17. Benign and Malignant Condition of the Vulva/Vagina Flashcards
(55 cards)
1
Q
Ambigous genitalia of the vulva can present with what on PE?
A
- Clitormegaly/ clitoral agenesis
- Bifed clitoris
- Midline fusion of the labiascrotal folds
- Cloaca = no separation between the vagina and bladder
2
Q
With ambiogus genitalia, careful examination is required: ____, ____, ____, ____
A
- PE
- Hormonal studies
- US
- Karyotyping
3
Q
What is the difference between how female pseudohermaphroditism and male PH is caused?
A
- Femal PseudoHerm = masculinization in utero of the female fetus due to hormonal problems: congenital adrenal hyperplasia, ingestion of exogenous hormones, androgen-secreting rumors
- Male = mocasism and occurs with different degrees of virulization and mullerian development
4
Q
Androgen insensitivity syndrome (46 XY)
- What is it?
- Is most commonly inherited how?
- Results in what?
A
- Genetic deficiency in androgen receptors
- X-linked recessive
- External female genitals: undescended testes, Mullerian inhibiting substances causes lack of mullerian duct development (no uterus or fallopian tubes)
5
Q
What is Fox-Fordyce disease?
A
severe, itchy, raised yellow cysts in the axilla and labia majora and minor due to from keratin-plugged apocrine glands => inflammation.
6
Q
What is the most common type of genital cyst?
A
Epidermal inclusion cyst = mobile, non-painful, spherical, and slow growing cyst that form when hair follicle is obstructed, causing the deeper part to swell to accomodate desquamted cells
7
Q
Sebaceous cysts of the vulva are most commonly found where and contain what?
A
- Small, smooth, nodular mass found on the inner surface of labia minora and majora
- Contain a cheesy sebaceous material
8
Q
What is the most common benign solid tumor of the vulva; what are its growth characteristics?
A
- Fibromas
- Slow growing, most range from 1-10cm => but can become gigantic (250 lbs!!!!)
9
Q
What is at the rare conditions that occurs when 1 or more of the minor vestibular glands becomes infected?
A
Vulvar vestibulitis (vestibular adenitis) => Small (1-4mm) red dots on the vulva that are tender.
10
Q
When does vulvar vestibullitis (adenitis) come to attention?
Treatment?
A
- Pain during sex (dypareunia)
- Vulvar pain
- Treatment: topical estrogen/hydrocortison or surgery
11
Q
What is a urethral caruncle?
What causes it in children/post-menopausal women?
A
- Small, beefy, red outgrowth at the distal edge of the urethra.
- Children = spontaneous prolapse of the urethral epithelium
- Post-menopausal women = contraction of the hypoestrogenic vaginal epithelium => everts urethral epithelium
12
Q
What is the treatment for labial agglutination?
A
Estrogen cream and massage to separate the labia majora
13
Q
Vuvlvar hematomas (bruising) most often arise following what; how are they managed?
A
- Arise following trauma i.e., bike injuries (straddle injury), birth trauma or sexual assault
- Close observation and occasional surgical exploration may be warranted
14
Q
Atrophic vaginitis: what is it, is due to what; treated how?
A
- Minora regress, majora shrinks, no rugae on vagina, closed vagina
- DT: loss of estrogen
- Treatment: topical estrogen and oral estrogen to prevent recurrance
15
Q
Linchen Simplex Chronicus
- What is it?
- Symptoms?
- Biopsy:
- Treatment
A
- Thick epithelium (white/red thick epithelium) due to prolonged scratching
- Pruritis = itching
- Hyperkeratosis, acanthosis + elongated rete ridges, dense inflammatory infiltrate (lymphocytes) in superficial dermis
- Steroid ointments and anti-itch agents
16
Q
Linchen Sclerosis
- MC occurs:
- Symptoms?
- Complications:
- Biopsy:
- Treatment
A
- MC occurs: VULVA in MENOPAUSAL women
- Symptoms: Pruritis, dysparenuria, burning pain
- Complication: can progress to SQCC of the vulva
- Biopsy: Hyperkeratosis + Thin epithethlium + hyaline zone in superficial dermis d/t edema and degeneration of collagen + inflamm cells in BM
- Treatment: Clobetasol
17
Q
What findings do you see in linchen sclerosis?
