female external Genitalia D/O Flashcards
how many sexually active people will get an STI by 25?
1 in 2 people (50%)
what is vulvitis? is it common?
Inflammation of vulva: possible involvement of introitus and/or vault
- very common
symptoms of vulvitis (6)
itching redness swelling discharge pain/irritation lesions
most common cause of vulvitis?
Most commonly 2º to vaginitis (3 kinds)
- BV
- Candida
- Trichomonas
lesser common infectious causes of vulvitis?
cellulitis and HSV
other kinds of causes of vulvitis?
contact dermatitis/irritation
dermatologic (lichen planus, lichen simplex chronicus, lichen sclerosus) & psoriasis
if the vulvititis presenting symptom is erythema, what is the likely cause?
infectious: Vaginitis or cellulitis
if the vulvitis presenting symptom is pale appearance/atrohpy, what is the likely cause?
derm: lichen planus OR menopausal changes
if the vulvitis presenting symptom is skin thickening/plaques, what is the likely cause?
derm (lichen planus, lichen sclerosus (*this one may actually cause skin thinning), lichen simplex chronicus)
Most common chronic vulvar condition?
vulvar lichen sclerosus
what causes vulvar lichen sclerosus? (weeds)
many things.. vitamin A deficiency autoimmune process excess of elastase decreased activity of 5-α reductase
how does vulvar lichen sclerosus present? what is the general progression of symptoms? (7)
- first, erythema & edema
- WHITE PLAQUES
- intense “ITCH-SCRATCH” CYCLE … leading to telangectasias and subepithelial hemorrhages… leading to erosions/fissures/ulcerations
- thin wrinkled, white skin (CIGARETTE PAPER SKIN)
- agglutination (sticking together) of labia minora –> phimosis over clit
- contraction of vulvar structures –> introital stenosis
- involvement of perianal region
txt for vulvar lichen sclerosus (initial)
- stop itch-scratch cycle
- minimize inflammation
- general vulvar hygiene
what is the general vulvar hygiene for lichen sclerosus? (3)
- avoiding tight underwear
- cleansing daily with mild soap
- drying the vulvar skin with a hair dryer
two medical txts for vulvar lichen sclerosus? whats the major benefit of these?
- oral anti-histamine each night
- high-potency topical steroid (at the start)
* gives immediate relief to stop the itch-scratch cycle and restores pts belief in provider-care.
txt for those who dont respond to topical steroids for vulvar lichen sclerosus? (3) (maybe weeds)
- tacrolimus cream, retinoid, antimalarial agents, or photo therapy (if NO steroids work)
- steroid injection
- surgery: undercut nerve fibers (mering procedure)
why is vulvar lichen sclerosus harderto diagnose in younger children?
can present as shiny/waxy skin
- hypopigmentation harder to see on natural pale young skin
- purpura and fissures can be mistaken as child abuse
HIGH rate of ____ in women with lichen sclerosus
SCC (squamous cell carcinoma) 3-5%
*biopsy all new lesions!
what is vulvar lichen simplex chronicus? what causes it?
benign epithelial thickening and hyperkeratosis from chronic irritation: (i.e. use of perfumed pads or chronic vulvovaginal infections)
vulvar lichen simplex chronicus.. presenting symptoms?
itch-scratch cycle from pruritis
ALWAYS itching
-burning, pain & tender
-may have skin thickening
txt for vulvar lichen simplex chronicus? (3)
- vaginal hygiene
- sitz bath and lubricants
- oral antihistamines
- topical steroids (injectable if it doesnt work)
lichen simplex chronicus: Vulvar epithelium takes at least ___ weeks to heal
6
what is vulvovaginal lichen planus ?
Relatively rare mucocutaneous dermatosis
what characterizes vulvovaginal lichen planus?
sharply marginated flat-topped papules on the skin
but LESS sharply marginated white plaques on oral and genital mucous membranes
-leukoplastic lesions & (later) erosive lesions
what are the 6 Ps of lichen planus?
Pruritus Polygonal Planar Purple Papules Plaques (but the moist environment and walking around can really alter the morphology of the primary lesions here)
generalized glazed erythema, Some erosions, beginning loss of clitoris and labia minora. what is this?
advancing vulvovaginal lichen planus
treatment of vulvovaginal lichen planus?
initial then step-up..
- topical: vaginal hydrocorticone foam
- stronger corticosteroids
- tacrolimus cream
- systemic steroids
* careful exam for formation of adhesions.. may need vaginal dilators
vulvitis from menopausal atrophy: 3 main characteristics?
- enlarged clitoris
- shiny atrophic vestibule
- loss of hair
vulvitis from severe ulcerative allergic contact dermatitis: 2 characteristics
- severe, generalized erythema & swelling
- erosions, and extensive ulceration
vulvitis txt is diagnosis-specific but in general, what are the txt guidlines? (3)
- txt underlying infection (if there is one) & avoid irritants
- sitz baths
- steroids (medium potency)
Most common STI in the world?
HSV
how is most HSV spread? ( at what percent?)
