16
Q
- 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?
A
- 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
17
Q
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
A
- 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
18
Q
Risk factors for Candidiasis
4
A
- DM
- Increased estrogen levels (e.g. OCP, pregnancy)
- Immunosuppression
- Antibiotic use (up to 1/3 of women develop it)
19
Q
Diagnosis for Candidiasis:
3
A
- On speculum exam
- KOH wet mount slide (up to 50% negative)
- In rare cases cultures for candida are indicated:
20
Q
What would you find on the spectulum exam for candiasis? 3
A
- Thick, white, sometimes “cottage cheese”, discharge
- In severe cases a gray membrane
- pH = 4.0-4.5
21
Q
Wen would you get a culture for candida?
2
A
- In multiple recurrent or persistent cases not responsive to treatment (may have resistant pathogen)
- Women with normal pH, no visible pathogen on wet mount
22
Q
Vulvovaginal Candidiasis
Prevention/Education
5
A
- 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
23
Q
Treatment for candidiasis:
Uncomplicated infection (Mild to moderate signs/symptoms, Probable infection with C. albicans, Healthy, nonpregnant)?
2
A
- 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
24
Q
What would make a candida infection complicated?
7
A
- Severe signs/symptoms
- Infection with other than C. albicans, usually C. glabrata
- Pregnancy,
- DM,
- immunosuppression,
- debilitation
- History of verified (> 4 infections yr.) vaginal candidiasis
25
Treatment of complicated candida?
| 4
1. Fluconazole 150 mg 2-3 doses 72 hrs apart
2. Topical therapy w/ clotrimazole/miconazole/terconazole for 7 – 14 days
3. Intravaginal boric acid tablets for 2 weeks (FATAL IF SWALLOWED)
4. Flucytosine cream intavaginally qHS for 2 wks
26
What is the most common STI in the world?
Trichomonas Vaginitis
27
What is Trichomonas caused by?
Flagellated protozoan—Trichomonas vaginalis—causative organism
28
Trichomonas Vaginitis
1. How can the symptoms from this range in women? 2
2. How is the disease transmitted? 3
1. 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)
2.
- Women can acquire the infection from men or
- other infected women;
- men do not acquire it from other men
29
Trichomonas Vaginitis
Presentation?
4
1. Malodorous, thin, green/yellow vaginal discharge (70%)
2. Burning, dysuria, frequency (urethra commonly involved also)
3. Pruritus, dyspareunia, pelvic discomfort
4. Post-coital bleeding
30
Trichomonas Dx?
| 5
1. On speculum exam MAY see green, malodorous, frothy discharge (
31
What is a sign that occurs in 2% of trichomonas infection?
“Strawberry” Cervix
32
Who should we treat for trich?
| 2
1. All women even if asymptomatic should be treated if there is evidence of infection
2. All partners involved need to be treated and MUST abstain from sex until finishing antibiotic and asymptomatic
33
1. Non-pregnant females & men with trich should be treated for what? 2
2. Pregnant females?
3. Nursing females?
4. HIV positive pts?
5. Recurrent infections:
- what is it usually due to?
- May treat with what?
- If the above fails?
- If still refractory?
1.
-Tinadazole (Tindamax) or
-metronidazole (Flagyl)
1 time dose of 2 grams (4-500mg pills)
2. Pregnant females: 2 g dose of metronidazole
3. Nursing females: 2 g dose of Flagyl but pump breast milk and discard for 24 hours after taking
4. HIV positive patients: 7 day course of either med BID
5. 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
34
1. Gentital herpes is caused by what?
| 2. Which episode will be the worst?
1. caused by the herpes simplex virus
- HSV-1 and HSV-2
2. The primary outbreak is the worst episode and recurrent outbreaks are generally less severe
35
Symptoms of genital herpes?
| 4
1. Painful genital ulcers and itching
2. Dysuria
3. Tender inguinal lymphadenopathy
4. May have systemic symptoms like headache and fever
36
1. Genital herpes: Physical exam? 4
| 2. Dx should be confirmed by what? 2
1. Physical exam:
- Multiple vesicles on an
- erythematous base are noted,
- vulvar swelling,
- lymphadenopathy
2. Diagnosis should be confirmed by
- viral cell culture or
- PCR (polymerase chain reaction)
37
Herpes Simplex - Management
1. Treatment for PRIMARY infection needs to be started within __ hours—length _____ days
2. What is the treatment? 3
3. Recurrent disease treatment? 3
4. Suppressive therapy? 3
1. 72, 7-10
2.
