Vulval Conditions Flashcards
What are the differentials of vulval itch?
Candidiasis, trichomoniasis, pubic lice, scabies, vulval intra-epithelial neoplasia, atrophic vulvovaginitis, dermatitis, psoriasis, lichen sclerosis/planus/simplex chronicus
What is lichen sclerosis?
Inflammatory scarring dermatoses of ano-genital skin
Who tends to suffer from lichen sclerosis?
6-10x more common in women
2 peaks = prepubertal girls and postmenopausal women
What tends to be the clinical course of lichen sclerosis?
Usually resolves in children but tends to be more chronic and relapsing in adults
What are the symptoms of lichen sclerosis?
Itch = worse at night
Pain, dyspareunia, constipation (especially children)
What are some red flag signs for vulval cancer?
Persistent ulcer, lump, weight loss
What are some risk factors for lichen sclerosis?
21% linked with other autoimmune diseases (especially thyroid)
Smoking carries higher risk of developing complications
Can lichen sclerosis have a psychosocial impact?
Yes
What are the examination signs of lichen sclerosis?
White papules and plaques = figure 8 pattern on vulval and perineal skin, vagina not involved
Ecchymosis, erosions, fissures, architectural change
How common is extra-genital skin involvement in lichen sclerosis?
Occurs in 10% of women with vulval disease
What is the main differential of lichen sclerosis?
Lichen planus
What are some features of lichen planus?
Affects genital skin and mucous membranes
Usually patients aged 50-60
Associated with autoimmune disease
What are the symptoms of lichen planus?
Itch, pain, dyspareunia, discharge
May be oral, nail or hair involvement
What are the other differentials of lichen sclerosis?
Vitiligo, mucous membrane pemphigoid, morphoea
What is the main complication of lichen sclerosis?
Squamous cell carcinoma = up to 5% risk
What is some general skin care advice for patients with vulval itch?
Wash gently once daily with soap substitute and try to avoid scratching/irritants
Apply emollients to relieve dryness and itching, and to act as barrier = Epimax is first line
What is the treatment of lichen sclerosis?
General skin care
Super potent topical steroid = clobetasol propionate 0.05% (dermovate), 1/2 fingertip amount, 12 week regime
What initial investigations are done for vulval itch?
High vaginal swab for infection and STI screen
What are the symptoms of atrophic vulvovaginitis?
Itch, pain, mild thin white discharge, vaginal dryness, dyspareunia
What are the signs of the atrophic vulvovaginitis?
Atrophy of labia, narrowing of vaginal opening, petechial haemorrhage
What is atrophic vulvovaginitis associated with?
Low levels of oestrogen = tends to occur in postmenopausal women
What are the symptoms of the genitourinary syndrome of the menopause?
Narrowing of the vaginal opening, labial atrophy, decrease in vaginal length, thinning of vaginal wall, urinary symptoms
How is atrophic vulvovaginitis treated?
Vaginal oestrogen = can be taken with HRT
Perineal massage, lubricants, vibrator
How can vaginal oestrogen be delivered?
Cream, oestring implant (lasts 3 months), pessary
What are the benefits of vaginal oestrogen?
Doesn’t cause endometrial hyperplasia/cancer with long term use and has little systemic absorption
What may women with atrophic vaginitis develop?
Secondary vaginismus = body anticipates pain and tenses, increasing pain during sex further
What are the differentials of vulval pain?
Acute = herpes, aphthous ulcers, shingles, trauma, Bartholin's cyst or abscess, dermatitis Chronic = vulvodynia, female genital mutilation, pudendal nerve dysfunction, lichen sclerosis/planus, vulval intraepithelial neoplasia
What is vulvodynia?
Vulval discomfort, usually described as burning pain, occurs in absence of relevant findings or neurological disorder
What are the classifications of vulvodynia?
Generalised or localised
Provoked, unprovoked or mixed
What it usually required for vulvodynia to develop?
Usually requires a trigger in vulnerable individual
What are the symptoms of vulvodynia?
Vulval pain during sex, burning/raw pain, feeling like there is a blockage
What are the signs of vulvodynia?
High tone at introitus, tender on advancing speculum
What are the differentials of vulvodynia?
Psychosexual issue, pudendal neuropathy, sacro-iliac joint problems, pelvic organ prolapse, skin conditions
What is the management of vulvodynia?
