Vulval Disorders

Question 1

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]

Answer 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

Question 2

Clinical appearance of VIN [4]

Clinical appearance of differentiated VIN

Answer 2

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

Question 3

How can we diagnose VIN? [2]

Answer 3

With a punch biopsy under LA. It’s a histological diagnosis

Question 4

Laser ablation in VIN treatment
Cons [2]
Pros [2]

Answer 4

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

Question 5

Topical treatments in VIN
Options [5]
Not as effective as surgery but preserves the tissue
Indication [1]

Answer 5

Imiquimod has 60% response rate
5FU cream
Alpha-interferon
Cidofivir - injectable antiviral 
Photodynamic therapy

Indicated for multiple lesions

Question 6

What risk factors lead to VIN? [4]

Answer 6

Smoking
Other genital intra-epithelial neoplasia including anal, lichens sclerosis
Previous related malignancy
Immunosuppression
HPV types 16, 18, 31, 33

Question 7

If we don’t catch or treat VIN it can lead to vulval cancer, what is the major type?

Answer 7

SCC

Question 8

Symptoms of vulval cancer [5]

Signs [3]

Answer 8

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

Question 9

How treatable is vulval cancer?

Answer 9

Stage 1 has a 97% cure rate

Late stage is more like 50%

Question 10

Treatment of vulval cancer that is >1mm deep [2]

Treatment of advanced disease [2]

Answer 10

> 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

Question 11

What nodes are removed when treating vulval cancer? [2]

Answer 11

Inguinal and upper femoral

Either unilateral or bilateral

Question 12

When do we use RT & Chemo for vulval cancer? [3]

Answer 12

Either neo-adjuvantly

• if they arn’t suitable for surgery
• Relapse

Question 13

What are the risks of vulval cancer surgery? [3]

Answer 13

Wound infection
Lymphocysts
Nerve damage

Question 14

VIN staging
Stage 1 - 4
Dependent on size and nodes

Answer 14

Stage 1 <2cm
Stage 2 > 2cm
Stage 3 - local spread + unilateral nodes
Stage 4 - distant or advanced spread + pelvic nodes

Question 15

Treatment of VIN [3]

Answer 15

Topical treatment and emollients to preserve sexual image and ameliorate sx
Laser ablation or surgery
Follow up and surveillance

Question 16

Lymph invasion in VIN - management
Central tumour
Unilateral tumour

Answer 16

If tumour is central then bilateral node dissection

If tumour is one one side then unilateral node dissection on ipsilateral side

Question 17

Treatment of stage 1 vulval cancer

Answer 17

Local excision without node dissection

Question 18

Lichen sclerosis
Ep
Ax
Px [2]
Symptoms
Signs [4]
Mx

Answer 18

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

Question 19

Explain the instructions for prescribing steroid cream for lichen sclerosis [3]

Answer 19

• daily for 28d
• valternate days for 4w
• then twice weekly for 8 weeks

Question 20

Lichen planus
Ep
Ax
Px [2]
Symptoms [2]
Signs [4]
Mx

Answer 20

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)

Question 21

Lichen simplex
Ep
Ax [3]
Symptoms
Signs [2]
Mx [4]

Answer 21

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

Question 22

Vulvovaginitis
Ax [2]
Symptoms [2]
Signs [2]
Mx [2]

Answer 22

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

Question 23

Urethral caruncle
Ax
Symptoms [2]
Signs [2]
Mx [2]

Answer 23

Ax: meatal prolapse
Sy: pain on micturition, red swelling
Si: red swelling at urethral orifice, tenderness
Mx: excision or diathermy

Question 24

Bartholins cyst or abscess
Ax
Pathophysiology [2]
Symptoms [3]

Answer 24

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)

Question 25

Bartholins cyst or abscess
Signs
Management [3]

Answer 25

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