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Womens Health > Vulva & Vaginal Disease > Flashcards

Vulva & Vaginal Disease Flashcards

1
Q

Lichen Sclerosis epidemiology

A

Most common benign epithelial vulvar disorder
Chronic, inflammatory process
Most common in postmenopausal women (>60)

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2
Q

Lichen Sclerosis etiology

A

unknown (?autoimmune, genetic, HPV, trauma)

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3
Q

Lichen Sclerosis Acute disease symptoms

A

erythema/edema of vulvar skin, vulvar pain, white plaques, intense pruritis, telangectasias/subepithelial hemorrhages from scratching, erosions/fissures and ulcerations, dyspareunia, though may be a symptomatic

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4
Q

Lichen Sclerosis chronic disease

A

thin, wrinkled and white skin, anterior parts of labia minora agglutinate/fuse, stenosis of introitus, perianal involvement

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5
Q

Lichen Sclerosis complications

A

5% increased risk of SCC of vulva therefore biopsy all new lesions/changes

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6
Q

Lichen Sclerosis treatment

A

Control pruritis to minimize inflammation (avoid tight undergarments, good hygiene- cleanse w/ mild soap daily and dry w/ a hairdryer)
Antihistamine
Topical steroids (taper till improved then prn)
Topical testosterone

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7
Q

Lichen sclerosis prognosis

A

Chronic, recurs w/ cessation of treatment

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8
Q

Vulvar Lichen Simplex Chronicus is what?

A

Benign epithelial thickening and hyperkeratosis secondary to chronic irritation
Dermal layer is spared

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9
Q

Vulvar Lichen Simplex Chronicus symptoms

A

pruritis, rubbing/scratching, thickening of epithelium, maceration d/t humid environment of vulva, raised white lesion

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10
Q

Vulvar Lichen Simplex Chronicus diagnosis and treatment

A

Diagnosis: Biopsy
Treatment: Good vulvar hygiene, lubricants, sitz baths, antihistamines, topical steroids
Typically take 6 weeks to heal

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11
Q

red lesions are secondary to what?

A

Thinning of epidermis revealing capillary vessels
Vasodilation associated w/ inflammation
Neovascularization of a neoplasia
Ex. Psoriasis, acute candida infection, Paget’s disease, seborrheic dermatitis, SLE

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12
Q

What is the treatment for red lesions?

A

primarily topical corticosteroids (psoriasis, seborrheic dermatitis) and tx of any underlying infectious cause (ie. Candidiasis)

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13
Q

What are dark lesions?

A

Secondary to increased quantity or concentration of melanin or hemosiderin pigments or trauma.
Others: Melanoma, Kaposi’s sarcoma, dermatofibroma, seborrheic keratosis
All dark lesions require biopsy

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14
Q

What is melanosis?

A

benign pigmented flat lesion

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15
Q

What is melanoma?

A

uncommon, but aggressive and may arise from a pigmented nevi

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16
Q

What are 5 types of ulcerative lesions?

A 
Genital Herpes
Behcet’s Syndrome
Syphilis 
Chancroid
Lymphogranuloma venereum
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17
Q

3 ways to prevent genital herpes

A

Avoid direct contact w/ active lesions
Condom use
Suppression therapy

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18
Q

Herpes Genitalias

A

Type I and 2 affect the vulva and vagina
60% of primary genital infections are secondary to Type 2
Primarily sexually transmitted
Increases risk of other STI (ex. HIV) through the open ulcerations/erosions
Incubation time is 2-7 days, w/ periods of viral shedding w/o symptoms which can result in transmittance to a sexual partner as well as recurrence of lesions
50% of patients have a recurrence w/in 6 months of primary infection

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19
Q

Genital Herpes signs and symptoms

A

tingling, burning, itching, flu-like symptoms (fever, malaise, HA, myalgias), ulcerations w/ painful erosion, urinary symptoms
**flu-like symptoms are common with initial infection and uncommon with recurrent outbreaks
20% of primary infections are asymptomatic

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20
Q

Physical exam for genital herpes

A

Erosions/ulcerations surrounded by a red halo in a serpentine-like fashion
B/l inguinal lymphadenopathy
Recurrent ulcers tend to be smaller, fewer, and confined to one area

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21
Q

Diagnosis of Genital Herpes

A 
Viral culture is the gold standard (vesicle fluid or scraping)
Serologic testing (IgM and IgG) of Type I and 2 is performed
IgM will be positive w/in 21 days of exposure in 85% of cases
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22
Q

