LM 7.2: Vulva Anatomy & Dermatologic Conditions Flashcards
what is opening of the vagina called?
introitus
the introits is bound by the hymeneal ring
what is the vestibule of the vagina?
the area spanning from the urethra down to the posterior introitus
what is the posterior fourchette?
the spot where the labia minora meet posteriorly
what is the posterior commissure?
aka posterior introitus
where the labia majora meet
what structure provides lubrication to he vaginal opening?
Bartholin glands
they are located in the posterolateral area of the vestibule
what is the anterior commissure?
the anterior meeting of the labia majora
what is another name for the clitoral hood?
prepuce
it is formed by the meeting of the two labia minora
what is the frenulum?
the inferior portion of the clitoris is known as the frenulum
it is also formed by the labia minora
what structure provides lubrication for the distal urethra?
Skene’s glands
Skene’s glands are paraurethral glands that provide lubrication for the distal urethra
when does sexual differentiation begin and when are the external genitalia fully formed?
4 weeks: undifferentiated external genitalia of ectodermal original aka the genital tubercle, urogenital folds, and labioscrotal swellings
9 weeks: sexual differentiation begins
12 weeks: the external genitalia are fully formed
what type of tissue is the labia majora?
epidermis lined by stratified squamous epithelium
the dermis contains hair follicles and glands:
- merocrine/eccrine (sweat glands)
- holocrine (sebaceous glands)
- apocrine (vulvar secretions)
what type of tissue is the labia minora?
labia minora are different from the majora in that they don’t contain a granular layer of epithelium, they don’t have hair follicles, and they have less apocrine glands
what type of tissue is the clitoris?
the crura of the clitoris contain spongy vascular female erectile tissue known as corpora cavernosa
these bilateral structures fill with blood and cause the clitoris to swell and harden with stimulation, similar to the male penis during an erection
the vestibular bulbs contain trabecular and erectile tissue that similarly swell and harden
what are Bartholin’s glands? what type of tissue are they?
aka the major vestibular glands
part of the external genitalia, and provide lubrication to the opening of the vagina
they contain mucous-secreting columnar epithelial cells, which are shown in the image
the duct of the gland is lined by transitional epithelium, and the orifice of the gland is lined by stratified epithelium
what type of tissue is the urethra?
muscular tube lined by transitional epithelium
the distal tip and orifice is comprised of stratified squamous epithelium
the urethra is lined by tons of little periurethral glands, with the two biggest being the Skene’s gland
what is the purpose of Skene’s glands?
to secrete lubricant with antimicrobial properties which may help protect the urethra from UTIs
what is contact dermatitis of the vagina?
aka reactive vulvitis
caused by local irritants like soaps, synthetic fibers, and scented hygiene products
treated with topical corticosteroids for pruritus, and elimination of the causative agent
what is vaginal psoriasis?
erythematous plaque covered by a silver scale
if this scale gets picked off, you’ll see pinpoint bleeding, which is called Auspitz’s sign
however, due to the moisture in the area, the psoriatic lesion may look different than it would in other parts of the body, and can resemble a nonspecific dermatitis
how do you treat vaginal psoriasis?
topical cyclosporine or methotrexate
what is intertrigo?
a lesion resembling a fissure occurring in body folds
the skin is often macerated, meaning it is chronically exposed to moisture and begins to soften and break down –> common in obese patients, and occasionally the lesion may become infected with bacteria, viruses, or fungi
most common locations for intertrigo are the intercrural, interlabial, and inframammary areas
how do you treat intertrigo?
reduce moisture in the area, and reduce obesity
pruritus can be treated with topical corticosteroids, and concomitant infections can be treated with appropriate topical
what is tine cruris?
ringworm in the groin
a superficial skin infection caused by dermatophytes, a type of fungus
appears as an erythematous, well-circumscribed area with peripheral scaling
treat with antifungal imidazole cream
what is lichen planus?
6 P’s:
- pruritic
- polygonal
- planar
- purple
- papules
- plaques
lesions may exhibit Wickham striaeare which are whitish, lacy bands of keratosis
treat with topical corticosteroids
what is lichen sclerosus?
characterized by white, thin, pruritic vulvar skin
affected area may extend perianally, resembling a figure-8 pattern since it surrounds the vulva and anus = very specific for lichen sclerosus
skin is often described as resembling “onion skin” or “cigarette paper.”
sclerosis may cause normal antomic landmarks to be lost, for example the labial folds may fuse and there may be narrowing of the vaginal introitus
treated with a topical corticosteroid like clobetasol
what is the histology seen with lichen sclerosus?
