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OB/GYN > Disorders of the Vulva and Vagina > Flashcards

Disorders of the Vulva and Vagina Flashcards

1
Q

Causes of vaginitis?

A
  • bacterial vaginosis
  • trichomonas
  • candidiasis
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2
Q

Normal cell structure of the vulva?

A
  • keratinized squamous epithelium, hair follicles, sebaceous glands, sweat glands, apocrine glands
  • occasionally contains breast tissue: may swell and become tender after delivery
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3
Q

Normal cell structure and flora of the vagina?

A
  • nonkeratinized squamous epithelium
  • vaginal pH is 4.0-4.5 in premenopausal women
  • vaginal flora - lactobacillus and other aerobic and anaerobic bacteria
  • normal vaginal secretions: no odor
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4
Q

How common are vaginal sxs?

A
  • extremely common, account for over 10 million office visits/yr
  • many women use OTC products (usually anticandidial tx) w/o ever seeing a provider
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5
Q

What are the sxs of vaginitis?

A
  • change in volume, color, or odor of vaginal d/c
  • pruritus
  • burning
  • dyspareunia
  • dysuria
  • spotting
  • erythema
  • pelvic discomfort
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6
Q

Can you determine etiology of vaginitis just by H and P?

A
  • no, may mistreat condition
  • impt that lab documentation of etiology of vaginitis is determined
  • sxs are nonspecific
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7
Q

PE of vagintis?

A

careful external exam of vulva:

  • in bacterial vaginitis the vulva appears normal
  • erythema, lesions or fissures may suggest a dermatitis of the vulva
  • may be changes suggesting chronic inflammation
  • may detect fb
  • note characteristics of d/c
  • check cervix for erythema and d/c
  • check for vaginal trauma
  • bimanual exam to check for cervical motion tenderness and uterine tenderness
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8
Q

pH testing for vaginitis?

A

swab with pH swab or dry swab the wall of the vagina, not pooled secretions

  • use narrow range pH paper or swab
  • premenopausal women= 3.5-4.5
  • trichomoniasis= 5.0-6.0
  • bacterial vaginosis= greater than 4.5
  • candidiasis= 4.0-4.5
  • in pregnant women amniotic fluid raises pH
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9
Q

Are bacterial cultures of the vagina helpful?

A
  • NOPE!
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10
Q

What are saline wet mounts for? What will be seen?

A
  • eval in 20 min
  • see clue cells - bacterial vaginosis
  • trichomonads
  • increased PMNs- cervicitis
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11
Q

What is a KOH used for? What does it reveal? What otehr test is used along with this?

A
  • destroys regular cells and reveals hyphae and budding of yeast
  • amine test - smelling the slide immediately after adding KOH for fishy smell (BV or trich)
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12
Q

What other tests are available for trich and BV?

A
  • rapid antigen and nucleic acid tests
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13
Q

What is the MC cause of d/c of women of childbearing age? What is the cause of this? Findings on exam?

A
  • Bacterial vaginosis (40-50%)
  • abnormality of normal vaginal flora: decrease in hydrogen-peroxidase lactobacilli and increase in primarily gram negative rods
  • findings on exam:
    fishy odor, clue cells, and thin, white/gray, fishy smelling d/c
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14
Q

Usual complaint of a pt with BV?

A
  • malodorous or copious d/c

- up to 75% of infections may be asx

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15
Q

What is the amsel criteria for the dx of BV?

A

at least 3/4 criteria:

  • homogenous, thin, grayish white d/c that smoothly coats the vaginal walls
  • vaginal pH greater than 4.5
  • positive whiff-amine test
  • clue cells on saline wet mount, comprising at least 20% of epithelial cells
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16
Q

Tx for BV?

