Vulva and Vagina Flashcards
clue cells
epithelial cells with bacteria on them- in BV
Layers of vagina
adventitia (inner), muscularis (middle), mucosa (outer)
what are secretions from vagina composed of?
mucous from the cervix, moisture from the endometrial fluid, and exudates from bartholin and skene’s glands
what type of cells shed from the vagina?
squamous cells
rugae of vagina composed of what layers? What is purpose of rugae?
composed of the epithelial and mucosal layers. stimulate penis during intercourse
where does vagina get its acidity from?
mucosal (outer layer) of vagina releases glycogen which is metabolized by anaerobic bacteria. This causes the acidity which is hostile to sperm and protects the vagina from infection
raised ridges of mucosal layer-
rugae of vagina
recess around cervix=
vaginal fornix (anterior, posterior, and lateral)
difference between vulva and vagina
vulva- stratified squamous epithelium, associated hair follicles, sebaceous glands, apocrine gland, “covering”. Vagina- non-keratinized squamous cells, no associated hair follicles, no sebacous glands, no apocring glands, “sheath”
pudendum=
vulva
What is homogenous to prostate gland in males
skene’s glands
equivalent to bulbourethral glands in males
bartholins glands (greater vestibular glands)- secrete mucus
Name anomalies of the humen
imperforate hyman, microperforate humen, septate hymen, acquired labial adhesions, hematocolpos
hematocolpos, an anomaly of the hymen is when vagina fills with menstrual blood. often occurs in combination of…
menstruation and imperforate hymen
vaginal opening not visiible, completely closed by hymen=
imperforate hymen
vaginal opening not visible, mostly covered by hymen=
microperforate hymen
vaginal opening visible behind hymen tissue=
septate hyman (might have trouble getting tampon on)
Name vaginal anomalies:
transverse vaginal septa, longitudinal vaginal septum, vaginal agenesis, partial vaginal agenesis
what anomaly results when distal ends of mullerian ducts fail to fuse properly?
longitudinal vaginal septum (double barreled vagina)
how does transverse vaginal septa result?
faulty fusion of urogenital sinus and mullerian ducts
Rare complete vs. incomplete transverse vaginal septa
rare complete- diagnoses usually after menarche. Incomplete- diagnosis usually after intercourse
normal female karyotype woman presents with primary amenorrhea. you do an assessment and observe a vaginal anomaly….
vaginal agenesis
how does partial vaginal agenesis result?
when urogenital sinus fails to contribute to the lower portion of vagina- lower portion of vagina consists of fibrous tissue
vaginitis
inflammation of vagina
vulvovaginitis
inflammation of vulva and vagina
vaginosis
bacterial overgrowth
Types of vulvodynia
Generalized and Localized (each can be provoked, unprovoked, or mixed)
types of localized provoked vulvodynia
primary, secondary, pure, and complicated
Pure localized provoked vulvodynia
without concomitant vulvovaginitis
secondary localized provoked vulvodynia
pain after an initial period of pain free intercourse
complicated localized provoked vulvodynia
with recurrent vulvovaginitis
vulvar pain in absence of relevant visible physical findings
vulvodynia
25 year old young women comes into clinic with complaint of dyspareunia, vestibular tenderness. The pain is localized to her vestibule. Upon PE, you don’t see any physical findings to explain the symptoms. What may it be? There is no redness or swelling. How would you treat this?
localized provoked vulvodynia- 3 months of pelvic floor rehabilitation, maintain vulvar hygiene, topical 5% lidocaine once daily, soothing oils, estrogenic cream, low oxalate diet. If not improved, next 3 months TCA. If still nto improved surgical tx, refer to pain clinic.
Remember the 3 LEVEL TX PLAN in this disorder
localized provoked vulvodynia
65 year old woman complains of random pains in her vestibular area from time to time. It is a painful burning that sometimes occurs with periods of reliefs and flares. You r/o infections, neuropathic viruses, and don’t see anything significant on PE (no redness, swelling). Patient also has history of HTN. What do you suspect and how to treat?
Generalized Unprovoked Vulvodynia (DIAGNOSIS OF EXCLUSION)- TCA (amitriptyline), maintain vulvar hygiene- keep away from irritants. If no relief after 3 months, anticonvulsants.
Patient presents with pain in vulvar area (not related to any visible Physical findings), edema, pain during sex. You notice she has difficulty walking with adducted thighs. Upon physical exam, you can palpate a fluctuant tender mass unilaterally. What is your next step?
Suspect Bartholin gland cyst. Need to drain the infected cyst. Mucopurulent secretions need to be cultured to make diagnosis. If surrounding cellulitis- Abx
Cause of bartholin gland cyst
infection, trauma
how does bartholin gland cyst develop?
obstruction of main duct of bartholin’s gland- results in retention of secretions and cystic dilation
the most common NON-neoplastic epithelial vulvar condition
vulvar lichen sclerosis
Patient presents with pruritis, burning, irritation, and vaginal discharge. When asking about history, admitted to an allergic reaction condition with latex male condoms upon last sexual encounter. Tx?
Switch from latex to non-latex, short course of corticosteroid tx, sitz baths, topical vegetable oils
Describe vulvar lichen sclerosis in 4 words
benign, chronic, inflammatory, and progressive
“cigarette paper” appearance of vulva
vulvar lichen sclerosis
Match these histological findings with disorder: Flattening of papillae, thin hyperkeratotic layer, depp lymphocytic infiltration, thinning of epithelial layer, homogenation of stroma
vulvar lichen sclerosis
RETE PEGS on histology:
vulvar lichen sclerosis. represent flattening of papillae
complications of vulvar lichen sclerosis
3-5% can become squamous cell carcinoma- if goes untreated or . BIOPSY!!
