vulval and pelvic pain (additional on top of Sian's deck) Flashcards
what are the broad spectrum antibiotics recommended by US guidelines for treatment of a batholiths abscess?
- septrin 7 days (co-trimoxazole)
- co-amox + clindamycin
Can’t find any UK guidance on what we use.
what is the recurrence rate of batholiths cysts following
a) marsupilisation
b) word balloon catheter
a = 24%
b= 17% (one RCT)
what are groups of patients are most commonly affected by LS (Lichen sclerosis)
bimodal - pre-pupertal and post menopausal women
if struggling on examination to diagnose LS versus LP other than doing a biopsy what is another way to help you determine if it is LS
LS does NOT affect the vagina. whereas Lichen planus can.
The histology comes back reported as the following “Irregular, saw-toothed acanthosis, increased granular layer and basal cell liquefaction” what inflammatory dermatological condition is it describing?
Lichen planus
The histology comes back reported as the following:-
Epidermal atrophy
Hyperkeratosis with sub-epidermal hyalinisation of collagen below dermo-epithelial junction
Lichenoid infiltrate
what inflammatory skin condition is it describing>
lichen scelosis (HEL = hyperkeratosis, Epidermal atrophy, lichenoid infiltration)
what is the risk of lichen scelosis developing into SCC
5%
what is the risk of lichen planus developing into SCC
3%
what is the name of a sedative antihistamine used as part of the management in lichen simplex
what is the MHRA warning associated with it?
hydroxyzine - MHRA states small increased risk of QT prolongation and torsade de pointes - avoid in elderly (or caution) and in those with known QTC prolongation or on other drugs that could cause this!
note chlorphenamine (piriton) and promethazine are also sedating so maybe choose this.
what is lichen simplex
lichen simplex is a neurodermatosis that starts due to an itch, over time excessive itching and scratching causes the development of well demarcated plaques or thickening of the skin (known as lichenification)
what is thought to cause lichen simplex
unknown thought to be multi-factorial
- environmental - e.g tight clothing, bug bite
- psychological - anxiety, depression, OCD,
-systemic disorders - underlying skin condition e.g. LS/LP/eczema
what are the signs of genital psoriasis in females
well demarcated, red (erythematous) plaques (usually thin), commonly symmetrical, but lacks the usual scale appearance as friction rubs it off.
INVOLVES natal cleft
plaques can be fissured and painful
unusual to be in isolation check the extensors of arms, legs, scalp etc
how does genital psoriasis present in men
can affect any part of the scrotum, common to involve the penis and glans penis and corona.
In circumcised men, plaques can be more scaly than on the rest of the genital skin. In uncircumcised men, nonscaling plaques are more common.
in premenopausal women with a simple cyst how would you manage?
do not do a CA-125, only do this if identify a complex cyst on scan – then calculate RMI
if simple cyst then management depends on size
<50mm - discharge and reassure will resolve over next 2 -3 cycles
50-70mm - annual USS follow up (TV USS)
>70mm - consider additional imaging e.g. MRI and consider surgical intervention
if a pre-menopausal women has a simple cyst >70mm what type of surgery would be performed to remove it
laparoscopic cystectomy +/- BSO (discuss this with patient re preferences
always aim to remove the cyst in a ‘bag’ through the umbilical port rather than lateral ports as this decreases post op pain and reduces morbidity
Rarely if cyst not amenable to laparoscopic removal then do laparotomy
what additional bloods tests should be done in women aged < 40 years who have a complex ovarian cyst on USS
LDH, aFP, HCG, + CA-125
(exlcuding germ cell tumours)
what level CA-125 in a premenopausal women with a complex cyst would you want to discuss it with gynae
Ca-125 > 200
CA-125 is not very specific and high false positives in pre-menopasual women, ideally shouldn’t be used in pre-menopausal women but if complex cyst and want to calculate RMI? or could just use IOTA rules
what are the IOTA B and M rules
B rules
- presence of acoustic shadowing
-no blood flow - unilocular
- solid component < 7mm
-smooth mulitlocular tumour with largest diameter < 100mm
M rules:
- good blood flow
- irregular solid tumour
- irregular multilocular cyst solid component >100mm
>= 4 papillary projections - ascites
- mets
does the combined oral contraceptive pill promote resolution of functional cysts
no
in pre-menopausal women is aspiration of ovarian cysts recommended>
no - because likely to re-occur and less effective than cystectomy
in postmenopausal women what level RMI would make you considered regarding risk of ovarian cancer
RMI >200 (RCOG); >250 (NICE)
what is the best imaging modality for evaluating ovarian cysts in pre and postmenopausal women?
