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Vulvar things Flashcards

1
Q

How do you diagnose HSV, syphilis, chancroid, lymphogranuloma venereum and granuloma inguinale?

A

HSV: viral culture, PCR, serology
Syphilis: serology, fluorescent ab testing, darkfield microscopy
Chancroid: gram stain, culture, PCR
Lymphogranuloma venereum: culture, serology, PCR
Granuloma inguinale: giemsa/wright stain (Donovan bodies), PCR

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2
Q

What is differential diagnosis for genital ulcers?

A

HSV - most common -painful.
Syphilitic chancre: painless (Treponema pallidum)
Chancroid - painful (Haemophilus ducreyi)
Lymphogranuloma venereum (Chlamydia trachomatis)
Granuloma inguinale (Calymmatobacterium granulomatis)
Cancer
Erosive disease: lichen planus
Allergic reaction

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3
Q

What is Lymphogranulom venereum ?

A

from chlamydia trachomatis
- incubation: 1-4 wks
single painless flat pastule/vesicle
tender suppurative lymph nodes
- “groove sign”=clinical sign, double genitocrural fold
ddx: culture, PCR
Tx: Doxycycline x 21d

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4
Q

What is chancroid?

A

2/2 haemophilus ducreyi (more common in males)
-incubation 2-6 days
PAINFUL papule/pustule (1-5 of them)
- red undetermined margins, yellow/gray base
- purulent, hemorrhagic secretions
ddx: culture/gram stain (“school of fish pattern”, PCR
- Tx: Erythromycin x 7d

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5
Q

What is granuloma inguinale?

A

2/2 Calymmato-bacterium granulomatis
- seen in tropics, aka DONOVANOSIS
- incubation 8-12 wks
- painless papule
- ROLLED, ELEVATED MARINS w/ red rough base
- lymph nodes: pseudoadenopathy
- lasts weeks
- ddx: Giemsa staining W/ DONOVAN BODIES
- tx: azithro

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6
Q

What is toxic shock syndrome?

A

exotoxin release by S. Aureus. associated w/ tampons/diaphragms. rarely leads to sepsis and multi-organ failure.

Differential: gastroenteritis, PID, vaginitis, incomplete/septic abortion, infectious mononucleosis, influenza.

If presents as septic, differential is toxic shock, multi organ failure/sepsis, pyelonephritis, severe dehydration, hemolytic uremic syndrome, E. coli, septic abortion

Tx: B-lactamase resistant anti-staph agent (cephalosporin, unsays, nafcillin, oxacillin, amino glycoside)

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7
Q

What is the pH in patient with BV, yeast and trichomoniasis?

A

BV approx 5.0
Yeast < 4.5 (as is a normal pH)
Trichomonas > 5

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8
Q

How do you differentiate BV, yeast and trich on a wet prep?

A

BV clue cells, amine odor with KOH
Yeast KOH hyphae, budding yeasts
Trichomonas motile, flagellated Trichomonads parasites

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9
Q

How would you evaluate vaginitis on physical exam

A

External genitalia: erythema, irritation, lesions
Vagina: discharge (color, consistency, pH, odor), lesions
Cervix: discharge, lesions, surface abnormalities, CMT
Uterus/adnexa: tenderness, signs of PID
Abdomen: tenderness, signs of PID

Workup: wet prep, pH, GC/CT, maybe UA. consider physiologic discharge!

Differential diagnosis for vaginal discharge: vaginitis, atrophy, STI, foreign body, ulcerative lesion of vulva.

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10
Q

What is the CDC recommendation for outpatient management of PID?

A

Ceftriaxone 250mg IM + Doxycycline 100mg po bid x14 days WITH or WITHOUT Flagyl 500mg po bid
OR
Cefoxitin 2g IM and Probenecid 1g +Doxycycline 100mg po bid x14 days WITH or WITHOUT Flagyl 500mg po bid

If PCN allergic, Levaquin 500mg po qDay x 14 or Ofloxacin 400mg po bid x 14 days WITH or WITHOUT Flagyl 500mg po bid

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11
Q

What is HSV?

