EXAM #1: VULVAR & VAGINAL DISEASE Flashcards
What is the differential diagnosis for vulvovaginitis?
1) Bacterial vaginosis
2) Candida
3) Trichomoniasis
4) Atrophic vaginitis (elderly)
What two causes of vulvovaginitis will cause an increase in vaginal pH?
1) Bacterial vaginosis
2) Trichomoniasis
What is the wet mount finding that is pathognomonic for Bacterial Vaginosis?
Clue cells
What are the findings that are diagnositc for Bacterial vaginosis?
1) Gray discharge
2) pH greater than 4.5
3) Positive whiff test
4) Clue cells on wet mount
How is Bacterial vaginosis treated?
1) Oral metronidazole
2) Topical Clindamycin
Why is Candidiasis more common in younger women?
Infection requires estrogen
How will wet mount appear in Candidiasis?
Blastosphores or pseudohyphae
What are the classic findings in Candidiasis?
1) Odorless cottage-cheese like discharge
2) pH between 4-5 (normal)
What is the treatment for Candidiasis?
1) Vaginal application of an imidazole
2) Oral dose of fluconazole
3) Nystatin can be used in PREGNANCY
How does a yeast infection that is positive for T. glabrata alter the treatment regimen?
- Resistant to all azoles; must treat with:
1) Boric acid
2) Gentian violet
What are the clinical manifestations of Trichomoniasis?
1) Foul-smelling green-yellow discharge
2) pH greater than 4.5
3) “Strawberry cervix”
How is Trichomoniasis identified on wet mount?
Mobile flagellates on wet mount
If you are going to diagnose a patient with Trichomoniasis, what else do you need to screen them for?
STIs i.e. Chlamydia and N. gonorrhea
How is Trichomoniasis treated?
Oral metronidazole (treat partner as well)
What is atrophic vaginitis?
Atrophy of the vagina in elderly women due to decreased estrogen
How is atrophic vaginitis treated?
Topical or oral estrogen
What is Linchen Sclerosis? What is the classic presentation of Linchen Sclerosis?
- Thinning of the epidermis and fibrosis of the dermis of the vulva
- Presents with leukoplakia and “parchment-like” vulvar skin
How is Linchen Sclerosis treated?
1) Biopsy to rule out neoplasia*
2) Treat any secondary infections (yeast)
*Long-standing linchen sclerosis can lead to vulvar carcinoma in elderly women
What are the general care measures for Linchen Sclerosis?
1) Cotton underwear
2) No tight/occlussive clothing
3) No soap to vulva
What is the initial pharmacologic treatment for Linchen Sclerosis?
1) Superpotent steroid ointment taper
2) Oral steroids
What is Lichen Simplex Chronicus (LSC)? How does LSC classically present?
- This is hyperplasia of the vulvar squamous epithelium
- Presents with thick leathery vulvar skin
- Associated with chronic irritation and itching/ scratching
How is LSC treated?
1) Discontinue any irritants
2) Oral antipruritic med (diphenhydramine) w/ moderate strength steroid cream
3) Trial of oral anti-depressant
If LSC does NOT improve, what do you need to do?
Vulvar biopsy to rule out neoplasia
What is Lichen Planus?
Cell-mediated immune response of unknown origin that causes a desquamative lesion of the vagina
Aside from itching, what else is Lichen Planus associated with?
1) Insertion pain
2) Profuse vaginal discharge
How is Lichen Planus diagnosed?
Biopsy
How is Lichen Planus treated?
1) Topical steroid cream
2) Intravaginal hydrocortisone/ suppository
What is Psoriasis?
Excessive keratinocyte proliferation causing salmon-color plaques with silver scale
*Autosomal dominant
When Psoriasis is suspected in the vagina, what is the clinical clue to the diagnosis?
Psoriasis in other areas
How is Psoriasis treated?
1) Topical coal tar followed by UV light
2) Topical steroid “Betamethasone”*
What are the two types of eczema?
1) Exogenous= irritant and contact dermatitis
2) Endogenous= atopic dermatitis
How is exogenous eczema treated?
Remove the offending agent
What is Seborrheic Dermatitis?
Chronic inflammation of the sabecous glands in the vagina
How does Seborrheic Dermatitis present?
- Pale red to yellow-pink
- Oily appearing and scaly crust
How is vulvar dermatitis treated?
1) Remove offending agent
2) Good perineal hygiene
3) Aluminum acetate solution
4) Topical corticosteroids
5) Oral antipruritic agents
What are sebaceous cysts?
- Blockage of the sebaceous gland duct resulting in a cysts
- Small nodular mass with a cheesy sebaceous material inside
*Treatment is excision
What is a cyst of the Canal of Nuck?
Hydrocele i.e. fluid collection in the round ligament of the uterus that inserts into the labia majora
*Treatment is excision
What are the premalignant conditions of the vulva?
1) Pagets Disease
2) Vulvar Intraepithelial Neoplasia (VIN)
What are the clinical manifestations of Paget’s Disease?
Erythematous, pruritic, ulcerated vulvar skin
*More common in women over 60
How is Paget’s Disease diagnosed?
Biopsy
How is Paget’s Disease treated?
Wide local excision
What is VIN?
Vulvar Intraepithelial Neoplasia
- Precursor to vulvar carcinoma
- Often high-risk HPV related
How is VIN diagnosed? What major diagnoses are you trying to differentiate between?
Colposcopy and biopsy
*Need to rule out melanoma
How is VIN treated?
1) Laser excision
2) Wide local excision
3) Follow-up frequently b/c of high recurrence rate
Colposcopy every 6 months until disease free for 2 years; then annual
What is the most common cell-type of vulvar cancer?
Squamous cell carcinoma (85-90%)
Where is vulvar cancer typically found?
Labia major
What are the risk factors for Vulvar Cancer?
1) Post-menopausal
2) CIN, VIN, HPV
3) Smoking
4) Immunosuppression
5) Hx. of cervical cancer
How is vulvar cancer diagnosed?
Biopsy
How is vulvar cancer treated?
1) Wide local excision plus ipsilateral inguinal lymph node dissection
2) Pelvic radiation if positive mets to nodes
What is VAIN?
Vaginal Intraepithelial Neoplasia
*This is the precursor to vaginal carcinoma
How is VAIN diagnosed?
1) PAP smear
2) Colposcopy
3) Biopsy
What is the treatment for VAIN?
1) Local resection
2) Laser ablation (no sample for pathology)
3) 5-FU (chemotherapy cream w/ a lot of adverse effects)
What is the proper follow-up for VAIN?
Colposcopy every 6 months until disease free for 2 years; then annual
What is the most common type of vaginal cancer?
SCC
*Associated with extension from the cervix
What is clear cell adenocarcinoma associated with?
In utero exposure to DES
What is the treatment for Stage I or II vaginal cancer?
Surgical resection
What is the treatment for Stage III or IV vaginal cancer?
Radiation
