Vulva & Vaginal Disease

Question 1

Lichen Sclerosis epidemiology

Answer 1

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

Question 2

Lichen Sclerosis etiology

Answer 2

unknown (?autoimmune, genetic, HPV, trauma)

Question 3

Lichen Sclerosis Acute disease symptoms

Answer 3

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

Question 4

Lichen Sclerosis chronic disease

Answer 4

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

Question 5

Lichen Sclerosis complications

Answer 5

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

Question 6

Lichen Sclerosis treatment

Answer 6

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

Question 7

Lichen sclerosis prognosis

Answer 7

Chronic, recurs w/ cessation of treatment

Question 8

Vulvar Lichen Simplex Chronicus is what?

Answer 8

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

Question 9

Vulvar Lichen Simplex Chronicus symptoms

Answer 9

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

Question 10

Vulvar Lichen Simplex Chronicus diagnosis and treatment

Answer 10

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

Question 11

red lesions are secondary to what?

Answer 11

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

Question 12

What is the treatment for red lesions?

Answer 12

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

Question 13

What are dark lesions?

Answer 13

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

Question 14

What is melanosis?

Answer 14

benign pigmented flat lesion

Question 15

What is melanoma?

Answer 15

uncommon, but aggressive and may arise from a pigmented nevi

Question 16

What are 5 types of ulcerative lesions?

Answer 16

Genital Herpes
Behcet’s Syndrome
Syphilis 
Chancroid
Lymphogranuloma venereum

Question 17

3 ways to prevent genital herpes

Answer 17

Avoid direct contact w/ active lesions
Condom use
Suppression therapy

Question 18

Herpes Genitalias

Answer 18

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

Question 19

Genital Herpes signs and symptoms

Answer 19

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

Question 20

Physical exam for genital herpes

Answer 20

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

Question 21

Diagnosis of Genital Herpes

Answer 21

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

Question 22

Complications of genital herpes

Answer 22

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

Question 23

Treatment for genital herpes

Answer 23

*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

Question 24

First Episode of genital herpes tx:

Answer 24

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

Question 25

Recurrent genital herpes tx:

Answer 25

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

Question 26

Genital Herpes prophylaxis/suppression tx:

Answer 26

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

Question 27

prognosis for genital herpes

Answer 27

Chronic infection that can reactivate | Factors that contribute to reactivation include: stress, fever and menstruation

Question 28

Transmission to fetus is high in women who?

Answer 28

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

Question 29

What should all women with recurrect genital herpes do?

Answer 29

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

Question 30

Classic symptom triad for Behcet’s Syndrome

Answer 30

1. Recurrent oral ulcers 2. Recurrent genital ulcers 3. Uveitis

Question 31

What is Behcet’s Syndrome

Answer 31

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

Question 32

Condyloma Acuminatum (genital warts)

Answer 32

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

Question 33

Condyloma Acuminatum symptoms? | where does it affect?

