Obj 35: Vulvar and Vaginal Disorders Flashcards
A 32-year-old G0 woman with a last menstrual period three weeks ago, presents with a three-month history of a malodorous vaginal discharge. She reports no pruritus or irritation. She has been sexually active with a new partner for the last four months. Her past medical history is unremarkable. Pelvic examination reveals normal external genitalia without rash, ulcerations or lesions. Some discharge is noted on the perineum. The vagina reveals only a thin, gray homogeneous discharge. The vaginal pH is 5.0. A wet prep is shown in the image below. Which of the following is the most appropriate treatment for this patient?
A. Ceftriaxone
B. Doxycycline
C. Metronidazole
D. Azithromycin
E. Penicillin
C. Bacterial vaginosis is the most common cause of vaginitis. The infection arises from a shift in the vaginal flora from hydrogen peroxide-producing lactobacilli to non-hydrogen peroxide-producing lactobacilli, which allows proliferation of anaerobic bacteria. The majority of women are asymptomatic; however, patients may experience a thin, gray discharge with a characteristic fishy odor that is often worse following menses and intercourse.
Modified Amsel criteria for diagnosis include three out of four of the following:
1) thin, gray homogenous vaginal discharge;
2) positive whiff test (addition of potassium hydroxide releases characteristic amine odor);
3) presence of clue cells on saline microscopy; and
4) elevated vaginal pH >4.5.
Treatment consists of Metronidazole 500 mg orally BID for seven days, or vaginal Metronidazole 0.75% gel QHS for five days.
A 64-year-old G2P2 woman presents with a 12-month history of severe vulvar pruritus. She has applied multiple over-the-counter topical therapies without improvement. She has no significant vaginal discharge. She has severe dyspareunia at the introitus and has stopped having intercourse because of the pain. Her past medical history is significant for allergic rhinitis and hypertension. On pelvic examination the external genitalia show loss of the labia minora with resorption of the clitoris (phimosis). The vulvar skin appears thin and pale and involves the perianal area as in the picture below. No ulcerations are present. The vagina is mildly atrophic, but appears uninvolved. Which of the following is the most likely diagnosis in this patient?
A. Squamous cell hyperplasia
B. Lichen sclerosus
C. Lichen planus
D. Candidiasis
E. Vulvar cancer
B. Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women. The exact etiology is unknown, but is most likely multifactorial. Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia. Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation. The vagina is not involved. More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema and surface vascular changes. Ultimately, scarring with loss of normal architecture, such as introital stenosis and resorption of the clitoris (phimosis) and labia minora, may occur. Treatment involves use of high-potency topical steroids. There is less than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus.
A 32-year-old G0 woman presents with a one-month history of profuse vaginal discharge with mild odor. She has a new sexual partner with whom she has had unprotected intercourse. She reports mild to moderate irritation, pruritus and pain. She thought she had a yeast infection, but had no improvement after using an over-the-counter antifungal cream. She is concerned about sexually transmitted infections. Her medical history is significant for lupus and chronic steroid use. Pelvic examination shows normal external genitalia, an erythematous vagina with a copious, frothy yellow discharge and multiple petechiae on the cervix. Vaginal pH is 7. Which of the following findings on a wet prep explains the etiology of this condition?
A. Hyphae
B. Clue cells
C. Trichomonads
D. Lactobacilli
E. Normal epithelial cells
C. This patient has signs and symptoms of trichomoniasis, which is caused by the protozoan, T. vaginalis. Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green discharge with vulvar irritation. However, some women have minimal or no symptoms.
Diagnosis of vaginal trichomoniasis is performed by saline microscopy of vaginal secretions, but this method has a sensitivity of only 60% to 70%.
The CDC recommended treatment is metronidazole 2 grams orally in a single dose. An alternate regimen is metronidazole 500mg orally twice daily for seven days. The patient’s sexual partner also should undergo treatment prior to resuming sexual relations.
A 42-year-old G2P2 woman presents with a two-week history of a thick, curdish white vaginal discharge and pruritus. She has not tried any over-the-counter medications. She is currently single and not sexually active. Her medical history is remarkable for recent antibiotic use for bronchitis. On pelvic examination, the external genitalia show marked erythema with satellite lesions. The vagina appears erythematous and edematous with a thick white discharge. The cervix appears normal and the remainder of the exam is unremarkable except for mild vaginal wall tenderness. Vaginal pH is 4.0. Saline wet prep reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide prep shows the organisms. Which of the following is the most appropriate treatment for this patient?