- hyperkeratosis
- a thin epithelium
- flattening of rete ridges
- a collagenized layer
- a band of chronic inflammatory cell
what is lichen simplex chronicus?
this progresses from a longstanding irritant dermatitis
vulva becomes pruritic, which causes even more damage by scratching an already irritated area
this ultimately leads to epidermal hyperplasia and inflammatory cell infiltrate, and the skin will appear diffusely red with hyperplastic or hyperpigmented plaques
how do you treat lichen simplex chronicus?
diphenhydramine to help with unconscious nighttime scratching, and a topical steroid
biopsy if no relief within 3 months
how can Crohn’s disease effect the vulva?
it can create rectoperineal or rectovaginal fistulas
what is Behcet’s disease?
an inflammatory disorder characterized by blood vessel and mucous membrane involvement
oral lesions are particularly common, and vulvovaginal lesions can be seen
- oral ulcers
- genital ulcers
- anterior uveitis and hypopyon
how does diabetes effect the vagina?
chronic yeast infections, which can lead to a thick, gray, ulcerated epithelium
how does uremia effect the vagina?
high levels of urea that may lead to development of uremic frost on the vulva
manifests as a flaky, powdery substance made of crystallized urea that deposits on the skin of patients with uremia
what is syphilis?
STD caused by spirochete Treponema pallidum
what are the stages of syphilis?
stage 1: chancre
stage 2: rash, condyloma lata
latent stage
stage 3: gammas, CNS, cardiac
what is stage 1 of syphilis?
chancre sore
a small, painless, firm, punched-out-looking lesion with rolled edges
appears within 10-60 days of exposure, often on the genitals, and heals spontaneously within 3-6 weeks without treatment
patients may also experience mild adenopathy and systemic symptoms
at this stage, they are usually serologically negative
what is stage 2 of syphilis?
4-8 weeks after the primary chancre appears
- rough textured rash on the palms and soles
- flue-like symptoms
- patchy alopecia
- highly infectious mucocutaneous patches
- condyloma lata: flat-topped papules that are broader and flatter than condyloma acuminata/genital warts
what is the latent phase of syphilis?
a latent stage where they exhibit no signs or symptoms
they become serologically positive
as the latent period becomes longer, they become slightly less infectious
what is the 3rd stage of syphilis?
tertiary syphilis has low transmission to others
- gummas: necrotic, destructive, granulomatous lesions
- CNS
- cardiac
- ocular
how do you diagnose syphilis?
- dark field microscopy allows for direct visualization of the spirochetes
- nontreponemal tests: VDRL and RPR
- treponema tests: fluorescent antibody test on lesion aspirate
nontreponemal tests are typically used to screen, and if it is reactive, the diagnosis is confirmed with a treponemal test
nontreponemal tests react to cardiolipin, women with lupus and other conditions can have false positive results
treponemal tests will stay positive for life, so they’re not good to gauge treatment efficacy
how do you treat syphilis?
benzathine penicillin G
if a patient is pregnant and allergic to penicillin, consideration is to desensitize her
tetracycline can be considered in non-pregnant penicillin allergic patients
what is a chancroid?
a very rare STD in the US caused by the bacteria Hemophilus ducreyi
what is the clinical presentation of a chancroid?
- extremely painful ulcers with ragged/irregular borders and a greyish-yellow bas
- tender suppurative inguinal adenitis –> lymph nodes in the groin swell and fill with pus, enough to the point that they can actually rupture out onto the skin
how do you diagnose a chancroid?
typically clinical
but it’s important to rule out herpes and syphilis, and chancroid can be confirmed with PCR testing of lesions
how do you treat a chancroid?
azithromycin, ceftriaxone, ciprofloxacin, or erythromycin
what is a granuloma inguinale?
aka donovanosis
infection caused by C. granulomatis
generally manifests as a painless vulvar nodule that evolves into a vascularized, friable, “beefy red” ulcer
how do you diagnose and treat granuloma inguinale?
