vulvar anatomy

Question 1

what is lichen sclerosus?

Answer 1

Autoimmune: AA’s attack extracellular matrix and basement membrane
- Immune dysfunction affecting all levels of the skin

also, genetic & environmental (incontinence, infx, Koebner’s phenomenon)

Question 2

presentation of lichen sclerosus?

Answer 2

mostly in postmenopausal women

Pruritus

pain: dysuria, dyspareunia, anal discomfort

Question 3

PE findings for lichen sclerosus

Answer 3

Diffuse involvement of vulva
Sharply, well-demarcated, white plaques
Fragility = hallmark (purpura, erosions, fissures)
Severe cases – loss of normal anatomic landmarks

Question 4

can lichen sclerosus be malignant?

Answer 4

Squamous cell carcinoma occurs in ~ 5%

RF: elderly, hyperkeratotic lesions

Question 5

what findings are assoc. w/ malignancy?

Answer 5

atypical nevi and melanoma

Take any pigmented lesions very seriously

Question 6

dx of lichen sclerosus

Answer 6

Vulvar punch Biopsy

Question 7

tx for lichen sclerosus

Answer 7

Topical super-high potency steroid OINTMENT

1st line = Clobetasol 0.5% BID until norm texture then 1-3x per wk for maintenance

Question 8

side effects of Topical super-high potency steroid

Answer 8

atrophy, dermatitis, rosacea

**does NOT go away. Need long-term f/u

Question 9

pathophys of lichen simplex chronicus

Answer 9

unknown but hx of atrophy more prone

Emotional tensions may induce sensation of pruritis

environmental triggers: sweating, excessive hygiene, panty liners, topical meds, tight clothes

Question 10

clinical presentation of lichen simplex chronicus?

Answer 10

“itch that rashes”

Progressive vulvar pruritis and/or burning for weeks to months

itch – scratch cycle

likely have anxiety/depression

Question 11

physical exam findings for lichen simplex chronicus?

Answer 11

eczematous process

poorly marginated, red, scaling papules and plaques

Initial signs: weeping, excoriations, crusting

chronic: Lichenification and hypopigmentation w/moisture

Question 12

dx for lichen simplex chronicus?

Answer 12

clinical based on PE

vulvar punch bx for definitive dx

Question 13

Tx for lichen simplex chronicus?

Answer 13

identify underlying triggers

bath tub soaks, lubricants

topical steroid cream

antihistamine QHS

SSRI daily

Question 14

which topical steroid creams can be used to tx lichen simplex chronicus?

Answer 14

hydrocortisone 1-2% traimcinolone acetonide

betamethasone valerate

Question 15

lichen planus pathophys

Answer 15

Autoimmune

Immunosuppressive therapy is useful

Question 16

clinical presentation of lichen planus?

Answer 16

women 50 – 60yo
introital irritation
burning
vaginal dc

Question 17

PE for lichen planus

Answer 17

Disruption of vulvar anatomy

Can be seen on mucosal and/or keratinized surface

Non-Erosive disease: lacy, white striae

erosive dz: deep vaginal redness, vulvar erosions

Question 18

Tx for lichen planus

Answer 18

1st line: topical steroid creams (Hydrocortisone acetate 25mg suppository QHS)

2nd line = topical tacrolimus 0.1% or systemic corticosteroids

vaginal estrogens

vaginal dilators

Question 19

is lichen planus curable?

Answer 19

yes but high reoccurance

Question 20

what is vulvar intraepithelial neoplasia

Answer 20

Neoplastic cells confined to squamous epithelium

Question 21

Classification of VIN

Answer 21

grading of abnormal cells = VIN 1, 2 or 3

VIN 2 & 3 true percursors to vulvar cancer

VINu (usual) assoc. w/high risk HPV

VINd (differentiated)

Question 22

which types of HPV is VINu assoc. w/?

Answer 22

HPV type 16,18, and 31

Question 23

who gets VINu?

