Vulva and Vaginal Disorders

what does the vulva consist of?

- mons pubis

- labia majora and minora

- clitoris

- glandular structures that open into the vestibulum

- vaginal and urethral opening

what is the vagina?

strong, hollow fibromuscular canal ~7-9 cm long that extends from the uterus to the vestibule of the external genitalia

what is the fornix?

the circular cul-de-sac formed around the cervix

how are the fornices divided?

4 regions, 2 lateral, 1 posterior, 1 anterior

what is the vagina in close relationship with anteriorly?

bladder

what are common causes of vaginal itching?

- yeast infection

- diabetes

- bacterial vaginosis

- STDs

- menopause

- chemical irritants and allergens

- lichen sclerosis

what is acanthosis?

Abnormal but benign thickening of the prickle-cell layer of the skin

what is erosion?

Superficial damage to the skin, generally not deeper than the epidermis, although more superficial than an excoriation, it can bleed mildly

what is an excoriation?

Erosion caused by mechanical means, appearing in the form of a scratch of the skin. It is commonly seen in skin disorders causing itching/pruritus.

what is eczema?

A form of dermatitis, or inflammation of the upper layers of the skin, includes dryness and recurring skin rashes characterized by one or more of the following symptoms: redness, skin edema, itching and dryness, crusting, flaking, blistering, cracking, oozing, or bleeding

what is hyperkeratosis?

Excess of keratins in the stratum corneum, thick superficial layer of the skin

what is lichenification?

- Thickening of the skin (or epidermis) with accentuation of the normal lines of the skin, creating an appearance resembling a tree bark

- commonly seen in chronic eczema (or atopic dermatitis), where there is constant scratching and rubbing of the skin, and in lichen simplex chronicus.

- often associated with pruritic(itching) disorders

what is an ulcer?

Loss of both epithelium and part of the dermis

what is lichen sclerosus?

benign, chronic, inflammatory process, white lesion results in thinning of skin

what is the most common vulvar dermatologic (non-neoplastic) disorder?

lichen sclerosus

what are some possible etiologies of lichen sclerosus?

- Vit A deficiency

- autoimmune process

what age is lichen sclerosus common?

women older than 60 years

what symptoms are lichen sclerosus?

- pruritis

- vulvar pain

- dyspareunia

- asymptomatic white lesions

what are clinical findings of ACUTE lichen sclerosus?

- Erythema and edema of vulvar skin

- Development of white plaques representing lichenification and hyperkeratosis

- Uniting of white plaques

- Intense pruritus leading scratch-itch cycle

- Telangiectasias and subepithelial hemorrhages resulting from scratching

- Erosions, fissures, and ulcerations

what are clinical findings of CHRONIC lichen sclerosus?

- Thin, wrinkled, and white skin with a cigarette-paper appearance

- Agglutination of the anterior parts of the labia minora of both sides to cover the clitoris and create phimosis

- Involvement of the perianal region in the form of 8; around the vulva and around the anus

- Introital stenosis (kraurosis)

what are the 5 histologic features on biopsy of lichen sclerosus?

1. Thin hyperkeratotic layer

2. Thinning of the epithelial layer

3. Flattening of the papillae (Rete pegs)

4. Homogenization of the stroma

5. Deep lymphocytic filtration

what are some differential dx of lichen sclerosus that also have white lesions?

- vitiligo

- lichen simplex chronicus

- lichen planus

what is the presentation of lichen simplex chronicus?

- Characterized by benign epithelial thickening and hyperkeratosis resulting from chronic irritation

- Can get lesions that become diffuse and the perineum or perianal skin

what does a histological exam of lichen simplex chronicus show?

- hyperkeratosis and acanthosis with elongation of the rete pegs

- no dermal inflammatory infiltrate seen with lichen sclerosus

what is the presentation of lichen planus?

- Sharply marginated flat-topped papules on the skin and less sharply marginated white plaques on the oral and genital mucous membranes

- rarely affects vulva

what is a differential dx of lichen sclerosus with red lesions?

psoriasis

What is the presentation of psoriasis?

- lesions are raised and erythematous, most sharply demarcated

- sometimes can just affect vulvar skin

what is the treatment for lichen sclerosus?

- stop the itch-scratch cycle and minimize dermal inflammation

- vulvar hygiene

- medication

what are some general measures of vulvar hygiene to treat lichen sclerosus?

- avoid tight undergarments

- cleansing daily with mild soap

- dry the vulvar skin with a hair dryer

what are some medications to treat lichen sclerosus?

- oral antihistamine at bedtime

- dermovate (clobetasole diproprionate 0.05%) topical application

what is an example of a taper for dermovate?

