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OBSTGYN715 Exam > Vulval Problems > Flashcards

Vulval Problems Flashcards

1
Q

What is the median age of presentation of vulval cancer?

A

Mid 30s

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2
Q

What are the common presenting symptoms of vulval cancer?

A

Irritation and itching of the vulva or a warty pigmented area.

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3
Q

What are some abnormalities of vulval architecture?

A
  • Hypertrophy of labia majora or minora
  • Loss of all or part of the labia minora with asymmetry/posterior flattening/unilateral absence/bilateral absence/agglutination of a portion of the labium to the interlabial sulcus/skipped areas
  • Loss of the prepuce or fusion of it to the clitoris/lack of mobility of the prepuce/scarring of the prepuce to a portion of the glans
  • Clitoral enlargement or cysts
  • Synechiae formation in the vestibule or stricture in the vestibule
  • Abnormality of the hymen (usually lack of an opening)
  • Hernia
  • Evidence of female genital cutting
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4
Q

What are some common vulval symptoms?

A

Pruritis
Superficial dyspareunia (2nd most common sx)
Dysuria – urine on inflamed skin
Vulval pain and burning
Change in colour
Lumps
Ulceration
Discharge
Odour

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5
Q

Describe what vulval papillomatosis looks like. Is this normal or abnormal

A

Symmetrical with papilla discrete to the base, rounded non tapering unlike warts. Normal in premenopausal vulva

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6
Q

What causes Fordyce spots?Are they normal or abnormal ?

A

Enlarged sebaceous glands.
Normal premenopausal women.

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7
Q

What is angiokeratoma and what does it look like?

A

Benign blood vessel growths on scrotum and vulva. Multiple, purple to black spots

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8
Q

How are HSIL and VIN differentiated?

A

HSIL is basaloid and warty

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9
Q

Is HSIL HPV related?

A

Yes

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10
Q

Is VIN HPV related?

A

No

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11
Q

What condition is VIN associated with?

A

Lichen Sclerosis

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12
Q

How do you treat HSIL/VIN?

A

Excision/laser/imiquimod/efudix

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13
Q

What symptoms are associated with Lichen Sclerosis?

A

Itch worse at night, disturbing sleep; pain if fissures and erosions; dyspareunia; can be asx; constipation if perianal esp when prepubertal

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14
Q

What does Lichen Sclerosis look like?

A

localised or all of the vulva can be involved; porcelain white papules or plaques; ecchymoses; post inflammatory pigmentation; can get fusion/resorption of the interlabial sulci, labia minora, clitorial head fusion (spares the mucosa unlike lichen planus); 30% perianal involvement; extragenital in <10% (groin flexures, medial thighs, axillae, buttocks, trunk

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15
Q

What are the complications of Lichen Sclerosis?

A

Differentiated VIN,
SCC associated with anogenital sclerosus; verrucous carcinoma;
scarring leading to introital narrowing,
dyspareunia, or difficulties with micturition;
pseudocyst of clitoris;
sensory abnormalities; psychosexual problems esp if introital narrowing

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16
Q

What are the treatments for Lichen Sclerosis?

A

Topical Clobetasol propionate nocte for 4/52 then alternate nights biweekly for 4/52 (30g tube should last 12 weeks); then once weekly;
If steroid resistant use topical Pimecrolimus, topical retinoids (esp if hyperkeratotic);
Surgery for significant scarring or malignancy

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17
Q

Describe genital Lichen planus

A
  • Mucocutaneous with sharply marginated violaceous flat topped papules on skin; less sharply marginated white plaques on mucous membranes; affects vulva and vagina; commonly erosive. May be papular and pigmented on the vulva; can get atrophy and scarring
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18
Q

What are the symptoms of Lichen Planus?

A

vulvar burning spontaneously or with the slightest contact; severe dyspareunia +/- post coital bleeding;
brown discharge

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19
Q

What signs are associated with Lichen Planus?

A

erosive erythema of the vestibular mucosa +/- epithelial desquamation; at periphery of erosive red lesion there will be a narrow rim of white +/- haemorrhagic +/- white reticulated pattern

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20
Q

What are the complications of Lichen Planus?

A

Scarring due to chronicity and recurrence, dyspareunia, pain and ongoing pruritis, malignancy

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21
Q

Can lichen planus and lichen sclerosis coexist?

A

Yes

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22
Q

What are the treatments for Lichen Planus?

A

Potent topical corticosteroids for the vulva and hydrocortisone foam for the vagina (if not improving within a few weeks try 0.5mg/kg systemic steroids; alternatives are hydroxychloroquine, cyclosporine, methotrexate, topical tacrolimus 0.1%

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23
Q

What are common symptoms of Psoriasis?

