Vulva- Questions Flashcards
Regarding vulval anatomy:
1 - Hart’s line is the anatomical boundary between the labia majora and the labia minora
2 - Skene’s glands are located in the vulval vestibule
3 - Vulval skin is more prone to contact irritation than skin elsewhere on the body
4 - The blood supply to the skin is from the internal pudendal artery
1 - The answer is false. It is the anatomical line between the vestibule and the labia minora. It is not seen in all women but can be easily seen in some women. It represents a change in epithelium from keratinised stratified squamous epithelium (labia) to non-keratinised stratified squamous (vestibular skin).
2 - The answer is true. They are also called periurethral glands.
3 - The answer is true.
4 - The answer is true.
Regarding lichen sclerosus:
1 - Loss of anatomy is an early sign of disease
2 - Mothers and daughters are commonly affected
3 - The histological picture is epidermal thinning, hyperkeratosis and a wide band of homogenised collagen below the dermoepidermal junction and a lymphocytic infiltrate beneath the homogenised area
4 - The equivalent condition in men is balanitis xero obliterans
1 - The answer is false. This is a late sign of disease.
2 - The answer is false. There is a slightly higher incidence of disease in first degree relatives but this is not common.
3 - The answer is true.
4 - The answer is true.
Regarding other vulval problems:
1 - Vulvodynia patients often respond to steroid ointments
2 - Most vulval problems should be managed with a combination of emollients and antiseptic bath washes
1 - The answer is false. Most topical agents make the condition worse as the skin is ‘normal’ in vulvodynia and the pain is neuropathic in origin.
2 - The answer is false. Only emollients and bland hygiene using water to wash should be used.
A 67-year-old woman presents with lichen sclerosus and has been using her steroid cream regularly. At her consultation, she was advised to ensure that she did not use the cream across Hart’s Line. Though it was explained to her at the time, she is seeking clarification as to exactly its location.
How would you describe its boundary to her?
The anal and perianal region The labia majora and the labia minora The mons pubis and clitoral hood The vaginal fourchette and lower third of the vagina The vestibule and labia minor
It is the anatomical line between the vestibule and the labia minora. It is not seen in all women but can be easily seen in some women. It represents a change in epithelium from keratinised stratified squamous epithelium (labia) to non-keratinised stratified squamous (vestibular skin).
A 45-year-woman presents with a history of superficial dyspareunia. Her GP has queried the possibility of a cyst of Skene’s duct. You are arranging for her to have an ultrasound scan.
What anatomical area do you specify on your request that should be particularly addressed?
Distal urethral area In the labia minora In the labia majora Medial to the Bartholin’s glands In the posterior fourchette
Distal urethral area
They are also called periurethral glands.
Regarding patient assessment:
1 - Microbiological swabs are usually helpful in the diagnosis of a vulval problem
2 - Nerve blocks (e.g. pudendal blocks) may be helpful in the management of some vulval problems
3 - Systemic diseases are an uncommon cause of vulval problems
4 - Approximately 10% of all gynaecological referrals are vulval problems
5 - Biofeedback treatment is defined as is a form of treatment that involves measuring a subject’s bodily processes and conveys such information to the patient in order to raise her awareness and conscious control of the related physiological activities
1 - The answer is false.
2 - The answer is true. These have a role in difficult patients with vulvodynia.
3 - The answer is true.
4 - The answer is true.
5 - The answer is true. This treatment can be used for patients who have sex-related pain.
Regarding patient assessment:
1 - All pigmented lesions on the vulva should be biopsied
2 - The beneficial effects of different emollients on the vulva is the same
3 - Multiple biopsies of the vulva may be helpful in patients with vulval problems
4 - All women with vulval problems should be referred to a vulval clinic
5 - Secondary vaginismus may develop after any vulval condition
1 - The answer is true.
2 - The answer is false. Although these are all usually bland, they do vary according to content and some women will report differing degrees of irritancy, i.e. soreness, on application.
3 - The answer is true. This is relevant in vulval intraepithelial neoplasia when cancer needs to be excluded.
4 - The answer is false. All health professionals looking after women should be able to assess and treat women presenting with a vulval problem.
5 - True
A 72-year-old woman has vulval itching and soreness. On examination you see the following (see image.)
What is the most appropriate initial investigation?
Lichen sclerosus
Biopsy
Examination under anaesthetic
Patch testing
Skin swab
Thyroid function tests
Thyroid function tests
Biopsy is only mandatory if the diagnosis is uncertain, there are atypical features or coexistent vulval intraepithelial neoplasia (VIN) / squamous cell carcinoma (SCC) is suspected. Investigation for autoimmune disease if clinically indicated, especially thyroid dysfunction (i.e. T4 and TSH) as it is often asymptomatic and has been found be associated. Skin swab is only useful to exclude co-existing infection if there are symptoms or signs suggestive of this. Patch testing is rarely required and only if secondary medicament allergy suspected. The advice of a dermatologist should be sought.
A 67-year-old woman has vulval itching and soreness. On examination she has pale, white patches with vulval atrophy.
Which is the most appropriate first line treatment?
Clobetasol proprionate Clotrimazole Dermovate Fucibet Hydrocortisone
Clobetasol proprionate
Ultra-potent topical steroids e.g. Clobetasol proprionate. Various regimens are used, one of the most common being daily use for one month, alternate days for one month, twice weekly for one month with review at 3 months. It can then be used as needed depending on symptoms. There is no evidence on the optimal regimen.
30gm of an ultra-potent steroid should last at least 3 months. Ointment bases are much better to use on the ano-genital skin because of the reduced need for preservatives in an ointment base, and hence less risk of a secondary contact allergy.
Regarding lichen sclerosus:
1 - There is a malignancy risk of 30%
2 - Mildly potent topical corticosteroids are the treatment of choice
3 - Loss of pigmentation is an early change in the vulval skin
4 - A Fenton’s procedure alone can cure the majority of women with sex-related pain
5 - Asymptomatic disease should be treated
1 - The answer is false. The risk is around 3%.
2 - The answer is false. Very potent steroids are used.
3 - The answer is true.
4 - The answer is false. The skin will reform very quickly, therefore, vaginal dilators are crucial postoperatively.
5 - The answer is true. Although this is controversial, it will hopefully prevent permanent vulval skin changes.
Regarding the care of women with vulval conditions:
1 - On the whole, vulval ointments are better than creams
2 - Allergic contact dermatitis is a common side effect of topical treatment
3 - Irritancy is more common in the vulval skin than at other skin sites
4 - Emollients are often contraindicated
5 - A vulval biopsy should only be considered when a patient fails to respond to treatment
1 - The answer is true. They cause less irritation.
2 - The answer is false. This is rare; irritancy is more common.
3 - The answer is true. This skin is thinner.
4 - The answer is false.
5 - The answer is false.