usually diagnosed clinically, but it can be confirmed with special stains on swabs
treated with tetracyclines, ampicillin, or chloramphenicol
what is lymphogranuloma venereum?
a disease caused by chlamydia trachomatis serotypes L1, L2, L3
can be transmitted vaginally or anally, and symptoms will differ accordingly
what is the clinical presentation of lymphogranuloma venereum?
vaginal transmission leads to painful inguinal and/or femoral lymphadenopathy, and anal transmission leads to anal bleeding, purulent discharge, constipation, and anal spasms
often initially begins with a self-limiting, often overlooked vesicle or papule at site of entry
can progress to vulvar edema and draining sinuses, which ultimately can lead to strictures
in the chronic state, the lesions may show malignant potential
how do you treat lymphogranuloma venereum?
tetracycline, erythromycin, azithromycin, ofloxacin,and aspiration of fluctuant lymph nodes if necessary
what is genital herpes?
infection caused by the herpes simplex virus
a DNA virus, and most cases of genital herpes are caused by HSV-2, with oral herpes, or coldsores, mostly being caused by HSV-1
what are the symptoms of genital herpes?
up to 75% of primary infections of genital herpes may go unrecognized despite often being pretty symptomatic
- general malaise
- fevers
- myalgia
- nausea
- dysuria
- neurologic involvement
what is neurologic involvement associated with genital herpes?
it refers to the viral prodrome that often precedes a herpes outbreak, and includes a tingling, burning, painful, itching sensation in the area where the vesicles will erupt
three to seven days after initial exposure, clusters of painful vesicles will often appear on the vulva, vagina, cervix, perineum, and buttocks
the vesicles lyse and leave shallow, painful ulcers with a red border
in addition, patients with a primary HSV infection may have vulvar edema and enlarged, tender inguinal lymph nodes
after the primary infection, the virus migrates to and remains latent in the dorsal root ganglia
how does genital herpes recurrence presence?
patients can get the classic neurologic prodrome we mentioned earlier, followed by the clusters of vesicles
recurrences can also present as unilateral fissures or vulvar irritation
viral shedding can occur for up to three weeks after lesions appear, so just because someone doesn’t have an active outbreak, doesn’t mean they aren’t infective
how do you diagnose herpes?
Tzanck smear –> a smear would show enlarged, multinucleated cells with eosinophilic intranuclear inclusions and a ground glass
can also be made with viral culture, which has a low sensitivity, or antibody tests, though this is not routinely recommended appearance
current preferred method is PCR
how do you treat herepes?
you can’t cure it
therapy is rather aimed at reducing viral shedding and shortening the symptomatic phase
for an initial episode, antivirals such as acyclovir, famciclovir, or valacyclovir are given for 7-10 days
for infrequent recurrences, episodic therapy can be used to decrease duration of the episode, amount of lesions, pain, and viral shedding – antivirals are initiated during the prodrome or right at the start of the outbreak, and given for 3-5 days
patients with more frequent recurrences, or whose partners do not have HSV, suppressive therapy can be used, meaning the patient takes an antiviral daily
what is moluscum contagious?
a common condition caused by a highly infectious DNA poxvirus
transmitted sexually or through fomites
characterized by small, painless, centrally umbilicated papules that often resolve spontaneously within 6 months to 1 year
if the patient desires treatment, the papules can be removed with cryotherapy or topical trichloroacetic acid and benzoyl peroxid
what is condyloma acuminata?
aka genital warts = soft-fleshy, cauliflower-like growths often caused by human papillomavirus 6 and 11
spread by direct skin-to-skin contact, so symmetrically-distributed lesions are common in the skin folds
diagnosis is clinical but biopsy can be done
how do you treat condyloma acuminata?
- cryosurgery
- laser surgery
- surgical excision
- intralesional interferone infections
- topical tricholoracetic acid
- podofilox or imiquimod
warts tend to be more persistent and difficult to remove in patients with diabetes, who smoke, or who are immunosuppressed
what is hidradenitis suppurative?
aka acne inversa
an infection of the apocrine glands by staph aureus
characterized by deep-seated, painful, subcutaneous nodules, which can coalesce and create large draining masses
typically found in the axillae, groin, perianal region, and inner thigh due to the high density of sweat glands in those locations
treatment includes antibiotics, anti-inflammatories, anti-androgens, incision and drainage, or excision of sweat glands altogether