A

chronic lifelong infection. mostly transmitted by pts unaware they’re infected or asymptomatic during transmission.

incubation: 4-7 days after contact
lesion: solitary or multiple painful ulcers w/ clear marins
adenopathy: usually in primary outbreaks
prodrome: “flu-like” sx - myalgias, HA, low fever.

ddx: if lesions present (viral testing of lesion w/ NAAT/PCR, cultures have high false neg rates). If lesions absent, serologic antibody testing.
- virus preset in lesion only for first 2-3 days of episode.

  • test all pts w/ herpes for HIV! can have more frequent/severe outbreaks
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12
Q

What is treatment for HSV?

A

1st outbreak:
- acyclovir 400mg TID x 7-10d
- valacyclovir 1000mg BID x 7-10d
famciclovir 250mg TID x 7-10d

Episodic treatment
- Acyclovir 800mg BID x5d
Valtrex 500mg BID x3d or 1000mg BID x5d
Famciclovir 1g BID x1d

Suppression for frequent recurrence (>10/yr)
- Acyclovir 400mg BID or valtrex 1000 BID qd

Pregnancy:
- valtrex 500 BID for suppression!

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13
Q

What is differential diagnosis for painful pustular vulvar ulcers?

A
  • Herpes lesions
  • Vulvar skin maceration from frequent pro-genital contact
  • Non-infectious ulcerative disease (Behcet’s, lichen planus)
  • less commonly Chancroid
  • Trauma
  • infected contact dermatitis.
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14
Q

What is differential for pre-pubertal vulvar itching?

A

Inflammation/infection
Trauma (suspect sexual abuse)
Foreign body
Urologic pathology
Genital tract neoplasm
skin dermatosis (atopic dermatitis, lichen sclerosis)

Eval: hx, recent UTI/diarrheal illness, concern for abuse

Exam: supine with frog-leg position or prone in knee-chest position. or EUA.

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15
Q

What is vaginitis?

A

Normal vaginal pH <4.5 in reproductive aged women. estrogen incr glycogen production (bacteria love this).

3 most common causes: BV (40%), candidiasis (30%), trich (20%). If postmenopausal, atrophic vaginitis.

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16
Q

What is evaluation of vaginitis?

A

-History: pattern, assocaited factors, use of douches, condoms, medication use
- physical exam:
- vaginal PH
- KOH and saline prep
- STI testing
- possibly UA/UCx, diabetic screening, HIV.

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17
Q

What is management of yeast infection?

A

uncomplicated: infrequent episodes, mild/mod sx, C. albicans suspected, non-immunocompromised: intra-vaginal azole or PO fluconazole

COMPLICATED (Any present): recurrent >4 episodes/yr, severe sx, non-albicans yeast suspected, DM, immunocompromised: need yeast culture!

  • non-albicans less response to azoles. Rx=600mg vaginal boric acid qHSx14d
  • serve sx: erosions, erythema, fissures, edema. rx=prolonged course of vaginal azalea 10-14d or 2-3 doses of diflucan q3d.
  • recurrent yeast (>4/yr): diflucan 150qd x 3 then suppression 150 weekly x 6 mo. OR boric acid. eliminate dietary/hygiene causes. consider treating partner.
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18
Q

What is bacterial vaginosis?

A

shift in normal vaginal flora w/ incr in anaerobic bacteria and decrease in lactobacilli.

ddx: Amsel’s criteira (3/4 required):
pH>4.5, +amine test, white/gray discharge, >20% clue cells on wet prep
OR NAAT/POC tests.
- clue cells: vaginal epithelial cells coated with bacteria

  • recurrent BV >3 episodes/yr

Tx:oral or vaginal metronidazole (flagyl) 500mg BID x7d or clinda.
- recurrent BV: 7-14d flagyl then twice weekly metro gel x 6mo.