A 
- TOC: metronidazole 
oral 500 mg BID for 7 days (no alcohol), or intravaginal (gel) 5g qday for 5 days
- clindamycin:
oral 300 mg po BID for 7 days
intravaginal:
2% cream 5g qday for 7 days
ovules 100 mg intravaginal x 3 days
clindesses 2%, single intravaginal dose of 5 g
  • probiotics as adjunctive therapy may be helpful, sexual partners don’t need to be tx
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17
Q

Recurrence rates of BV? How should these be tx?

A
  • recurrence rates are high
  • may retx with same or different regimen
  • women who have 3 or more documented cases of BV in 12 months be offered maintenace therapy - metronidazole gel for 7-10 days then 2x weekly dosing for 4-6 months
  • not clindamycin b/c of toxicity
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18
Q

2nd MC cause of vaginitis sxs? What are the etiologic agents?

A
  • vulvovaginal candidiasis
  • accounts for 1/3 of vaginitis cases (not an STI)
  • primary etiologic agent: candida albicans, C. glabrata accounts for remainder
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19
Q

Pathogenesis of vulvovaginal candidiasis?

A
  • 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
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20
Q

RFs for candidiasis?

A
  • DM
  • increased estrogen levels (OCP, pregnancy)
  • immunosuppression
  • abx use (up to 1/3 of women develop it)
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21
Q

Dx of candidiasis?

A
  • on speculum exam:
    thick, white, sometimes cottage cheese d/c.
    in severe cases a gray membrane, pH will be 4.0-4.5
  • KPH wet mount slide (up to 50% negative)
  • in rare cases cultures for candida are indicated:
    in multiple recurrent or persistent cases not responsive to tx (may have resistant pathogen), women with normal pH, no visible pathogen on wet mount
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22
Q

Education for pt to prevent candidiasis?

A
  • keep external genital area clean and dry
  • avoid irritating soaps, vaginal sprays, douches
  • change tampons and sanitary napkins frequently
  • wear loose cotton (rather than nylon) underwear that doesn’t trap moisture
  • take abx only when rx and never take them for longer than necessary
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23
Q

Tx of uncomplicated candidiasis infection?

A

this includes pts with mild to moderate signs/sxs, have probable infection with C. albicans, pt is healthy and not pregnant
tx:
- many OTC intravaginal txs available and highly effective, women may prefer oral tx:
fluconazole (diflucan) 150mgx1 dose - this can interact with many drugs, stays in vaginal secretions for 72 hrs

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24
Q

Tx for complicated candidiasis infection?

A

this includes pts with severe signs/sxs, infection with other C. albicans (usually C. glabrata), pregnancy, DM, immunocompromised, debilitated, hx of verified (more than 4 infections a yr) of vaginal candidiasis
tx:
- fluconazole 150mg 2-3 doses 72 hrs apart, or topical therapy with clotrimazole/miconazole/terconazole for 7-14 days, or intravaginal boric acid tablets for 2 wks (fatal if swallowed) or flucytosine cream intravaginally qhs for 2 wks

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25
Q

What is the most common STI worldwide? What type of organism is this? Who does this infect? Sxs?

A
  • Trichomonas vaginitis
  • flagellated protozoan (causative agent = trichomonas vaginalis)
  • females infections range from asx (50%) to acute, severe, inflammatory disease
  • males are generally asx and infection resolves spontaneously 90% of the time (the remainder get typical urethritis sxs)
  • women can acquire the infection from men or other infected women, but men can’t acquire it from other men
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26
Q

Presentation of trichomonas vaginitis?

A
  • malodorous, thin, green/yellow vaginal d/c (70%)
  • burning, dysuria, frequency (urethra commonly involved also- presents like a UTI)
  • pruritus, dyspareunia, pelvic discomfort
  • post-coital bleeding
27
Q

Dx of trichomonas?

A
  • on speculum exam you may see green, malodorous, frothy d/c (less than 10%)
  • will see strawberry cervix in 2%
  • pH 5-6
  • mobile T. vaginalis on wet mount (seen 60-70%)
  • can do rapid antigen and nucelic amplification tests (usually available where prevalence is high)
  • on males can do PCR test on urine or a urethral swab, trying to look for motile trich has very low yield
28
Q

Tx of trichomonas?

