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My MRCOG Part 2 > Module 1 - TOG - Vulval Disorders in PAG > Flashcards

Module 1 - TOG - Vulval Disorders in PAG Flashcards

1
Q

What 3 factors make paediatric and adolescent patients prone to vulval disorders?

A
  1. Hypoestrogenic environment
  2. Neutral pH
  3. Exposed vulva
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2
Q

What proportion of PAG ED Gynae attendances are regarding vulval disorders?

A

50%

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3
Q

What affects does a hypoestrogenic environment have on the vulval tissue?

A

Exposed vulval and vaginal tissues.
Thin, atrophic labia.
Hypersensitive.
Neutral pH (lack of lactobacilli).
Close proximity to rectum (potential for faecal contamination).

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4
Q

What vulval changes occur at puberty that results in a lower chance of developing (or resolution) of vulval disorders?

A

Increased oestrogen.
Increased labial fat pads.
Increased lactobacilli (lowers pH, more acidic).
Androgen secretion causes pubic hair.

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5
Q

What vulval presentations can diabetic children present with?
(This might be their first presentation)

A

Vulvovaginitis
(60% due to candida).

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6
Q

How and when can IBD present in a PAG vulval clinic?

A

Vulval IBD can present with pain, oedema, ulcers, fistulae and abscesses.

Vulval IBD can proceed GI IBD.

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7
Q

When examining PAG patients, how should examination be carried out?

A

With a small wet swab on the perineum only.
Vaginal swabs should only be done under GA (hypersensitivity).
Examine underwear (discharge, PVB, hygiene).

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8
Q

What should be considered in PAG patients who present with recurrent PVB or persistent pain/discharge?

A

CSA (child sexual abuse).
Remember that trauma isn’t always seen due to rapid regeneration of the tissues.

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9
Q

Define vulvovaginitis

A

Inflammation of the vagina and vulva

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10
Q

What is the most common PAG vulval disorder?

A

Vulvovaginitis

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11
Q

Vulvovaginitis accounts for what percentage of:
- Attendances in ED
- Referrals to GOPD.

A
  • 50% ED attendances.
  • 20% GOPD Referrals.
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12
Q

What are the symptoms of vulvovaginitis?

A

Vulval erythema (82%).
Vaginal soreness (74%).
Discharge (60%).
Pruitis (60%).

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13
Q

What is the peak onset of vulvovaginitis?

A

3-7 years old.

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14
Q

What % of vulvovaginitis is infectious vs non infectious?

A

80% NON infectious
20% infectious.

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15
Q

What are the common causes of infectious vulvovaginitis?

A

Gut or resp tract organisms:
- E Coli
- GAS
- GBS
- H Influenzae
(Candida only in immunocompromised - think ?DM).

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16
Q

What investigations should be carried out to investigate vulvovaginitis?

A

None, these rarely change the management plan or outcome.

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17
Q

What is the treatment for vulvovaginitis? What proportion of patients will respond to this treatment?

A

Conservative treatment with strict hygiene, avoidance of irritants, barrier creams and treatment of contraception.

2/3 cases resolve with conservative management.

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18
Q

What proportion of Lichen Sclerosis occurs in the PAG population?

A

7-15%

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19
Q

When does the incidence of Lichen Sclerosis peak?

A

Pre-pubertal girls (due to hypo-oestrogenic environment).

20
Q

What are the potential causes of Lichen Sclerosis?

A

Genetic (10% have an affected parent).
Autoimmune (lymphatic infiltration of IL-1).

21
Q

What proportion of PAG patients with Lichen Sclerosis experience symptom relief at puberty?

A

75%

22
Q

What proportion of PAG patients with Lichen Sclerosis experience relapse after a latent phase?

A

66%

23
Q

What are the symptoms of Lichen Sclerosis?
In what pattern do these symptoms occur?

A

Puritis, bleeding, pain, dysuria, painful deification.
White, demarcated, thin lesions that progress to erosions, scaring, hyperkeratosis and labial adhesions.