BV assoc w/ pTL/PROM/post hyst cuff cellulitis, PID, STIs.

19
Q

What is the treatment for trichomoniasis?

A

flagyl 500mg BID x 7d OR 2g PO x1
can also use tinidazole (2g PO x1) if not pregnant.
- treat partner, test for reinfection in 3 months

incr pH, trimonoads on wet prep, NAAT for diagnsis
- assoc w/ PTL/PROM/STI.

20
Q

What is treatment for chlamydia?

A

doxycycline 100mg BID x7d

Alternatives: Azithromycin 1 g PO OR Levofloxacin 500 mg PO x7d

After treatment, test of cure within 3 months?
- encourage partner treatment and testing.

gonorrhea tx=ceftriaxone.

21
Q

What is evaluation and differential diagnosis for vulvar itching?

A

H&P, pelvic exam close attention to the vulvar area (color, tenderness, erythema lesions).

differential: lichen sclerosis, lichen planus, lichen simplex chronicus, malignancy (squamous cell carcinoma), trauma, atrophy, vulvar candidasis, VIN, Paget’s.

22
Q

How do you perform vulvar biopsy?

A

Obtain consent, explain procedure. Perform a punch biopsy if erosive disease. Do biopsy at margins of ulcers and include intact epithelium.

23
Q

What is lichen planus and how would you manage it?

A

Chronic inflammatory disease
Papules, plaques, pruritic, leathery appearance. white lacy striae
- erosive disease, can have vaginal involvement
- sx: vulvar pain, burning, pruritus, soreness, or dyspareunia, vaginal discharge

differential: lichen sclerosis or simplex chronicus, Behcet’s syndrome, vulvovaginal atrophy

Tx: counsel on chronic dz w/o cure,
- topical steroid (clobetasol propionate 0.05%). tacrolimus=other option
- if erosive disease: oral prednisone, IM triamcinolone

24
Q

What is a Bartholin’s gland?

A
  • glands at introitus at 4 and 8 o’clock
  • can have cyst, abscess or mass
    -biopsy/excise to r/o adenocarcinoma if: age >40, persistent mass w/ solid components, recurrent infections.
25
Q

What is management of Bartholin abscess?

A

I&D then word catheter for 4-6wks
- culture abscess to r/o MRSA

if abscess recurs, repeat I&D/word or marsupialization and add antibiotics.

26
Q

What bacteria cause Bartholin abscess?
When to give antibiotics for bartholin’s abscess?
What antibiotic do you give?

A

E. Coli=most common. S. aureus, polymicrobial, GBS, Enterococcus.

on exam: soft, tender, warm, or fluctuant mass

recurrent abscess
surrounding cellulitis
pregnant
immunocompromised
MRSA+
signs of systemic infection.

Bactrim DS 5-7d. Can add flagyl or augmentin.

27
Q

What is differential ddx for vulvar pruritis?

A

Infectious: candiditis, scabies, pediculosis
Dermatoses: atopic/contact dermatitis, lichen sclerosis, lichen planus, lichen chronicus
Neoplasia: Paget’s disease, vulvar LSIL, HSIL, vulvar cancer
Hormonal deficiencies: vulvovaginal atrophy

Acute: infectious causes -> vaignal pH, saline/KOH, amine test
Chronic: dermatoses (lichens), psoriasis, neoplasia-> biopsy

28
Q

What is differential for vulvar pain?

A

Infectious: recurrent vulvovaginal candidasis, herpes
Dermatoses: lichen sclerosis/planus
Neoplasia: paget’s, vulvar LSIL/HSIL, cancer
Neurologic: postherpetic neuralgia, nerve compression
Trauma: genital mutilation

Pruritis: lichen planus or genitourinary syndrome of menopause (need pH, amine test)
No pruritis: consider vulvodynia.