- Acyclovir (Zovirax): 400 mg TID or 200 mg 5 x a day
- Famcyclovir (Famvir): 250 mg TID
- Valocyclovir (Valtrex): 1000 mg BID
3.
- Acylovir: 800 mg BID x 3 days
- Famcyclovir: 1000 mg BID x 1 day
- Valocyclovir: 500 mg BID x 3 days
4.
- Acyclovir: 400 mg BID
- Famcyclovir: 250 mg BID
- Valocylovir: 500 mg 1 x a day
38
MOST common viral sexually transmitted disease in the U.S.?
Codylomata acuminata (anogenital warts)
39
Codylomata acuminata (anogenital warts)
1. Etiologic agent?
2. Clinical manifesation? 7
1. HPV serotypes 16 and 18
1.
- Pruritus,
- burning,
- pain
- Bleeding,
- vaginal discharge
- May have no symptoms
- When very large can interfere with defecation & coitus
40
Treatment for Genital Warts
| Education? 3
1. Must inform patient that prolonged treatment with frequent follow-up is necessary
2. Clearance of warts is 35 – 100% but latent HPV can still exist and 20-30% have recurrence
3. Spontaneous regression occurs up to 40% of cases
41
Treatment for Genital Warts
| Indication for treatment? 4
1. Alleviation of bothersome symptoms
2. Cosmetic
3. Because of obstruction, dyspareunia or psychological distress
4. To decrease risk of transmission
42
Genital Warts: Reccommend a biopsy if what?
| 4
1. Diagnosis is uncertain
2. Lesion has suspicious features (irregular or unusual pigmentation)
3. Patient is postmenopausal or immunocompromised
4. Lesion is refractory to medical therapy
43
What are the types of treatment for genital warts? 3
1. Chemical destruction
2. Immunologic
3. Surgery
44
Describe the different treatment options that are in each of the following categories:
1. Chemical destruction? 3
2. Immunologic? 2
3. Surgery? 3
1. 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
2. Immunologic:
- Imiquimod (Aldara) —externally applied cream
- Interferon alpha—systemic therapy
3. Surgery:
- Cryotherapy—liquid nitrogen, or probe cooled with nitrous oxide
- Laser therapy—done in operating room with anesthesia
- Excisional—knife or scissors, requires anesthesia
45
1. Vertical transmission can occur:
HPV can manifest in young children as what?
3
2. What is the most severe manifestation of Vertical transmission from genital warts?
1.
- Mucosal,
- conjunctival or
- laryngeal disease
2.
- Juvenile-onset respiratory papillomatosis (JRP) is the most severe although rare
46
Vulvar Disease-Mulloscum Contagiosum
1. What does it look like? 6
2. What might it contain?
3. Can be transmitted how?
4. Treatment? 3
1.
- Multiple,
- 1-2 mm
- raised,
- painless lesions
- Dome-shaped with
- central dimple
2. Contain cheesy-white material
3. Can be sexually transmitted
4. Treatment:
- cryosurgery,
- bichloracetic acid,
- dermal curette.
47
Atrophic Vaginitis
1. Can occur in women of any age who experience a decrease in what?
2. Estrogen stimulation function? 6
1. estrogenic stimulation of urogenital tissue
2.
- 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)
48
Atrophic Vaginitis—Risk factors
8
1. Natural menopause
2. Bilateral oophorectomy
3. Spontaneous premature ovarian failure
4. Ovarian failure due to radiation, chemo or surgery
5. Premenopausal meds with anti-estrogenic effect
6. Post-partum reduction in estrogen production during lactation
7. Prolactin elevation
8. Amenorrhea secondary to suppression of the hypothalamic-pituitary axis because of chronic treatment with glucocorticoids
49
Atrophic Vaginitis- Clinical Manifestations
| 7
1. Vaginal dryness, burning or itching
2. Decreased lubrication during sex
3. Dsypareunia
4. Vulvar or vaginal bleeding (postcoital bleeding)
5. Vaginal discharge
6. Pelvic pressure or vaginal bulge
7. Urinary tract symptoms—frequency, dysuria, hematuria
50
PE findings for atrophic vaginitis?