A
  • all women even if asx should be tx if there is an infection
  • all partners involved need to be tx and must abstain from sex until finishing abx and are asx
  • non-preg females and males:
    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 hrs after taking
  • HIV pts: 7 day course of either med BID
29
Q

Why do recurrent infections of trichomonas occur? Tx?

A
  • usually due to return to sexual activity too soon and reinfection
  • may tx with metronidazole 2g dose again or use 7 day course of 500 mg BID of either drug
  • if above fails - can tx with 2 g a day for 5 days
  • if still refractory - culture to see if resistant strain
  • in general there isn’t a 2nd line abx, desensitization is recommended if pt allergic
30
Q

Cause of genital herpes? How common in US? What outbreak is the worst?

A
  • caused by HSV 1 and 2
  • among the most ubiquitous of human infections
  • HSV-2 affecting 26% of adult females and 18% adult males in US (approx 50 mill)
  • much higher in certian pops
  • Primary outbreak is the worst episode and recurrent outbreaks are generally less severe
31
Q

Sxs of genital herpes?

A
  • painful genital ulcers and itching
  • dysuria
  • tender inguinal lymphadenopathy
  • may have systemic sxs like HA and fever
32
Q

Dx of genital herpes?

A
  • PE: multiple vesicle on an erythematous base, vulvar swelling, lymphadenopathy
  • dx should be confirmed by viral cell culture (Tzanck smear) or PCR
33
Q

Management of genital herpes - primary infection?

A
  • needs to be started w/in 72 hrs for 7-10 days:
    acyclovir 400mg TID or 200mg 5x a day
    famcyclovir 250mg TID
    valocyclovir 1000mg BID
34
Q

Management of genital herpes - recurrent outbreak?

A
  • acylovir: 800 mg BIDx 3 days
  • famcyclovir: 1000mg BIDx 1 day
  • valocyclovir: 500 mg BIDx 3 days
35
Q

Suppressive therapy for herpes simplex?

A
  • acyclovir 400 mg BID
  • famcyclovir 250 mg BID
  • valocyclovir 500 mg 1x a day
36
Q

What is the most common viral STI in US? Etiologic agent?

A
  • codylomata acuminata (anogenital warts)
  • HPV - serotypes 6 and 11
  • as many as 50-75% of sexually active people infected with HPV during their lifetime
  • women account for 67% of the affected pop.
37
Q

Clinical manifestations of genital warts?

A
  • pruritus, burning, pain
  • bleeding, vaginal d/c
  • may have no sxs
  • when very large can interfere with defecation and coitus
38
Q

Tx success for genital warts? Indications for tx?

A
  • must inform pt that prolonged tx with frequent f/u 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

indications:

  • alleviation of bothersome sxs
  • cosmetic
  • b/c of obstruction, dyspareunia, or psychological distress
  • to decrease risk of transmission
39
Q

When should a bx be recommended for genital warts?

A

if:

  • dx is uncertain
  • lesion has suspicous features (irregular or unusual pigmentation)
  • pt is postmenopausal or immunocompromised
  • lesion is refractory to medical therapy
40
Q

Diff types of tx for genital warts?

A

chemical destruction:

  • podophyllin: must not be used in pregnancy
  • trichloracetic acid: highly caustic, can be used in pregnancy
  • 5-FU gel is injected into 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
41
Q

Can vertical transmission of genital warts occur?

A
  • yes, HPV can manifest in young children as:

mucosal, conjunctival or laryngeal disease, juvenile-onset respiratory papillomatosis (JRP) is most severe although rare

42
Q

Presentation of mulloscum contagiosum?

A
  • multiple, 1-2 mm raised, painless lesions
  • dome shaped with central dimple
  • contains cheesy-white material
  • can be sexually transmitted
  • tx: cryosurgery, bichloracetic acid, dermal curette but will clear on own eventually
43
Q

When does atrophic vaginitis occur? What can be done to tx this?

