ICL 9.2: Benign Diseases of the Vagina/Vulva

Question 1

what are some of the symptoms of vaginal discharge?

Answer 1

1. itching
2. irritation, burning
3. malodorous discharge
4. odd appearance of vaginal discharge

associated symptoms: fever, dysuria, pelvic pain, post-coital bleeding

Question 2

what are signs of bad vaginal discharge during a pelvic exam?

Answer 2

1. friable cervix (when you touch cervix it bleeds)
2. abnormal appearing vaginal discharge
3. adherent to sidewalls
4. clumped, discharge at introitus

Question 3

what does a normal premenopausal vagina look like?

Answer 3

1. pink, rugated vaginal tissue
2. pH < 4.5
3. non-keratinized epithelium
4. responsive to hormones
5. normal microbiome with a 5:1 aerobic:aerobic ration
6. normal vaginal secretions that are white and usually in posterior fornix –> increase in thin clear mucuous from the cervix midcycle

Question 4

why is it important that the vagina responds to hormones? specifically estrogen

Answer 4

1. estrogen increases glycogen in the cells which makes glucose available to the normal bacteria of the vagina which allows for the formation of lactic acid from the bacteria which makes the normal acidic environment of the vagina!
2. maintains the elasticity and normal epithelial thickness

Question 5

38 year old with increased itching and discharge for 1 week. discharge is different from the past in that it is white, clumped and without odor. she hasn’t tried anything over the counter to treat

PMH: BMI 45, 24 weeks pregnant

PE: no abdominal tenderness, vagina with white, clumped discharge and white plaques on vaginal walls but otherwise normal, vaginal pH is 4.0

which conditions are in your differential? what is the most likely diagnosis?

Answer 5

1. BV
2. candidiasis
3. trichomonas
4. allergic/contact (not common for this presentation)

she probably has candidiasis!

treat with vaginal metronidazole instead of a oral azole because she’s pregnant so that way you limit exposure of the baby to drugs

Question 6

what are the risk factors for yeast infection?

Answer 6

1. uncontrolled diabetes
2. pregnancy
3. immunosuppression/on steroids
4. antibiotics (get rid of normal vaginal biome and why you shouldn’t douche)

Question 7

what is a complicated yeast infection?

Answer 7

someone who has DM and a yeast infection has a complicated yeast infection and you need to treat differently

Question 8

what does a vaginal candidiasis infection look like?

Answer 8

thick, white, clumpy

adherent to the cervix

not thin or homogenous

Question 9

what tests do you do for a candida infection?

Answer 9

1. wet mount

take a q-tip and sample the posterior fornix to get some of the discharge and put a drop of normal saline on it and then look under the microscope right there with the patient and can give them the diagnosis right there!

2. DNA testing to send to lab

comes back within 24 hours; checks for BV, candidiasis and trichomoas but it’s $600 and takes time so wet mounts are better

Question 10

what does candida look like under wet mount?

Answer 10

segmented pseudohyphae like bamboo!

little buds on the end

also looks like there’s snowmen everywhere aka a single ball that’s budding into 2

Question 11

how do you treat candida?

Answer 11

1. oral fluconizoles
2. topical azoles
3. vaginal metronidazole

non-pseudohyphae candida probably isn’t candida albicans and it isn’t as susceptible to normal candida treatment

Question 12

what is bacterial vaginosis?

Answer 12

overgrowth of vaginal bacteria

NOT inflammatory so there’s barely any leukocytes!!! (in candida you get a lot of WBCs)

elevated pH greater than 4.5

Question 13

what is the KOH test?

Answer 13

drop KOH on specimens and it releases putramines – any time you make the pH more alkaline, it releases putramines and it smells really bad

this is the whiff test!

used to diagnose bacterial vaginosis

Question 14

what is a clue cell?

Answer 14

sign of bacterial vaginosis

looks like the edges of the cell are totally obliterated and it kinda looks like the whole cell is made of snow

Question 15

what is important when it comes to educating patients about trichomonas infections?

Answer 15

partner needs to be treated as well because it’s an STD!! this is unlike candida and BV

flagellated protozoa that roll and tumble across the screen

inflammatory infection so tons of WBCs will be present

also check the patient for other STDs!!! gonorrhea, syphilis, HIV, HepB, chlamydia

Question 16

24 year old at 16 weeks pregnant. new partner 8 weeks ago. no cramping or bleeding. presents with genital sores. no complaints or concerns though.

Answer 16

primary syphilis

bilateral chancers aka non-tender lesions which is different than HSV lesions which are super painful

look for hyper pigmented, papulosquamous rash of the palms and if they’re there it would make it secondary syphilis – primary syphilis can be less widespread and tends to just be one dominant lesion and if there’s more than 1, it means there’s a matching lesion on the other side

Question 17

is syphilis contagious?