Genital skin care and emollients
Localised provoked pain = lidocaine 5% ointment
Vaginal trainers and physiotherapy
Unprovoked pain = tricyclics, gabapentin/pregabalin
What should be covered in the subjective assessment of a patient with vulvodynia by the physio?
Presenting complaint, location and characteristic of pain, co-morbidities, psychogenic factors, surgery
What should be covered in the objective assessment of a patient with vulvodynia by the physio?
Examination of joints and vagina, muscle testing, vaginismus, posture, body language and behaviour
What treatments can the physio offer for vulvodynia?
Lumbar spine and/or pelvic girdle mobilisation techniques, posture, movement strategies, core stability exercises, manual handling and stretching, biofeedback, acupuncture
What is female genital mutilation?
All procedures involving partial or total removal of external female genitalia or other injury to female genital organs for non-medical reasons
Why is female genital mutilation practiced?
Insurance of virginity and chastity, cultural identity, religious beliefs (not supported by any doctrine)
What is type 1 female genital mutilation?
Clitoridectomy = partial or total removal of clitoris and/or prepuce
What is type 2 female genital mutilation?
Excision = partial or total removal of clitoris and labia minora, with or without excision of labia majora
What is type 3 female genital mutilation?
Infibulation = narrowing of vaginal orifice with creation of covering seal by cutting and appositioning labia minora and/or labia majora, with or without excision of clitoris
What is type 4 female genital mutilation?
All other harmful procedures to female genitalia for non-medical purposes
What is the legal stance on female genital mutilation?
Illegal in UK to perform FGM, assist any girl to carry out FGM or assist a non-UK person to carry out FGM outside UK on UK resident
What are the short term complications of female genital mutilation?
Haemorrhage, urinary retention, genital swelling, infection, sepsis
What are the long term complications of female genital mutilation?
UTI (types 2 and 3), urinary stricture or fistula, dyspareunia or apareunia, PTSD, haematocolpos, HIV, hep B
What are the obstetric complications of female genital mutilation?
Obstructed labour, postpartum haemorrhage, perineal trauma and sphincter injury, C-section, stillbirth
What should be included in the examination of a patient with female genital mutilation?
Inspection of the vulva = needed to determine type of FGM
How is type 3 female genital mutilation treated?
De-infibulation = ideally offer before first intercourse and pregnancy
When should antenatal de-infibulation be offered?
Before last 2 months of pregnancy = can give under spinal if mother chooses to have C-section
What should be done if female genital mutilation is identified?
Must explain UK law on FGM
Report to social work if unborn child at risk
Individual risk assessment done by midwife/obstetrician using FGM safeguarding risk assessment tool
Do you have to report all pregnant women identified as having suffered female genital mutilation?
No = not mandatory to report all women but have duty to protect any children recognised to be at risk
What are the acute differentials of painful genital lesions?
Ulceration = herpes, shingles, aphthous ulcers
Lumps = Bartholin’s abscess, abscess, furuncle/caruncle, hydradenitis supparative
Trauma
What are the chronic differentials of painful genital lesions?
Lichen sclerosis, lichen planus, vulval intraepithelial neoplasia, vulval cancer
How can vulval cancer present?
May present with burning sensation in vulva associated with itching
What may be seen on examination of vulval cancer?
Raised vulval ulcer = may have keratinisation in middle and indurated edges
May have satellite lesions
What investigations can be done for vulval cancer?
Lesion biopsy
USS of groin if lymph node involvement
MRI of perineum if lesion close to anus
What area should be included in a biopsy for vulval cancer?
Area of epithelium where there is transition of normal to malignant tissue in biopsy
Is vulval cancer common?
No = most common type is squamous cell carcinoma
Where do vulval adenocarcinomas tend to occur?
In Bartholin’s glands
What are the precursors of vulval cancer?
HPV in young women
Lichen sclerosis in older women
How is vulval cancer treated?
Mainstay is surgery = chemoradiotherapy can be used as adjuvant, may need reconstruction by plastic surgeons
How long do you follow vulval cancer up for?
5 years post-treatment
What vulval cancer lesions are suitable for wide local excision without groin node dissection?
Lesions confined to vulva/perineum with stromal invasion <=1mm
What vulval cancer lesions are suitable for wide local excision and groin node dissection?
Lesion confined to pelvis, but >1mm depth of invasion
How are vulval cancer lesions with obvious groin node involvement treated?
Chemoradiotherapy