29
Q

Initial approach to vulvovaginal symptoms?

A

H&P - aggravating/alleviating, new things, severity/duration (acute vs chronic). If acute, rule out infections (BV, trich, candida, scabies). IF chronic, rule out (dermatoses and dysplasia).

If pain, see if associated pruritis. I
f pruritis + pain, dermatoses or vaginal atrophy.
IF just pain, vulvodynia.

30
Q

When should you do a vulvar biopsy? How is it done?

A

Atypical lesion (new pigmentation, bleeding, ulcerated, affixed)
Concern for malignancy
Lesion in immunosupcomprimsed
Doesn’t respond to standard therapy or gets worsed
Stable lesions that rapidly increase in size

punch or excisional biopsy.

31
Q

How does patient with contact dermatitis present clinically?
What is the treatment?

A

Range of symptoms: Mild erythema, swelling, scaling, fissures, erosions, ulcers. Typically associated rash.
Chronic itching/burning
Type 4 delayed hypersensitivity
Treatment: vulvar care/removal of irritants, topical corticosteroids and oral antipruritic meds prn. AVOID topical antipruritic (benadryl) bc can cause allergic contact dermatitis.

32
Q

How does lichen simplex chronicus present?
What is treatment?

A

chronic/intermittent prutitis w/ scratching/rubbing
Erythematous scaling or lichenified plaques.
Thick plaques w/ hyper and hypopigmentation. Erosions/ulcers develop from chronic scrapping

Hx allergies, asthma or eczema.

Ddx: clinical. Consider vaginal fungal culture to r/o candidas

Treatment: vulvar care/hygiene, antipruritic meds, topical medium or high potency corticosteroid once or twice daily.

How often to follow up on pts using high potency topical corticosteroids: schedule close interval follow up 4 wks post initiation. Additional visits based on pts response to therapy. Tx failures from use of low-potency or shorter than recommended use of high potency steroids

33
Q

How does lichen sclerosis present clinically?

A

Chronic scarring affecting anogenital skin of postmenopausal woman and pre-pubertal girls.
Exam w/ porcelain-white papules/plaques with area sof ecchymosis. Skin is thin, whitened, crinkled (cigarette paper)
Involvement of mucutaneous junctions → introital narrowing. Involves superior vulva to perianal tissue to create “figure of eight” shape
Fusion of labia minora, fissures.

Ddx: Biopsy. Incr risk squamous cell carcinoma (2-5%). Tx=medium or high potency topical corticosteroids. Clobetasol propionate 0.05 ointment qhS x 4 weeks, alternate nights for 4 weeks then twice weekly for 4 weeks.

34
Q

What is follow up for lichen sclerosis?

A

Monitor at 3 months. Then follow up 3-6 mo later. Biopsy any new growths.

Do you need long-term maintenance therapy: long-term individualized topical corticosteroid to prevent scarring. Titrate to lowest dose needed.

How do you treat resistant/poorly controlle cases? Intra-lesional corticosteroids injections. 10-20mg intralesionsal triamcinolone.
If no response to intralesional corticosteroids? Topical calcineurin inhibitors (tacrolimus or pimecrolimus)
What if calcineurin inhibitors fail? Refer to specialist.

35
Q

How does lichen planus present clinically?

A

Scarring inflammatory disorder. sx=dyspareunia, burning, soreness, itching, incr vaginal discharge
Affects perimenopausal/menopausal
Up to 70% have oral involvement

Types: Classical (white, reticulate, lacy, fernlike striae), hypertrophic (least common, white thick), Erosive (Deep, painful erosions and extend to labia minora - can cause oblieration of vaginal space. INVOLVES VAGINA. Eval of oral cavity recommended) - refer to oral specialist.

