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Benign pelvic disease > Vulva > Flashcards

Vulva Flashcards

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1
Q

)What care regimens are recommended for patients with vulval disorders?

A
  • 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
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2
Q

What is pruritus vulvae?

A

Vaginal itch

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3
Q

What are the causes of pruritus vulvae?

A 
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
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4
Q

What may follow pruritus vulvae?

A

Psychosexual sequelae

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5
Q

What exacerbates symptoms of pruritus vulvae?

A

Obesity

Incontinence

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6
Q

What does not cause vaginal itch (commonly thought to)?

A

Postmenopausal atrophy

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7
Q

What is involved in diagnosing the origin of pruritus vulvae?

A

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

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8
Q

What should be considered when examining the vulva?

A

Scratching and self-medication may have altered the appearance

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9
Q

How should pruritus vulvae be managed?

A

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

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10
Q

Which topical steroid can be used in pruritus vulvae?

A

Betamethasone valerate cream 0.1%

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11
Q

What is lichen sclerosis?

A

Possibly autoimmune, elastic tissue in the vulval epithelium turns to collagen

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12
Q

What percentage of lichen sclerosis patients have another autoimmune condition?

A

40%

Thyroid disease and vitiligo may coexist

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13
Q

When does lichen sclerosis typically onset?

A

After middle age/just before puberty

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14
Q

How does lichen sclerosis present?

A

‘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

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15
Q

Why is lichen sclerosis a potentially worrying diagnosis?

A

Can be premalignant; 5% go on to develop vulval carcinoma

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16
Q

What are the complications of lichen sclerosis?

A

Inflammatory adhesions can form, potentially causing fusion of labia and narrowing of introitus

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17
Q

What is the first line management of lichen sclerosis?

A

Clobetasol propionate cream daily for 28d, then every other day for 4w, then twice weekly for 8w, then as needed

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18
Q

What is the next treatment of lichen sclerosis if first line fails?

A 
Topical tacrolimus (used in specialist clinic only, for <2y)
For 4-10% unresponsive to Clobetasol propionate
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19
Q

What percentage of children with lichen sclerosis resolve?

A

50%

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20
Q

What is leukoplakia?

A

White vulval patches due to skin thickening and hypertrophy. Possibly premalignant (so consider biopsy).

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21
Q

How is leukoplakia treated?

A

Topical corticosteroids (but assoc with mucosal thinning, absorption
Psoralens with UV phototherapy
Methotrexate
Cyclosporin

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22
Q

What is lichen planus?

A

Common disease, may affect skin anywhere but particularly around mouth and genitals

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23
Q

What is the aetiology of lichen planus?

A

Unknown, possible autoimmune link

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24
Q

How does lichen planus present?

A

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

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25
Q

How is lichen planus treated?

A

High potency steroid creams

Surgery should be avoided

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26
Q

What is lichen simplex (chronic vulval dermatitis)?

A

Chronic inflammatory skin condition; vulval presentation in women with sensitive skin, dermatitis or exzema

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27
Q

How does lichen simplex present?

A

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)

28
Q

What can exacerbate lichen simplex?

A

Stress
Sensitising chemicals (chemical or contact dermatitis)
Low body iron stores

29
Q

How is lichen simplex treated?

A

Vulval care
Steroids/emollients to break itch/scratch cycle
Antihistamines/antipruritics can help

30
Q

What is vulvovaginitis?

A

Desquamative inflammatory vaginitis of unknown cause, characterised by shiny erythematous patches +/- petechiae

31
Q

What causes vulvovaginitis?

A

Fixed drug reactions (NSAIDs, statins); stop for 2w

32
Q

Treatment for vulvovaginitis?

A

2-4w intravaginal clindamycin cream + hydrocortisone to vulva

33
Q

What can cause vulval lumps?

A 
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
34
Q

What is the main cause of vulval warts?

A

HPV 6 and 11; 16, 18 and 33 can cause vulval and cervical intraepithelial neoplasia (warts may also cause anal carcinoma)
(incubation period weeks)

35
Q

How is the infectious agent of vulval warts typically spread?

A

Sexual contact

36
Q

Who should be treated in cases of vulval warts?

A

Both partners (male may not have presenting symptoms but should still be treated)

37
Q

What areas are affected by warts?

A

Vulva, perineum, anus, vagina or cervix; note that in pregnant women warts may be particularly florid

38
Q

How can vulval warts be removed?

A

Cryotherapy
Trichloroacetic acid
Electrocautery/excision/laser

39
Q

What medication can be used for vulval warts?

A

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

40
Q

What cream is recommended for vulval warts?

A

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

41
Q

What may happen with vulval warts after treatment?

A

Relapse is common

42
Q

What is different about vulval warts in pregnancy?

A

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)

43
Q

What else should be performed in older women with vulval warts?

A

Biopsy to rule out malignancy

44
Q

What is a urethral caruncle?

A

Small red swelling at urethral orifice

45
Q

What causes urethral caruncle?

A

Meatal prolapse

46
Q

What are the symptoms of urethral caruncle?

A

Tenderness

Pain on micturition

47
Q

How are urethral caruncles managed?

A

Excision

Diathermy

48
Q

What do the Bartholin glands do?

A

Ducts/glands lie under labia minora and secrete thin lubricating mucus during sexual excitement

49
Q

What happens if a Bartholin gland becomes blocked?

A

Bartholin cyst formation (painless)

50
Q

What happens if a Bartholin’s cyst becomes infected?

A

Very painful abscess forms; large, red and tender swelling of labium seen and woman may not be able to sit down

51
Q

What are the common infective agents responsible for Bartholin’s abscess?

A

Staphylococcus

E. Coli

52
Q

What is the treatment for a Bartholin’s abscess?

A

Incision of abscess
Permanent drainage by marsuplialisation (inner cyst wall folded back and stretched to skin, or by balloon catheter insertion)

53
Q

What test should also be performed to exclude a particular microorganism in Bartholin’s abscess?

A

Gonococcus

54
Q

What causes vulvitis?

A

Infections e.g. candida, herpes simplex

Chemicals e.g. bubble bath, detergents

55
Q

What is vulvitis often associated with?

A

Vaginal discharge

56
Q

What is candidiasis commonly associated with?

A

Diabetes
Obesity
Pregnancy
Abx use/immunocompromise

57
Q

How is candidiasis managed?

A

Prolonged topical or antifungal therapy may be necessary

58
Q

What are the causes of vulval ulcers?

A 
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
59
Q

What form of herpes is normally responsible for genital infection?

A

Type 2 (although 30% are caused by type 1)

60
Q

When is herpes infection most severe?

A

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

61
Q

What other symptoms will herpes infection cause?

A

Urinary retention (from autonomic nerve dysfunction)

62
Q

What causes recurrent attacks?

A

Illness
Stress
Sex
Menstruation

63
Q

How is herpes infection treated?

A 
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
64
Q

What should be considered for patients with >6 outbreaks of herpes in a year?

A

Suppressive acyclovir for 6-12 months

65
Q

How is herpes transmitted in the asymptomatic/viral shedding phases?

A

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)

Benign pelvic disease (8 decks)

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