Figure of 8 pattern (i.e. affects labia, clitoral hood and perineum. But spares the hymen and vaginal mucosa).

24
Q

What is the treatment of Lichen Sclerosis in the PAG population?

A

Potent topical steroids:
- Clobetasol Propionate 0.05%
- Betamethasone valorate 0.05%
With emollients

25
Q

What are the SEs of topic potent steroids in treatment of vulval LS in PAG population?

A

Steroid induced atrophy.
Erythema.
Telangtactasia.
Breast hypertrophy.
Therefore PAG patients need 6 monthly follow up to assess for these SEs.

26
Q

What treatment can be used for refractory LS?

A

Calcineurin inhibitors (tacrolimus) (But patients have to be >2 years and there is a risk of SCC and lymphoma).
Topical or oral antihistamines.
Barrier ointments.

27
Q

What is the estimated prevalence of labial adhesions?

A

2-39%

28
Q

What is the likely cause of labial adhesions?

A

Vulval irritation in a hypoestrogenic environment.

29
Q

What is the treatment for labial adhesions in the PAG population?

A

Reassurance that most resolve at puberty.

6/52 Topical ostrogen (with a swab in a gentle downward motion).
80% success of conservative/medical treatment.

Surgery only if fusion persistent past puberty, but this has a 40% reoccurrence rate.

30
Q

What are the common causes of clitoromegaly?

A

DSD (Difference in sex Development).
Extreme prematurity.

90% of pathological clitoromegaly is due to CAH (i.e. 21 hydroxylase enzyme deficiency).
If persists in adolescence, think mild CAH.

31
Q

Should surgery be offered in patients with clitoromegaly?

A

Only in severe cases.
There is a risk of cliteral nerve injury.
80% need further corrective surgery.

32
Q

What are the 4 types of hymenal variations that could be seen in the PAG clinic?

A

Septate (a little septum between hymen edges).
Microperforate (tiny hole in hymen covering vaginal entrance).
Cribiform (multiple holes like a sieve).
Imperforate (complete covering).

33
Q

What hymenal variations may present in adolescence with difficulty inserting tampons or inability to have sex?

A

Septate or Microperforate.

34
Q

What hymenal variations may present at menarche with amenorrhoea, cyclical pelvic pain, a mass, constipation or urinary retention?

A

Cribiform or Imperforate.

35
Q

What US findings are seen in girls with a cribiform or imperforate hymen?

A

Normal pelvic organs.
Distended vagina.
Thick echogenic fluid (blood - haematocolpus).

36
Q

What is the aim of surgery in hymenal variation surgery?

A

Remove as much hymenal tissue as possible.
Using a crutiate or circumfrencial incision.
With application of post op topical oestrogen.

37
Q

What causes urethral protrusion in PAG population?

A

hypo-estrogen.

38
Q

What is the treatment for urethral protrusion in PAG population?

A

Topical oestrogen.
Occasionally surgery.

39
Q

What is IPPP?
What does this look like?
What is the prevalence?

A

Infantile Perineal Pyramidal Protrusion.

A small, flesh coloured single sensile protrusion on the perineum, anterior to the anus.

7% prevalence.

40
Q

What are the 3 types of vaginal/vulval injuries that can occur in PAG paitnets?

A
  1. straddle injuries
  2. accidental penetrating
  3. vaginal insufflation (water slides).
41
Q

What HPV subtypes case genital warts?

A

HPV 1-4 cause cutaneous warts
6 and 11 (sexually transmitted)

42
Q

How can warts be differentiated from herpes?

A

Herpes is PAINFUL but warts are painless.

43
Q

What is the incubation period for genital warts?

A

8 weeks to 18 months.

44
Q

What proportion of gentile warts resolve spontaneously?

A

> 50%

45
Q

If they do not resolve spontaneously, what treatment can be offered to treat vulval warts?

A

Cryotherapy
Imiquimod (immune modifying)
Podophyllin (cytotoxic).

My MRCOG Part 2 (37 decks)

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