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Vulvar disorders Flashcards

1
Q

What is Lichen Sclerosis

A

autoimmune disease where autoAbs attack extracellular matrix and basement membrane, affecting all levels of the skin

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2
Q

Lichen sclerosis is associated with

A 
thyroid disorders (esp. hypothyroid) 
HLA
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3
Q

The two predicted etiologies of lichen sclerosis are

A

Genetic (22% have positive FHx)

Environmental (incontinence, infx, contact dermatitis, trauma- koebner phenomenon)

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4
Q

What age women does Lichen Sclerosis affect

A

mostly POST-menopausal

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5
Q

What are the MC symptoms of lichen sclerosis

A

**Pruritis!

Dysuria, dyspareunia, anal discomfort

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6
Q

What does lichen sclerosis look like oh physical exam

A

Sharp, well demarcated white plaques (cellophane paper*) that start around the clitoral area and spread to the perineum
Can look waxy, or hyperkeratotic
Classic: white figure 8 sign

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7
Q

What is the hallmark of lichen sclerosis

A

purpura
erosions
fissures

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8
Q

Bad cases of lichen sclerosis can present like this

A

loss (or fusion) of normal anatomical landmarks

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9
Q

Is lichen sclerosis associated with cancer

A

5% of cases progress to squamous cell carcinoma- RF are elderly and hyperkeratotic lesions
A few cases of atypical nevi and melanoma have been reported (take pigmented lesions SERIOUSLY)

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10
Q

How do you diagnose lichen sclerosis

A

Full thickness vulvar punch biopsy

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11
Q

How do you treat lichen sclerosis

A

Topical VERY HIGH potency steroid OINTMENT- Clobetasol 0.5%, apply BID until nl texture, then 1-3x week to maintian

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12
Q

ADE of clobetasol high potency (lichen sclerosis) are

A

atrophy
dermatitis
rosacea
-SO, when applying make sure it is only to the affected area

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13
Q

Can you cure lichen sclerosis

A

No, it is autoimmune so it does not go away
need long term follow up!
Squamous cell carcinoma visit after 1 year

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14
Q

What causes lichen simplex chronicus

A

unknown!
environmental trigger (sweating, excessive hygiene, panty ilners, topical meds, tight clothing)
Emotional tensions induce pruritis
Hx of atopy (eczema) are more prone

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15
Q

What cycle is associated with lichen simplex chronicus

A

itch-scratch cycle!

itch= scratch= irritate= epidural thickening= inflammatory cells increase sensitivity= itch and REPEAT

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16
Q

How does lichen simplex chronicus present

A

vulvar pruritis/ BURNING, relieved when scratching

“the itch that rashes”

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17
Q

Patients with lichen simplex chronicus often have underlying

A

depression or anxiety

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18
Q

On physical exam, lichen simplex chronicus presents as

A

poorly marginated, red, scaling papules and plaques

initial: weeping, excoriations, crusting
chronic: lichenification, hypopigmentation w/ moisture (anogenital macerated look)

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19
Q

How do you diagnose lichen simplex chronicus

A

clinically (PE)

can also do a confirmation vulvar punch biopsy

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20
Q

How do you treat lichen simplex chronicus

A

Remove underlying trigger (wear loose clothing, no panty liners, less aggressive hygiene, decrease stree)
Bath tub soaks
lubricant
low potency steroid cream (hydrocortisone 1-2%, triamcinalone acetonide, betamethasone valerate)
Anti-histamine QHS to Tx pruritis
SSRI daily

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21
Q

What is lichen planus

A

autoimmune d/o more common in extra-genital areas that occurs mostly in women 50-60

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22
Q

Lichen planus presents with

A 
introital irritation (SF dyspareunia) 
burning 
vaginal discharge
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23
Q

On PE for lichen planus you note

A

Disruption of vulvar anatomy (agglutination of labia minora, introital narrowing) on mucosal or keratinized surface
Non-erosive: lacy, white epithelium (fern like), white striae
Erosive: deep vaginal redness, vulvar erosions, purulent vaginal secretions

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24
Q

How do you treat lichen planus

A

Low potency topical steroids (like simplex chronicus)- hydrocortisone acetate 25mg suppository QHS
2 line: topical tacrolimus ointment BID, or systemic corticosteroids
vaginal estrogens
vaginal dilators (if you have narrowing of introitus)