A
  • can occur in women of any age who experience a decrease in estrogenic stimulation of urogenital tissue
  • estrogen stimulation:
    maintains a well epithelialized vaginal vault, it acts on receptors in the vagina, vulva, urethra, and trigone of bladder
  • maintains the collagen content of epithelium
  • keeps epithelial surfaces moist
  • maintains optimal genital blood flow
  • maintains acidic vaginal pH (w/o estrogen pH would be over 5)
44
Q

Main RFs of atrophic vaginitis?

A
  • *- 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 prod. during lacatation
  • prolactin elevation
  • amenorrhea secondary to suppression of hypothalamic pituitary axis b/c of chronic tx with glucocorticoids
45
Q

Clincal manifestations of atrophic vaginitis?

A
  • vaginal dryness, burning or itching
  • decreased lubrication during sex
  • dyspareunia
  • vulval or vaginal bleeding (post-coital bleeding)
  • vaginal d/c
  • pelvic pressure or vaginal bulge
  • urinary tract sxs - freq., dysuria, and hematuria
46
Q

PE findings of atrophic vaginitis?

A
  • pale, smooth or shiny vaginal epithelium
  • loss of elasticity
  • sparsity of pubic hair
  • introital narrowing
  • fusion or resorption of labia minora
  • friable, unrugated epithelium of vagina
  • shortened, narrowed and poorly distensible vaginal vault
47
Q

Common presentation and findings of pt with atrophic vaginitis?

A
  • 2 yrs since natural menopause
  • loss of labial and vulvar fullness
  • pallor of urethral and vaginal epithelium
  • narrow introitus
  • minimal vaginal moisture
  • loss of urethral meatal turgor
48
Q

Tx for atrophic vaginitis? Most effective tx?

A
  • indicated if sxs are causing a woman distress
  • for vaginal dryness: replens, vagisil, K-Y (use 1-2x a wk)
    use lubricants for intercourse: watersoluble (k-y), silicone (Pjur eros)
    oil based: elegance women’s lubricant
  • sexual activity itself may improve vaginal fxn

vaginal estrogen therapy:
most effective, CIs: estrogen dependent tumor
- assoc with urinary tract benefits, usually start with vaginal estrogen therapy: cream, tablet, ring
SE: irritation, bleeding or breast tenderness
- some women need systemic therapy (refer)
- SERM:
ospemifene (osphena)
SE: hot flushes, thromboembolism, endometrial cancer

49
Q 
lichen sclerosis:
etiology
PP
dx
sx - hallmark?
A
  • etiology: may be genetics or autoimmune
  • pp: intense inflammatory rxn
  • 2 peaks: prepubertal girls and postmenopausal women
  • dx: bx
  • 4% risk of cancer occurring

-sxs:
vulvar pruritus is hallmark and may be so intense as to interfere with sleep, pruritus ani, painful defecation, anal fissures, dyspareunia

50
Q

Exam findings of lichen sclerosis?

A
  • chronic inflammation
  • well-demarcated white, finely wrinkled, atrophic patches
  • labia minora often shrink and adhesions of labia majora may cover clitoris
51
Q

Tx for lichen sclerosis?

A
  • clobetasol propionate 0.05% cream for 6-12 wks (topical steroids)
  • then for maintenance therapy apply 1-3x/wk
52
Q

How common are bartholin gland disorders? Why is a good DDx needed?

A
  • 2-3% of women develop cysts or abscesses of Bartholin glands
  • carcinoma and benign tumors are rare
  • many vaginal and vulvar lesions mimic bartholin gland disorders need a good ddx
53
Q

How big are bartholin duct cysts? Sxs? Tx?

A
  • most common large cyst of vulva: 1-3 cm size
  • most are asx:
    tx not necessray in women less than 40 unless infected or sx
  • in women older than 40, bx and drainage is performed to exclude carcinoma
  • if cyst is large and not resolving then it can be tx with techniques described for tx an abscess
54
Q

Clinical manifestations of bartholin duct abscess?