~70% transmitted via asymptomatic viral shedding
HSV vulvovaginitis symptoms
Prodrome: itching or tingling, constitutional (effect many body systems)
- Multiple, small, painful blisters then . . .
Shallow ulcers
-Crusts over in 7-10 days
recurrences of HSV in what percent of cases? (maybe weeds)
50%
Dx of HSV: what is good and what isnt?
clinical (multiple vesicles/ulcers, PAINFUL), then ELISA to type it
- tzank smear, DNA PCR, and viral cultures ARE NOT sensitive enough
txt for HSV
symptomatic: topical barriers, analgesics (xylocaine)
systemic- NSAIDS + narcs
sitz baths
anti-virals: “-cyclovirs”
3 kinds of vaginitis/vaginosis and what causes each?
Bacterial Vaginosis: Gardnerella
Candidiasis: Candida albicans
Trichomonas: Trichomonas vaginalis
most common cause of vaginal discharge in women of reproductive age. also found in ___% of asymptomatic women
BV , 40%
what is BV?
alteration of normal vaginal flora (lactobacilli)
increase # anaerobes (which produce ammines)
what is Amsel’s criteria for BV?
need 3 of the 4…
- a thin, homogeneous, white, non-inflammatory adherent discharge
- clue cells (make up at least 20% of all epithelial cells seen)
- vaginal pH of ≥4.5
- positive “whiff” test: a fishy odor after adding KOH
what are clue cells?
gardnerella vaginalis bacteria taking up 75% of the border of epithelial cells
(in BV)
3 txt options for BV
- flagyl PO
- flagyl topical (metroGel) - intravaginal
- 2% clindamycin cream - intravaginal
what is vaginal candidiasis ?
yeast part of normal flora of vagina (present in 25-50% of healthy patients. BUT an overgrowth leads to this yeast infection
what % of women will get a yeast infection? how many will have more than one episode?
75%
40-50% have more than one episode
5 risk factors for yeast infection (maybe weeds)
- DM
- pregnancy
- antibiotic therapy (broad-spectrum usually)
- steroids or other immunosuppressive therapy
- HIV infection
symptoms of yeast infection (vaginal candidiasis) (4)
- perivaginal pruritis or burning. . .
- . . . with or without associated dysuria
- perhaps mild erythema
- thick, white, curd-like discharge
what does KOH show with yeast infection?
spores and hyphae
yeast infection txt
antifungals : azoles
2nd line- nystatin (suppository- cheap)
most prevalent non-viral STI in the world. men or women?
trichomonas
men- carrier- asymptomatic
women- symptomatic
what causes trichomonas ?
T. vaginalis: flagellated anaerobic protozoa that attacks the vaginal epithelium or the perivaginal glands
transmission and incubation of trichomonas?
transmission: almost EXCLUSIVELY sexually
incubation: 4-28 days
trichomonas symptoms
- vulvar and vaginal pruritis
- copious, yellow-green, frothy discharge
- strawberry cervix
trichomonas generally presents with what other things?
other STIs and BV
txt for trichomonas?
- systemic therapy! Flagyl
topical only has effective txt of less than 50%
why do you need systemic therapy for trich?
infection can be multifocal, involving vaginal epithelium, the urethra, or perivaginal glands such as Bartholin’s or Skene’s glands.
what is bratholin’s cyst/abscess?
bartholin’s glands: bilateral in labia minora
-usually pea-sized, can become cystic (blocked and fluid filled)and form an abscess
what age group do bratholin’s cyst/abscess usually present in? fast or slow onset?
fast, women 20-30yo
*usually delay in seeking care so by the time they show up, they area abscesses
what organisms cause bratholin’s cyst/abscess?
anaerobes(majority)
gonorrhea
bartholin’s abscess txt (3 part process)
- local anesthesia & sterile prep. incision 1-1.5cm long (from INSIDE the labia)
- hemostat to break up loculations
- word catheter placed to drain
do NOT txt barthonlin’s abscess with what?
antibiotics!
most common cause of STIs and cervicitis?
GC and chlamydia
how many cases of chlamydia a year (maybe weeds)
1.2 million
STI/cervicitis presentation (7)
dysuria, frequency, urgency, pelvic pain,VAGINAL BLEEDING, and vaginal discharge
Mucopurulent cervicitis is often _______
asymptomatic.
is mucopurulent discharge sensitive predictor of GC or chlamydia infection?
no, most patients with these infections actually do not present with mucopurulent discharge.
pelvic exam for STI/cervicitis
may reveal a tender, friable cervix with mucopurulent discharge
but can be completely normal
Dx of cervicitis
mostly presumptive
cervical swab & culture
Txt of cervicitis- gonorrhea
250mg IM rocephin (ceftriaxone)
or 400mg PO cefixime
(amox or erythromycin if allergic)
txt of cervicitis- gonorrhea but pregnant?
same txt as if not pregnant….
just NO quinolones or TCN
txt cervicits- chlamydia
single dose azithromycin or doxycycline
- amoxicllin if pregnant
- erythromycin if allergic