A

Rash
Mild to moderate itching;
Can be asx

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24
Q

What are the signs of Psoriasis?

A

erythematous plaques, roughened surface, silvery scale (not present in deep flexures), sharply marginated. Affects hair bearing skin, nails, umbilicus; once scratched the margins may be blurred

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25
Q

What is the treatment for Psoriasis?

A

Medium potency betamethasone valerate, hydrocortisone butyrate; clobetasol propionate if severe;
alternative is Calcipotriene ointment BD or systemic therapy for widespread or resistant disease

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26
Q

What is the treatment for vulval eczema?

A

Avoid irritant; regular emollient use, topical steroid +/- antibiotics if also infected; resistant eczema: topical tacrolimus/pimecrolimus; systemic corticosteroids, azathioprine, MTX or cyclosporine

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27
Q

What are the symptoms of vulval candidiasis

A

Cottage cheese discharge, itching, redness and soreness of the vulval area

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28
Q

Describe tinea cruris and its distribution

A

only in the folds not on the vulva; tends to be asymmetric, scaly and begins in the groin skin fold

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29
Q

What factors might influence the treatment of genital HPV warts?

A

Size, location and number of warts, changes in the warts, patient preference, the cost of treatment, convenience, possible adverse effects and the health care provider’s expertise

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30
Q

What treatments are offered for HPV associated genital warts?

A

Podophyllotoxin/ imiquimod cream/ cryotherapy/ trichloroacetic acid/ laser therapy
- May recur within first 3 months

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31
Q

Which group has the highest burden of HPV associated anal cancer?

A

MSM and HIV positive MSM

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32
Q

Can you screen for anal HPV associated cancer?

A

No

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33
Q

What examination is recommended for HIV positive MSM who are aged 50 years or over

A

Annual digital anorectal examination

34
Q

What other parts of the genital tract should be inspected if there are visible warts on the vulva

A

Anal area

35
Q

What is thought to be the % of visible warts that will spontaneously resolve?

A

30%

36
Q

Are salt water baths helpful for genital warts?

A

Yes, salt water baths are a useful thing the patient can do to help soothe and heal the genital area during treatment. Two handfuls of plain salt per bath or two tablespoons in a large bowl, preferably twice daily, and dry with hairdryer.

37
Q

Does the elimination of visible warts decrease infectivity?

A

No, as it may not represent the entire viral burden

38
Q

How does Aldara 5% cream (Imiquimod) work on genital warts?

A

Can be self applied for for 16 weeks: enhances interferon and cytokine production.

39
Q

How does Condyline 0.5% (podophyllotoxin) solution work on genital warts?

A

Self applied for 4-5 weeks: antimitotic and causes localised tissue necrosis and intracellular oedema

40
Q

What are the ADRs for Aldara (Imiquimod)?

A

Localised erythema, swelling and rarely ulceration. If having localised skin reaction stop using for a few days then restart.
Hyperpigmentation.
Flu like sx in a small number of people

41
Q

What are the ADRs for Condyline 0.5% (podophyllotoxin) solution?

A

Mild erythema with slight pain/superficial ulceration. Rarely can be severe.
Avoid in women as difficult to see to apply safely

42
Q

What treatments can be used for genital warts in pregnancy?

A

Cryotherapy, electrocautery, surgery and laser therapy

43
Q

What is the most important differential diagnosis to consider if there is ongoing lack of response to treatment of external warts?

A

HSIL

44
Q

When is LSCS warranted if a woman has genital warts present in the last semester of her pregnancy?

A

Very large genital warts where the pelvic outlet is obstructed or if vaginal delivery would result in significant bleeding

45
Q

What treatments for warts are OK to use when breast feeding?

A

Laser/cryo/surgical/electrocautery + imiquimod.

46
Q
  1. What % of patients are likely to have a recurrence of warts after treatment?
A

30%

47
Q

Describe lichen simplex and its characteristic feature

A

Skin looks leathery; get unremitting itching; usually bilateral

48
Q

What are some common triggers of Lichen Simplex?

A

Often develops in women who are atopic, stressed and environmental triggers can be heat, sweating, excess dryness.

49
Q

What is the treatment for Lichen Simplex?

A

Sitz baths + fatty cream/cetomacrogol BD. Loose cotton clothing, avoid prolonged seating esp on vinyl surfaces.
Clobetasol propionate for a short time (2-3 weeks max at a time).
Try sedatives/sedating antihistamines to break the itch scratch cycle.

50
Q

What is VIN

A

A precancerous lesion on vulva (type of SCC in situ) -2 types, usual and differentiated

51
Q

What is usual VIN associated with?

A

HPV infection

52
Q

What % of usual VIN self resolves in a year?

