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Reproductive > Vulvovaginal Diseases > Flashcards

Vulvovaginal Diseases Flashcards

1
Q

Important in history items to cover with regard to vulvovaginal complaints

A

1) use of chemicals
2) previous/recent treatment
3) sexual activity
4) comorbidities
5) symptoms
6) medications
7) pregnancy status
8) particular concerns/recent exposure for STD
9) postcoital or intermenstrual bleeding

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2
Q

Contact dermatitis

A

Shows symmetric raised bright red plaques that present intestine pruritis
- **usually extend to areas of use of irritant

Irritants
- soaps, lotions, irrigation’s, etc.

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3
Q

Vulvovaginal candidiasis

A

Is also candida species
- contain pseudohyphae and true hyphae

Most common subtypes

  • Candida albicans = 80-90%
  • candida Galbrata = 9%
  • candida krusei = 1%

Symptoms

  • vulvar pruritus
  • external dysuria
  • pain (at rest, during sex, during urinate, etc)
  • erythema
  • maculopapular rash with “satellite lesions” around it (not tied to the maculopapular rash)
  • white curry vaginal discharge

Risk factors:

  • diabetes
  • prescience of IUD
  • exogenous estrogen
  • recent antibiotics
  • immunocompromised

frequent intercourse = NOT well associated with candidiasis

Diagnosis

  • wet prep with KOH drop and saline drop and looks for pseudohyphae/true hyphae
  • only culture discharge if you try to treat first with azoles and it doesnt respond
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4
Q

Complicated vs uncomplicated vulvovaginal candidiasis

A

Non-Complicated

  • sporadic and infrequent
  • candida albicans infections
  • non-immunocompromised
  • mild symptoms and findings

Complicated

  • recurrent > 4 infections in 1 year
  • severe symptoms (very bright erythema and excoriations)
  • is not albicans species
  • immunocompromised
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5
Q

Treatment for vulva candidiasis

A 
1st line = short course of topical or oral azole cream 
- if complicated = longer and high 
Dosages 
- **most common = 1 dose fluconazole 
**if using long term = monitor LFTs**

Usually complicated = oral fluconazole (100mg,150mg,200mg) for 2 weeks**

If non-candida = treat with boric acid or nystatin (capsules in vagina ONLY, can kill if ingested)

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6
Q

Allergies to fluconazole

A

Rare but difficult to distinguish between allergy to fluconazole vs entire azole class
- there fore if fluconazole allergy = DONT prescribe itraconazole or ketoconazole

however you can prescribe topical miconazole or clotrimazole

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7
Q

Treatment for complicated VVC with severe symptoms

A

7-14 day topical fluconazole

OR

150 mg fluconazole in two sequential doses (2nd dose = 72 hrs after initial)

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8
Q

Pregnancy and HIV infection VVC treatment

A

Pregnancy = topical azole for 7 days ONLY
- NO oral dose

HIV infection
- topical only as well

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9
Q

Herpes simplex virus (HSV)

A

HSV and HSV 1 can be genital (HSV 2 is more common)

Symptoms of primary infection

  • fevers
  • dysuria
  • pruritus
  • PAINFUL vesicular lesions that are yellow-white that become ulcers overtime and can spread around surrounding area
  • **disseminated = lethal

Symptoms of secondary infection

  • weaker than primary and usually no prodromal
  • also usually 1 or 2 lesions at most
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10
Q

Diagnosis of syphillus

A

Dark-field microscopy = most specific technique

Non-treponema tests = test for VDRL, however this isnt super specific. Also can do RPR (rapid plasma reagin)
- **NOTE RPR titers show be >1.8 if real syphills

Treponema specific tests = IgM/IgG/IgA to specific syphills antigens
- FTA-ABS and MHA tests

**many false positive causes of syphillus

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11
Q

Treatment of syphilis

A

Benzathine penicillin IM 1 time

Monitor with RPR and make sure this is decreasing (usually 4x decrease every 3 months)
- examine every 3 months at least

some patients who are treated properly may become “serofast (+)” which means their RPR will always be around 1.8 and flange false positive syphills. There are not continuous though and dont have the infection

ALLERGIES:

  • IF PREGNANT = desensitization and still give penicillin parenteral (gotta save child)
  • Non-pregnant = doxycycline or ceftriaxone if neurosyphillis is present
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12
Q

Chancroid

A

Casued by haemophilus ducreyi and is a gram (-) coccobacilli
- on histology these coccobacilli often group together and form “railroad tracks” or “school of fish” appearance

Are painful large lesions that often shows unilateral ipsilateral lymphadenopathy
- will shows (-) RPR levels/treponemal tests and (-) herpes cultures

often need to test for this if you tried treating herpes and nothing happens

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13
Q

Treatment for chancroid

A

Either a macrolides or augmentin (amoxicillin-clavulanate)

Can also use ceftriaxone if disseminated

**follow-up in 3-7 days

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14
Q

Molluscum contagiosum

A

Benign self limiting raised papules caused by pox virus infections
- often mimics herpes or condyloma however has the central “dimple” apperance which these others dont have

Dont need biopsy but you can if you want

Usually self-limiting 6-12 months

  • can do cryotherapy
  • trichloroacetic acid 75% or imiquimod
  • surgery = almost never unless patient insists
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15
Q

