Vulval Itching/Lesion

Question 1

What is the vulva

Answer 1

area of skin that stretches from the labia majora laterally to the mons pubis anteriorly and the perineum posteriorly, overlapping with the vestibule (area between labia minora and the hymen)

Question 2

What are the causes of vulval itching

Answer 2

Infection: candidiasis, condylomata acuminata (HSV warts), pubic lice, scabies
Derm: eczema, psoriasis, lichen simplex, lichen sclerosus, lichen planus, dermatitis
Neoplasia: carcinoma, VIN
Other: Bartholin’s cyst, vaginal cyst, vaginal adenosis

Question 3

What are the symptoms of condylomata acuminata

Answer 3

Asymptomatic
or
Painful ulcers on the external genitalia ± cervix & rectum
Dysuria
Vaginal discharge
Fever/myalgia (rare)

Question 4

What is the management for condylomata acuminata

Answer 4

Saline baths
Analgesia, topical anaesthetics
Antiviral drugs (oral better than topical) e.g. Acyclovir, valaciclovir, famciclovir
Catheterisation for acute urinary retention

Question 5

What is lichen simplex

Answer 5

Chronic inflammatory skin condition
AKA chronic vulval dermatitis
Sensitive skin, dermatitis or eczema result in lichen simplex

Question 6

What are the symptoms and signs of lichen simplex

Answer 6

Severe intractable pruritus, especially at night
- May be exacerbated by chemical or contact dermatitis
- May be linked to stress or low iron
Area (typically labia majora) is inflamed and thickened with hyper and hypopigmentation

Question 7

What investigations should be done for lichen simplex

Answer 7

Clinical diagnosis

If in doubt - vulval biopsy

Question 8

What is the management for lichen simplex

Answer 8

Aim is to break the itch-scratch cycle
Avoid irritants e.g. soap
Emollients
Steroid creams
Antihistamines

Question 9

What is lichen sclerosus

Answer 9

Vulval epithelium is thin with the loss of collagen
May have an autoimmune basis

(associated with vulval carcinoma - 5%)

Question 10

What are the symptoms and signs of lichen sclerosus

Answer 10

Severe pruritus, Worse at night
Trauma with bleeding and skin splitting
Discomfort, pain, dyspareunia
Pink-white papules → coalesce to form parchment-like skin with fissures
Inflammatory adhesions → labial fusion → narrows the introitus

Hx thyroid issues or vitiligo

Question 11

What investigations should be done for lichen sclerosus

Answer 11

Biopsy - exclude carcinoma and confirm diagnosis

Question 12

What is the management for lichen sclerosus

Answer 12

Ultra-potent topical steroids (e.g. clobetasol proprionate (dermovate))

Second line: tacrolimus (topical calcineurin inhibitor) + biopsy (as steroid-resistant)

Question 13

What is lichen planus

Answer 13

Affects mucosal surfaces and the genital region

Unknown aetiology

Question 14

What are the signs and symptoms of lichen planus

Answer 14

Flat, papular, purplish lesions
- Mouth and genital regions
- Erosive
- Painful (rather than itchy)
- May see fine white lines

Question 15

What is the management for lichen planus

Answer 15

1st line: High-dose topical steroids (e.g. Clobetasol)
2nd line: topical calcineurin inhibitor (e.g. tacrolimus)

If vaginal stenosis, dilatation with manual measures should be attempted in the first instance

Question 16

Define VIN

Answer 16

Vaginal intraepithelial neoplasia (VIN) = presence of atypical cells in the vulval epithelium

Question 17

What are the types of VIN

Answer 17

Usual type
- Warty, basaloid, mixed
- Common in women aged 35-55
- RF: HPV (esp. HPV-16) | cervical intraepithelial neoplasia CIN | smoking | chronic immunosuppression
- Multifocal: Appearance varies widely: red, white, pigmented, plaques, papules, patches, erosions, nodules, warty, hyperkeratosis

Differentiated type
- Associated with lichen sclerosis
- Seen in older women
- Unifocal: ulcer or plaque
- Associated with keratinising squamous cell carcinomas of the vulva
- Risk of progression to cancer is higher than usual type VIN

Question 18

What is the management for VIN

Answer 18

Local surgical excision to relieve symptoms
Supportive: emollients, mild topical steroid

Question 19

What are the most common carcinomas of the vulva and what are the risk factors

Answer 19

95% of vulval malignancies are squamous cell carcinomas, the rest are melanomas, basal cells carcinomas, adenocarcinomas, and a variety of others

RF: lichen sclerosis | immunosuppression | smoking | Paget’s disease of the vulva

Question 20

What are the signs and symptoms of vulval carcinoma

Answer 20

Presentation: pruritus, bleeding, discharge, mass found
Examination: ulcer or mass (most commonly labia majora, clitoris) | tender and/or hard inguinal lymphadenopathy

Question 21

What investigations should be done for vulval carcinoma

Answer 21

• Biopsy of lesion
• Fitness for surgery: CXR, ECG, FBC, U&Es, cross match

Question 22

What is the staging for vulval carcinoma

Answer 22

1a: confined to vulva/perineum <2cm, stromal invasion <1mm
1b: confined to vulva/perineum >2cm, stromal invasion >1mm
2: adjacent spread (urethra, vagina, anus)
3. Positive inguinofemoral nodes
4: invades upper urethra/vagina, rectum, mets

