Vulvar and Vaginal Disease

Question 1

Pathophysiology of bacterial vaginosis

Answer 1

Shift in flora from H2O2-producing to non-H2O2-producing lactobacilli, allowing proliferation of anaerobic bacteria

Question 2

What are the Modified Amsel criteria for diagnosing bacterial vaginosis?

Answer 2

1. Thin, gray homogenous vaginal discharge
2. Positive whiff test (KOH releases amine odor)
3. Clue cells on saline microscopy
4. Elevated pH >4.5

Question 3

Bacterial vaginosis treatment

Answer 3

Metronidazole 500 mg bid 7d or 0.75% gel qhs 5d

Question 4

Describe the early and late skin changes of lichen sclerosus

Answer 4

Early: Polygonal ivory papules, waxy sheen on labia minora and clitoris, hypopigmentation

Late: Fissures/erosions, mucosal edema, vascular changes

Very late: Introital stenosis and resorption of clitoris (phimosis) and labia minora

<5% risk of squamous cell cancer - pink-red appearance with overlying white keratin

Question 5

How does lichen planus differ from lichen sclerosus?

Answer 5

Lichen planus has:
Vaginal involvement with progressive adhesion formation and loss of normal architecture
Reticular pattern

May also affect hair-bearing skin/scalp, nails, oral mucous membranes

Question 6

What is vestibulodynia syndrome?

Answer 6

Vulvar vestibule:
Severe pain on touch or attempted vaginal entry (sharp, burning, raw)
Tenderness to pressure
Variable erythema

Question 7

Treatment for vestibulodynia?

Answer 7

TCAs to block sympathetic afferent pain loops
Topical anesthetics
Biofeedback
Pelvic floor rehabilitation

Surgery

Question 8

Thick, lichenified, enlarged, rugose labia (leather-like) is associated with what disease?

Answer 8

Lichen simplex chronicus - results from chronic scratching and rubbing –> even more severe itching, which may be worse at night

Question 9

Red velvety lesion of vulva with discharge is?

Answer 9

Paget’s disease of the vulva - adenocarcinoma on pathology

Question 10

RECURRENT genital herpes are associated with which HSV subtype?

Answer 10

HSV-2

Question 11

Treatments for VIN

Answer 11

Wide local excision
Laser ablation
Imiquimod 5%

Question 12

What is a Word catheter? What is an alternative treatment for recurrence?

Answer 12

Placed in symptomatic Bartholin cyst/abscess to reduce risk of recurrence

Marsupialization is an alternative that involves incision & drainage, followed by everting and suturing edges of cyst/abscess to mucosal edge

Question 13

Vaginal cancer risk factors

Answer 13

HPV
Tobacco use
In utero diethylstilbestrol exposure (clear cell adenocarcinoma only)