vulvar anatomy Flashcards
what is lichen sclerosus?
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)
presentation of lichen sclerosus?
mostly in postmenopausal women
Pruritus
pain: dysuria, dyspareunia, anal discomfort
PE findings for lichen sclerosus
Diffuse involvement of vulva
Sharply, well-demarcated, white plaques
Fragility = hallmark (purpura, erosions, fissures)
Severe cases – loss of normal anatomic landmarks
can lichen sclerosus be malignant?
Squamous cell carcinoma occurs in ~ 5%
RF: elderly, hyperkeratotic lesions
what findings are assoc. w/ malignancy?
atypical nevi and melanoma
Take any pigmented lesions very seriously
dx of lichen sclerosus
Vulvar punch Biopsy
tx for lichen sclerosus
Topical super-high potency steroid OINTMENT
1st line = Clobetasol 0.5% BID until norm texture then 1-3x per wk for maintenance
side effects of Topical super-high potency steroid
atrophy, dermatitis, rosacea
**does NOT go away. Need long-term f/u
pathophys of lichen simplex chronicus
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
clinical presentation of lichen simplex chronicus?
“itch that rashes”
Progressive vulvar pruritis and/or burning for weeks to months
itch – scratch cycle
likely have anxiety/depression
physical exam findings for lichen simplex chronicus?
eczematous process
poorly marginated, red, scaling papules and plaques
Initial signs: weeping, excoriations, crusting
chronic: Lichenification and hypopigmentation w/moisture
dx for lichen simplex chronicus?
clinical based on PE
vulvar punch bx for definitive dx
Tx for lichen simplex chronicus?
identify underlying triggers
bath tub soaks, lubricants
topical steroid cream
antihistamine QHS
SSRI daily
which topical steroid creams can be used to tx lichen simplex chronicus?
hydrocortisone 1-2% traimcinolone acetonide
betamethasone valerate
lichen planus pathophys
Autoimmune
Immunosuppressive therapy is useful
clinical presentation of lichen planus?
women 50 – 60yo
introital irritation
burning
vaginal dc
PE for lichen planus
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
Tx for lichen planus
1st line: topical steroid creams (Hydrocortisone acetate 25mg suppository QHS)
2nd line = topical tacrolimus 0.1% or systemic corticosteroids
vaginal estrogens
vaginal dilators
is lichen planus curable?
yes but high reoccurance
what is vulvar intraepithelial neoplasia
Neoplastic cells confined to squamous epithelium
Classification of VIN
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)
which types of HPV is VINu assoc. w/?
HPV type 16,18, and 31
who gets VINu?
Seen in younger women
Same risk factors seen with CIN:
Smoking (50-80%), immunosuppression, multiple sexual partners
Presentation of VINu
May be asx
Vulvar burning and pruritus
assoc. w/ high grade CIN (colposcopy and pap smear)
bx all pigmented lesions
Dx for VINu
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
Tx for VINu
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%
VINd
unrelated to HPV, seen in older women (>70y/o) involving lower 1/3 of epithelium
assoc. w/ squamous cell hyperplasia
Prevention and tx for VINd
Proper treatment of underlying condition
tx= surgical excision
f/u for VINu and VINd?
Gardasil for VINu
post-tx f/u = colposcopic vulvar inspection at 6 and 12 months, then annually
vulvar cancer incidence
(uncommon)
bimodal peak
women 20-40yrs is HPV related (VINu)
women 60-70yrs is due to chronic irritation (VINd)
clinical presentation of vulvar cancer
ASYMPTOMATIC (inspect the vulva)
MC sx = pruritus
vulvar bleeding and pain
PE for vulvar cancer
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
Tx for vulvar cancer
staging based on FIGO
tx = complete surgical removal of tumor w/inguinal node dissection
radiation therapy indicated w/LN spread
behcets dz pathophys
unknown, autoimmune
Exposure to agent triggers disease in patients with a predisposition
Bacterial / viral antigens, heavy metals, chemicals
clinical presentation of behcet’s dz
Oral ulcerations, Urogenital lesions, skin lesions, ocular dz
dx of behcet’s dz
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)
Tx for behcet’s dz
Temovate 0.05% ointment
Intralesional Triamcinolone 5 – 10mg/mL
Systemic corticosteroids for refractory cases
what is a bartholin cyst?
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)
clinical presentation of bartholin cyst/abscess
Acute, painful unilateral labial swelling (less pain w/ cyst)
Dyspareunia
Pain w/ sitting/walking
Drainage
PE for bartholin cyst/abscess
Tender, fluctuant labial mass
Surrounding erythema and edema
Cellulitis
Abscess formation
Fever
tx for bartholin cyst?
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
what bacteria are fond in bartholin cyst/abscess?
Polymicrobial, E. coli, MRSA, STI
clinical presentation of vulvodynia?
vulvar “burning”, raw, sore, stabbing
absent clinical findings
introital pain w/intercourse
PE for vulvodynia
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
nonpharmacologic tx for vulvodynia
sitz baths BID followed by thin film of petroleum jelly, couples counseling, pelvic floor PT
Pharm tx for vulvodynia
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