Question 23

What is the management for vulval carcinoma

Answer 23

1a: local excision ± plastic surgeon
1b/2/3/4:
- sentinel lymph node biopsy
- Wide local excision and groin lymphadenectomy (triple incision radical vulvectomy)
± Plastic surgeon input

Question 24

Describe vaginal malignancies

Answer 24

Primary
- Older women
- Squamous origin
- Presentation: bleeding or discharge and a mass or ulcer evident
- Management: intravaginal radiotherapy, radical surgery
- 5-year survival 50%
- Vaginal adenosis (in-utero DES exposure) → clear cell adenocarcinoma
Secondary: from cervix, endometrium, vulva etc.

Question 25

Describe Vulvar dysaesthesia (vulvodynia) (S&S, RF)

Answer 25

Vulval pain syndrome
Diagnosis of exclusion
Provoked or Spontaneous
Local (vestibular) or generalised
- Generalised: burning pain, older patients
- Localised: superficial dyspareunia or pain on tampons, younger patients
RF: Hx genital tract infections, former oral contraceptive use, psychosexual disorders

Question 26

What is the management for vulvar dysaesthesia

Answer 26

amitriptyline OR gabapentin

Question 27

Define female genital mutilation

Answer 27

all procedures that involve partial or total removal of the external female genitalia, or injury to the female genital organs for non medical reasons. It is a violation of the rights of the child and woman. It is child abuse and illegal in the UK

Question 28

What are the types of FGM

Answer 28

Type 1: Clitoridectomy: partial/total removal of the clitoris and sometimes the prepuce (clitoral hood)
Type 2: Partial/total removal of the clitoral glans and the labia minora, with or without removal of the labia majora
Type 3: . Pharaonic: the labia majora are removed and the skin is stitched together (vaginal opening no longer exposed)
Type 4: All other harmful procedures to the female genitalia for non-medical purposes e.g. pricking, piercing, incising, cauterizing, nicking

Question 29

What is the epidemiology of FGM

Answer 29

200 million girls and women worldwide living with the consequences of FGM, 5% global female population.
Occurs mainly in North/central-Africa (Somalia, Egypt, Sudan, Ethiopia), Malaysia, Indonesia, India, Yemen, Syria but occurs globally, practiced in over 28 African countries
Age of FGM varies from a few days old to adulthood depending on the geographical area and community, but usually averages 5-14 years old.
18% of all FGM is performed by healthcare providers.

Question 30

What are the procedural options for FGM

Answer 30

Deinfibulation
The opening procedure for women with type 3 FGM.
It can help alleviate some physical symptoms but cannot replace the tissue that has been removed.
It can be done under local, spinal or general anaesthetic
The incision should be made along the vulval incision scar and the urethra identified before surgery commences to reduce damage
Screen for UTI and consider Abx prophylaxis
Offered to those unable to have sex comfortably, pass urine, or pregnant women at risk during delivery

Clitoral/labial reconstruction
Not currently available in the UK.

Question 31

What is Reinfubulation

Answer 31

Re-closure of a woman with Type 3 FGM, usually after childbirth. It is illegal in the UK. This can happen multiple times with the birth of each child.

Question 32

What are the short term complications of FGM

Answer 32

Haemorrhage
Severe pain and shock
Urine retention
Injury to adjacent tissue
Tetanus, HIV, hep B/C
Fracture or dislocation of limbs as a result of being restrained
Death through severe bleeding → haemorrhagic shock, neurogenic shock, infection, septicaemia

Question 33

What are the long term complications of FGM

Answer 33

Dysuria/recurrent UTIs
Renal failure
Recurrent candida infections
Abscesses due to infected cysts/horns
Dysmenorrhoea
Dyspareunia
Sexual dysfunction and lack of sexual pleasure
Infertility
Acute/chronic pelvic infections
Clitoral neuroma

Question 34

What obstetric issues may arise with FGM

Answer 34

May not be identified antenatally
Difficulty with Vaginal examinations
Scarring and stricture of the vaginal canal
Possible obstructed labour
Psychological trauma
Flashbacks
Increased risk of caesarean sections, PPH< foetal asphyxia/anoxia
Perineal trauma/tears -> scar tissue, fistulae

Question 35

What is the management for FGM

Answer 35

1. Safeguarding and reporting
2. Document FGM in notes (name, DoB, address, type, in red book if young)
3. Women should be identified and referred to specialist gynaecology/ FGM clinic
4. Counsel on FGM and its risks
5. Offer and recommend deinfibulation
6. Mental health support

Question 36

What are the reporting guidelines for FGM

Answer 36

<18: report to the police (serious crimes 2015) via 101 non-emergency within 1 month
+ inform the FGM specialist midwife or the safeguarding team + social care referral
>18: safeguarding and assess risk to female children or younger siblings, reporting not required, must document in notes

If a mother discloses that her daughters or siblings have had FGM, the MR duty does NOT apply - but you must do a normal safeguarding referral to children’s social care.