- twice daily x 2 weeks

- once daily x 2 weeks

- twice weekly x 2 weeks

- as needed for rest of life

what is the prognosis for lichen sclerosus?

- chronic and usually recurs

- dermovate provides symptoms relief and reverses skin changes in ~50% of pts

what is a possible complication of lichen sclerosus?

- squamous cell CA in 3-5% of women

- ALL new lesions need to be biopsied

- CA more likely in those with continued itching and neglect treatment

lichen sclerosus summary

- intense pruritus

- thin, wrinkled, white with areas of lichenification and hyperkeratosis

- labia minora of both sides agglutinate

what is condyloma acuminatum?

genital warts caused by HPV

what are the main types of HPV that cause genital warts?

6 and 11

what types of HPV cause intraepithelial and invasive neoplasia in the vagina, cervix, vulva, oropharynx, perineum, and perianal areas?

16, 18, 45, 31, 53

how are genital warts transmitted?

sexually, often infects both partners

what are the types of vaccines available against HPV?

- bivalent

- quadrivalent

- nonavalent

what does the bivalent vaccine protect against?

high-risk HPV types 16 and 18

what is the quadrivalent vaccine called?

Guardasil

what does Guardasil protect from?

types 6, 11, 16, 18

what ages is the Guardasil vaccine approved for?

women 9-45 yo and boys/men 9-26 yo

what does the nonavalent vaccine protect against?

types 6, 11, 16, 18, 31, 33, 45, 52, 58

what ages is the nonavalent vaccine approved for?

women 8-26 yo and boys 9-15 yo

around what age/time are the vaccines recommended?

given before sexual debut

which vaccines are designed to prevent genital warts?

quadrivalent and nonavalent vaccines

what is the minimum age the HPV vaccine can be given?

9 years

what age is the HPV vaccination routinely recommended?

age 11-12, with catch up for all age 18 if not adequately vaccinated

at what age and schedule is the 2 dose vaccine series given?

age 9-14 years at initial vaccination: 1st 0, 2nd dose 6-12 months after 1st, minimum 5 months

at what age and schedule is the 3 dose vaccine series given?

age 15+ at initial vaccination: 0, 1-2 months, 6 months (minimum for dose 1-2 is 4 weeks, dose 2-3 is 12 weeks, dose 1-3 is 5 months)

what are some special situations regarding the HPV vaccination?

- immunocompromising conditions, HIV: 3 dose series

- H/O of sexual abuse or assault: start age 9

- pregnancy: recommended after pregnancy, but non-urgent

what are the clinical findings of genital warts?

- white, exophytic, or papillomatous growth

- papillary growths small at first, coalesce and form large cauliflower-like masses

- lesions can be small and unseen to eye, may need colposcopy

what are some differential diagnoses for genital warts?

- molluscum contagiosum

- epidermal cysts

- apocrine sweat gland cysts

- arcochordon

what is molluscum contagiosum?

benign epithelial tumors that are dome-shaped with a typical umbilicus, up to 1 cm, caused by the poxvirus

what are epidermal cyst?

aka keratin cysts

- Epidermal, lined with squamous epithelium and filled with oily material often occurring due to occlusion of pilosebaceous ducts

- Usually small solitary and asymptomatic

what are apocrine sweat gland cysts?

- apocrine sweat glands abundant in skin of labia major and mons, active after puberty

- due to occlusion of ducts with keratin and cause vulvar pruritus

what is arcochordon?

AKA skin tag, no clinical importance

what is the diagnosis for genital warts?

- exam all lower genital tract with colposcopy and get cytologic smear

- lesions can extend into urethra and anus

- biopsy

when should a biopsy be considered for genital warts?

- cervix involved

- condyloma does not response to standard treatment

- lesion is pigmented, indurated, fixed, and/or ulcerated

what are treatments for condyloma acuminatum by a health care provider?

- Bichloracetic acid or trichloroacetic acid (TCA), 50-80% solution

- Podophyllin 10-25% in tincture of benzoin

- Cryosurgery, electrosurgery, simple surgical excision, laser vaporization

what are treatments for condyloma acuminatum by a patient at home?

- Podofilox 0.5% solution or gel

- Imiquimod 5% cream (topically active immune enhancer that stimulates production of interferon and other cytokines)

how do genital warts grow during pregnancy?

grow rapidly

what can bleeding of the warts during delivery expose baby to?

- presdispose the newborn to genital warts or recurrent respiratory papillomatosis (RRP)

what are RRPs?

papillomas on the vocal cords, rarely can descend to the pulmonary parenchyma

are genital warts of the vulva, vagina, and cervix a contraindication to a vaginal delivery?

