vulvovaginal Flashcards
what general advice can be given to pts with vulval conditions?
avoid contact with chemical irritants - soaps, lubricants
avoid tight fitting garments
lichen sclerosis aetiolgoy
autoantibodies to ECM protein 1
immunopathogenic mechanisms involved
features of lichen sclerosus
ithcy
sore
dyspareunia
dysuria
constipation - if perianal invovlement
what areas does lichen sclerosis affect?
labia majora/minora
clitoral hood
perianal skin
extragenital lesions in 10%
signs o/e in lichen sclerosis
allow
purpura
loss of architecture
erosions
lichenifcation, hyperkeratosis
figure of 8 distribution
complications of lichen sclerosus
SCC
clitroal pseudo-cyst
sexual dysfunction
urinary symptoms
vulvodynia
reactivation of latent HSV or HPV
how do you diagnose lichen sclerosus?
clinical
biopsy (younger women)
when is biopsy needed in lichen scelrosus
dx uncertain
atypical features
suspicion of VIN or SCC
failure to respond to first line tx
atypical pigmented areas
what is seen histologically in lichen sclerosu
epidermal atrophy
sub-epidermal hyalinisation of collagen
lymphocytic dermal infiltrate
tx lichen sclerosus
emollients
dermovate - clobetasone steroid with tapering regime
steroid + anti fungal
topical calcineurin inhibitors eg tacrolimus
oral retinoids in severe hyperkeratotic disease
UVA
how does lichen scelrosus affect pregnancy + breastfeeding?
improves in pregancy
no CI to vaginal delivery
steroids safe
tacrolimus CI
oral retinoids CI during breastfeeding + pregnancy, and for 2 yrs before
lichen planus aetiology
probably immunological response by activated T cells
weak circulating basement membrane antibodies present
what is lichen planus
inflammatory disorder of skin, oral and genital mucosa
may involve hair + nails, causing scarring alopecia + nail dystrophy
symptoms lichen planus
itch - hypertrophic
sore
dyspareunia
urinary symptoms
vaginal discharge
types of lichen planus
classic
hypertrophic
erosive
what is classical lichen planus
papule found on keratinised anogenital skin /- striae on inner vulva
hyperpigmentation following resolution, esp in darker skin
what is hypertrophic lichen planus
perineum + perianal area
thickened warty plaques
may become ulcerated, infected + painful
what is erosive lichen planus?
mucosal surfaces eroded with pale lilac lace network (Wickham’s striae)
consist of friable telangectasia with patchy erythema
cause post coital bleeding, dyspareunia, serosanguinus discharge
seen in oral mucosa
what is vulvo-vaginal gingival syndrome + symptoms
erosive disease n three sites
symptoms inc soreness, dyspareunia, blood-stained vaginal discharge
complications of lichen planus
scarring, vulval + vaginal adhesions
SCC in hypertrophic
how do you ix lichen planus
biopsy - if dx uncertain
autoimmune disease eg TFTs
skin swab
patch testing
Hep C
tx of lichen planus
dermovate - clobetasol steroid
topical calcineruin inhibitors eg tacrlimus
systemic eg oral sprednisolone, methotrexate, hydroxycholoriquine, mycophenolate
biologics in oral + cutaneous disease eg basiliximab
photodynamic therapy
sugary for severe adhesions
aetiology of vulval atopic eczema?
gene ,mutation in strucutral epidermal protein filaggrin leading to disturbance of the normal epidermal barrier function and increased epidermal susceptibility to allergens and microbes, resulting in chronic inflammation
what can cause irritation of genital skin?
urine, faeces, sweat
fragrances, preservatives
spices, peppermint
spermicides, lubricants
overzealous cleaning of genital skim, friction from exercise, tight synethetic underwear
what can be seen in vulval seborrhoea eczema?
mildly pink, glazed appearance, poorly defined patches with slight greasy scale
can affect pubic region, groin flexures + natal cleft, vulva
hisptolgical finding for vulval eczema?
spongiosis
what is VIN
vulvar intraepithelial neoplasia
premalignant lesion of vulval skin
aetiology of VIN
caused by HPV, usually 16
higher risk in smokers + immunocompromised
symptoms of VIN
burning itch/irritation
pain/soreness
lump or thickening
signs of VIn
white, erythematous or pigmented plaques
warty in appearance
hyperkeratotic, erosive or ulcerated
appear at clotpris, labia minor, vaginal introitus, inner labia majora
complications of VIn
SCC
multifocal disease
recurrent
psychosexual issues
diagnosis of VIN
findings?
biopsy
histology:
high nuclear-cytoplasmic ratios
hyperchromasia
pleomorphism
cytological atypia + motises
P16 in HSIL and p53 in dVIN
tx of VIN
dVIN = surgical excision eg partial vulvectomy
HSIL = local excision, imoquimod cream
maybe cidofivir 1% gel, ablative laser
who is usually affected by dVIN and HSIL
dVIN =post meonpausal
HSIL = 35-49yo
can you use imiquimod + cidofovir in pregnancy or breastfeeding
NO
what causes acute ulcers?
sexually acquired = HSV, syphilis, MPox, tropical STIs
non sexually acquired = Lipschultz
how can you diagnose acute vulval ulcers?
how can you diagnose chronic vulval ulcers?
what is Lipschultz ulcer aetiology
assoc with EBV, CMV, COVID 19
features of lipschultz
painful ulcers affecting labia minor and majora
assoc with flu symptoms
deep, well demarcated borders
superficial fibrinous coating
kissing ulcers
<20yo with little sexual history
ix for lipschultz
PCR for HSV and syphilis
syphilis serology
screening for gonorrhoea and chla,mydisa
Mpox testing
bacterial culture
serology for EBV, CMV, mycoplasma, toxoplasmosis, flu, salmonella
tx of lipschultx
topical local anaesthetic
NSAIDs for pain
acicilovir 400mg TDS 5 days
potent topical steroids - clobetasol
short course oral steroids if severe
female genital pain classifications
provoked vulvodynia - pain at vestibule on penetration
unprovoked vulvodynia
what causes vulvodynia?
maladaptive function of NS leading to a perpetuation of pain after inflammation or a triggering noxious stimulus has resolved
may be induced by exposure to acute phsyoica; +/- psychological events
how is vulvodynia charatcerised
burning, stabbing +/- shooting pain
allodynia or hyperalgesia
tx of provoked vulvodynia?
topical local anaesthetics
physiotherapy
psychosexual discussion
tx for unprovoked vulvodynia
pain modifiers eg tricyclic antidepressants eg amitryptilline