Women that is 65 years old comes in complaining of intense itching of her vulva region. She just cannot stop. She also complains of difficulty with sex, it has become painful. Upon physical examination of the skin, you note the vulvar skin is thin, wrinkled, white, with areas of lichenification and hyperkeratosis. The anterior parts of the labia majora are fused as well. There is an “8” around the vulva and anus indicating perianal region involvement. What do you suspect and how would you treat?
vulvar lichen schlorosis. This has potential to be malignant- need to biopsy. Tx: stop itch-scrath cycle, oral anti-histamine at night for itching, vulvar hygiene (avoid tight underwear, unsceneted soap, tampons rather than pads), CLOBETASOLE DIPROPINATE 0.05% ointment- BID x 2 weeks, then 1 everyday x 2 weeks, then twice a week for 2 weeks
F/U with vulvar lichen sclerosis
every 3 Months, then yearly or every 6 months indefinitely
Benign epithelial thickening and hyperkeratosis of vulva. Itch scratch, itch scratch- women suffering and finally comes in. What do you suspect and tx?
vulvar lichen simplex chronicus. Biopsy to exclude intraepithelial neoplasia and invasive tumor. Tx includes vulvar hygiene, oral anti histaimines, white cotton gloves at night, TOPICAL MEDIUM POTENCY CORTICOSTEROID BID- hydrocortisone valerage
how long does it take for vuvar epithelium to heeal
6 weeks
Women 50 yo comes in with mild itching of vulva region. painful as well. Upon physical examination, you notice papulosquamous papules and plaqyes on vulva with white lacy pattern. What are you thinking? tx?
Lichen planus. tx with topical steroids
is it common to have vaginal involvement in lichen planus?
yes- in 70% of women
destructive, scarred lichen planus on the vulva with a desquamative vaginitis, variable erosions plus atrophy. PAIN, BURNING, IRRITATION, not so much itching. Skin of vulva has glazed erythema. tx?
EROSIVE lichen planus. aka vulvovaginal gingival syndrome. tx tends to be resistant
lichen planus that is intensely itchy, looks a lot like lichen sclerosis. tx tends to be resistant
hypertrophic lichen planus
5 characteristics of vulvovaginities
abnormal discharge, vulvodynia, foul odor, irritaiton, pruritis
PE of vulvovaginitis
examine vulva and speculum examination of vagina and cervix. specimen of vaginal discharge- wet mount (saline, KOH) and sample of cervix for gonococcus or chlamydia. Check vaginal pH
Amsel’s criteria
for BV-3 of 4 must be positive: Whiff test positive (amine, fishy smell), pH greater than 4.5, clue cells,a nd maladorous, gray, slightly frothy discharge
most common infection of BV
gardnerella vaginosis
BV tx
metronidazole 500 mg BID x 7 days, tell patient to avoid douching, use of panty liners (stays on panty- irritaition), tampons instead of pads, pantyhose, occlusive pants and undergarments. Regular use of condoms may also help because less exposure to semen
Patient presents with intense pruritis, burning sensation after urination, vulvar erythema, and white curd like discharge. how would you diagnose and tx?
candidiasis- get wet mount with 10% KOH solution to look for yeast. Gold standard: Vaginal culture. OTC Miconazole or fluconazole for 1-7 days, gentian violet (warn- can turn teeth/lips purple if have oral sex)
Put patient on fluconazole for candidiasis. what precautions do you make sure to check before administering tx?
make sure not preggo. also advise patient to avoid alcohol.
most common CURABLE sexually transmitted infection
trichomonas vaginitis
Strawberry spots on cervix and profuse, frothy, greenish, foul smelling discharge
trichomonas vaginits- get wet mount. pH greater than 5. Metronidazole 500 mg BID x 7 days OR 2 grams once. treat partner. Evaluate for gonorrhea, chlamydia, trachomatis, syphilis, and HIV
wet prep of vulvovaginities shows…
NORMAL
normal discharge at midcycle estrogen surge
clear, elastic, mucoid secretions form cervical os. profuse
normal discharge at luteal phase and pregnancy
vaginal secretions thicker, white
normal vaginal pH
3.4-4.5- promotes normal vaginal flora (lactobacilli and acideogenic corynebacteria)
patient presents with vaginal bleeding, foul smelling vaginal discharge, dysuria, pelvic pain
foreign body often tampon
causes of primary irritant contact dermatitis
overwashing, use of creams with drying bases, wetness (urine, feces, menstruation)
causes of allergic contact dermatitis
neomycin, benzocain, preservatives
difference between irritant vs. allergic contact dermatitis
allergic takes 1-2 days, irritant is immediate
what effect does estrogen have on vaginal epithelium
it THICKENS it. so when you have lack of estrogen, the epidermal barrier gets weakened, thinned
Acute onset of intense itching plus vesiculation and weeping
suspect allergic contact dermatitis
vulvar contact dermatitis tx
stop irritant or allergic exposure, clobetasol or halobetasol ointment BID x 5-7 days, then daily, mineral oil, antihistamine for sleeping aid, . if very severe- prednisone
rugae of vagina composed primarily of
epithelial and mucosal layers