Complications of genital herpes

A 
Pain
Potential for recurrent outbreaks
Transmittance to sexual partners	
Transmittance to fetus in utero 
60% mortality rate if infection of newborn occurs
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23
Q

Treatment for genital herpes

A

*Lesions are self-limiting and heal spontaneously unless develop a secondary infection
Symptomatic tx:
Good genital hygiene, loose fitting undergarments, cool compresses, oral analgesics
Antiviral Treatment:
Dependent on whether it is an initial or recurrent episode
Prophylaxis

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24
Q

First Episode of genital herpes tx:

A

Acyclovir 400mg po tid x 7-10 days
Acyclovir 200mg po 5 times/d x 7-10 days
Famciclovir 250mg po tid x 7-10 days

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25
Q

Recurrent genital herpes tx:

A

Acyclovir 400mg po tid x 5 days
Acyclovir 800mg po bid x 5 days
Acyclovir 800mg po tid x 2 days

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26
Q

Genital Herpes prophylaxis/suppression tx:

A

Acyclovir 400mg po bid
Famciclovir 250mg po bid
Valacyclovir 500mg po QD

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27
Q

prognosis for genital herpes

A

Chronic infection that can reactivate

Factors that contribute to reactivation include: stress, fever and menstruation

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28
Q

Transmission to fetus is high in women who?

A

acquire genital herpes near the time of delivery (30-50%)

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29
Q

What should all women with recurrect genital herpes do?

A

All women w/ recurrent genital herpetic lesions at the onset of labor should deliver by C-S to prevent neonatal HSV infection
Acyclovir is the tx of choice

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30
Q

Classic symptom triad for Behcet’s Syndrome

A
  1. Recurrent oral ulcers
  2. Recurrent genital ulcers
  3. Uveitis
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31
Q

What is Behcet’s Syndrome

A

Rare immune-mediated systemic vasculitis
May also result in thrombophlebitis, erythema nodosum, involve the joints or the nervous system
Prevalence- highest in Eastern Europe and Mediterranean
Etiology: unknown

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32
Q

Condyloma Acuminatum (genital warts)

A

Caused by Human Papilloma Virus Types 6 and 11
30 million cases diagnosed annually
Sexually transmitted
Incubation period days to years

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33
Q

Condyloma Acuminatum symptoms?

where does it affect?

A

Usually painless
White, exophytic or papillomatous growth that tend to coalesce and form large cauliflower-like masses
Affects the vulva, vagina, cervix, oropharynx, perineum and perianal areas

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34
Q

Condyloma Acuminatum Complications

A

Can be transmitted to sexual partners
Can be transmitted to a newborn during vaginal delivery if current infection resulting in genital warts or Recurrent Respiratory Papillomatosis (RRP)
If untreated, they can become large resulting in pain and obstruction

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35
Q

Condyloma Acuminatum Treatment:

Application by health provider

A

Trichlorocetic acid topically on a weekly basis
Podophyllin 10-20% in tincture of benzoin
Cryosurgery, electrosurgery, surgical excision, laser

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36
Q

Condyloma Acuminatum Treatment:

Application by patient

A

Podofilox 0.5% solution or gel- wash off 4-6 hours after applied
Imiquimod

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37
Q

Bartholin Gland location

A

Gland is located deep in the posterior third of each labia majora w/ the duct opening into the vestibule at the 4 and 8 o’clock position

38
Q

Bartholin Gland Cyst/Abscess

A

Obstruction of the duct leads to retention of secretions and dilation of the cyst  infection

39
Q

Bartholin Gland Cyst/Abscess signs and symptoms

A 
Pain 
Tenderness 
Palpable “mass”
Dyspareunia
Pain w/ walking
40
Q

Bartholin Gland Cyst/Abscess PE

A

Palpable, tender, fluctuant mass

Surrounding edema and inflammation may be present if there is a secondary bacterial infection

41
Q

Bartholin Gland Cyst/Abscess treatment

A

Drainage of the infected cyst/abscess either by:
Marsupialization (not used in presence of an abscess)
Word catheter placement (inflatable bulb-tipped catheter).
Antibiotics if infection
Excision if recurrent
***If enlargement occurs in a postmenopausal female, r/o malignancy w/ a biopsy

42
Q

Vulvar cancer

A

90% are Squamous cell carcinomas
Others: BCC, melanoma, Carcinoma of Bartholin Gland
Uncommon- 4% of gynecologic cancers
Peak incidence: Age 60-70 years

