Vaginal/vulval disorders Flashcards
Vaginal discharge causes
BV candida Chlamydia gonorrhea trichomonas vaginalis foreign body cervical ectropion polyps malignancy pregnancy ovulation (cyclical) hormonal contraception
pruritis vulvae
irritants: soaps, detergents, barrier contraception atrophic vaginitis candida, pubic hair lice skin conditions such as eczema vulval malignancy pregnancy-related vaginal discharge urinary or faecal incontinence stress
bartholin glands location
4 o clock and 8 o clock
secrete mucus to lubricate vagina
abscess
batholin abscess organisms
E.coli
MRSA
STIs
risk factors for bartholin’s cysts
nulliparous women of child-bearing age
personal history of Bartholin’s cyst
sexually active (STIs can cause Bartholin’s cyst or abscess)
history of vulval surgery
clinical features of bartholins cysts
superficial dyspareunia
vulvar pain
spontaneous rupture
soft, fluctuant and non-tender
bartholin’s abscess presentation
acute onset of pain
difficulty passing urine
tense and hard, surrounding cellulitis
differential diagnosis bartholins cyst
Bartholin’s gland carcinoma
bartholin’s benign tumour: adenomas and nodular hyperplasia
sebaceous cyst, Skene’s duct cyst, mucous cyst
fibroma, lipoma, leiomyoma
investigations bartholins cyst
clinical diagnosis
>40, biopsy for vulval carcinoma
STI: swabs needed
management of bartholin’s cyst
warm bath is cyst is small and asymptomatic
word catheter
marsupialisation
lichen sclerosus epidemiology
It has a bimodal incidence, peaking in prepubescent girls and post-menopausal women. Although uncommon, it can be a debilitating disease – which has the potential to progress to squamous cell carcinoma (~5% of the postmenopausal group).
risk factors lichen sclerosus
Genetics – family history of lichen sclerosus can increase risk.
Other autoimmune disorders – such as thyroid disease, type 1 diabetes, alopecia areata.
clinical features lichen sclerosus
white atrophic patches: axillae, buttocks, thighs
clitoral hood fusion
fusion of labia minora to labia majora
posterior fusion resulting in loss of vaginal opening
DD lichen sclerosus
Lichen simplex Vitiligo Vulvae cancer or intraepithelial neoplasia Candidiasis Post-inflammatory hypopigmentation
lichen sclerosus investigations
The diagnosis of lichen sclerosus is usually made clinically, with no investigations required. Often it is preferable to test by treating and assessing any response.
A biopsy can be performed if there is uncertainty about the diagnosis – especially in cases of treatment failure, or when malignancy needs to be excluded.
management of lichen sclerosus
The mainstay of management of lichen sclerosus is with immunosuppression. Patients should be given advice regarding avoiding irritants to the area, and minimising urinary contact.
First line therapy is the use of topical steroids, such as clobetasol propionate. In the UK, the recommended regime is once daily at night for 4 weeks, then on alternate nights for 4 weeks, and then twice weekly for a further 4 weeks.
Patients with lichen sclerosus should be followed-up, as there is a risk of developing squamous cell carcinoma in chronic cases (2-5% lifetime risk).
vulval cancer
90% SCC
HPV association
vulval cancer presentation
pruritis, burning, soreness, bleeding, pain, lump
labia majora
diagnosis of vulval cancer
Keye’s punch biopsy
staging of vulval cancer
Stage I – Carcinoma confined to the vulva
Stage II – Carcinoma extending to the lower third of the vagina, urethra or anus
Stage III – Carcinoma extending to the upper two thirds of vagina or urethra, OR invasion in to bladder or rectal mucosa OR lymph nodes (non-ulcerated)
Stage IV – ulcerated lymph nodes, disease fixed to the pelvic bone OR distant metastases
management of vulval cancer
resection and groin lymphadenectomy
types of vulval surgery
Wide local excision is recommended for small cancers.
Partial radical vulvectomy is recommended for cancers that are confined to either side of the vulva, or the front or back only. This may mean that a large part of the vulva is removed. Usually, nearby lymph nodes are also removed.
Complete radical vulvectomy is recommended for cancers that cover a large area of the vulva. The surgeon removes the entire vulva and the deep tissues around the vulva. Invariably the nearby lymph nodes are also removed.