A
  • swelling of bartholin gland w/ exquisite pain
  • occurs in 2% of women
  • on exam: erythematous, warm, tender, and usually fluctuant
  • there may be surrounding cellulitis
  • infection: usually polymicrobial, STIs less likely but should be tested for in pts who are at higher risk of STIs
    Rise in MRSA as etiologic agent
55
Q

Tx of cyst or abscess?

A
  • I&D: lanced at or behind hymenal ring
  • place a word cath into cavity: left in place for at least 4 wks
  • marsupialization: done under local anesthesia, longer procedure, reserved for pts who fail 1-2 placements of word catheter, complications: hematoma, scarring, and dyspareunia
56
Q

What is a cystocele? Causes?

A
  • prolapsed bladder
  • bulging of bladder into vagina
  • occurs when supportive tissues and muscles b/t bladder and vagina weaken and stretch - bladder bulges into vagina
  • causes:
    childbirth
    repetitive straining for BM
    constipation
    chronic or violent coughing
    heavy lifting
    obesity
57
Q

Tx of cystocele?

A
  • graded - depending on severity
    tx:
  • watchful waiting, avoid heavy lifting or straining
  • kegels to strengthen pelvic muscles
  • pessary: silicone medical device placed in vagina that supports vaginal wall and hold bladder in place
  • anterior vaginal wall repair (colporrhaphy)
58
Q

What is paget’s disease?

A
  • intraepithelial adenocarcinoma
  • extramammary disease may involve genital, perianal, and axillary areas: may be an indication of underlying malignancy
  • lesions are brick red, scaly, velvety eczematoid plaque with sharp border
  • S/S: itching, burning, bleeding
  • cellular origin unclear
59
Q

Tx of paget’s?

A
  • primary: excision with more than 3 mm border from visible margin
  • recurrent disease may be tx with:
    radiotherapy
    laser
    photodynamic therapy
    5-FU
    imiquimod
  • local recurrence rate 31-43%
60
Q

How common is vulvar cancer? RFs?

A
  • 4th MC gyn cancer
  • represents 5% of malignancies of female
    genital tract
  • RFs:
    HPV infetion (60%)
    smoking
    lichen sclerosis
    vulvar or cervical intraepithelial neoplasia
    immunodeficiency syndromes
    prior hx of cervical cancer
    Northern European ancestry
61
Q

Clincal manifestations of vulvar cancer?

A
  • 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 2nd malignancy: usually cervical CA is found in up to 22% of pts with vulvar malignancy
  • pruritus is common complaint
  • many pts are asx: need to inspect
62
Q

Histological types of vulvar cancer?

A
  • squamous cell: over 90% - keratinizing, differentiated or simplex type - more common
    may have warty appearance, predom. assoc with oncogenic strains of HPV (found in younger women)
  • verrucous carcinoma: variant of squamous cell
  • melanoma: 2nd most common vulvar CA
  • basal cell carcinoma: 2%
  • extramammary paget disease: less than 1%
63
Q

Mode of spread of Vulvar cancer?

A
  • direct extension to adjacent structures
  • lymphatic embolization to regional lymph nodes: can occur early
  • hematogenous dissemination: occurs late in the disease
64
Q

What is VAIN? Cause? Tx?

A
  • vaginal intraepithelial neoplasia - carcinoma: this is a reason why PAPs should be cont. after hysterectomy
  • vaginal squamous cell atypia w/o invasion
  • consistently assoc with prior or concurrent neoplasia elsewhere in lower genital tract
  • 50-90% of pts with VAIN had or currently have either intraepithelial neoplasia or carcinoma of cervix or vulva
  • HPV (types 6, 11)assoc with 80% of VAIN cases
    -tx:
    laser ablation
    local excision
    5-FU intravaginal
    vaginectomy and skin graft

OB/GYN (17 decks)

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