NO

are herpetic lesions a contraindication to a vaginal delivery?

YES

when should genital warts during pregnancy be treated?

at 30-32 weeks gestation to allow healing before delivery

what is treatment for genital warts during pregnancy?

- electrocoagulation

- cryotherapy

- CO2 laser therapy

what treatments SHOULD NOT be used for genital warts during pregnancy?

- podophylin

- podofilox

- imiquimodo

condyloma acuminatum summary

- Asymptomatic white papillary growths, small at first, tend to coalesce

- Affects the vulva, vagina, and cervix in females, the penis and scrotum in males, the pubis, perineum, perianal, and oropharyngeal areas in both sexes

- A colposcopy is necessary to identify small and flat lesions

- Biopsy may be needed to rule out neoplasia

what causes Bartholin's duct cyst and/or abscess?

Obstruction of the main duct of Bartholin's gland results in retention of secretions and cystic dilatation

where are the Bartholin gland and duct located?

deep in the posterior 1/3 of each labia major with the duct opening into the vestibule

what is the etiology of Bartholin's duct cyst and/or abscess?

- infection

- thickened mucus

- congenital narrowing of the duct

what are some symptoms of Bartholin's duct cyst and/or abscess?

- pain

- tenderness

- dyspareunia

- difficulty walking with adducted thighs

what are some different findings with a Bartholin's cyst vs abscess?

abscess will be red and warm due to infection, a cyst will not be

what will be found on exam of Bartholin's duct cyst and/or abscess?

- Fluctuant, tender mass palpable

- Surrounding tissues becomes edematous and inflamed

what is the treatment for Bartholin's duct cyst and/or abscess?

- drainage of cyst or abscess = marsupialization (pin it out to chronically drain it)

- needle aspiration or I&D (more temporary relief)

- excision of cyst in recurrent case

- antibiotics if red, hot

what are some other infections of the vulva?

- impetigo

- furunculosis

- hidradenitis suppurativa

what is impetigo caused by?

hemolytic staph aureus or streptococci

what is impetigo?

- Thin-walled vesicles and bullae that develop reddened edges and crusted surfaces after rupture that spread quickly throughout the body, including the vulva

what is the treatment for impetigo?

topical antibiotics such as Clindamycin

what is vulvar folliculitis caused by?

staphylococcal infection of the hair follicle

when does furunculosis occur?

if the infection spreads into the perifollicular tissue causing cellulitis

how does furunculosis present?

hard, tender subcutaneous nodule that ruptures through the skin, discharging blood and purulent material

what usually causes hidradenitis suppurativa?

staphylococci or streptococci

what is hidredenitis suppurativa?

- refractory process of the apocrine sweat glands that is often recurrent and involves multiple abscesses that require chronic draining

- involves skin and entire vulva

what are infestations of the vulva?

- pediculosis pubis

- scabies

how is pediculosis pubis spread?

- sexual contact or from shared infected bedding or clothing

- Eggs are laid at the base of the hair shaft, eggs hatch in 7-9 days, louse must attach to the skin to survive

what are some symptoms of pediculosis pubis?

intense pubic and anogenital itching

what are the clinical findings of pediculosis pubis?

minute pale brown insects and ova

what is the treatment for pediculosis pubis?

- permethrin 1% cream

- lindane 1% shampoo (Lindane not recommended for pregnant, lactating women, or children under 2)

what is scabies causes ?

Sarcoptes scabiei

what are the symptoms of scabies?

intractable itching and excoriation in the vicinity of minute burrows where parasites deposit ova

what is the treatment for scabies?

- Hot soapy bath scrubbing the burrows

- Permethrin cream 5% applied to the entire body from the neck down and washed off 8-14 hours later

what is vulvodynia?

Vulvar pain in the absence of relevant physical findings (for at least 3 months)

what are the symptoms of vulvodynia?

- Burning

- Rawness

- Irritation

- Dryness

- Hyperpathia

can be localized/generalized or provoked/unprovoked

what age is vulvodynia common in?

20-30 yo

what are the classifications for vulvodynia?

- Primary: pain since first attempt at sex

- Secondary: pain after initial period without pain with sex

- Pure: w/o concomitant vulvovaginitis (infxn)

- Complicated: with recurrent vulvovaginitis (infxn)

- with or w/o continuous vulvar pain

what are clinical findings of localized provoked vulvodynia?

- Severe pain or burning on vaginal penetration

- Extreme sensitivity during bimanual pelvic exam

- Expression of fear from speculum insertion

- history