Exam 1 - vulva and vaginal disorders

vagina

strong, hollow fibromuscular canal 7-9 cm long extending from uterus to vestibule

cul-de-sac

circular, formed around the cervix

known as the fornix, divided into 4 regions

7 common causes of vaginal itching

yeast infection

diabetes

BV

STDs

menopause

chemical irritants and allergens

lichen sclerosis

acanthosis

abnormal, benign thickening of prickle-cell layer of the skin

hyperkeratosis

excess keratin in stratum corneum, the thick superficial layer of the skin

lichenification

thickening of skin with accentuation of normal skin lines, resembles tree bark

commonly associated with pruritic disorders

lichen sclerosus can progress to

vulvar cancer

lichen sclerosus

benign, chronic inflammation

is a white lesion, results in thinning of the skin

possible etiologies of lichen sclerosus

vitamin A deficiency

Autoimmune

clinical findings of lichen sclerosus

women over 60

pruritus

vulvar pain (dyspareunia)

asymptomatic white lesions

acute lichen sclerosus

-erythema and edema of vulva

-white plaques = lichenification + hyperkeratosis

-white plaques unite

-intense pruritus = scratch-itch cycle

-telangiectasias and subepithelial hemorrhage from scratching

-erosions, fissures, ulcerations

chronic lichen sclerosus

-cigarette-paper: thin, wrinkled, white

-agglutination of anterior labia minora of both sides to cover clitoris = phimosis

-involvement of perianal region to form 8 around vulva and anus

-introital stenosis (kraurosis)

5 bx histologic features to dx lichen sclerosus

1. thin hyperkeratotic layer

2. thinning of epithelium

3. flattening of papillae (rete pegs)

4. homogenization of the stroma

5. deep lymphocytic filtration

other causes of white lesions on the vulva

vitiligo

lichen simplex chronicus

lichen planus

lichen simplex chronicus is characterized by

benign epithelial thickening and hyperkeratosis from chronic irritation

lesions of lichen simplex chronicus

lesions are diffuse and involve adjacent things like perineum and perianal skin

histology of lichen simplex chronicus

hyperkeratosis and acanthosis w/ elongated rete pegs

no dermal inflammatory infiltrate seen

lichen planus

rarely affects vulva

-sharply marginated, flat-topped papules on skin

-less sharply marginated white plaques on oral and genital mucus membranes

cause of red lesions on vulva

psoriasis

psoriasis on vulva

sometimes only on the vulva

lesions raised and erythematous, most are sharply demarcated

goal of treating lichen sclerosus

stop itch-scratch cycle and minimize dermal inflammation

vulvar hygiene to stop lichen sclerosus

avoid tight undergarments

clean skin with mild soap

dry vuvla w/ hair dryer

medications for lichen sclerosus

oral antihistamine at bedtime

-dermovate (clobetasol dip 0.05%) topical

dermovate (clobetasol dip 0.05%) dosing

BID x2 weeks

QD x2 weeks

2x weekly x2 weeks

PRN, lifelong

prognosis of lichen sclerosus

chronic, recurs w/ cessation of treatment

dermovate = sx relief in 50% of patients

complication of lichen sclerosus

3-5% progress to SCC

All new lesions MUST be biopsied

CA more likely in women w/ vulvar itching + neglected treatment

summary of lichen sclerosus

1. most common non-neoplastic vulvar disorder

2. intense itching over 60 yo

3. vulvar skin is thin, wrinkled, white w/ areas of lichenification and hyperkeratosis

4. anterior labia minor agglutinates

5. erosions, fissures, subepithelial hemorrhage, ulcers

Bx may be needed

cause of condyloma acuminatum

HPV serotypes 6 and 11

serotypes of HPV responsible for cervical cancer

16

18

45

31

53

3 HPV vaccines

Bivalent

Quadrivalent (Gardasil)

Nonvalent

bivalent hpv vaccine

against high-risk types 16 and 18

quadrivalent (gardasil) hpv vaccine

Against 6, 11, 16, 18

women 9-45 yo

men 9-26 yo

nonvalent hpv vaccine

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

women 8-26

men 9-15

which 2 types of HPV vaccine prevent condyloma acuminatum

quadrivalent and nonavalent

recommended age of HPV vaccine

11-12 (as early as 9)