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25
Is lichen planus curable
It responds well to Tx, but has a high rate of recurrence
26
What is vulvar intraepithelial neoplasia
neoplastic cells confined to squamous epithelium | classified as VIN 1, 2, or 3
27
What are each classification of VIN associated with
VIN1: genital warts | VIN2-3: true precursor to cancer
28
VIN 2-3 are further classified as
VINu: usual, high risk for HPV VINd: differentiated
29
VINu is associated with
HPV 16, 18, 31 | younger women
30
RF for VINu include
smoking* immunosuppression multiple sex partners
31
How does VINu present
ASx | vulvar burning and pruritis
32
How do you diagnose VINu
colposcopy/ pap smear (bc it is associated w/ high grade CIN) must biopsy ALL pigmented lesions
33
How do you do a vulvar colposcopy
stain w/ 3-5% acetic acid, let sit 3-5 min (tissue turns white over lesions) -DO NOT use acetic acid over inflamed or broken skin lesions can be raised or flat, turn gray/white or even red/black
34
How do you treat VINu
No gauranteed cure, but you can try these OFF-label meds (30-50% recurrence rate): 5FU (Efudex) cream Interferon (Intron A) Imiquimod (Aldara) 5% cream
35
Standard of care treatment for VINu is
surgery; CO2 laser vaporization (destroy entire thickness) local wide excision (must for VIN3) vulvectomy
36
do NOT preform CO2 laser vaporization to Tx VINu if
invasion is suspected
37
VINd occurs in
older women (>70) LOWER 1/3 of vagina (upper 2/3 have no abn cells) -unrelated to HPV
38
VINd is associated with
squamous cell hyperplasia (Lichen Sclerosis) unidentified carcinogens + chronic irritated skin -many have associated untreated lichen sclerosis, lichen simplex chronicus, or squamous hyperplasia
39
How can you prevent VINd
treat underlying condition! | if lichen sclerosus, high potency Clobetasol ointment
40
How do you treat VINd
surgical excision
41
ACOG/ASCCP recommend
Vaccinate (Gardasil) | F/u post Tx w/ colposcopic vulvar inspection at 6-12 months, and annually after that
42
ACOG/ASCCP state
women with a Hx of VIN are considered at risk for recurrence throughout their lifetime
43
What is the 4th MC malignancy of the female genital tract
vulvar cancer! | Occurs more in women w/ T2DM, obese, or hypertensive
44
What is the incidence of vulvar cancer
bimodal peaks; VINu in women 20-40 (HPV related) VINd in women 60-70 (chronic irritation)
45
How does vulvar cancer present
ASx!! so always inspect the vulva! *Pruritis vulvar bleeding and pain
46
On PE what are different findings associated with vulvar cancer
SCC: large, cauliflower lesion - small, ulcerative lesion w/ surrounding hyperkeratosis Malignant melanoma: raised, dark lesion MC at labia majora and clitoris BCC: raised lesion w/ ulcerated center and rolled border
47
What is vulvar cancer staging based on
FIGO
48
How do you treat vulvar cancer
Primary: complete surgical removal w/ inguinal node resection Radiotherapy if w/ lymph node spread
49
What is Behcet's disease
Autoimmune d/o triggered by exposure in susceptible individuals (bacterial/viral antigens, heavy metals, chemicals)
50
How does Behcet's disease present
- Oral ulcers (aphthous ulcers) - Urogenital lesions (ulcers) - Skin lesions (erythema nodosum, SF thrombophlebitis, palpable purpura, papulopustular lesions - Ocular disease (uveitis)
51
What is the criteria needed to Dx Behcet's disease
recurrent aphthous ulcers 3x in 1 year PLUS 2 of following: recurrent genital ulcers uveitis skin lesions + pathergy test (2mm papule at injection site w/in 48 hrs)
52
How do you treat Behcet's disease
Temovate (clobetasol) 0.05% ointment (high potency) Intralesional triamcinolone systemic corticosteroids if refractory
53
Where are bartholin glands found and what do they do
at 4 and 8 o'clock position w/in labia minora they open into vestibule adjacent to introitus they secrete mucus like material to maintain moisture of vaginal mucosa
54
What is a bartholin cyst
ductal obstruction 2/2 trauma or non-specific inflammation 1-3cm large can develop an abscess from an infected cyst or primary gland infection (STI)
55
How do bartholin cysts present
acute, painful unilateral labial swelling (less pain if only a cyst) dyspareunia pain with sitting or walking drainage
56
On PE, a bartholin cyst will look like
tender, fluctuant labial mass w/ surrounding erythema and edema cellulitis abscess formation fever
57
How do you treat a bartholin cyst
I%D w/ wood catheter to occupy space and prevent recurrence Culture purulent material +/- Abx (bactrim, augmentin, 2/3 gen Ceph+Doxy) Sitz bath 2-3 days 2/p I&D No intercourse until catheter is removed
58
What bacterial likely will be found on bartholin cyst culture
polymicrobial; E. coli, MRSA, or STI
59
In order to prevent recurrence, what can you do for a bartholin cyst
Marsupialization after draining!
60
What is Vulvodynia
Unexplaines pain and burning in the vulvar area
61
What causes Vulvodynia
``` unknown! Suspected causes include: Drop in estrogen (menopause) pelvic floor dysfunction Mood/anxiety d/o (4x more likely) poor allostasis Neuro sensitization 2/2 chronic inflammation (increased epithelial nerve endings and SF blood flow= more sensitive) ```
62
How does vulvodynia present
*Burning* stinging, irritated, sore, raw, or stabbing absent clinical findings no underlying pathology Introital pain w/ intercourse (avoid coitus!)
63
What are categories of vulvodynia
generalized vs localized provoked vs non-provoked non-sexual, sexual, or both
64
On PE for vulvodynia you will find
pain limited to vestibule (use Q-tip to palpate vestiule, labia majora, perineum, and interlabial folds) spasm or ttp on single digit exam non-specific vestibular erythema
65
How do you treat vulvodynia (non-pharm)
avoid scented products, tight clothes, vigorous exercise, panty liners Sitz baths BID w/ thin film of petroleum jelly couples counseling pelvic floor PT
66
How do you Tx vulvodynia (pharm)
topical lidocaine ointment topical vaginal estrogen w/ testosterone Amitriptyline/Nortriptyline QHS (start at 10mg, titrate to 50) SNRI Gabapentin TID (start at 100, titrate to 1200)

SG F3 E5 (23 decks)

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