Vulva Flashcards
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)What care regimens are recommended for patients with vulval disorders?
- Use soap substitute with water for washing
- Shower, bath (with emollient) or clean vulva once daily only
- Wash vulva with hand (not sponge/flannel); dab dry or blow with hairdryer on cool setting (held well away from skin)
- Wear loose fitting silk or cotton white or light coloured underwear (blue/black dyes can be irritant); sleep without underwear
- Avoid tight jeans/cycling trousers and wear loose trousers/dresses/skirts; at home, a skirt without underwear may be more comfortable
- Avoid soap, bubble bath, shower gel, biological washing powder, fabric conditioners, vulval creams/douches, antiseptics, regular sanitary towel/panty liner wear, baby wipe use, coloured toilet paper, nail varnish
- Regular emollient use (throughout day) can soothe and reduce flares
- Dab aqueous cream kept cool to soothe irritate skin
What is pruritus vulvae?
Vaginal itch
What are the causes of pruritus vulvae?
Disorder causing general pruritus Skin disorder (Psoriasis, lichen planus) Local -Infection and vaginal discharge (e.g. candida) Allergy -Washing powder -Fabric dyes etc Infestation -Scabies -Pubic lice -Threadworm Vulval dystrophy -Lichen sclerosis -Leukoplakia -Carcinoma
What may follow pruritus vulvae?
Psychosexual sequelae
What exacerbates symptoms of pruritus vulvae?
Obesity
Incontinence
What does not cause vaginal itch (commonly thought to)?
Postmenopausal atrophy
What is involved in diagnosing the origin of pruritus vulvae?
Hx (ask about autoimmune disorders and atopy)
Examination (general, dermatological)
Examine vulva and genital tract, under magnification if possible
Take cervical smear (if due)
Consider vaginal and vulval swabs, and tests for diabetes and thyroid disease
If suspected vulval dermatitis, take serum ferritin and dermatology patch tests
Biopsy if diagnosis in doubt, if no response to treatment or if VIN/carcinoma suspected
What should be considered when examining the vulva?
Scratching and self-medication may have altered the appearance
How should pruritus vulvae be managed?
Treat underlying cause if possible
Avoid sensitisers
Maintain good vulval hygiene and care
Short course topical steroids (betamethasone valerate); but avoid any topical treatments that may sensitize skin
Which topical steroid can be used in pruritus vulvae?
Betamethasone valerate cream 0.1%
What is lichen sclerosis?
Possibly autoimmune, elastic tissue in the vulval epithelium turns to collagen
What percentage of lichen sclerosis patients have another autoimmune condition?
40%
Thyroid disease and vitiligo may coexist
When does lichen sclerosis typically onset?
After middle age/just before puberty
How does lichen sclerosis present?
‘Bruised’ red purpuric skin (may mimic abuse); erosions, bullae and ulceration may also be present (from uncontrollable scratching)
Vulva may then become flat, white and shiny
May be hourglass shape around vulva and anus
Pruritus, intense, worse at night
Why is lichen sclerosis a potentially worrying diagnosis?
Can be premalignant; 5% go on to develop vulval carcinoma
What are the complications of lichen sclerosis?
Inflammatory adhesions can form, potentially causing fusion of labia and narrowing of introitus
What is the first line management of lichen sclerosis?
Clobetasol propionate cream daily for 28d, then every other day for 4w, then twice weekly for 8w, then as needed
What is the next treatment of lichen sclerosis if first line fails?
Topical tacrolimus (used in specialist clinic only, for <2y) For 4-10% unresponsive to Clobetasol propionate
What percentage of children with lichen sclerosis resolve?
50%
What is leukoplakia?
White vulval patches due to skin thickening and hypertrophy. Possibly premalignant (so consider biopsy).
How is leukoplakia treated?
Topical corticosteroids (but assoc with mucosal thinning, absorption
Psoralens with UV phototherapy
Methotrexate
Cyclosporin
What is lichen planus?
Common disease, may affect skin anywhere but particularly around mouth and genitals
What is the aetiology of lichen planus?
Unknown, possible autoimmune link
How does lichen planus present?
Pain>pruritus
Flat, popular, purplish lesions
In mouth and genital area can be erosive, appearing with well demarcated glazed appearance around introitus
Affects all ages
How is lichen planus treated?
High potency steroid creams
Surgery should be avoided
What is lichen simplex (chronic vulval dermatitis)?
Chronic inflammatory skin condition; vulval presentation in women with sensitive skin, dermatitis or exzema
How does lichen simplex present?
Chronic intractable itching (esp at night)
More common in those with sensitive skin/eczema
Labia majora typically inflamed and thickened with hypo- or hyperpigmentation
May be non-specific inflammation of vulva (+/- mons pubis and inner thighs)
What can exacerbate lichen simplex?
Stress
Sensitising chemicals (chemical or contact dermatitis)
Low body iron stores
How is lichen simplex treated?
Vulval care
Steroids/emollients to break itch/scratch cycle
Antihistamines/antipruritics can help
What is vulvovaginitis?
