Gynecology - Benign and malignant vulvar disorders Flashcards
The most common cause of vulvar pruritus?
Contact/Allergic dermatitis
Epidermal thickening (lichenification) due to excessive itching, usually secondary to some kind of irritation (allergic or contact dermatitis, vulvar eczema, psoriasis). Vulvar itching is typically the chief complaint.
Lichen Simplex Chronicus
What does Lichen Simplex Chronicus look like?
Symmetric lichenification, vulva usually appears discolored (gray), leathery and thick, excoriations from frequent itching may be noted.
How do you treat Lichen Simplex Chronicus?
- Topical corticosteroid ointments (e.g betamethasone)
- Non-irritative lubricants
- Size baths
- PO antihistamines
- Clip nails
Vulvar and/or anogenital pruritus that’s usually worse at night, may be a burning sensation or dyspareunia. (Chronic inflammatory disease affecting the labiae and perianal skin, usually presents in postmenopausal women)
Lichen Sclerosus
What does Lichen Sclerosus look like?
Affected areas are thin appearing, crinkled, often described as “cigarette paper”, there may be distortion of the external anatomy including introital stenosis.
Diagnosing Lichen Sclerosus
Can be presumed clinically. Biopsy is useful to exclude neoplasia.
How do you treat Lichen Sclerosus?
No curative options. The mainstay of therapy is short-term high potency steroid ointments (e.g clobetasol).
- Estrogen creams may be used for concurrent atrophic vaginitis
- Tacrolimus may be used for concurrent vulvar eczema
- Surgery is reserved for severe cases unresponsive to steroids, particularly those causing sexual dysfunction.
How many % of Lichen Sclerosus go on to develop vulvar cancer (SCC) ?
4-6 %
Atrophic inflammatory condition causing vulvar pruritus -> characterized by shiny white-purple papules especially on labiae minorae which may be eroded and inflamed (is also a systemic condition, and can have manifestations elsewhere)
Lichen Planus
Causes of Lichen Planus
Assoc. w/certain drugs, but may also be spontaneous. May be exacerbated w/stress. Usually seen in middle-aged women.
How does Lichen Planus look like?
Shiny, purple papules on affected areas which may be painful and are invariable itchy. There may be whitish discoloration of the skin. Adhesions may be present,resulting in stenosis. May be mild exudate.
How do you diagnose Lichen Planus?
Clinical. Biopsy is useful if diagnosis is uncertain or to establish an initial diagnosis.
How do you treat Lichen Planus?
- Vaginal hydrocortisone suppositories
- Discontinue irritants
- May manage adhesions w/vaginal dilators/surgery
Vulvar eczema - the classical patient
young girls in the first 5 years of life. Often have eczema elsewhere, may have atopic diseases. Presents with relapsing and remitting vulvar itching.
How do you treat Vulvar Eczema?
Similar to lichen simplex chronicus;
- Mild-medium potency topical corticosteroids (e.g bethamethasone)
- PO antihistamines at night
Vulvar pruritus w/lesions, thick, red plaques w/silvery scales found on the vulva and often elsewhere. Autoimmunologic dermatological condition of varying severity.
Vulvar psoriasis
How do you treat vulvar psoriasis?
Short-term, high potency corticosteroids (e.g clobetasol).
Epidermal inclusion cyst is also known as?
Epidermoid cyst OR sebaceous cyst
What happens in a epidermal inclusion cyst? /pathophysiology
Proliferation of epidermal cells within a circumscribed area of the dermis. This may result in plugging of a pilosebaceous unit (the most common mechanism for epidermal cysts on the vulva) -> Leads to: most often asymptomatic; they can become irritated resulting in pain/tenderness. They may also become infected resulting in odor and pus.
How does an Epidermal inclusion cyst look like?
Flesh-colored cyst < 1 cm in diameter; if infected, there is overlying erythema and tenderness. There may be cysts elsewhere.
How do you treat epidermal inclusion cyst?
- Non-infected cysts do not reqire any management. Elective excision may be performed if the pt finds it disfiguring.
- Non-infected cysts do not require any management. Elective excision may be performed if the pt finds it disfiguring.
- Infected cysts may be managed w/incision and drainage, f/b antibiotic therapy targeted at staph (e.g dicloxacillin, cefalexin)
Benign cyst of the apocrine sweat gland is called?
Apocrine hidradenoma or apocrine sweat gland cyst
Symptoms of Hidraadenoma?
