Module 1 - TOG - Vulval Disorders in PAG Flashcards
What 3 factors make paediatric and adolescent patients prone to vulval disorders?
- Hypoestrogenic environment
- Neutral pH
- Exposed vulva
What proportion of PAG ED Gynae attendances are regarding vulval disorders?
50%
What affects does a hypoestrogenic environment have on the vulval tissue?
Exposed vulval and vaginal tissues.
Thin, atrophic labia.
Hypersensitive.
Neutral pH (lack of lactobacilli).
Close proximity to rectum (potential for faecal contamination).
What vulval changes occur at puberty that results in a lower chance of developing (or resolution) of vulval disorders?
Increased oestrogen.
Increased labial fat pads.
Increased lactobacilli (lowers pH, more acidic).
Androgen secretion causes pubic hair.
What vulval presentations can diabetic children present with?
(This might be their first presentation)
Vulvovaginitis
(60% due to candida).
How and when can IBD present in a PAG vulval clinic?
Vulval IBD can present with pain, oedema, ulcers, fistulae and abscesses.
Vulval IBD can proceed GI IBD.
When examining PAG patients, how should examination be carried out?
With a small wet swab on the perineum only.
Vaginal swabs should only be done under GA (hypersensitivity).
Examine underwear (discharge, PVB, hygiene).
What should be considered in PAG patients who present with recurrent PVB or persistent pain/discharge?
CSA (child sexual abuse).
Remember that trauma isn’t always seen due to rapid regeneration of the tissues.
Define vulvovaginitis
Inflammation of the vagina and vulva
What is the most common PAG vulval disorder?
Vulvovaginitis
Vulvovaginitis accounts for what percentage of:
- Attendances in ED
- Referrals to GOPD.
- 50% ED attendances.
- 20% GOPD Referrals.
What are the symptoms of vulvovaginitis?
Vulval erythema (82%).
Vaginal soreness (74%).
Discharge (60%).
Pruitis (60%).
What is the peak onset of vulvovaginitis?
3-7 years old.
What % of vulvovaginitis is infectious vs non infectious?
80% NON infectious
20% infectious.
What are the common causes of infectious vulvovaginitis?
Gut or resp tract organisms:
- E Coli
- GAS
- GBS
- H Influenzae
(Candida only in immunocompromised - think ?DM).
What investigations should be carried out to investigate vulvovaginitis?
None, these rarely change the management plan or outcome.
What is the treatment for vulvovaginitis? What proportion of patients will respond to this treatment?
Conservative treatment with strict hygiene, avoidance of irritants, barrier creams and treatment of contraception.
2/3 cases resolve with conservative management.
What proportion of Lichen Sclerosis occurs in the PAG population?
7-15%
When does the incidence of Lichen Sclerosis peak?
Pre-pubertal girls (due to hypo-oestrogenic environment).
What are the potential causes of Lichen Sclerosis?
Genetic (10% have an affected parent).
Autoimmune (lymphatic infiltration of IL-1).
What proportion of PAG patients with Lichen Sclerosis experience symptom relief at puberty?
75%
What proportion of PAG patients with Lichen Sclerosis experience relapse after a latent phase?
66%
What are the symptoms of Lichen Sclerosis?
In what pattern do these symptoms occur?
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).
What is the treatment of Lichen Sclerosis in the PAG population?
Potent topical steroids:
- Clobetasol Propionate 0.05%
- Betamethasone valorate 0.05%
With emollients
What are the SEs of topic potent steroids in treatment of vulval LS in PAG population?
Steroid induced atrophy.
Erythema.
Telangtactasia.
Breast hypertrophy.
Therefore PAG patients need 6 monthly follow up to assess for these SEs.
What treatment can be used for refractory LS?
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.
What is the estimated prevalence of labial adhesions?
2-39%
What is the likely cause of labial adhesions?
Vulval irritation in a hypoestrogenic environment.
What is the treatment for labial adhesions in the PAG population?
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.
What are the common causes of clitoromegaly?
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.
Should surgery be offered in patients with clitoromegaly?
Only in severe cases.
There is a risk of cliteral nerve injury.
80% need further corrective surgery.
What are the 4 types of hymenal variations that could be seen in the PAG clinic?
Septate (a little septum between hymen edges).
Microperforate (tiny hole in hymen covering vaginal entrance).
Cribiform (multiple holes like a sieve).
Imperforate (complete covering).
What hymenal variations may present in adolescence with difficulty inserting tampons or inability to have sex?
Septate or Microperforate.
What hymenal variations may present at menarche with amenorrhoea, cyclical pelvic pain, a mass, constipation or urinary retention?
Cribiform or Imperforate.
What US findings are seen in girls with a cribiform or imperforate hymen?
Normal pelvic organs.
Distended vagina.
Thick echogenic fluid (blood - haematocolpus).
What is the aim of surgery in hymenal variation surgery?
Remove as much hymenal tissue as possible.
Using a crutiate or circumfrencial incision.
With application of post op topical oestrogen.
What causes urethral protrusion in PAG population?
hypo-estrogen.
What is the treatment for urethral protrusion in PAG population?
Topical oestrogen.
Occasionally surgery.
What is IPPP?
What does this look like?
What is the prevalence?
Infantile Perineal Pyramidal Protrusion.
A small, flesh coloured single sensile protrusion on the perineum, anterior to the anus.
7% prevalence.
What are the 3 types of vaginal/vulval injuries that can occur in PAG paitnets?
- straddle injuries
- accidental penetrating
- vaginal insufflation (water slides).
What HPV subtypes case genital warts?
HPV 1-4 cause cutaneous warts
6 and 11 (sexually transmitted)
How can warts be differentiated from herpes?
Herpes is PAINFUL but warts are painless.
What is the incubation period for genital warts?
8 weeks to 18 months.
What proportion of gentile warts resolve spontaneously?
> 50%
If they do not resolve spontaneously, what treatment can be offered to treat vulval warts?
Cryotherapy
Imiquimod (immune modifying)
Podophyllin (cytotoxic).