A

12% - this is usually papular and pigmented multifocal disease

53
Q

What is differentiated VIN associated with?

A

Inflammatory diseases of the vulva – lichen sclerosus and lichen planus.

54
Q

What % of differentiated VIN will progress to SCC if untreated?

A

85%

55
Q

What are the sx of VIN?

A

Vulval itching, burning, one or more flat or slightly raised well defined lesions that vary in colour and can occur on any part of the vulva

56
Q

What is the treatment for VIN?

A

Surgical excision, if extensive vulvectomy;
May use laser ablation if not invasive.
Medical tx sometimes works – Imiquimod 3 times weekly for 12-20 weeks – results in red, inflamed and eroded tissue and discomfort
5-FU cream BD for several weeks – causes severe inflammation and less effective;
Photodynamic therapy - not appropriate for dVIN

57
Q

What sort of cancer is vulval cancer dominantly?

A

80% SCC; remainder is melanoma and BCC.
Extramammary Paget disease and Bartholin gland carcinoma are uncommon causes

58
Q

What are the risk factors for progression to VIN?

A

> 40 years, immunosuppression, previous lower genital tract neoplasia,
proximity to anal margin

59
Q

What are the symptoms that should prompt women to seek review ? vulval cancer?

A
  • A lasting itch
  • Pain or soreness
  • Thickened, raised, red, white or dark patches on the skin of the vulva
  • An open sore or growth visible on the skin
  • Burning pain when you pass urine
  • Vaginal discharge or bleeding
  • A mole on the vulva that changes shape or colour
  • A lump or swelling of the vulva.
60
Q

How do you diagnose vulval cancer?

A

Biopsy
Also need to examine for lymph nodes and metastases

61
Q

What are the risk factors for vulval SCC?

A

Age,
Smoking,
Multiple sexual partners, Immunosuppression

62
Q

How is vulval SCC staged?

A

FIGO system

63
Q

What is the treatment for vulval cancer?

A

HPV vaccination primary prevention;
treatment of VIN,
WLE +/- SLNB +/- CRTx

64
Q

What are the signs of vulval melanoma?

A

Irregular pigmented lesion on labia majora or clitoris often amelanotic on the vulval mucosa; dermoscopy shows polymorphous vessels, structureless zones, multiple colours, peripheral radial lines, and thick reticular lines.

65
Q

How is vulval melanoma staged?

A

AJCC system

66
Q

How do you treat vulval melanoma?

A

Surgical excision with margins + sentinel node biopsy; 1/3 will have met at dx.

67
Q

What is the 5 year survival for vulval melanoma?

A

50%

68
Q

What are the causes of vulval BCC?

A

Immunosuppression,
chronic irritation,
pelvic radiation,
trauma

69
Q

What are the signs of vulval BCC?

A

Solitary lesions usually nodule on labia majora with shiny indurated well demarcated papule or plaque

70
Q

What are the sx and signs of vulval extramammary pagets disease?

A

Longstanding itch and pain; asymmetric circumscribed scaly/crusty plaque/ patchy/multifocal/ red/hypopigmented/hyperpigmented

70
Q

How do you treat vulval BCC?

A

Local surgical excision or Mohs micrographic surgery or medical rx with Imiquimod or 5-FU

71
Q

How do you treat vulval extramammary pagets?

A

local surgical excision or Mohs micrographic surgery or medical rx with Imiquimod or 5-FU

72
Q

What are the sx of a Bartholin gland carcinoma?

A

painless mass; visible tumour on posterior half of the vulva

73
Q

How is a Bartholin gland carcinoma staged?

A

FIGO

74
Q

How is Vulval extramammary pagets disease diagnosed?

A

Multiple biopsies

75
Q

What are the symptoms of Lymphogranuloma venerum?

A

painless gential pustules, papules or shallow ulcers; these are transient –> painful swollen inguinal lymph nodes with buboes (inflammatory swelling around the groin) that can rupture;
20% have the groove sign (guttering along blood vessels).
Women may present with pelvic and back pain.

76
Q

What causes Chanchroid?

A

Gram negative Ducreyi

77
Q

What are the symptoms of Chanchroid?

A

Painful genital ulcers and painful swollen inguinal LNs. 1+ red erythematous papules –> deep painful ulcers with shaggy undermined borders with purulent exudate at the base (bleeds easily also). Affects sites prone to friction. Buboes.
Untreated can persist for 1-3 months and result in scarring.

78
Q

How do you treat Chanchroid?

A

With azithromycin, ceftriaxone, ciprofloxacin, or erythromycin

79
Q

Describe molluscum contagiosum

A

Viral skin infection of childhood (gen <10 yrs) with clusters of umbilicated epidermal papules

OBSTGYN715 Exam (6 decks)

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