Answer 17

secondary syphilis lesions on the hands are highly contagious!!

Question 18

how would you diagnose syphilis in this patient?

Answer 18

1. direct testing of the lesion

• dark field microscopy
• some local lads have validated PCR tests for T pallidum
• biopsy with silver stain

2. serology

• primary serology is often negative (2-4 weeks after exposure so IgG hasn’t formed yet)
• treponemal serology (TP-PA, FTA-ABS): specific to syphilis, will always stay positive once they’re positive
• non-treponemal (RPR, VDRL): used as titers, used to monitor response to treatment, can revert back to negative after treatment, can be positive for other treponemal diseases like YAWS

Question 19

what should be in your differential if you think a lesion is syphilis and how do you differentiate?

Answer 19

1. molluscum contagiosum

can be literally anywhere on the body, bumps have little pits in the middle

2. HSV

highly inflammatory, shallow, painful ulcer

3. condyloma acuminata (genital warts, have cauliflower appearance, can be different colors)

Question 20

what is primary vs secondary vs tertiary syphilis?

Answer 20

PRIMARY

1. 10-60 days after acquisition
2. charmer at the site of entry that heals spontaneously
3. serology negative

secondary

1. 4-8 weeks after chancre appears
2. rash, maculopapular
3. condyloma lata
4. resolves in a few weeks to months

TERTIARY

1. cardiac, CNS manifestations
2. gumma formation

1-2% of patients with secondary syphilis will have neurosyphilis; patients with HIV that also have syphilis have a really high chance of this happening to them

Question 21

how do you treat syphilis? why is a certain treatment mandated for pregnancy?

Answer 21

1. benzathine penicillin IM

alternative is oral tetracycline or doxycycline but the mandated treatment in pregnancy is penicillin because the spirochete crosses the placenta! so you can have congenital effects of having syphilis like mulberry teeth, syphilis rhinitis, etc. so you need to give penicillin which crosses the placenta and would make sure the baby is treated too! if someone has a penicillin allergy and they’re pregnancy you still treat them with penicillin you just desensitize them!

Question 22

how do you diagnose herpes?

Answer 22

1. PCR of lesion
2. serology to see if patient has IgG which will be different for HSV1 vs HSV2

primary has no IgG conversion yet but secondary outbreak would have IgG

Question 23

how do you treat herpes?

Answer 23

once you have herpes you have it forever, you are just trying to control outbreaks and protect your partner so you need to counsel!!!!

Question 24

58 years old female present with vulvar irritation and discomfort. menopause at 52.

this vulvar irritation started 1 year ago and they’re worsening. she’s tried oatmeal baths and uses vaginal estrogen because she had painful intercorse

differential?

Answer 24

1. lichen sclerosis
2. lichen planus
3. contact dermatitis

Question 25

what is vulvar contact dermatitis?

Answer 25

due to allergic reaction or irritant

tends to be symmetric

caused by soaps, lotions, feminine hygiene products

also washing too much or with harsh agent can cause this

anything that creates a wet environment makes it worse like incontinence or pad usage

Question 26

what is lichen planus?

Answer 26

1. inflammatory scarring; erosive lesions that can lead to vaginal scarring – they are superficial lesions of the vagina and it looks like a chemical burn because part of the epithelium is literally gone
2. systemic so it also involves skin and oral mucosa

oral involvement is common; 70% of those with erosive vaginal lesions have oral invovlement

3. ulcerative and pain
4. may be a dysfunction of cell-mediated immunity but we don’t really know why it happens
5. seen mostly in perimenopausal women

Question 27

what is lichen simplex chronicus?

Answer 27

1. chronic, non scarring lesions that causes thickened, leathery appearing skin
2. inflammatory
3. intense and persistent itching/scratching
4. may occur during the night
5. most common cause of vulvar pruritus and secondary effect of any pruritic vulvar issues

primarily in middle and late adulthood

you have to break the itch/scratch cycle!! give the patient something cold to put on or topical steroids or wear gloves at night to prevent itching

Question 28

what is lichen sclerosus et atrophicus?

Answer 28

chronic, scarring with loss of architecture (labia minor can literally be destroyed)

can have thickened areas

inflammatory

looks like thin white epithelium; cigarette paper looking appearance with hour glass distribution

maybe autoimmune but not really sure….

highly responsive to topical steroids

Question 29

why is it important to monitor vulvar lesions?

Answer 29

increases the risk for vulvar cancer! you need to monitor for changes in the lesion

vulvar intraepithelial neoplasia (VIN): can be result of chronic inflammation, may be asymptomatic or just have mild irritation, itching

Question 30

why should you biopsy a vulvar lesions?

Answer 30

1. persistent
2. atypical
3. ulcerative
4. appearance is concerning
5. skin, thickening, focal change
6. poor response to reasonable therapy
7. worsens during therapy
8. immunocompromised patient