Disorders of vulva and vagina

Question 1

Vagina drains into the

Answer 1

inguinal lymph nodes- femoral- external iliac nodes

Question 2

Causes of pruritis vulvae

Answer 2

Infection- 
Candidiasis +/- vaginal discharge
Vulval warts (condylomata acuminata
Public lice/scabies
Dermatological- eczema, psoriasis, lichen simplex/sclerosus/planus, contact dermatitis
Neoplasia- Carcinoma/VIN

Question 3

Chronic vulval dermatitis

Answer 3

Lichen simplex-chronic inflammatory skin condition

Question 4

How does lichen simplex present?

Answer 4

Severe intractable pruritis on a background of sensitive skin/dermatitis/eczema, inflamed labia majora with hyper/hypopigmentation.

Question 5

What is lichen simplex associated with metabolically?

Answer 5

Low body iron stores

Question 6

Treating lichen simplex?

Answer 6

Potent steroid creams and anti-histamines to break itch-scratch cycle

Question 7

Appearance of Lichen planus

Answer 7

Flat, papular purplish lesions

Question 8

Lichen planus presents where on the body

Answer 8

All regions, particularly mouth and genital mucosa where it is erosive and most commonly associated with pain.

Question 9

Treatment of lichen planus

Answer 9

High potency steroid creams, avoid surgery

Question 10

Appearance of vulva in Lichen sclerosus

Answer 10

Thin vulval epithelium with loss of collagen. Pink-white papules which coalesce to form parchment like skin with fissures.

Question 11

Who gets lichen planus

Answer 11

All ages

Question 12

Aetiology of lichen sclerosus

Answer 12

Autoimmune cause- related to thyroid disease, may have vitiligo. 40% get AI disease

Question 13

Complications of Lichen Sclerosus

Answer 13

Inflammatory adhesions- fusion and narrowing of introitus- vulval carcinoma in 5%

Question 14

Management of lichen Sclerosus

Answer 14

Biopsy to assess carcinoma, Ultrapotent topical steroids.

Question 15

Presentation of lichen Sclerosus

Answer 15

Severe pruritis, worse at night, uncontrollable scratching- trauma with bleeding and skin splitting- discomfort pain dyspareunia.

Question 16

What is vulvar dysaesthesia and how is it categorized?

Answer 16

Provoked vs spontaneous and generalized vs local/vestibular

Question 17

Generalized vulvar dysaesthesia

Answer 17

Burning pain in older women

Question 18

Vulvar dysaesthesia of the vestibule

Answer 18

Young women dyspareunia pain with tampons

Question 19

Treatment of vulvar dysaesthesia

Answer 19

amitriptyaline or gabapentin

Question 20

Common infections of the vulva and vestibule

Answer 20

HSV, Vulval warts, syphilis, donovanosis, candidiasis

Question 21

Candidiasis of the vulva occurs most commonly in

Answer 21

Diabetics, obesity, pregnancy, post Abx and immunocompromise

Question 22

Candidiasis of the vulva presents as

Answer 22

Irritation and soreness of vulva and anus rather than discharge

Question 23

Bartholin’s gland

Answer 23

Glands behind labia minora producing lubrication for coitus

Question 24

Bartholins cyst

Answer 24

Blockage of the ducts

Question 25

Bartholins abscess

Answer 25

blocked duct with infection-Staph aureus and ecoli

Question 26

Treatment of bartholins abscess

Answer 26

Incision, drainage and marsupialization- incision is sutured open to reduce risk of reformation

Question 27

Introital damage can be due to

Answer 27

Childbirth - tightening, incorrect apposition at perineal repair, scar tissue

Question 28

Intraoital damage presents as

Answer 28

superficial dyspareunia

Question 29

Vaginal cysts appearance and prognosis

Answer 29

smooth white large as golf ball can be mistaken for prolapse. excise if dyspareunia

Question 30

Vaginal adenosis

Answer 30

Columnar epithelium in vagina instead of squamous

Question 31

What condition is common in women who’s mothers recieved DES (diethylstilboestrol)?

Answer 31

Vaginal adenosis can lead to clear cell carcinoma of vagina– with genital tract abnormalities,

Question 32

VIN- name and presentation

Answer 32

Vulval intraepithelial neoplasia, Pruritis and pain

Question 33

Categorizing VIN (2)

Answer 33

Usual type VIN/ Differentiated type VIN

Question 34

Usual type VIN associated with (5)

Answer 34

35-55 years old, associated with HPV, CIN, smoking, immunosuppresion

Question 35

Differentiated type VIN associated with

Answer 35

lichen sclerosis, older women, high risk conversion to malignancy (keratinized squamous cell carcinomas of vulva)

Question 36

Difference in appearance of usual type and differentiated type VIN

Answer 36

usual- multifocal vs diff-unifocal ulcer/plaque

Question 37

Gold standard treatment for VIN

Answer 37

Local surgical excision to relieve symptoms, confirm histology and exclude invasive disease

Question 38

Carcinoma of the vulva most common in age

Answer 38

60 years or above

Question 39

Squamous carcinoma of the vulva (95%) is associated with (4)

Answer 39

Lichen sclerosis, immunosuppresion, smoking and paget’s disease of the vulva

Question 40

Clinical features of Vulva carcinoma

Answer 40

Pruritis, bleeding, discharge, mass at labia majora/clitorus, enlarged inguinal lymph nodes

Question 41

Vulval carcinoma spreads

Answer 41

superficial then deep inguinal lymph nodes, femoral then external iliac nodes

Question 42

How would you stage a vulval carcinoma

Answer 42

Stage 1a- confined to vulva/perineum with 1mm spread
Stage 2- adjacent spread
Stage 3- positive inguinofemoral nodes
Stage 4- A Upper urethra/vagina/rectum/bladder/bone/distal mets B

Question 43

Establish the diagnosis of vulval carcinoma by

Answer 43

biopsy

Question 44

Treatment of vulval carcinoma

Answer 44

Local excision for stage 1
All others- wide local excision and groid lymphadenectomy with the ‘skin sparing’ incision- triple incision radical vulvectomy
Radiotherapy to shrink/palliative lymph nodes

Question 45

Clear cell adenocarcinoma of the vagina presents in

Answer 45

Daughters of DES treated mothers (miscarriage prevention)