A. Clindamycin
B. Azole cream
C. Metronidazole
D. Doxycycline
E. Ciprofloxacin
B. Vulvovaginal candidiasis (VVC) usually is caused by C. albicans, but is occasionally caused by other Candida species or yeasts. Typical symptoms include pruritus and vaginal discharge. Other symptoms include vaginal soreness, vulvar burning, dyspareunia and external dysuria. None of these symptoms are specific for VVC.
The diagnosis is suggested clinically by vulvovaginal pruritus and erythema with or without associated vaginal discharge.
The diagnosis can be made in a woman who has signs and symptoms of vaginitis when either:
- a) a wet preparation (saline or 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae;
- or b) a vaginal culture or other test yields a positive result for a yeast species.
Microscopy may be negative in up to fifty percent of confirmed cases.
Treatment for uncomplicated VVC consists of short-course topical Azole formulations (1-3 days), which results in relief of symptoms and negative cultures in 80%-90% of patients who complete therapy.
A 52-year-old G0 woman presents with long-standing vulvar and vaginal pain and burning. She has been unable to tolerate intercourse with her husband because of pain at the introitus. She has difficulty sitting for prolonged periods of time or wearing restrictive clothing because of worsening vulvar pain. She recently noticed that her gums bleed more frequently. She avoids any topical over-the-counter therapies because they intensify her pain. Her physical examination is remarkable for inflamed gingiva and a whitish reticular skin change on her buccal mucosa. A fine papular rash is present around her wrists bilaterally. Pelvic examination reveals white plaques with intervening red erosions on the labia minora as shown in below picture. A speculum cannot be inserted into her vagina because of extensive adhesions. The cervix cannot be visualized. Which of the following is the most likely diagnosis in this patient?
A. Squamous cell hyperplasia
B. Lichen sclerosus
C. Lichen planus
D. Genital psoriasis
E. Vulvar cancer
C. Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva. This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares. The exact etiology is unknown, but is thought to be multifactorial.
Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia and extragenital rashes. Treatment is challenging, since no single agent is universally effective and consists of multiple supportive therapies and topical high potency corticosteroids.
A 27-year-old G0 woman presents with a three-year history of dyspareunia. She reports a history of always having painful intercourse, but she is now unable to tolerate intercourse at all. She has avoided sex for the last six months. She describes severe pain with penile insertion. On further questioning, she reports an inability to use tampons because of painful insertion. She also notes a remote history of frequent yeast infections while she was on antibiotics for recurrent sinusitis that occurred years ago. Her medical history is unremarkable, and she is not on medications. Pelvic examination is remarkable for normal appearing external genitalia. Palpation of the vestibule with a Q-tip elicits marked tenderness and slight erythema. A normal-appearing discharge is noted. Saline wet prep shows only a few white blood cells, and potassium hydroxide testing is negative. Vaginal pH is 4.0. The cervix and uterus are unremarkable. Which of the following is the most likely diagnosis in this patient?
A. Vaginal cancer
B. Genital herpes infection
C. Vestibulodynia
D. Contact dermatitis
E. Chlamydia infection
C. Vestibulodynia (formally vulvar vestibulitis) syndrome consists of a constellation of symptoms and findings limited to the vulvar vestibule, which include severe pain on vestibular touch or attempted vaginal entry, tenderness to pressure and erythema of various degrees. Symptoms often have an abrupt onset and are described as a sharp, burning and rawness sensation. Women may experience pain with tampon insertion, biking or wearing tight pants, and avoid intercourse because of marked introital dyspareunia. Vestibular findings include exquisite tenderness to light touch of variable intensity with or without focal or diffuse erythematous macules. Often, a primary or inciting event cannot be determined.
Treatment includes use of tricyclic antidepressants to block sympathetic afferent pain loops, pelvic floor rehabilitation, biofeedback, and topical anesthetics. Surgery with vestibulectomy is reserved for patients who do not respond to standard therapies and are unable to tolerate intercourse.
A 30-year-old G1P1 woman presents with a history of chronic vulvar pruritus. The itching is so severe that she scratches constantly and is unable to sleep at night. She reports no significant vaginal discharge or dyspareunia. She does not take antibiotics. Her medical history is unremarkable. Pelvic examination reveals normal external genitalia with marked lichenification (increased skin markings) and diffuse vulvar edema and erythema. Saline microscopy is negative. Potassium hydroxide testing is negative. Vaginal pH is 4.0. The vaginal mucosa is normal. Which of the following is the most likely diagnosis in this patient?
