Disorders of vulva and vagina Flashcards
Vagina drains into the
inguinal lymph nodes- femoral- external iliac nodes
Causes of pruritis vulvae
Infection- Candidiasis +/- vaginal discharge Vulval warts (condylomata acuminata Public lice/scabies Dermatological- eczema, psoriasis, lichen simplex/sclerosus/planus, contact dermatitis Neoplasia- Carcinoma/VIN
Chronic vulval dermatitis
Lichen simplex-chronic inflammatory skin condition
How does lichen simplex present?
Severe intractable pruritis on a background of sensitive skin/dermatitis/eczema, inflamed labia majora with hyper/hypopigmentation.
What is lichen simplex associated with metabolically?
Low body iron stores
Treating lichen simplex?
Potent steroid creams and anti-histamines to break itch-scratch cycle
Appearance of Lichen planus
Flat, papular purplish lesions
Lichen planus presents where on the body
All regions, particularly mouth and genital mucosa where it is erosive and most commonly associated with pain.
Treatment of lichen planus
High potency steroid creams, avoid surgery
Appearance of vulva in Lichen sclerosus
Thin vulval epithelium with loss of collagen. Pink-white papules which coalesce to form parchment like skin with fissures.
Who gets lichen planus
All ages
Aetiology of lichen sclerosus
Autoimmune cause- related to thyroid disease, may have vitiligo. 40% get AI disease
Complications of Lichen Sclerosus
Inflammatory adhesions- fusion and narrowing of introitus- vulval carcinoma in 5%
Management of lichen Sclerosus
Biopsy to assess carcinoma, Ultrapotent topical steroids.
Presentation of lichen Sclerosus
Severe pruritis, worse at night, uncontrollable scratching- trauma with bleeding and skin splitting- discomfort pain dyspareunia.
What is vulvar dysaesthesia and how is it categorized?
Provoked vs spontaneous and generalized vs local/vestibular
Generalized vulvar dysaesthesia
Burning pain in older women
Vulvar dysaesthesia of the vestibule
Young women dyspareunia pain with tampons
Treatment of vulvar dysaesthesia
amitriptyaline or gabapentin
Common infections of the vulva and vestibule
HSV, Vulval warts, syphilis, donovanosis, candidiasis
Candidiasis of the vulva occurs most commonly in
Diabetics, obesity, pregnancy, post Abx and immunocompromise
Candidiasis of the vulva presents as
Irritation and soreness of vulva and anus rather than discharge
Bartholin’s gland
Glands behind labia minora producing lubrication for coitus
Bartholins cyst
Blockage of the ducts
Bartholins abscess
blocked duct with infection-Staph aureus and ecoli
Treatment of bartholins abscess
Incision, drainage and marsupialization- incision is sutured open to reduce risk of reformation
Introital damage can be due to
Childbirth - tightening, incorrect apposition at perineal repair, scar tissue
Intraoital damage presents as
superficial dyspareunia
Vaginal cysts appearance and prognosis
smooth white large as golf ball can be mistaken for prolapse. excise if dyspareunia
Vaginal adenosis
Columnar epithelium in vagina instead of squamous
What condition is common in women who’s mothers recieved DES (diethylstilboestrol)?
Vaginal adenosis can lead to clear cell carcinoma of vagina– with genital tract abnormalities,
VIN- name and presentation
Vulval intraepithelial neoplasia, Pruritis and pain
Categorizing VIN (2)
Usual type VIN/ Differentiated type VIN
Usual type VIN associated with (5)
35-55 years old, associated with HPV, CIN, smoking, immunosuppresion
Differentiated type VIN associated with
lichen sclerosis, older women, high risk conversion to malignancy (keratinized squamous cell carcinomas of vulva)
Difference in appearance of usual type and differentiated type VIN
usual- multifocal vs diff-unifocal ulcer/plaque
Gold standard treatment for VIN
Local surgical excision to relieve symptoms, confirm histology and exclude invasive disease
Carcinoma of the vulva most common in age
60 years or above
Squamous carcinoma of the vulva (95%) is associated with (4)
Lichen sclerosis, immunosuppresion, smoking and paget’s disease of the vulva
Clinical features of Vulva carcinoma
Pruritis, bleeding, discharge, mass at labia majora/clitorus, enlarged inguinal lymph nodes
Vulval carcinoma spreads
superficial then deep inguinal lymph nodes, femoral then external iliac nodes
How would you stage a vulval carcinoma
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
Establish the diagnosis of vulval carcinoma by
biopsy
Treatment of vulval carcinoma
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
Clear cell adenocarcinoma of the vagina presents in
Daughters of DES treated mothers (miscarriage prevention)