Answer 23

Seen in younger women

Same risk factors seen with CIN:
Smoking (50-80%), immunosuppression, multiple sexual partners

Question 24

Presentation of VINu

Answer 24

May be asx

Vulvar burning and pruritus

assoc. w/ high grade CIN (colposcopy and pap smear)

bx all pigmented lesions

Question 25

Dx for VINu

Answer 25

Vulvar Colposcopy
using 3-5% acetic acid, sit for 3-5 mins, reapply often

lesions are raised/flat, range in color from gray/white/red/black

Question 26

Tx for VINu

Answer 26

no guaranteed cure

all meds are off-label use: 5FU cream, interferon, imiquimod

standard of care = surg w/ CO2 laser vaporization

post-tx recurrence = 30-50%

Question 27

VINd

Answer 27

unrelated to HPV, seen in older women (>70y/o) involving lower 1/3 of epithelium

assoc. w/ squamous cell hyperplasia

Question 28

Prevention and tx for VINd

Answer 28

Proper treatment of underlying condition

tx= surgical excision

Question 29

f/u for VINu and VINd?

Answer 29

Gardasil for VINu

post-tx f/u = colposcopic vulvar inspection at 6 and 12 months, then annually

Question 30

vulvar cancer incidence

Answer 30

(uncommon)

bimodal peak
women 20-40yrs is HPV related (VINu)

women 60-70yrs is due to chronic irritation (VINd)

Question 31

clinical presentation of vulvar cancer

Answer 31

ASYMPTOMATIC (inspect the vulva)

MC sx = pruritus

vulvar bleeding and pain

Question 32

PE for vulvar cancer

Answer 32

Squamous cell carcinoma - varies, cauliflower, small ulcerative lesion

Malignant Melanoma - raised, darkly pigmented lesion

Basal Cell Carcinoma- raised lesion w/ulcerated center and rolled borders

Question 33

Tx for vulvar cancer

Answer 33

staging based on FIGO

tx = complete surgical removal of tumor w/inguinal node dissection

radiation therapy indicated w/LN spread

Question 34

behcets dz pathophys

Answer 34

unknown, autoimmune

Exposure to agent triggers disease in patients with a predisposition
Bacterial / viral antigens, heavy metals, chemicals

Question 35

clinical presentation of behcet’s dz

Answer 35

Oral ulcerations, Urogenital lesions, skin lesions, ocular dz

Question 36

dx of behcet’s dz

Answer 36

clinical, no labs
Recurrent oral aphthae at least 3 times in 1 year plus 2 of the following:
-Recurrent genital ulcers
-Uveitis
-Skin lesions: (+) Pathergy test (2mm papule at injection site within 48h)

Question 37

Tx for behcet’s dz

Answer 37

Temovate 0.05% ointment

Intralesional Triamcinolone 5 – 10mg/mL

Systemic corticosteroids for refractory cases

Question 38

what is a bartholin cyst?

Answer 38

Cysts form as a result of ductal obstruction due to trauma or non-specific inflammation (1-3cm)

abscess formation results from an infx’d cyst or primary gland infx (STI’s, polymicrobial)

Question 39

clinical presentation of bartholin cyst/abscess

Answer 39

Acute, painful unilateral labial swelling (less pain w/ cyst)

Dyspareunia

Pain w/ sitting/walking

Drainage

Question 40

PE for bartholin cyst/abscess

Answer 40

Tender, fluctuant labial mass

Surrounding erythema and edema

Cellulitis

Abscess formation

Fever

Question 41

tx for bartholin cyst?

Answer 41

I&D w/insertion of word catheter

culture purulent material

+/- empiric abx (bactrim, augmentin, or 2/3rd gen cephalosporin +doxy

sitz baths 2-3days

no sex until catheter removed

Question 42

what bacteria are fond in bartholin cyst/abscess?

Answer 42

Polymicrobial, E. coli, MRSA, STI

Question 43

clinical presentation of vulvodynia?

Answer 43

vulvar “burning”, raw, sore, stabbing

absent clinical findings

introital pain w/intercourse

Question 44

PE for vulvodynia

Answer 44

Use a Q-tip to palpate vestibule, labia majora, perineum, interlabial folds

pain limited to vestibule

single digit exam for spasm/TTP of pelvic floor mm.

non-specific vestibular erythema

Question 45

nonpharmacologic tx for vulvodynia

Answer 45

sitz baths BID followed by thin film of petroleum jelly, couples counseling, pelvic floor PT

Question 46

Pharm tx for vulvodynia

Answer 46

Topical lidocaine ointment

Topical vaginal estrogen w/testosterone

Amitriptyline or nortriptyline 50mg QHS
(start w/10mg and titrate)

SNRIs

Gabapentin 1200mg TID
Begin w/100mg TID and