Vulvar disease Flashcards
what are the ddx for vulvovaginitis?
- bacterial vaginosis
- candidiasis
- trichomoniasis
- atrophic vaginitis
what makes up the majority of the discharge in vulvovaginitis? what color is it?
cervical mucous
white to off-white
what is bacterial vaginosis?
polymicrobial infection characterized by a lack of normal H2O2 lactobacilli and an overgrowth of anaerobes
what color is discharge from BV?
thin gray-white / yellow
what is the pH in BV?
over 4.5
what is seen under the microscope in BV?
- increase in WBCs
- clumps of bacteria
- loss of normal lactobacilli
- CLUE CELLS
what are clue cells? what condition is it seen in?
epithelial cells with cocci bacteria attached to their surfaces so that borders appear indistinct and cytoplasm looks like “ground glass”
BV
what does candida require?
estrogenized tissue
what is the gold standard stain for BV?
gram
how is diagnosis usually made for BV?
3 out of 4 of:
- abnormally gray discharge
- pH over 4.5
- whiff test
- clue cells
what is the treatment for BV?
- oral or topical metronidazole
- topical clindamycin
in candida infection what color are the tissues?
bright red
what is the discharge appearance in candida?
thick, odorless, adherent “cottage cheese”
what is the pH in candida?
pH 4-5
what is required for candida diagnosis?
visualization of blastospores or pseudohyphae on saline of 10% KOH microscopy or a positive culture
what is the treatment for candida?
- vaginal application of an imidazole - miconazole, clotrimazole, terconazole
- single dose oral fluconazole
- nystatin in pregnancy
what causative organism of candida is resistant to all azoles?
T. glabrata
what is the discharge appearance in trichomoniasis?
copious “frothy” discharge with rancid odor - yellow green / gray
which condition is associated with a “strawberry cervix”?
trichomoniasis
how is trichomoniasis diagnosed?
direct visualization on microscopy
what is the treatment for trichomoniasis?
- oral metronidazole or tinidazole
- treat sexual partners
what is atrophic vaginalis? what happens to the epithelium?
- atrophy of vaginal epithelium due to decreased estrogen levels
- vaginal epithelium is thinned, pH elevated to 4.7+
what is the pH in atrophic vaginalis?
4.7+
what is the treatment for atrophic vaginalis?
- local water based moisturizing applications
- topical or oral estrogen therapy
what is lichen sclerosus? what are the clinical symptoms, what is the most common symptom?
common chronic inflammatory vulvar disease
- keyhole vagina
- most common symptom is pruritis
what is the treatment regimen for lichen sclerosus?
- general care measures (emollients, 100% cotton underwear, no soaps)
- high potency steroid ointment
what is lichen simplex chronicus (LSC)? how does it develop?
- an “itch that rashes”
- usually develops secondary to an irritant dermatitis, which progresses to LSC
what is the physical exam appearance of lichen simplex chronicus?
labia majora and minora and perineal body diffusely reddened with occasional hyperplastic or hyperpigmented plaques of red to red/brown
what is lichen planus? in what two ways can it present?
- rare inflammatory skin condition
- presents as a desquamative lesion of the vagina; can develop lesions on inner labia minora and vulvar vestibule
- can also present with whitish, lacy bands (wickham striae) of keratosis near the reddish ulcerated-like lesions
what is necessary to confirm diagnosis of lichen planus? what is seen?
- biopsy
- vaginal discharge shows large numbers of acute inflammatory cells without significant numbers of bacteria
- histology: thinning epithelium, loss of rete ridges, lymphocytic infiltrate
what is the treatment for lichen planus?
- topical steroid cream
- intravaginal 1% hydrocortisone douches or vaginal suppositories
what is the inheritance of psoriasis?
autosomal dominant
what are the two types of eczema?
exogenous and endogenous
- exogenous: irritants, contact dermatitis
- endogenous: atopic dermatitis
what is vulvar seborrheic dermatitis? what is the appearance?
- chronic inflammation of sebaceous glands
- pale, red to yellow-pink and may be covered by oily appearing scaly crust
what is the treatment for vulvar dermatitis?
- 5% aluminum acetate several times
- topical corticosteroids
what is vulvodynia?
involves acute and chronic inflammation of vestibular glands
- new onset insertional dyspareunia
- worsening over 3-4 months
- pain with tampon insertion, sitting, bathing perineal area
vulvodynia
- small, smooth nodular masses
- contain cheesy material
- may be excised
sebaceous gland cyst
- round ligament insertion into labia majora
- peritoneal fluid collects within
- excision may be needed
cyst of canal of Nuck (hydrocele)
fibromas arise from what tissue?
connective tissue
what is hidradenitis suppurativa?
- chronic skin condition
- area of high density sweat glands
- indurated occluded follicles
where are the bartholin glands located? what type of secretion? where do they open?
- 4:00 and 8:00 on posterolateral aspect of introitus
- mucous secreting glands
- open into external hymenal ring
if there is a bartholin gland growth in a woman over 40, what should you do? why?
- biopsy
- suspect rare bartholin gland carcinoma
what are the important premalignant conditions of the vulva?
- pagets disease
- vulvar intraepithelial neoplasia (VIN)
what is the clinical presentation for pagets disease of the vulva?
- chronic prutitis
- velvety-red lesions become eczematous and scar into white plaques
how is pagets disease of the vulva treated?
local excision (without local metastases)
one must assume that vulvar intraepithelial neoplasia will proceed to what?
vulvar carcinoma
what is a colposcope? what is it used for?
microscope on wheels
used for VIN, vulvar cancer
WHAT IS THE MOST COMMON VULVAR CANCER?
SQUAMOUS CELL CARCINOMA (85-90%)
vulvar cancer is is usually found in what region, anatomically? what is the appearance?
labia majora
cauliflower-like masses to hard indurated ulcers
what is important in the diagnosis of vulvar cancer?
- annual exam
- signs and symptoms
- biopsy
what is the treatment for vulvar cancer?
- wide local excision with inguinal lymph node dissection
- pelvic radiation of + mets to nodes
what is VaIN?
vaginal intraepithelial neoplasia
how is diagnosis of VaIN made?
- usually found on PAP
- colposcopy
- biopsy
what is the treatment for VaIN?
- local resection
- laser ablation
- 5-FU
what is the most common type of vaginal cancer?
squamous cell carcinoma
what are the signs / symptoms of vaginal cancer?
- water, blood tinged vaginal discharge
- postmenopausal bleeding
- vaginal pruritis
what is the treatment for stage I and II vaginal cancer?
surgical resection
what is the treatment for stage III and IV vaginal cancer?
radiation
what type of cancer is associated with in utero exposure to DES (1970s)?
clear cell adenocarcinoma