Bartholins cyst

A

Very painful cyst that occurs in between the labia minora and vagina
- patients often cant walk well and are tearful

Are abscesses that need to be cut open or removed

  • use a word catheter to drain pus and then inject saline fluids and have patient come back in 3 days to check before removing catheter
  • also can “marsupialization the cyst” buy cutting it open and suture it to the adjacent mucosa usually only used for recurrent cysts
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16
Q

Lichens sclerosis of vagina

A

Inflammatory skin condition that occurs usually in postmenopasual women
- occurs in 1/300-1/1000 women

Shows smooth, white papules/plaques and resemble parchment paper

Histology shows:

  • thinning of the epidermis and disappearance of rete pegs
  • hydropic degeneration fo basal cells
  • superficial hyperkaratosis
  • dermal fibrosis
  • mononuclear inflammatory infiltrate

may or may not increase risk for SCC of the vagina

Symptoms

  • pruritis
  • dysuria and at rest burning sensations
  • dyspareunia
  • **is often associated with other autoimmune conditions (patient has a history of one usually)

Diagnosis = vulvar biopsy
- can do empirical therapy if you have high clinical suspicion

17
Q

Treatment of lichen sclerosis

A

1st line = clobetasol cream 1-2x/day for 1 month
- 90% effective

Can also use tacrolimus or methotrexate as off-label if doesnt respond to first line however these come with serious ADRs

no hormonal therapy is recommended and no surgery

18
Q

Lichen planus

A

Infalmmatory skin condition that is believed to be autoimmune but not sure
- affects skin and mucosa

shows pruritic, purple shiny papules “polygonal purple papules”

Histology = “sawtooth pattern” of epidermal hyperplasia and hypergranulosis

Symptoms

  • pain
  • pruritus
  • dyspareunia
  • postcoitus bleeding
  • vaginal narrowing

Diagnosis = biopsy if you want (usually do just to play it safe). Can do empirical therapy if high suspecion though

19
Q

Treatment of lichen planus

A

Cloebetasol again (similar to lichen sclerosis)

20
Q

Lichen simplex chronicus

A

End results of chronic itching and scratching results in lichenifcation and excoriation of skin

  • *must try to identify underlying cause (irritants, VIN, Paget’s disease, psychiatric condition and psoriasis are most common)**
    • IS NOT a primary process

Symptoms
- intense pruritus and bleeding/pain

Can biopsy if you want and will show elongated rete ridges and prominent dermal papillae

Treatment = topical steroids with night time antihistamines

  • **have to find and treat underlying cause
  • if psychiatric = SSRI usually
21
Q

Diagnosis Treatment of condyloma

A

Diagnosis = clincially (light pink wart growths that asymmetric)

  • can also add 4% acetic acid (vinegar) = turns whitish with prominent papillae (especially if biopsy)
  • molluscum doesn’t turn white with vinegar

Histology = KOLIOCYTES (squamous papilloma doesnt show this, another condition often confused)
- also no HPV serotype

Treatment = tricloroacetic acid 80-90% (apply carefully and avoid skin = 1st line

  • can also do cryotherapy or podophyllium resin
  • electrocautery = last line
22
Q

Vulvar intraepithelial neoplasia (VIN)

A

Two types

  • usual type (uVIN) high grade
  • differentiated type (dVIN) low grade

Common things

  • mild pruritus and burn or asymptomatic
  • flat slightly raised well-defined skin lesions that can be pink/red/brown or white

Histology of uVIN

  • epithelium is acanthotic and hyperkeratotic
  • shows vacuoles and dysplastic cells
  • also shows (YES) koliocytes and multinucleated cells**
  • often looks like a “wind blown” pattern
  • shows p16 mutations

Histology of dVIN

  • dysplastic cell and mitoses confined to the basal layer
  • basal atypia
  • hypereosinophila
  • NO kolicytes*
  • looks kinda like lichen schlerosus
  • shows p53 mutations
23
Q

UVIN/HSIL specifics

A

Associated with HPV virus and is high grade (VIN2/3)

Use to be called “Bowen disease”

12% resolve spontaneously within 1 yr

Is not an invasive cancer by itself but can turn into SCC within 7 years if not treated (very invasive at this point)

Can be seen in any labia portion

Risk factors

  • immunocompromised
  • smokers
  • history of abnormal vertical/pap smears or cervical cancer
24
Q

DVIN specifics

A

Less common than uVIN

  • 85% progress to SCC with 15% spontaneous remission
  • turns to cancer in 2-4 years (much faster than uVIN)

Most commonly seen on non-hair bearing skin

Is associated with chronic vulvar inflammation and usually age is around 60 yrs

if any lesion si not responding to high potency corticosteroids = get a biopsy to exclude this since this is a common culprit

25
Q

Treatment for uVIN and dVIN

A

Both usually just do surgery to remove tissues
- can do laser if you want (only if noninvasive)

Medical therapy’s

  • imiquimod cream
  • 5-FU
  • photodynamic therapy (painful as hell)
  • *not really recommended in cancers**

must follow up every 6-12 months for 5 years after treating

Reproductive (66 decks)

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