Vaginal/vulval disorders

Question 1

Vaginal discharge causes

Answer 1

BV
candida
Chlamydia
gonorrhea
trichomonas vaginalis
foreign body
cervical ectropion
polyps
malignancy
pregnancy
ovulation (cyclical)
hormonal contraception

Question 2

pruritis vulvae

Answer 2

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

Question 3

bartholin glands location

Answer 3

4 o clock and 8 o clock
secrete mucus to lubricate vagina
abscess

Question 4

batholin abscess organisms

Answer 4

E.coli
MRSA
STIs

Question 5

risk factors for bartholin’s cysts

Answer 5

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

Question 6

clinical features of bartholins cysts

Answer 6

superficial dyspareunia
vulvar pain
spontaneous rupture
soft, fluctuant and non-tender

Question 7

bartholin’s abscess presentation

Answer 7

acute onset of pain
difficulty passing urine
tense and hard, surrounding cellulitis

Question 8

differential diagnosis bartholins cyst

Answer 8

Bartholin’s gland carcinoma

bartholin’s benign tumour: adenomas and nodular hyperplasia

sebaceous cyst, Skene’s duct cyst, mucous cyst

fibroma, lipoma, leiomyoma

Question 9

investigations bartholins cyst

Answer 9

clinical diagnosis
>40, biopsy for vulval carcinoma
STI: swabs needed

Question 10

management of bartholin’s cyst

Answer 10

warm bath is cyst is small and asymptomatic
word catheter
marsupialisation

Question 11

lichen sclerosus epidemiology

Answer 11

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).

Question 12

risk factors lichen sclerosus

Answer 12

Genetics – family history of lichen sclerosus can increase risk.
Other autoimmune disorders – such as thyroid disease, type 1 diabetes, alopecia areata.

Question 13

clinical features lichen sclerosus

Answer 13

white atrophic patches: axillae, buttocks, thighs

clitoral hood fusion

fusion of labia minora to labia majora

posterior fusion resulting in loss of vaginal opening

Question 14

DD lichen sclerosus

Answer 14

Lichen simplex
Vitiligo
Vulvae cancer or intraepithelial neoplasia
Candidiasis
Post-inflammatory hypopigmentation

Question 15

lichen sclerosus investigations

Answer 15

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.

Question 16

management of lichen sclerosus

Answer 16

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).

Question 17

vulval cancer

Answer 17

90% SCC

HPV association

Question 18

vulval cancer presentation

Answer 18

pruritis, burning, soreness, bleeding, pain, lump

labia majora

Question 19

diagnosis of vulval cancer

Answer 19

Keye’s punch biopsy

Question 20

staging of vulval cancer

Answer 20

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

Question 21

management of vulval cancer

Answer 21

resection and groin lymphadenectomy

Question 22

types of vulval surgery

Answer 22

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.