| 8
1. Pale, smooth or shiny vaginal epithelium
2. Loss of elasticity
3. Sparsity of pubic hair
4. Introital narrowing
5. Lack of moisture
6. Fusion or resorption of the labia minora
7. Friable, unrugated epithelium of the vagina
8. Shorten, narrowed, and poorly distensible vaginal vault
51
Atrophy: The clinical picture
| 6
1. 2 years since natural menopause
2. Loss of labial and vulvar fullness
3. Pallor of urethral and vaginal epithelium
4. Narrow introitus
5. Minial vaginal moisture
6. Loss of urethral meatal turgor
52
Treatment for atrophic vaginitis:
1. Who is it indicated for?
2. Rx for vaginal dryness? 3
3. What is the most effective therapy?
1. Treatment is indicated if the symptoms are causing a women distress
2. 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
3. vaginal estrogen therapy
53
Vaginal estrogen therapy:
1. Contraindications?
2. Advantage?
3. Ways to administer this?
4. SE? 3
5. Some women need what kind of therapy?
1. Contraindications: a woman with estrogen-dependent tumor
2. Associated with urinary tract benefits
3. Usually start with vaginal estrogen therapy:
- Cream,
- tablet or
- ring
4. SE:
- vaginal irritation,
- bleeding or
- breast tenderness
5. Systemic therapy
54
1. What is the systemic estrogen therapy option for atrophic vaginitis?
2. WHat drug?
3. SE? 3
1. Selective estrogen receptor modulator (SERM)
2. Ospemifene (Osphena)
3. SE:
- hot flushes,
- thromboembolism,
- endometrial cancer
55
Lichen Sclerosis
1. Etology may be linked to what? 2
2. PP?
3. Two peaks of incidence?
4. Dx?
5. Symptoms? (whats the hallmark?) 5
1. Etiology may be linked to genetics or autoimmune
2. Pathophysiology: Intense inflammatory reaction
3. Two peaks—prepubertal girls & postmenopausal women
4. Diagnosis—biopsy
4% risk of cancer occurring
5. Symptoms
- Vulvar pruritus is the hallmark and may be so intense as to interfere with sleep
- Pruritus ani,
- painful defecation,
- anal fissures,
- dyspareunia
56
Lichen sclerosis exam
Exam findings?
6
1. Chronic inflammation
2. Well-demarcated white,
3. finely wrinkled,
4. atrophic patches
5. Labia minora often shrink &
6. adhesions of the labia majora may cover the clitoris
57
Treatment for lichen sclerosis
| 2
1. clobetasol propionate 0.05% cream for 6-12 weeks (topical steroids)
2. Then for maintenance therapy apply 1-3 times per week
58
What is the most common large cyst of the vulva?
Bartholin Duct Cyst
| -average 1-3 cm size
59
Bartholin Glands Disorders
1. 2-3% of women develop what of the Bartholin glands? 2
2. What are rare? 2
3. Many what mimic Bartholin gland disorders—good differential diagnosis? 2
1. cysts or abscesses
2. Carcinoma and benign tumors
3. vaginal and vulvar lesions
60
Bartholin Duct Cyst
1. Most present how?
2. How should we treat in women under 40?
3. Over 40?
4. If the cyst is large and not resolving then it can be treated with what?
1. Treatment not necessary in women less than 40 unless infected or symptomatic
2. In women older than 40, biopsy & drainage is performed to exclude carcinoma
3. If the cyst is large and not resolving then it can be treated with the techniques described for treating an abscess
61
Bartholin Duct Abscess
1. Clinical manifestations? 4
2. Infection is usually what?
3. ____ less likely but should be tested for in patients who are at a higher risk of STIs
4. Rise in ______ as etiologic agent
1. 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:
2. Usually polymicrobial
3. STIs
4. MRSA
62
Treatment of Cyst or Abscess
| 2
1. I & D—lanced at or behind hymenal ring
| 2. Place a Word catheter into the cavity—left in place for at least 4 weeks
63
Treatment of Cyst or Abscess
1. What is marsupialization?
2. Reserved for who?
3. Complications? 3
1. 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
2. Reserved for patients who fail 1-2 placements of a Word catheter
3. Complications:
- hematoma,
- scarring,
- dyspareunia
64
Cystocele:
1. Aka?
2. What is it?
3. Occurs when?
4. Causes?6
1. AKA prolapsed bladder
2. Bulging of the bladder into the vagina
3. Occurs when the supportive tissues and muscles between the bladder and the vagina weaken and stretch…bladder bulges into vagina
4. Causes:
- childbirth
- Repetitive straining for bowel movements
- Constipation
- Chronic or violent coughing
- Heavy lifting
- Obesity
65
Cystocele: Treatment?
| 4
1. Watchful waiting, avoid heavy lifting or straining
2. Pelvic floor (Kegel) exercises to strengthen pelvic muscles
3. Pessary….silicone medical device placed in the vagina that supports the vaginal wall and hold the bladder in place
4. Anterior vaginal wall repair (colporrhaphy)
66
1. Whats Paget's Disease?
2. Extramammory dz may involve what? 3
3. This may be indicative of what?
4. Lesions look how? 4
5. S/S? 3
1. Intraepithelial adenocarcinoma
2. Extramammary disease may involve
- genital,
- perianal and
- axillary areas
3. May be indication of underlying malignancy
4. Lesions are
- brick red,
- scaly,
- velvety eczematoid plaque with
- sharp border
5. S/S:
- itching,
- burning,
- bleeding
67
Paget’s Disease
1. Primary treatment?
2. Recurrent disease may be treated with what? 5
3. Reoccurrence?
1. Primary treatment: excision with > 3 mm border from visible margin
2. Recurrent disease may be treated with:
- Radiotherapy
- Laser
- Photodynamic therapy
- 5-FU
- Imiquimod
3. Local recurrence rate is 31-43%
68
Vulvar cancer:
Risk factors?
7
1. HPV infection (60% )
2. Cigarette smoking
3. Lichen sclerosis
4. Vulvar or cervical intraepithelial neoplasia
5. Immunodefiency syndromes
6. Prior history of cervical cancer
7. Northern European ancestry
69
Vulvar cancer clinical manifestations?
| 6
1. Unifocal vulvar plaque, ulcer or mass
2. In 10% of cases the lesion is too extensive to determine the site of origin
3. Lesions are multifocal in 5% of cases
4. A second malignancy—usually cervical CA is found in up to 22% of patients with vulvar malignancy
5. Pruritis is a common complaint
6. Many patients are asymptomatic - NEED TO INSPECT
70
Histological Types of vulvar cancer?
| 5
1. Squamous cell: over 90%
2. Verrucous carcinoma—variant of squamous cell
3. Melanoma—second most common vulvar CA
4. Basal Cell carcinoma—2%
5. Extramammary Paget disease- less than 1%
71
1. Squamous cell vulvar cancer will have what histology?
| 2. How will it look?
1. Keratinizing, differentiated or simplex type—more common
| 2. May have a warty appearance —predominately associated with oncongenic strains of HPV (found in younger women)
72
Vulavar CA—Mode of Spread
| 3
1. Direct extension to adjacent structures
2. Lymphatic embolization to regional lymph nodes—can occur early
3. Hematogenous dissemination—occurs late in the disease
73
Vaginal Intraepithelial Neoplasia
1. What reason to continue what after hysterectomy?
2. Which strains of HPV associated with VAIN cases?
3. Treatment? 4
VAIN (carcinoma)
1. A reason to continue PAP smears after hysterectomy
2. HPV (types 6 & 11) assoc with 80% of VAIN cases
3. Treatment
- Laser ablation
- Local excision
- 5-fluorouracil intravaginal
- Vaginectomy and skin graft
74
Vaginal Intraepithelial Neoplasia
1. MC histology type?
2. Consistently associated with what?
3. 50 to 90% of patients with VAIN had or currently have either? 2
1. Vaginal squamous cell atypia without invasion
2. VAIN is consistently associated with prior or concurrent neoplasia elsewhere in the lower genital tract
3. intraepithelial neoplasia or carcinoma of the cervix or vulva
