Vulvovaginal Diseases Flashcards
Important in history items to cover with regard to vulvovaginal complaints
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
Contact dermatitis
Shows symmetric raised bright red plaques that present intestine pruritis
- **usually extend to areas of use of irritant
Irritants
- soaps, lotions, irrigation’s, etc.
Vulvovaginal candidiasis
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
Complicated vs uncomplicated vulvovaginal candidiasis
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
Treatment for vulva candidiasis
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)
Allergies to fluconazole
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
Treatment for complicated VVC with severe symptoms
7-14 day topical fluconazole
OR
150 mg fluconazole in two sequential doses (2nd dose = 72 hrs after initial)
Pregnancy and HIV infection VVC treatment
Pregnancy = topical azole for 7 days ONLY
- NO oral dose
HIV infection
- topical only as well
Herpes simplex virus (HSV)
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
Diagnosis of syphillus
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
Treatment of syphilis
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
Chancroid
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
Treatment for chancroid
Either a macrolides or augmentin (amoxicillin-clavulanate)
Can also use ceftriaxone if disseminated
**follow-up in 3-7 days
Molluscum contagiosum
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
Bartholins cyst
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
Lichens sclerosis of vagina
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
Treatment of lichen sclerosis
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
Lichen planus
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
Treatment of lichen planus
Cloebetasol again (similar to lichen sclerosis)
Lichen simplex chronicus
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
Diagnosis Treatment of condyloma
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
Vulvar intraepithelial neoplasia (VIN)
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
UVIN/HSIL specifics
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
DVIN specifics
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