A. Lichen simplex chronicus
B. Lichen sclerosus
C. Lichen planus
D. Candidiasis
E. Vulvar cancer
A. Lichen simplex chronicus, a common vulvar non-neoplastic disorder, results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier.
Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching.
Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema. The skin changes can be localized or generalized. Diagnosis is based on clinical history and findings, as well as vulvar biopsy. Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus.
A 20-year-old G0 college student presents with a one-month history of profuse vaginal discharge and mid-cycle vaginal spotting. She uses oral contraceptives and she thinks her irregular bleeding is due to the pill. She is sexually active and has had a new partner within the past three months. She reports no fevers or lower abdominal pain. She has otherwise been healthy. On pelvic examination, a thick yellow endocervical discharge is noted. Saline microscopy reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide testing is negative. Vaginal pH is 4.0. No cervical motion tenderness or uterine/adnexal tenderness is present. Testing for gonorrhea and chlamydia is performed, but those results will not be available for several days and the student will be leaving for Europe tomorrow. Which of the following is the most appropriate treatment for this patient?
A. Metronidazole and erythromycin
B. Ceftriaxone and azithromycin
C. Ampicillin and doxycycline
D. Azithromycin and doxycycline
E. No treatment is necessary until all tests results are known
B. Mucopurulent cervicitis (MPC) is characterized by a mucopurulent exudate visible in the endocervical canal or in an endocervical swab specimen.
MPC is typically asymptomatic, but some women have an abnormal discharge or abnormal vaginal bleeding. MPC can be caused by Chlamydia trachomatis or Neisseria gonorrhoeae; however, in most cases neither organism can be isolated. Patients with MPC should be tested for both of these organisms. The results of sensitive tests for C. trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid amplification tests) should determine the need for treatment, unless the likelihood of infection with either organism is high or the patient is unlikely to return for treatment.
Treatment: Antimicrobial therapy should include coverage for both organisms, such as azithromycin or doxycycline for chlamydia and a cephalosporin or quinolone for gonorrhea.
Uncomplicated cervicitis, as in this patient, would require only 125 mg of Ceftriaxone in a single dose. Ceftriaxone 250 mg is necessary for the treatment of upper genital tract infection or pelvic inflammatory disease (PID).
A 37-year-old G0 woman presents with a one-week history of a mildly painful vulvar ulcer. She reports no fevers, malaise or other systemic symptoms. She recently started use of a topical steroid ointment for a vulvar contact dermatitis. She is married and has no prior history of sexually transmitted infections. She reports no travel outside the United States by her husband or herself. Her last Pap smear, six months ago, was normal. A vulvar herpes culture later returns positive for herpes simplex virus type 2. A Rapid Plasma Reagin (RPR) is nonreactive, and HIV testing is negative. Which of the following is the most likely diagnosis in this patient?
A. Primary HSV episode
B. Recurrent HSV-1 episode
C. Recurrent HSV-2 episode
D. Atypical HSV episode
E. Contact dermatitis
C. Two serotypes of HSV have been identified: HSV-1 and HSV-2. Most cases of recurrent genital herpes are caused by HSV-2. Up to 30% of first-episode cases of genital herpes are caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than genital HSV-2 infection. Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV antibodies).
Systemic symptoms of a primary infection include fever, headache, malaise and myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The severity and duration of symptoms are intermediate between primary and recurrent disease, with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity. Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or serologic tests. Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.
A 74-year-old G0 woman complains of vulvar pain. She reports that the pain is present every day and she has had it for the past year. It now limits her ability to exercise, and she is no longer able to have sexual relations with her partner. On exam, her BMI is 32; blood pressure is 100/60; and heart rate is 77. Her vulva has an ulcerated lesion near the left labial edge. Which of the following is the next best step in the management of this patient?
A. Estrogen cream
B. Clobetasol cream
C. Vulva biopsy
D. Laser vaporization of the lesion
E. Vulvectomy
C. This patient has a vulvar lesion causing her pain. The next step is to perform a biopsy to evaluate for vulvar cancer. Estrogen cream and clobetasol (a high potency steroid) are treatments for vulvadynia. To diagnosis vulvadynia, all other causes of pain must first be excluded, including infectious etiologies as well as other vulvar conditions. Laser vaporization and vulvectomy are contraindicated until a definitive diagnosis is made.