TV USS
how should ovarian cysts in postmenopausal women be investigated initially?
TV USS and Ca-125 then go on to calculate RMI
if a PMW has an RMI <200 and the cyst on TV USS is <5cm and ‘simple’ i.e. unilocular, bilateral, presence of acoustic shadowing, no ascites etc and the patient is completely asymptomatic how would you manage this patient?
follow up in 4-6 months with TV USS and repeat CA-125
if follow up TV USS shows resolution of a simple cyst in PMW what would you do?
discharge
if follow up TV USSat 4-6 months in an asymptomatic PMW, with a simple cyst is the same what would you do?
further follow up in 4-6 months. at this point if it has unchanged or regressed as they have been monitored for a year can offer individualised approach
if follow up TV USS at 4-6 months in an asymptomatic PMW, with a simple cyst is the growing what would you do? or the patient is developing symptoms
refer to gynaecology and consider further imaging and surgical management
in a PMW with an RMI score <200 (i.e. low risk of malignancy), but has any of the following features how would you manage?
-symptomatic
-bilateral
-complex cyst
- >5cm
- mulitlocular
consider surgery usually BSO (laparoscopically)
if RMI index is greater than 200 how would you define the PMW risk of cancer
high risk - needs referral to gynaecology
what is the next step to do in a PMW with a RMI >200?
CTAP and refer to gynaecology
a PMW has had a CTAP as RMI >200 and been discussed at gynaecology MDT and considered to be low risk for malignancy, what would the management be
laparotomy + pelvic clearance (TAH+BSO +omentectomy)
a PMW has had a CTAP as RMI >200 and been discussed at gynaecology MDT and considered to be ‘high risk for malignancy’, what would the management be
laparotomy full staging surgery (midline incision, TAH+BSO+ omentecomy + ascites - cytology washings)
in PMW why do we not recommend aspiration of ovarian cysts?
In what circumstances would we consider doing aspiration of ovarian cysts
high risk of recurrence and risk of seeding malignancy. low sensitivity for differentiating between benign and malignant.
only time we consider it is for patients who are symptomatic and not fit for surgical intervention
what are the USS features for the ‘U’ when calculating RMI
acronym = Must Always Be Super Meticulous
M= multilocular
A= Ascites
B= Bilateral
S= Solid component
M= Metastases
0= no features
1= 1 feature
3= >=2 features
clues in questions regarding ovarian cysts
if describe torsion
dermoid cysts (as often grow)
also called mature cystic teratomas are benign
cyst a/s with precocious puberty
Juvenile granulose cell –> secrete oestrogen
midcyle pain what type of cyst
haemorrhagic
hCG, AFP, LDH used to investigate. exclude what types of ovarian cysts
Germ cell tumours
how does the ISVVD (international Society for the study of vulvovaginal diseases) classify vulvodynia
'’Vulvodynia is vulva discomfort often described as a burning pain, that occurs in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder’’
basically vulva discomfort - burning pain that doesn’t have an underlying medical cause.
how can vulvodynia be further subclassified
pain that is provoked or unprovoked and by anatomical site e.g. generalised vulvodynia, clitorodynia).
how would pudendal neuralgia differ in its presentation compared to vulvodynia
pain provoked on sitting down, relieved by standing up or lying down.
how does the ISVVD categorise vulval pain related to a specific disorder?
infectious causes e.g HSV, tropical STIs, batholin’s abscess
inflammatory causes e.g. dermatological inflammatory causes - LS, LP, lichen simplex, etc
neoplastic - scc, paget’s disease
neurological - pudendal neuralgia, herpes neuralgia, spinal nerve compression
how is vulvodynia classified according to ISVVD
Generalised or localised.
If generalised is it:-
1. provoked (sexual, nonsexual or both)
2. unprovoked
3. mixed
if localised - based on anatomical site
1. provoked
2. unprovoked
3. mixed
