Vulval Flashcards

1
Q

What is the definition of vulvodynia?

Classification B

A

Vulvar pain of at least 3 months duration, without clear identifiable cause, which may have potential associated factors

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2
Q

What are possible causes of vulval pain

Classification A

A
Infection
Inflammatory
Neoplastic
Neurological
Trauma
Iatrogenic
Hormonal deficiencies
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3
Q

What forms the basis of treatment of vulvodynia

A

4 Ps

Patient education and reassurance
- explain condition, give information. Skin care
Pain modification
- lignocaine ointment, Gabapentin cream, amitriptyline cream, avoid opioids, oral amitriptyline, gabapentin, pregabalin
Physical therapy
- physiotherapist
- consideration of vaginal Diazepam, Botox
Psychological and psychosexual therapy
- involve partner
- minimise stress
- CBT, relaxation techniques
- treat mental illness if present
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4
Q

What is localised provoked vestibulodynia?

A

Younger women 20-30
Superficial dyspareunia / inserting tampon / cycling
Pain may persist after SI
Pain free at other times
Develop hypertonicity in levator ani, secondary vaginismus

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5
Q

What is spontaneous generalised vulvodynia?

A
Involves large part of vulva
Usually postmenopausal
Chronic vulval discomfort
Symptoms worsen during the day
Intercourse doesn’t worsen symptoms
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6
Q

Lichen sclerosus epidemiology:
What is the peak age(s) of prevalence?
What is the prevalence of LS?
What is the associated incidence of vulvar SCC?

A

Peak:

  • Prepuberty
  • Peri and postmenopause

True prevalence unknown.

2-5% associated with vulvar SCC

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7
Q

What are the histopathological changes associated with lichen sclerosus?

A

· Epidermal atrophy/thinning

· Hyalinisation of the dermis (homogenous band of collagen in upper dermis) with underlying lymphocytic infiltrate.

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8
Q

Describe the examination findings associated with lichen sclerosus

A
  • thin and crinkly with pearly white appearance but may be hyperkeratotic if there is concurrent squamous hyperplasia.
  • Purpura, fissuring and erosions.
  • Bilateral and symmetrical
  • Figure of 8 encircling vulva and anus
  • Shrinkage of introitus, loss or fusion of labia minora, clitoral hood sealed over.
  • DOES NOT extend into vagina or anal canal
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9
Q

What are two differential diagnoses for lichen sclerosus and what distinguishing features help you tell them apart?

A

Lichen planus:

  • Can occur together
  • LP involves the vagina (inflammation and synechiae)

Lichen simplex chronicus:

  • Hyperkeratotic
  • Usually diagnosis of exclusion.
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10
Q

Outline management of lichen sclerosus

A
  • If unsure confirm with vulval biopsy
  • Swab and treat associated vulval infections
  • Autoimmune investigations if clinically indicated.
  • Ultra potent topical steroid e.g. clobetasol proprionate 0.05% 3 months then review
  • Topical emollient
  • Vaginal lubricant for dyspareunia
  • Refer if not improving or if concern for VIN/SCC develops.
  • Advise pt to report change e.g. lump, hardening of skin, pain etc.
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11
Q

What is the prognosis for LS?

A

Complete remission around 54%.
Prepubertal: often resolves spontaneously.
Over 70 years old; less likely to have complete remission.
Progression to SCC <5%.
Relapse common: 50% in 16 months, 84% in 4 years.

Other long term outcomes:
Sexual dysfunction
Dysaesthesia
Clitoral pseudocyst

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12
Q

What is the pathogenesis of lichen planus?

A

T-cell mediated autoimmune response against basal keratinocytes

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13
Q

What is the histopathology of lichen planus?

A
  • Apoptotic keratinocytes in epidermis
  • Upper dermis lymphocytic infiltration
  • Basal cell liquefaction
  • Increased granular layer
  • Irregular sawtoothed acanthosis
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14
Q

What symptoms are associated with lichen planus?

A
  • Itch
  • Soreness
  • Dyspareunia
  • Urinary sx
  • Vaginal discharge
  • Sometimes postcoital bleeding
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15
Q

What examination findings are associated with lichen planus?

A

Classical:
- Papules on keratinised anogenital skin with or without striae on the inner aspect of vulva; hyperpigmentation often follows resolution.

Hypertrophic:

  • Rare, mimics malignancy
  • Thickened warty plaques which may become ulcerated, infect and painful; no vaginal lesions.

Erosive: most common type on vulva

  • Mucosal erosions with Wickham’s striae
  • Vaginal lesions can lead to scarring and complete stenosis’ friable telangiectasia and patchy erythema
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16
Q

How do you definitively diagnosis lichen planus?

A

4 mm vulval biopsy + immunofluorescence.
Biopsy may fail to detect classic histologic features of LP and cannot rule it out alone.
Immunofluorescence: may show shaggy staining of basement membrane zonedue to deposition of immunoglobulin.

17
Q

List two differentials for LP

A
  • Lichen sclerosus

- Pemphigoid

18
Q

Outline management and prognosis of lichen planus

A
  • 3% risk of malignant transformation; ask pt to report changes in skin apperance or symptoms.
  • Ultrapotent topical steroid clobetasol proprionate and vaginal hydrocortisone/Colifoam.
  • Only 9% will have resolution of signs of inflammation and 54% become symptom free; 75% have symptomatic improvement.
  • Erosive type: refer for long term specialist follow-up.
  • Treat any secondary infections with antibacterial and antifungals.
19
Q

Condylomata accuminata (genital warts):

Which HPV types are implicated and what %?

A

HPV types 6, 11 implicated in 70-80%

20
Q

What treatment options are available for genital warts?

Which ones are safe in pregnancy?

A
  • Cryotherapy
  • Ablative: diathermy, laser
  • Surgical debulking
  • Imiquimod 5% cream
  • Trichloroacetic acid

Safe in pregnancy: cryotherapy, diathermy, laser, TCA.

21
Q

What general measures are helpful for genital warts?

A
  • Topical local anaesthetic gel prior to micturition and defecation
  • Saltwater baths
  • Treat associated candidiasis
  • 1% silver sulphadiazine cream for large reaw areas.
22
Q

What rare vertical transmission of genital warts/HPV can occur during vaginal delivery?

A

Recurrent respiratory papillomatosis: benign laryngeal tumours caused by HPV types 6 and 11.