9-14 get 2 dose series at 0 and 6-12 months

15+ get 3 dose series at 0, 1-2 months, and 6 months

special situations for HPV vaccination

1. all immunocompromised get 3 dose series

2. h/o SA = 9yo

3. pregnancy - not recommended until after, but will not harm baby

clinical findings of condyloma acuminatum

small at first, coalesce to form large cauliflower-like lesions

-white, exophytic, or papillomatous (above)

-lesions may not be visible

ddx for condyloma acuminatum

molluscum

epidermal cyst

apocrine sweat gland cysts

arcochordon

molluscum

benign epithelial tumor, dome-shape w/ umbilicus

caused by poxvirus

up to 1cm in size

epidermal cysts

-lined with squamous epi, filled with oily material

-usually from occlusion of pilosebaceous ducts

-solitary and asymptomatic

apocrine sweat gland cysts

-abundant in skin of labia majora and mons

-active w/ puberty

-occlusion w/ keratin = vulvar pruritus

arcochordon

skin tag

no clinical significance

before treatment of condyloma acuminatum...

examine lower genital tract w/ colposcopy and get cytologic smear of cervix - lesions can extend to urethra and anus

bx for condyloma acuminata considered when

1. cervix is involved

2. condyloma non-responsive to standard treatment

3. lesion is pigmented, indurated, fixed, or ulcerated

3 treatment options for condyloma acuminatum applied by provider

1. TCA 50-80% solution

2. Podophyllin 10-25% in incture of benzoin

3. cryo, electrosurgery, surgical exc, laser vaporization

2 treatment options for condyloma acuminatum applied by patient

1. Podofilox 0.5% solution or gel

2. Imiquimod 5% cream (stimulated interferon and cytokines to kill lesion)

Condyloma acuminatum and pregnancy

Not a contraindication to vaginal delivery

-genital warts grow rapidly in pregnancy

-introital warts can bleed during delivery = predisposition of newborn to genital warts

exposure of newborns to genital warts

can also expose to recurrent respiratory papillomatosis

-papillomas of the vocal cords

-rarely descent to the pulmonary parenchyma

what lesion is a contraindication to vaginal birth

herpetic lesions

treatment of condyloma acuminatum in pregnant women

30-32 weeks gestation to allow healing

-cryo, electrocoagulation, CO2 laser therapy

-NO PODOPHYLIN PODOFILOX OR IMIQUIMOD

summary of condyloma acuminatum

1. asymptomatic white papillary growth that are small at first then coalesce

2. vulva, vagina, cervix of females

3. penis and scrotum in males

4. colposcopy to ID small, flat lesions

5. bx to r/o neoplasia

causes of bartholian cysts

infection

thickened mucus

congenital narrowing of duct

sx of bartholian abscess

pain

tenderness

dyspareunia

difficulty walking w/ adducted thighs

exam of bartholian's cyst and abscess

fluctuant, tender mass is palpable

surrounding tissue edematous and inflamed

tx of bartholian cysts/abscesses

drain (marsupialization)

needle aspiration or I+D = temporary relief

excision of cyst

antibiotics

marsupialization

pin outside of cyst out for chronic drainage

why are bartholian cysts rarely removed

bleeding risk

impetigo of the vulva is caused by

hemolytic S. aureus or strep

sign of impetigo of the vulva

thin-walled vesicles and bullae develop reddened edges and crusted surfaces following rupture

treatment of vulvar impetigo

topical abx (clindamycin)

cause of vulvar folliculitis

staph infection of hair follicle

furunculosis

occurs if vulvar folliculitis infection spreads to perifollicular tissue causing cellulitis

