Vulval Disorders Flashcards
VIN
Mean age at presentation [1] compared to CIN
Compare natural progression between VIN and CIN
How would younger women with VIN present [1]
How would older women with VIN present [1]
Mean age is 36yrs (older than CIN)
VIN has a slower history natural progression than CIN - due to more stable epithelium
Younger women tend to be HPV +ve with multi-focal VIN
Older women tend to be uni-focal and unrelated to HPV
Clinical appearance of VIN [4]
Clinical appearance of differentiated VIN
Raised papular or plaque lesions with a keratotic roughened appearance (like warts)
They have a sharp border and may be discoloured (red, white or brown)
Differentiated VIN - unifocal ulcer or plaque
How can we diagnose VIN? [2]
With a punch biopsy under LA. It’s a histological diagnosis
Laser ablation in VIN treatment
Cons [2]
Pros [2]
Not as effective as surgery with 40-70% recurrence rate
Possibility of missed occult invasion
But it has a better cosmetic result
Can be used on mucosal skin
Topical treatments in VIN
Options [5]
Not as effective as surgery but preserves the tissue
Indication [1]
Imiquimod has 60% response rate 5FU cream Alpha-interferon Cidofivir - injectable antiviral Photodynamic therapy
Indicated for multiple lesions
What risk factors lead to VIN? [4]
Smoking Other genital intra-epithelial neoplasia including anal, lichens sclerosis Previous related malignancy Immunosuppression HPV types 16, 18, 31, 33
If we don’t catch or treat VIN it can lead to vulval cancer, what is the major type?
SCC
Symptoms of vulval cancer [5]
Signs [3]
Chronic vulvar itching
Burning, tingling or soreness in vulval area
Slightly raised skin lesions and other changes in appearance of vulva
Dyspareunia
Bleeding - underwear rather than toilet
Signs
- Irregular fumigating mass
- Irregular ulcer
- Enlarged groin nodes
How treatable is vulval cancer?
Stage 1 has a 97% cure rate
Late stage is more like 50%
Treatment of vulval cancer that is >1mm deep [2]
Treatment of advanced disease [2]
> 1mm deep:
Triple incision surgery
- Radical local excision >15mm margins
- Unilateral/bilateral node dissection
Advanced disease:
- Radical vulvectomy ie wide excision of vulva and inguinal glands
- Skin grafts
What nodes are removed when treating vulval cancer? [2]
Inguinal and upper femoral
Either unilateral or bilateral
When do we use RT & Chemo for vulval cancer? [3]
Either neo-adjuvantly
- if they arn’t suitable for surgery
- Relapse
What are the risks of vulval cancer surgery? [3]
Wound infection
Lymphocysts
Nerve damage
VIN staging
Stage 1 - 4
Dependent on size and nodes
Stage 1 <2cm
Stage 2 > 2cm
Stage 3 - local spread + unilateral nodes
Stage 4 - distant or advanced spread + pelvic nodes
Treatment of VIN [3]
Topical treatment and emollients to preserve sexual image and ameliorate sx
Laser ablation or surgery
Follow up and surveillance
Lymph invasion in VIN - management
Central tumour
Unilateral tumour
If tumour is central then bilateral node dissection
If tumour is one one side then unilateral node dissection on ipsilateral side
Treatment of stage 1 vulval cancer
Local excision without node dissection
Lichen sclerosis Ep Ax Px [2] Symptoms Signs [4] Mx
Ep: post-menopausal women
Ax: autoimmune disorder
Px: elastic tissue turns to collagen. Can be pre-malignant
Sy: pruitus vulvae
Si:
- bruised red purpuric signs (erosions, ulcerations, bullae),
- vulva gradually becomes white, flat and shiny, maybe hourglass shape around vulva and anus
Mx:
- clobetasol propionate cream
- Tacrolimus (off license)
- Surveillance if no response
Explain the instructions for prescribing steroid cream for lichen sclerosis [3]
- daily for 28d
- valternate days for 4w
- then twice weekly for 8 weeks
Lichen planus Ep Ax Px [2] Symptoms [2] Signs [4] Mx
Ep: all ages Ax: idiopathic Px: chronic inflammatory dermatosis due to keratinocyte apoptosis Sy: pain, pruitus Si: - demarcated - purple hypertrophic, areas - around genitals and mouth, introitus - may have glazed appearance Mx: topical corticosteroids (CLOBESTALOL or BETAMETASONE)
Lichen simplex Ep Ax [3] Symptoms Signs [2] Mx [4]
Ep: sensitive skin or eczema
Ax: stress, sensitising chemicals, low iron stores
Sy: chronic intractable itching
Si: non-specific inflammation of vulva +/- mons pubis and inner thighs
Mx:
- vulva care (soap substitute w/ water only
- cleaning vulva once a day, avoid tight clothing etc)
- topical corticosteroids
- anti-histamines
Vulvovaginitis Ax [2] Symptoms [2] Signs [2] Mx [2]
Ax:
- fixed drug reactions (NSAIDs, statins)
- desquamative inflammatory vaginitis of unknown cause
Sy: itching, pain
Si: shiny erythematous patches +/- petechiae
Mx:
- stop offending agent if drug reaction
- intravaginal CLINDAMYCIN w/ HYDROCORTISONE to vulva for 2-4 wks if unknown cause
Urethral caruncle Ax Symptoms [2] Signs [2] Mx [2]
Ax: meatal prolapse
Sy: pain on micturition, red swelling
Si: red swelling at urethral orifice, tenderness
Mx: excision or diathermy
Bartholins cyst or abscess
Ax
Pathophysiology [2]
Symptoms [3]
Ax: blocked Bartholin’s duct Px: - Bartholin’s glands secrete thin mucous on sexual excitation. - Can become blocked causing cyst which can become infected Sy: - painless lump (cyst) - painful (cannot sit down) - hot lump (abscess)
Bartholins cyst or abscess
Signs
Management [3]
Ix: exclude gonorrhea Si: - hugely swollen, hot red labium Mx: - abscess incised w/ permanent drainage - ensured by marsupialisation (inner cyst wall folded back and stitched to skin) - or balloon catheter insertion
