Vulval pathology

Question 1

Initial workup

Scenario 1 - 53yo p/w vulval irritation
Scenario 2 - Postmeno w vulval lesion

Answer 1

DDx
- LS/LP/LSC
- Dermatitis - atopic/contact/irritant
- infection - vulvo-candidiasis
- atrophic-vaginitis
- VIN/SCC

Ix
- Vulvoscopy - ACW +/- Bx
+/- MCS - urine +/- vulva
+/- TFT/HbA1c

Question 2

Mx of LS

Answer 2

risk of SCC up to 6% if untreated
- referral tert - vulval derm
- MDI - gyn/derm/sexual health
- ultra potent topical steroid - clobetasol - +/- antihistamine +/- antibiotics
- emollient + avoid irritant
- lubrication, topical E (if dyspareunia)
- F/U 3/12 to check response
- +/- TCA +/-pain modulator+/-resection
- life-long annual surveillance
- monitor sx - harden, lump

Question 3

Mx of VIN

Answer 3

• uVIN - HPV-related VIN
• risk to SCC (albeit less than dVIN)
• refer to tert - vulval derm unit
• options - med/ablation/surgical
• med - imiquimod, multifocal, self
• ablation - laser, multifocal, no surg
• surg - WLE, bx sample, scar, GA
• regular f/u 6-12mo for 5yrs
• CST according to schedule
• Other - HPV vax/smoke

Question 4

Vulval SCC mx

Answer 4

• SPIKES
• risk of progression
• further ix FBE/UEC/LFT/CTAP
• Ref Tertiary GONC
• GONC MDT
• MDI - GONC/RadOnc/Psych…
• Optimize comorbidity - ano/SPAC
• likely need WLE +/- groin SLN
• +/- adj RT if LN+’ve
• risk of surgery & RT (itis)
• F/U in GONC surveillance
• prog 90% 5yrs if LN-‘ve
• prog 60% 5yrs LN+’ve