Usually asymptomatic, but some can develop abscess.
Can lead to hidradenitis suppuritiva or Fox-Fordyce disease
Hidradenitis suppurativa is?
Chronic disease characterized by recurrent hidradenomas which abscess.
Fox-Fordyce disease is?
Chronic disease characterized by recurrent non-infected hidradenomas. Worsened with exposeure to heat and humidity.
How do you treat hidradenoma?
Similar to epidermal inclusion cysts
1. Non-infected cysts do not require tx.
- Infected cysts may be managed w/incision and drainage, AB-tx targeted at staph (dicloxacillin, cefalexin)
- For pt. with hidradenitis suppuritiva:
- Acute: I&D
- Long term: Antibiotics
- Refractory cases usually require surgical care, e.g. laser andphototherapy. Radical surgery is last resort.
What is the Bartholin’s gland?
Paired set of glands on the posterior vagina, opening to the vulva. Secrete mucus responsible for lubrication. Obstruction and cystic dilation leads to cyst/abscess.
What does a bartholin cyst/abscess look like?
Unilateral, round-ovoid cyst at the vaginal orifice. Maybe fluctuant or tense to palpation. Larger cysts may distort vulvar symmetry.
When do you need to do a biopsy of a bartholin-gland?
If a women over the age of 40 develops cysts/abscess.
How do you treat Bartholin’s gland cyst and abscess?
- Small, asymptomatic cysts require no intervention.
- Large, symptomatic cysts or abscesses: I&D with marsupialization or placement with a Word cathteter.
- In addition, AB may be prescribed after abscess drainage, particularly in women who have confirmed chlamydial or gonococcal disease.
What is the most common type of Vulvar cancers?
Squamous cell cancers (90%)
What is Vulvar Intraepithelial neoplasia (VIN)?
Premalignant changes in the vulvar epithelium, characterized by cellular atypia
What is the classic presentation of Vulvar malignancy?
A pruritic, keratinized or pigmented, possibly bleeding vulvar mass in a postmenopausal woman.
The mnemonic for Vulvar malignancy, “4P’s” = ?
Papule formation (raised lesion, +erosion/bleeding)
Pruritic
Patriotic (Red, white and blue in color)
Parakeratosis (Histologic finding, retention of nuclei in stratum corneum layer)
Indications to biopsy a vulvar lesion?
- Pigmented lesion or genital wart in an immunocompromised or postmenopausal woman.
- Genital warts that persist despite topical therapy
- Evolving lesion
What is the characteristics of VIN-1 ?
Atypia in the deep 1/3 of the epithelium
What is the characteristics of VIN-2?
Atypia in the deep 1/2 of the epithelium
What is the characteristics of VIN-3?
Atypia in the deep 2/3 of the epithelium.
What is the characteristics of VCIS ?
Atypia through the entire thickness of the epithelium but confined with an intact basement membrane. (søk opp dagens klassifikasjon på VIN)
Is treatment recommended for all women w/VIN? when do you do what?
Yes, it is recommended for all women.
- If invasive cancer suspected -> wide local exicion.
- If invasive cancer is not suspected -> Laser ablation is preferable.
Besides Squamous cell carcinoma, what other types may occur in vulvar region?
Melanoma
Bartholin’s gland adenocarcinoma
Risk factors for Vulvar Cancer
- VIN, esp. differentiated type
- High risk HPV infection
- Hx of HSV infection
- Lichen Sclerosus
- Smoking
- Chronic immunosuppression.
Staging og vulvar cancer:
Stage 1: Tumor is confined to the vulva, - nodes
- Stage 1A: < 2 cm in size and < 1 mm of stromal invasion
- Stage 1B: > 2 cm in size or > 1 mm of stromal invasion
Stage 2: Extension to adjacent perineal structures. - nodes
Stage 3: Extension to adjacent perineal structures, + nodes
Stage 4: Invasion of other regional or distant structures.
Management of Vulvar cancer, based on stages:
Stage 1A - wide local excision
Stage 1b and 2: Partial radical vulvectomy, including ipsilateral inguinofemoral lymphadenectomy.
Stage 3: Radical vulvectomy including inguinofemoral lymphadenectomy
- Often followed by irradiation +/- chemo
Stage 4: Radical vulvectomy including inguinofemoral lymphadenectomy
- Often followed or preceded by chemoradiation
What is the chemo regimen in vulvar cancer?
Usually platinum-based: Cisplatin/5-FU
