vulval and pelvic pain (additional on top of Sian's deck)

Question 1

what are the broad spectrum antibiotics recommended by US guidelines for treatment of a batholiths abscess?

Answer 1

1. septrin 7 days (co-trimoxazole)
2. co-amox + clindamycin

Can’t find any UK guidance on what we use.

Question 1

what is the recurrence rate of batholiths cysts following

a) marsupilisation
b) word balloon catheter

Answer 1

a = 24%
b= 17% (one RCT)

Question 2

what are groups of patients are most commonly affected by LS (Lichen sclerosis)

Answer 2

bimodal - pre-pupertal and post menopausal women

Question 3

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

Answer 3

LS does NOT affect the vagina. whereas Lichen planus can.

Question 4

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?

Answer 4

Lichen planus

Question 5

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>

Answer 5

lichen scelosis (HEL = hyperkeratosis, Epidermal atrophy, lichenoid infiltration)

Question 6

what is the risk of lichen scelosis developing into SCC

Answer 6

5%

Question 7

what is the risk of lichen planus developing into SCC

Answer 7

3%

Question 8

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?

Answer 8

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.

Question 9

what is lichen simplex

Answer 9

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)

Question 10

what is thought to cause lichen simplex

Answer 10

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

Question 11

what are the signs of genital psoriasis in females

Answer 11

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

Question 12

how does genital psoriasis present in men

Answer 12

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.

Question 13

in premenopausal women with a simple cyst how would you manage?

Answer 13

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

Question 14

if a pre-menopausal women has a simple cyst >70mm what type of surgery would be performed to remove it

Answer 14

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

Question 15

what additional bloods tests should be done in women aged < 40 years who have a complex ovarian cyst on USS

Answer 15

LDH, aFP, HCG, + CA-125

(exlcuding germ cell tumours)

Question 16

what level CA-125 in a premenopausal women with a complex cyst would you want to discuss it with gynae

Answer 16

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

Question 17

what are the IOTA B and M rules

Answer 17

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

Question 18

does the combined oral contraceptive pill promote resolution of functional cysts

Answer 18

no

Question 19

in pre-menopausal women is aspiration of ovarian cysts recommended>

Answer 19

no - because likely to re-occur and less effective than cystectomy

Question 20

in postmenopausal women what level RMI would make you considered regarding risk of ovarian cancer

Answer 20

RMI >200 (RCOG); >250 (NICE)

Question 21

what is the best imaging modality for evaluating ovarian cysts in pre and postmenopausal women?

Answer 21

TV USS

Question 22

how should ovarian cysts in postmenopausal women be investigated initially?

Answer 22

TV USS and Ca-125 then go on to calculate RMI

Question 23

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?

Answer 23

follow up in 4-6 months with TV USS and repeat CA-125

Question 24

if follow up TV USS shows resolution of a simple cyst in PMW what would you do?

Answer 24

discharge

Question 25

if follow up TV USSat 4-6 months in an asymptomatic PMW, with a simple cyst is the same what would you do?

Answer 25

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

Question 26

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

Answer 26

refer to gynaecology and consider further imaging and surgical management

Question 27

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

Answer 27

consider surgery usually BSO (laparoscopically)

Question 28

if RMI index is greater than 200 how would you define the PMW risk of cancer

Answer 28

high risk - needs referral to gynaecology

Question 29

what is the next step to do in a PMW with a RMI >200?

Answer 29

CTAP and refer to gynaecology

Question 30

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

Answer 30

laparotomy + pelvic clearance (TAH+BSO +omentectomy)

Question 31

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

Answer 31

laparotomy full staging surgery (midline incision, TAH+BSO+ omentecomy + ascites - cytology washings)

Question 32

in PMW why do we not recommend aspiration of ovarian cysts?
In what circumstances would we consider doing aspiration of ovarian cysts

Answer 32

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

Question 33

what are the USS features for the ‘U’ when calculating RMI

Answer 33

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

Question 34

clues in questions regarding ovarian cysts

if describe torsion

Answer 34

dermoid cysts (as often grow)
also called mature cystic teratomas are benign

Question 35

cyst a/s with precocious puberty

Answer 35

Juvenile granulose cell –> secrete oestrogen

Question 36

midcyle pain what type of cyst

Answer 36

haemorrhagic

Question 37

hCG, AFP, LDH used to investigate. exclude what types of ovarian cysts

Answer 37

Germ cell tumours

Question 38

how does the ISVVD (international Society for the study of vulvovaginal diseases) classify vulvodynia

Answer 38

'’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.

Question 39

how can vulvodynia be further subclassified

Answer 39

pain that is provoked or unprovoked and by anatomical site e.g. generalised vulvodynia, clitorodynia).

Question 40

how would pudendal neuralgia differ in its presentation compared to vulvodynia

Answer 40

pain provoked on sitting down, relieved by standing up or lying down.

Question 41

how does the ISVVD categorise vulval pain related to a specific disorder?

Answer 41

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

Question 42

how is vulvodynia classified according to ISVVD

Answer 42

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