43
Q

Risk factors for vulvar cancer

A 
Tobacco use, 
HIV, 
Hx of cervical carcinoma or dysplasia, 
HPV infection, 
Chronic vulvar irritation secondary to DM, venereal disease or vulvar dystrophy
44
Q

signs and symptoms for vulvar cancer

A

Vulvar pruritis and/or vulvar mass, bleeding, vulvar pain

20% are asymptomatic and found incidentally on exam

45
Q

PE for vulvar cancer

A

SCC- vary in appearance from large, cauliflower lesions to small ulcer craters over a dystrophic lesion

46
Q

treatment for vulvar cancer

A

Treatment:

Surgery

47
Q

Prognosis for vulvar cancer

A

Prognosis:
Lymph node status is the most important factor
Survival rate w/o lymph involvement is 90%
Survival rate w/ lymph involvement is 40%
Early diagnosis and tx is the key!!!

48
Q

Top 3 causes of vaginitis

A

Candidiasis
Bacterial Vaginosis
Trichomonas

49
Q

Vaginal Flora is composed of?

A

Complex and intricate balance of microorganisms

Organisms include lactobacilli, corynebacteria and yeast

50
Q

Vaginal pH is what?

A

Normal pH in postmenarchal and premenopausal women is 3.8-4.2

51
Q

Factors that alter the vaginal environment include

A 
Feminine hygiene products
Contraceptives (Hormones)
Vaginal medications
Antibiotics
STDs
Intercourse
Stress
Medical diseases
52
Q

What is a saline wet mount?

A

Vaginal discharge is placed on a slide with 1-2 drops of 0.9% isotonic sodium chloride solution and examined under high power microscope

53
Q

Potassium hydroxide preparation is what?

A

Vaginal discharge is placed on a slide with 10% KOH solution and examined under a microscope.

54
Q

What is the Whiff test?

A

release of a fishy odor after addition of 10% KOH to discharge. The odor is due to the release of amines

55
Q

Candidiasis epidemiology

A

75% of women experience at least 1 episode in their lifetime
Candida albicans is the most common species
Several systemic disorders are associated w/ yeast infections: DM, HIV, obesity

56
Q

Candidiasis signs and symptoms?

A

Vulvar pruritis
White, cheesy vaginal discharge (“cottage cheese”)
Vulvar erythema
Burning sensation following urination may occur

57
Q

physical exam findings for Candidiasis

A

Erythema
Swelling of the labia and vulva
Satellite lesions (discrete pustulopapular lesions)
Vaginal erythema w/ thick, cottage cheese-like vaginal d/c
*Cervix is usually not involved

58
Q

how to make a diagnosis of Candidiasis

A 
Vaginal Culture- gold standard		
Vaginal pH ≤ 4.5 
Wet Mount:  
 Hyphae and budding yeast forms are noted
 Whiff Test-  Negative
59
Q

Candidiasis Treatment

A

Imidazole medications (topical creams, vaginal suppositories and oral medications)

60
Q

Is treating the male partner for candidiasis necessary?

A

Treating the male partner is Not necessary unless he is uncircumcised or has inflammation of the glans of the penis

61
Q

Which oral antifungal comes in oral form for both adults and peds?

A

fluconazole

62
Q

Treatment of Recurrent Vulvovaginal Candidiasis

A

≥4 episodes in 1 year
Consider underlying systemic illness, resistant strain, insufficient duration of tx, or recontamination.
Wear cotton or microfiber underwear
Avoid or minimize clothing that traps heat and moisture (nylons, tight pants, leggings, panty liners)
Consume yogurt w/ active cultures daily
Consider treating male partner

63
Q

Bacterial Vaginosis is what?

A

Most common cause of symptomatic bacterial infection in reproductive-aged women

64
Q

Bacterial vaginosis signs and symptoms

A

fishy” vaginal discharge more noticeable after unprotected intercourse d/t increased pH caused by ejaculation
White to grey d/c and pruritis
Vaginal pain or vulvar irritation is uncommon
50% are asymptomatic

65
Q

Physcial exam findings for bacterial vaginosis

A

D/C is frothy and white/grey in color that is thin, homogenous and can adhere to the vaginal mucosa

66
Q

Diagnosis for bacterial vaginosis needs to include 3 of the 4 what?

