Disorders of Vulva & Vagina Flashcards
Normal vulva epithelium
Normal vagina epithelium
Vulva: keratinized squamous epithelium, occasionally breast tissue which can get swollen and tender after delivery
Vagina: Non-keratinized squamous epithelium - pH 4.0-4.5
- Lactobacillus, aerobic, anaerobic bacteria
- No odor w/ secretions
Vaginitis
Change in volume/odor/color discharge, pruritus, burning, dyspareunia
Always determine etiology w/ lab documentation before treatment
Bimanual exam to check for cervical motion and uterine tenderness
pH
- 5-4.5
- 0-6.0
>4.5
4.0-4.5
Pregnancy
- 5-4.5: normal in premenopause
- 0-6.0: trichomoniasis
>4.5: bacterial vaginosis
4.0-4.5: Candida
Pregnancy: raises pH
Bacterial Vaginosis (BV)
Most common, abnormal vaginal flora - vulva will appear normal
Decreased lactobacilli, increased Gram-negative rods
Fishy odor, clue cells, thin white/gray discharge - main complaint
Tx: Metronidazole (Flagyl) TOC - cannot drink ETOH while taking tablet, make you ill
-intravaginal gel available
Clindamycin alternative
Amsel Criteria for BV
Homogeneous thin grayish-white discharge
pH >4.5
Positive whiff-amine test
Clue cells on wet mount
>20% epithelial cells
Vulvovaginal Candidiasis
2nd most common, not an STI - usually C. albicans
Dx: Thick cottage cheese discharge, +/- gray membrane
pH 4.0-4.5, culture is rare
Tx: Uncomplicated - OTC or Fluconazole - one time dose stays in vaginal secretions for 72 hours
Complicated - Fluconazole 150 2-3 dose, or topical clotrimazole, intravaginal boric acid tablets (fatal w/ ingestion)
Trichomonas Vaginitis
Most common STI - flagellated protozoan
Male sx: asx w/ 90% spontaneous resolution, burning w/ urination
Female sx: ax to severe inflammatory dx
-Malodorous, thin green/yellow discharge, urethritis, pruritis, post-coital bleeding
Dx: Strawberry cervix
Tx: non-pregnant: Tinidazole (Tindamax) or Flagyl, Flagyl if pregnant or nursing
7 day course for HIV
Treat all partners, abstain from sex
Genital Herpes
Painful ulcers, itching, dysuria, tender inguinal lymphadenopathy, HA, fever
Dx: PCR
Herpes simplex, Condylomata acuminata - anogenital warts
Tx: Podophyllin - CI w/ pregnancy
Atrophic Vaginitis
Estrogen stimulation to prevent/maintain pH & blood flow
Sx: Dryness, burning, itching, decreased lubrication, dyspareunia, vaginal discharge
Tx: moisture & estrogen therapy
Lichen Sclerosis
Genetics or AI - peak in pubertal girls & postmenopausal women
Dx: biopsy
Sx: Vulvar pruritis, may interfere w/ sleep, pruritus, painful defecation, anal fissures
Tx: clobetasol propionate for 6-12 wks - high potency topical steroids
Bartholin Gland Cyst
Most common large vaginal cyst - usually asx <40 yo
->40 yo - do a bx and drainage to exclude carcinoma
If infected, usually polymicrobial, STI less likely, MRSA a risk
Tx: I&D, Marsupialization under local anesthesia
Complications: hematoma, scarring, dyspareunia
Cystocele
Prolapsed bladder - usually from weak supporting muscles
Tx: kegels, avoid heavy lifting, Pessary
Paget’s Disease
Intraepithelial adenocarcinoma - extramammary disease involved genitals and perianal, axillary
Sx: brick red, scaly, velvety eczematoid plaque w/ sharp border and itchy, burning, bleeding
Tx: excision w/ >3 mm
-recurrent: laser, 5-FU, radiotherapy
Vulvar Cancer
unifocal vulvar plaque/ulver/mass
- secondary malignancy cervical CA in 22%
90% SCC - keratinizing, differentiating, simplex type
Spreds directly to adjacent structure
- lymphatic embolization to regional nodes early on
- Hematogenous dissemination late stage
Vaginal Intraepithelial Neoplasia (VAIN)
HPV detected in 80% cases
Tx: ablation, excision, 5-FU, vaginectomy
Squamous cell atypical w/o invasion
Associated w/ prior/concurrent neoplasia in lower genital tract
50-90% have neoplasia or carcinoma of cervix or vulva
