Vulval Itching/Lesion Flashcards
What is the vulva
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)
What are the causes of vulval itching
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
What are the symptoms of condylomata acuminata
Asymptomatic
or
Painful ulcers on the external genitalia ± cervix & rectum
Dysuria
Vaginal discharge
Fever/myalgia (rare)
What is the management for condylomata acuminata
Saline baths
Analgesia, topical anaesthetics
Antiviral drugs (oral better than topical) e.g. Acyclovir, valaciclovir, famciclovir
Catheterisation for acute urinary retention
What is lichen simplex
Chronic inflammatory skin condition
AKA chronic vulval dermatitis
Sensitive skin, dermatitis or eczema result in lichen simplex
What are the symptoms and signs of lichen simplex
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
What investigations should be done for lichen simplex
Clinical diagnosis
If in doubt - vulval biopsy
What is the management for lichen simplex
Aim is to break the itch-scratch cycle
Avoid irritants e.g. soap
Emollients
Steroid creams
Antihistamines
What is lichen sclerosus
Vulval epithelium is thin with the loss of collagen
May have an autoimmune basis
(associated with vulval carcinoma - 5%)
What are the symptoms and signs of lichen sclerosus
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
What investigations should be done for lichen sclerosus
Biopsy - exclude carcinoma and confirm diagnosis
What is the management for lichen sclerosus
Ultra-potent topical steroids (e.g. clobetasol proprionate (dermovate))
Second line: tacrolimus (topical calcineurin inhibitor) + biopsy (as steroid-resistant)
What is lichen planus
Affects mucosal surfaces and the genital region
Unknown aetiology
What are the signs and symptoms of lichen planus
Flat, papular, purplish lesions
- Mouth and genital regions
- Erosive
- Painful (rather than itchy)
- May see fine white lines
What is the management for lichen planus
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
Define VIN
Vaginal intraepithelial neoplasia (VIN) = presence of atypical cells in the vulval epithelium
What are the types of VIN
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
What is the management for VIN
Local surgical excision to relieve symptoms
Supportive: emollients, mild topical steroid
What are the most common carcinomas of the vulva and what are the risk factors
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
What are the signs and symptoms of vulval carcinoma
Presentation: pruritus, bleeding, discharge, mass found
Examination: ulcer or mass (most commonly labia majora, clitoris) | tender and/or hard inguinal lymphadenopathy
What investigations should be done for vulval carcinoma
- Biopsy of lesion
- Fitness for surgery: CXR, ECG, FBC, U&Es, cross match
What is the staging for vulval carcinoma
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
What is the management for vulval carcinoma
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
Describe vaginal malignancies
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.
Describe Vulvar dysaesthesia (vulvodynia) (S&S, RF)
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
What is the management for vulvar dysaesthesia
amitriptyline OR gabapentin
Define female genital mutilation
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
What are the types of FGM
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
What is the epidemiology of FGM
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.
What are the procedural options for FGM
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.
What is Reinfubulation
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.
What are the short term complications of FGM
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
What are the long term complications of FGM
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
What obstetric issues may arise with FGM
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
What is the management for FGM
- Safeguarding and reporting
- Document FGM in notes (name, DoB, address, type, in red book if young)
- Women should be identified and referred to specialist gynaecology/ FGM clinic
- Counsel on FGM and its risks
- Offer and recommend deinfibulation
- Mental health support
What are the reporting guidelines for FGM
<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.