A

Homogenous white/gray, adherent d/c
Vaginal pH >4.5
+ Whiff test
Clue cells on wet mount (vaginal epithelial cells covered with many vaginal rods and cocci bacteria, creating a stippled or granular appearance)

67
Q

complications for bacterial vaginosis

A 
Increases risk of preterm labor
Premature rupture of membranes
Abnormal Paps
Infections of cervix w/ procedures
?Cervical dysplasia
Susceptibility to STDs
PID
68
Q

Initial treatment for bacterial vaginosis

A

Metronizaole 500mg po bid x 7d
Metronidazole gel
Clindamycin cream

69
Q

Alternative treatment for bacterial vaginosis

A

Clindamycin 300mg po bid x 7d
Clindamycin ovules 100mg intravaginally qhs x 3d
*Metronidazole interactions

70
Q

Trichomonas

A 
Unicellular flagellate protozoa
Infects the lower urinary tract in both fm and males
Most prevalent non-viral STD in the US
Identified in 80% of male partners
Incubation period is 4-28 days
20-25% are asymptomatic
71
Q

Trichomonas 3 risk factors

A

Tobacco use, unprotected intercourse, IUD

72
Q

Trichomonas signs and symptoms

A

May be asymptomatic
Purulent, malodorous, thin discharge (70%)
Classic green, frothy, and foul-smelling discharge is found in <10% of cases
+/- Vaginal burning, pruritis, dysuria, frequency and dyspareunia
Postcoital bleeding d/t cervicitis

73
Q

Trichomonas PE findings

A

Erythematous and edematous vulva

Generalized vaginal erythema w/ multiple small petechiae on cervix and/or vagina (“strawberry spots

74
Q

Diagnosis for Trichomonas

A

Vaginal pH >5.0
Saline wet mount: oval shaped protozoa, large # of WBCs and epithelial cells (60-70% sensitivity)
Whiff test may be positive
Point of Care testing is available

75
Q

Trichomonas Treatment

A

Metronidazole 2g po x1- tx of choice
Tinidazole
no intercourse for 10 days

76
Q

Chemical Vaginitis signs

A 
Pruritis 
Edema 
Irritation often occurring intermittently
Irritated vulva with excoriations
Vagina may also be irritated
77
Q

What are some causes of chemical vaginitis

A

Reaction to agents used in soaps, bath salts, bubble bath, toilet paper, scented feminine hygiene products

78
Q

Treatment for chemical vaginitis

A

identify and discontinue use of product

Hydrocortisone cream for sx

79
Q

Vaginal Neoplasms

A

rare
85% are Squamous cell carcinoma
Secondary carcinoma of the vagina is seen more frequently
Extension of cervical cancer is the most common malignancy involving the vagina

80
Q

Risk Factors for vaginal neoplasms

A 
Tobacco
HPV infection
Mult sexual partners
Hx of lower genital tract neoplasia
In utero DES exposure
81
Q

Signs and Symptoms of Vaginal Neoplasms

A

Often asymptomatic
Postmenopausal vaginal and/or postcoital bleeding are most common
Vaginal d/c, mass or urinary symptoms

82
Q

Prognosis of vaginal neoplasms

A

5 year survival 77% Stage I (limited to mucosa)
5 year survival 45% Stage II (involves subvaginal tissue, not wall)
5 year survivial 31% in Stage III (Extension into pelvic wall)
5 year survival 18% in Stage IV

83
Q

Dx and Treatment for vaginal neoplasms

A

Dx: Biopsy, but must r/o secondary causes (cervical, etc)
Treatment: Depends on the staging

84
Q

Pelvic Floor Muscle Disorders

A

Uterine prolapse
Cystocele
Rectocele
Enterocele

85
Q

Pelvic Organ Prolapse

A

Includes anterior vaginal, posterior vaginal and uterine prolapse as well as enteroceles
Prevalence increases w/ age
more common in menopausal women

86
Q

Pelvic Organ Prolapse etiology

A

Defects in the pelvic supporting structures pelvic relaxation abnormalities

87
Q

Pelvic Organ Prolapse risk factors

A 
Age 
Increasing parity 
Obesity 
Hx of pelvic surgery (hysterectomy) 
Chronic cough
Chronic constipation
88
Q

Pelvic Organ Prolapse

A

asymptomatic
vaginal fullness, pressure, heaviness, “something falling out”
Sensation of “sitting on a ball”
Soft bulging mass in the vagina
Symptoms are worse w/ bearing down (cough, straining)
Back pain/pelvic pain

89
Q

Pelvic Organ Prolapse conservative treatment

A

Pessary
Support the uterus and vaginal walls
SE: infections, fistulas if neglected (need to be cleaned/changed every 2-3 months)
Pelvic floor muscle exercises (kegal exercises)
Estrogen therapy (local)

90
Q

Pelvic Organ Prolapse more advanced treatment includes?

A

surgery

Womens Health (5 decks)

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