Vulva - Benign and malignant disease Flashcards
What is pruritis vulvae?
Vaginal itching
What are causes of pruitis vulvae?
- General pruritis
- Skin disease - psoriasis, lichen planus
- Infection - thrush
- Allergy to detergents, fabric dyes
- Infestation
- Vulval dystrophy - lichen sclerosis, leukoplakia, carcinoma
Does post-menopausal atrophy cause vaginal itch?
No
What can exacerbate vaginal itching?
- Obesity
- Incontinence
What is lichen sclerosis?
Thought to be an autoimmune condition which leads to elastic tissue turning to collagen
What are features of vulval lichen sclerosus?
- Red, purpuric rash
- White, flat, shiny plaques
- Intensely itchy
What is the following?
Vulval lichen sclerosus
How would you manage lichen sclerosus?
- Clobetasol propionate - daily for 28 days, then alternate days for 4 weeks
- May need immunotherapy - tacrolimus
What is the following?
Vulval leukplakia - white vulval patches due to skin thickening and hypertrophy
Is vulval leukoplakia a pre-malignant conditon?
Yes - need to be biopsied if found
What would you treat someone with vulval leukoplakia with?
- Topical steroids
- Psoralens
- Phototherapy
- Methotrexate/ciclosporin
What are causes of vulval lumps?
- Local varicose veins
- Boils
- Sebaceous cysts
- Keratocanthoma
- Viral warts
- Primary chancre/Conylomata lata
- Molluscum contagiosum
- Bartholin’s Cyst/abscess
- Uterine prolapse/polyp
- Inguinal hernia
- Varicocele
- Carcinoma
What can cause vulval warts?
HPV
What strains of HPV cause vulval warts?
6 and 11
How are viral warts treated?
- Podophyllotoxin cream
- Cryotherapy
- Excision
- Laser therapy
What is a Bartholin’s Cyst?
A tense cyst which forms due to blockage of the bartholin’s gland ducts. If this becomes infected, it can lead to an abscess forming
What is the function of the bartholins gland?
Secrete thin, lubricating mucus during sexual excitation
What can cause vulval ulcers?
- Syphillis
- HSV
- Carcinoma
- Chancroid
- Lymphogranuloma venerum
- Granuloma inguinale
- TB
- Behcet’s syndrome
- Crohn’s Disease
What is the following?
Bartholin’s Abscess - infected bartholins cyst
How would you manage a bartholin’s cyst/Abscess?
- If asymptomatic - no intervention
- Symptomatic - incision, drainage and marsupialisation
- Consider Antibiotics - broad spectrum
What is marsupialisation?
Cyst wall eversion (after incision of the cyst) then suturing the edges of the cyst open so that there is a continuous surface from inside to outside ensuring the cyst remains open and can drain freely
What organisms are commonly implicated in bartholin’s abscess?
- Aerobic - N Gonorrhoea, S Aureus, C Trachomatis, E Coli
- Anaerobic - B Fragilis and C Perfringens
What should you look for when assessing a lump?
SPACE SET
- Size
- Position
- Attachments
- Consistency
- Edge
- Site
- Evidence of inflammation - (Rubor, Tumor, Calor Dolor)
- Tethered
What features of a lump may suggest malignancy?
- Irregular
- Nodular
- Persistently Indurated
- Hard
- Fixed
What is the difference between herpetic and syphillitic vulval ulceration in terms of pain?
Herpetic is painful
What is the following (in a puerperal woman)?
Puerperal genital haematoma
The picture demonstrates a haematoma arising in an episiotomy. A Haematoma will generally be associated with significant pain and swelling. It is usually secondary to failure to achieve haemostasis especially at the apex of a tear.
What urological problem might occur with a genital haematoma?
Urinary retention
How would you manage a genital haematoma?
- ABC
- Prompt examination + Estimate blood loss, monitor ongoing loss - FBC, Coag screen, Group and Save
- Analgesia.
- Catheterisation - may be indicated
- Incision and drainage
What is vaginal intraepithelial neoplasia?
Pre-malignant phase of vulval cancer
What are causes of VIN?
- HPV - esp 16
- Smoking
- Previous malignancy
- Immunosuppression
What are features of VIN?
- Raised papular or plaques lesions
- Erosions, nodules, warty
- Keratotic roughened appearance
- Sharp border
- Differentiated VIN tends to be unifocal ulcer or plaque
- Discoloration - Red, White, Brown/pigmented
How would you investigate someone presenting with features of VIN?
- Punch biopsy
- Examine cervix, anal canal, natal cleft and breasts
How would you manage someone with VIN?
- Surveillance
- Surgery
- Topical treatments - Imiquimod, photodynamic therapy
- Laser ablation
What proportion of vulval cancers are squamous cell carcinomas?
90%
What are the main types of vulval cancers?
- SCC
- BCC
- Melanoma
- Bartholin’s Gland carcinoma
How does vulval cancer present?
- Lump
- Indurated ulcer
- Vulval pain
- Vulval bleeding
What age group does vulval cancer most commonly affect?
>60
What is stage 1 vulva carcinoma?
Tumour < 2cm
What is stage 2 vulval carcinoma?
>2cm and invdating the lower one-third urethra/vagina or lower one third of anus with negative nodes
What is stage III vulval cancer?
Tumour of any size with local spread and unilateral nodes
Which lymph nodes does vulval cancer usually spread to?
Inguinal lymph nodes
What is stage IV vulval cancer?
Distant/advanced local disease with pelvic lymph nodes
How would you manage someone with vulval cancer?
- Surgery - wide local excision, vulvectomy, Unilateral/Bilateral/groin node dissection
- Pelvic Radiotherapy
- Chemotherapy
What are causes of vulvar bleeding?
- Infection— STDs
- Benign lesions — sebaceous (epidermal) cysts, condylomata, and angiokeratoma
- Malignant and premalignant lesions
- Vulvar cancer and VIN
- Vulvar trauma - forceful sexual activity/assault or accidents