Answer 33

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

Question 34

Condyloma Acuminatum Complications

Answer 34

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

Question 35

Condyloma Acuminatum Treatment: | Application by health provider

Answer 35

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

Question 36

Condyloma Acuminatum Treatment: | Application by patient

Answer 36

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

Question 37

Bartholin Gland location

Answer 37

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

Question 38

Bartholin Gland Cyst/Abscess

Answer 38

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

Question 39

Bartholin Gland Cyst/Abscess signs and symptoms

Answer 39

``` Pain Tenderness Palpable “mass” Dyspareunia Pain w/ walking ```

Question 40

Bartholin Gland Cyst/Abscess PE

Answer 40

Palpable, tender, fluctuant mass | Surrounding edema and inflammation may be present if there is a secondary bacterial infection

Question 41

Bartholin Gland Cyst/Abscess treatment

Answer 41

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

Question 42

Vulvar cancer

Answer 42

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

Question 43

Risk factors for vulvar cancer

Answer 43

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

Question 44

signs and symptoms for vulvar cancer

Answer 44

Vulvar pruritis and/or vulvar mass, bleeding, vulvar pain | 20% are asymptomatic and found incidentally on exam

Question 45

PE for vulvar cancer

Answer 45

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

Question 46

treatment for vulvar cancer

Answer 46

Treatment: | Surgery

Question 47

Prognosis for vulvar cancer

Answer 47

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!!!

Question 48

Top 3 causes of vaginitis

Answer 48

Candidiasis Bacterial Vaginosis Trichomonas

Question 49

Vaginal Flora is composed of?

Answer 49

Complex and intricate balance of microorganisms | Organisms include lactobacilli, corynebacteria and yeast

Question 50

Vaginal pH is what?

Answer 50

Normal pH in postmenarchal and premenopausal women is 3.8-4.2

Question 51

Factors that alter the vaginal environment include

Answer 51

``` Feminine hygiene products Contraceptives (Hormones) Vaginal medications Antibiotics STDs Intercourse Stress Medical diseases ```

Question 52

What is a saline wet mount?

Answer 52

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

Question 53

Potassium hydroxide preparation is what?

Answer 53

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

Question 54

What is the Whiff test?

Answer 54

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

Question 55

Candidiasis epidemiology

Answer 55

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

Question 56

Candidiasis signs and symptoms?

Answer 56

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

Question 57

physical exam findings for Candidiasis

Answer 57

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

Question 58

how to make a diagnosis of Candidiasis

Answer 58

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

Question 59

Candidiasis Treatment

Answer 59

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

Question 60

Is treating the male partner for candidiasis necessary?

Answer 60

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

Question 61

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

Answer 61

fluconazole

Question 62

Treatment of Recurrent Vulvovaginal Candidiasis

Answer 62

≥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

Question 63

Bacterial Vaginosis is what?

Answer 63

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

Question 64

Bacterial vaginosis signs and symptoms

Answer 64

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

Question 65

Physcial exam findings for bacterial vaginosis

Answer 65

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

Question 66

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

Answer 66

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)

Question 67

complications for bacterial vaginosis

Answer 67

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

Question 68

Initial treatment for bacterial vaginosis

Answer 68

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

Question 69

Alternative treatment for bacterial vaginosis

Answer 69

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

Question 70

Trichomonas

Answer 70

``` 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 ```

Question 71

Trichomonas 3 risk factors

Answer 71

Tobacco use, unprotected intercourse, IUD

Question 72

Trichomonas signs and symptoms

Answer 72

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

Question 73

Trichomonas PE findings

Answer 73

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

Question 74

Diagnosis for Trichomonas

Answer 74

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

Question 75

Trichomonas Treatment

Answer 75

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

Question 76

Chemical Vaginitis signs

Answer 76

``` Pruritis Edema Irritation often occurring intermittently Irritated vulva with excoriations Vagina may also be irritated ```

Question 77

What are some causes of chemical vaginitis

Answer 77

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

Question 78

Treatment for chemical vaginitis

Answer 78

identify and discontinue use of product | Hydrocortisone cream for sx

Question 79

Vaginal Neoplasms

Answer 79

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

Question 80

Risk Factors for vaginal neoplasms

Answer 80

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

Question 81

Signs and Symptoms of Vaginal Neoplasms

Answer 81

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

Question 82

Prognosis of vaginal neoplasms

Answer 82

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

Question 83

Dx and Treatment for vaginal neoplasms

Answer 83

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

Question 84

Pelvic Floor Muscle Disorders

Answer 84

Uterine prolapse Cystocele Rectocele Enterocele

Question 85

Pelvic Organ Prolapse

Answer 85

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

Question 86

Pelvic Organ Prolapse etiology

Answer 86

Defects in the pelvic supporting structures pelvic relaxation abnormalities

Question 87

Pelvic Organ Prolapse risk factors

Answer 87

``` Age Increasing parity Obesity Hx of pelvic surgery (hysterectomy) Chronic cough Chronic constipation ```

Question 88

Pelvic Organ Prolapse

Answer 88

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

Question 89

Pelvic Organ Prolapse conservative treatment

Answer 89

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)

Question 90

Pelvic Organ Prolapse more advanced treatment includes?

Answer 90

surgery