Ddx: clinically. Vaginal discharge w/ predominance of inalmamtory cells and parabasal/basal cells. Incr vaginal pH (5-6). Biopsy is non-specific

Treatment: prognosis for remission is poor. High-potency topical corticosteroids: twice daily use w/ tapering.
How often to follow up? 2-3 mo.
How to treat resistance disease? Topical calcineurin inhibitors.
How to treat if vaginal involvement: if erosive w/ vaginal involement, intravaginal corticosteroids (hydrocortisone acetate suppositories inserted twice daily and tapered off). 80% pts will have improvement. Can use vaginal dilators to prevent scarring/obliteration.
How to treat extensive vaginal disease? High-dose hydrocortisone inserts.

36
Q

What is the classification of VIN?

A

Vulvar LSIL/HSIL: warty, basaloid, mixed - associated w/ genotypes of HPV and risk factors (smoking, immunocompromised)
Differentiated: NOT assoc w/ HPV. assoc w/ vulvar dermatoses. If have lichen sclerosis, likely to be associated with SCC.

New terminations: usual type is now vulvar HSIL. flat lesions assoc w/ basal atypia are LSIL (condyloma or HPV effect).

37
Q

How do you diagnose VIN?
When do you colpo warty lesions?
How do you treat VIN?

A

Visual assessment. Biopsy if needed - only if not responding to usual therapy.

Determine extent of disease if persistent pruritis/pain and if symptomatic despite treatment
Apply 3-5% acetic acid to vulva using soaked gauze pads.
- COLPO!

WLE if cancer suspected bc risk invasion (Include gross margins of 0.5-1cm around tissue w/ visible disease. If critical area lesion, refer to specialist.
- If occult invasion not a concern, vulvar HSIL (VIN usual type) treated w/ :
- excision
- laser (1mm in non-hair bearing and 3mm in hair-bearing areas)
- topical imiquimod 5%.

38
Q

When do you use laser ablation in VIN?

A

Treatment of vulvar HSIL when cancer NOT suspected.
Need 0.5-1cm margin of normal appearing skin to be treated. Need to destroy cells through entire thickness of epithelium.

39
Q

What is suggestive of vulvar cancer on physical exam?

A

Exophytic, ulcerative, indurated, poorly-defined borders

40
Q

What are steps of WLE?

A

– just know basics.

An indwelling bladder catheter is placed. The incision can be marked with a skin-marker to plan the extent and axis of the excision. The shape of the excision should be elliptical, running in long axis parallel to neighboring structures to be preserved

we start posteriorly so that venous oozing from the incision does not affect visualization in the direction of travel. The excised portion of the incision is grasped with a toothed forcep or Allis clamp and consistent tension is applied, allowing the operator to elevate and stretch the skin (figure 4). The epidermis, dermis, and underlying adipose tissue are dissected from the underlying perineal tissues using scissors, scalpel, or electrocautery.

41
Q

What is a wet prep?

A

A vaginal wet mount preparation is a test where a sample of vaginal discharge is observed by wet mount microscopy.

  • The swab collected sample is placed on a clean glass slide and mixed with either 0.9% saline or 10% potassium hydroxide (KOH).
  • Saline preserves cell membranes and allows observation of motile trichomonads, and vaginal epithelial cells coated with bacteria (clue cells), and white blood cells (WBCs).
  • If a yeast infection is suspected, the addition of 10% KOH will hydrolyze trichomonads, cells, and bacteria to provide a clearer view of yeasts and pseudohyphae. In many cases of BV or trichomoniasis infection, addition of KOH to the vaginal discharge will produce a strong amine or fishy odor.
42
Q

What is vulvar melanoma?

A

rare, accounts for 5-10% melanoma in women.
- BRCA2 AT INCREASED RISK
- avoid lots of sun exposure, need regular physical exams.
- eval w/ colposcopy. can do biopsy.

43
Q

What is treatment for genital warts?

Risk factors for genital warts?

A

Cryotherapy, TCA, surgical removal. Imiquinod=immune response modifier. Applied 3x/week until warts are gone.

HPV, increased # sexual partners, on oCPs, smoking

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