Desquamative inflammatory vaginitis of unknown cause, characterised by shiny erythematous patches +/- petechiae
What causes vulvovaginitis?
Fixed drug reactions (NSAIDs, statins); stop for 2w
Treatment for vulvovaginitis?
2-4w intravaginal clindamycin cream + hydrocortisone to vulva
What can cause vulval lumps?
Local varicose veins Boils Sebaceous cysts Keratoacanthomata (rare) Viral vulval warts (condylomata acuminata) Condylomata lata (syphilis) Primary chancre Molluscum contagiosum Bartholin's cyst or abscess Uterine prolapse or polyp Inguinal hernia Varicocele Carcinoma
What is the main cause of vulval warts?
HPV 6 and 11; 16, 18 and 33 can cause vulval and cervical intraepithelial neoplasia (warts may also cause anal carcinoma)
(incubation period weeks)
How is the infectious agent of vulval warts typically spread?
Sexual contact
Who should be treated in cases of vulval warts?
Both partners (male may not have presenting symptoms but should still be treated)
What areas are affected by warts?
Vulva, perineum, anus, vagina or cervix; note that in pregnant women warts may be particularly florid
How can vulval warts be removed?
Cryotherapy
Trichloroacetic acid
Electrocautery/excision/laser
What medication can be used for vulval warts?
Vulval and anal warts (condylomata acuminate) can be managed at home
Podophyllotoxin cream 4-6w, washed off after 30 mins (contraindicated in pregnancy)
Only treat a few warts at once, to avoid toxicity
What cream is recommended for vulval warts?
Podophyllotoxin cream 0.15%
(Warticon 5g tubes - enough for 4 treatment courses - is supplied with mirror)
Use every 12hrs for 3d, repeated up to 4 times at weekly intervals if area covered is less than 4cm2
What may happen with vulval warts after treatment?
Relapse is common
What is different about vulval warts in pregnancy?
May grow more rapidly
Usually regress after delivery
Warts are not an indication for delivery by CS
HPV 6 and 11 may cause laryngeal/respiratory papilloma in offspring of affected mothers (1 in 50-1500; 50% present <5y)
What else should be performed in older women with vulval warts?
Biopsy to rule out malignancy
What is a urethral caruncle?
Small red swelling at urethral orifice
What causes urethral caruncle?
Meatal prolapse
What are the symptoms of urethral caruncle?
Tenderness
Pain on micturition
How are urethral caruncles managed?
Excision
Diathermy
What do the Bartholin glands do?
Ducts/glands lie under labia minora and secrete thin lubricating mucus during sexual excitement
What happens if a Bartholin gland becomes blocked?
Bartholin cyst formation (painless)
What happens if a Bartholin’s cyst becomes infected?
Very painful abscess forms; large, red and tender swelling of labium seen and woman may not be able to sit down
What are the common infective agents responsible for Bartholin’s abscess?
Staphylococcus
E. Coli
What is the treatment for a Bartholin’s abscess?
Incision of abscess
Permanent drainage by marsuplialisation (inner cyst wall folded back and stretched to skin, or by balloon catheter insertion)
What test should also be performed to exclude a particular microorganism in Bartholin’s abscess?
Gonococcus
What causes vulvitis?
Infections e.g. candida, herpes simplex
Chemicals e.g. bubble bath, detergents
What is vulvitis often associated with?
Vaginal discharge
What is candidiasis commonly associated with?
Diabetes
Obesity
Pregnancy
Abx use/immunocompromise
How is candidiasis managed?
Prolonged topical or antifungal therapy may be necessary
What are the causes of vulval ulcers?
Always consider syphilis Herpes simplex (esp common in young) Other causes - Carcinoma - Chancroid - Lymphogranuloma venereum - Granuloma inguinale - TB - Behcets syndrome - Aphthous ulcers - Crohn's disease
What form of herpes is normally responsible for genital infection?
Type 2 (although 30% are caused by type 1)
When is herpes infection most severe?
Initial (primary) infection, starting with prodrome (itching/tingling of affected skin) and flu-like illness, progressing to vulvitis, pain and small vesicles on vulva.
Recurrent episodes less severe
What other symptoms will herpes infection cause?
Urinary retention (from autonomic nerve dysfunction)
What causes recurrent attacks?
Illness
Stress
Sex
Menstruation
How is herpes infection treated?
Strong analgesia Lidocaine gel Salt baths (and micturition in bath) Acyclovir orally shortens symptoms; 200mg five times daily PO or 400mg/8hr for 5 days (longer if new lesions appear/healing incomplete) - if immunocompromised or HIV +ve 400mg five times daily for 7-10 days during 1st episode or 400mg/8hr for 5-10 days during recurrent infection Topical acyclovir not benefical
What should be considered for patients with >6 outbreaks of herpes in a year?
Suppressive acyclovir for 6-12 months
How is herpes transmitted in the asymptomatic/viral shedding phases?
From areas of the skin not protected by barrier contraception
Men may be asymptomatic and may never have been aware of infection (so don’t assume infidelity)