furunculosis sx

begins as hard, tender subq nodule

ruptures thru skin, discharging blood and purulent material

HS

Refractory process of apocrine sweat glands

-Staph or strep

-recurrent

-skin and entire vulva

Pediculosis pubis

Crab louse

transmitted via sexual contact or shared infected bedding/clothing

process of pediculosis pubis infection

eggs laid at base of hair shaft

eggs hatch in 7-9 days

louse attach to skin to survive

sx and clinical findings of pediculosis pubis

intense pubic and anogenital itching

minute pale-brown insects and ova

tx of pediculosis pubis

permethrin 1% cream and lindane 1% shampoo

Lindane = no pregnant or lactating women, no kids under 2

scabies

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

treatment of scabies

hot soapy bath, scrub burrows

permethrin cream 5% to entire body from neck-down

-wash off after 8-14 hours

vulvar pain syndrome

vulvar pain in absence of clinical findings

localized vs. generalized

provoked vs. unprovoked

sx of vulvar pain syndrome

burning

rawness

irritation

dryness

hyperpathia

primary vulvodynia

pain since first attempt at sex

secondary vulvodynia

pain after initial period of painfree sex

pure vulvodynia

without concomitant vulvovaginitis

complicated vulvodynia

recurrent vulvovaginitis

vulvodynia

women 20-30

with or w/o continuous vulvar pain

clinical findings of vulvodynia that is localized and provoked

-severe pain or burning on penetration

-extreme sensitivity during bimanual exam

-speculum fear

history associated with vulvodynia - localized and provoked

prior surgery (episiotomy or laser therapy)

prior infections

urological disorders (interstitial cystitis)

2 clinical criteria required to dx vulvodynia - localized and provoked

1. introital pain on vestibular/vaginal entry

2. vestibular tenderness-pressure from cotton-tipped applicator at vestibule reproduces pain

ddx for localized and provoked vulvodynia

vaginismus

vulvovaginitis

complications of vulvodynia - localized and provoked

detrimental to intimate relationships

secondary depression

treatment of vulvodynia - localized and provoked

-pelvic floor PT

-maintain hygiene

-topical 5% lido QD

-soothing oils BID

-topical estrogen

secondary therapy for vulvodynia - localized and provoked

tricyclic antidepressants - amitriptyline (elavil) or nortriptyline (pamelor)

surgery - vulvar vestibulectomy w/ vaginal advancement

generalized unprovoked vulvodynia

pain is larger area than localized

over 60 w/ HTN

constant pain or burning

for definitive dx of generalized unprovoked vulvodynia you must r/o

-localized provoked vulvodynia

-infections

-pudendal nerve entrapment or injury

-referred pain from ruptured disc

-MS

treatment of generalized unprovoked vulvodynia

tricyclic antidepressants

anticonvulsants

pain management

vulvar intraepithelial neoplasia (VIN)

preinvasive disease of vulva

-from dysplasia to CA in situ

vulvar intraepithelial neoplasia (VIN) is associated w/

multiple foci of dysplasia and STIs (HIV and HPV)

smoking

what % of VIN lesions are positive for HPV and what serotypes

90%

16, 18, and 31

vulvar intraepithelial neoplasia (VIN) sx

lesions - white and hyperkeratotic

>60% have pruritus

vulvar intraepithelial neoplasia (VIN) diagnosis

colposcopy and bx of suspicious lesion

vulvar intraepithelial neoplasia (VIN) lesions

usually multicentric

discrete or diffuse lesions, single or multiple, flat or raised

vulvar intraepithelial neoplasia (VIN) tx

based on bx:

-wide, local exc

-laser ablation

-topical 5-FU or imiquimod

-superficial vulvectomy w/o split-thickness skin graft

vulvar intraepithelial neoplasia (VIN) untreated

progression to invasive CA

vulvar intraepithelial neoplasia (VIN) f/u

pelvic exams q6m

colposcopy and bx PRN for 5 years, then annually

cancer of vulva is usually in

postmenopausal 60-70 yo

vulvar cancer is mostly

SCC

arising from labia majora and minora

appearance of vulvar cancer

varied

large, exophytic cauliflower-like lesions

small, ulcer rate superimposed on dystrophic lesion of vulva

treatment of vulvar cancer

complete surgical removal

-now wide radical exc w/ inguinal lymph node dissection

-radiation recommended if lymph node spread