A
- Thin, white, skin that looks like parchment paper
- Figure 8/ key-hole vagina: Loss of labia minor, regression of majora, constriction of hole, clitoris can become inverted/trapped
18
Q
What is seen with lichen planus and what are the sx’s?
A
- Purplish, polygonal papules that look erosive
- Sx’s: vulvar burning, severe insertional dyspareunia
- Tx: topical and systemic steroids
19
Q
What is vulvar-vaginal-gingival syndrome?
A
When linchen planus involves the vulva, vagina and mouth
20
Q
What does a imperforate hymen look like if detected after birth vs after period?
A
- After birth = bulging membrane in opening of vagina that blocks mucus
- After period = thin, blue structure that blocks period blood.
21
Q
Transverse vaginal septums are most commonly found where in the vagina and may only become apparent when?
A
- Upper and middle 1/3 of the vagina
- May only become apparent when sex is impeded bc a small sinus tract or perforation will allow period flow
22
Q
Midline longitudinal vaginal septum creates what?
A
Double vagina
23
Q
What is the most extreme vaginal anomly?
A
Vaginal agenesis = NO vagina except for most distal part that is derived from urogenital sinus.
24
Q
What is Rokintansky-Kuster-Hauser Syndrome?
A
Mullerian agenesis characterizd by NO uterus but SPARES fallopian tubes
25
What is the most common **vulvovaginal tumor**?
**Bartholin's Cyst**
26
**Bartholin's cysts** are typically (uni-/bilateral); how does size dictate symptoms and when must you biopsy?
- Typically **unilateral** swelling
- **\< 3cm** =\> usually asymptomatic
- Need to **biopsy in women 40+ y/o** to rule out a Bartholin's carcinoma!
27
What is **Bartholin Gland Abcess?**
2 Treatment options?
* Infection of Bartholin cysts
* **- Word catheterization**: leave in catheter for 4-6 wks to drain secretions
* **- Marsupialization:** creates a new duct opening by suturing the cyst wall onto vaginal mucosa
28
What 4 structural changes of the vagina can occur over time?
1. **Cystocele (prolapsed bladder)** =\> anterior vaginal prolapse (
2. **Rectocele (prolapsed rectum)** =\> posterior vaginal prolapse
3. **Uterine** **prolapse**
4. **Fistula**
29
**_Vulvar neoplasms_**
* MC type of cancer in vulva
* MC occur in
* MC symptoms
* Which precursor lesion is linked to cancer?
* **Squamous** cell carcinoma of the vulva
* **Pos**tmenopausal women (65YO)
* **Chronic itching**
* **VIN III**
30
What is **VIN III usual**-type vs. **differentiated**-type?
* **- Usual-type**: assoc w/ _HPV (16/18),_ _smoking_, and _immunocompromised_ states; occur in _younger (35-65 y/o)_
* **- Differentiated-type: i**s NOT assoc. w/ HPV or smoking --\> more commonly w/ _vuvlar dermatologic conditions, such as Lichen Sclerosus_; _older (55-85 y/o)_
31
DX and MC treatment for **VIN Type III.**
* **Dx** = biopsy
* **Tx**=
* _Local superficial surgical excision_ (w 5mm margins)
* If small lesions on the clitoris, labia minor or perianal =\> _laser therapy._
32
**Paget's disease** of the vuvla is most common in whom and what are the signs/sx's?
- **Post**menopausal W females
- **Itching** and **tenderness** are common ---\> **map-like lesions:** well-demarcated fiery red background + white plaque-like lesions (looks like eczema)
33
How does **Squamous Cell Vulvar Carcinoma** spread?
1. **Direct extension:** vagina, urethra, anus
2. **Lymph**: regional LN
3. **Blood**: distant sites (lung, liver, bone)
34
What is the management for **SCC** of the **vulva**?
1. - **Radical vulvectomy** and **regional lymphadenectomy**
1. or
2. - **Wide local excision** of the tumor w/ **inguinal LN dissection**
1. or
3. If postive nodes =\> **pre-op radiation**
35
What do the lesions of **verrucous carcinoma of the vuvla** look like; what kind of tx is contraindicated?
- **Cauliflower-like lesions** and can be confused w/ condyloma
**- Radiation = contraindicated** because it may cause anaplastic transformation
36
What is tx for **Batholin's gland carcinoma**?
**Radical vulvectomy** and **bilateral lymphadenectomy** w/ **post-op radiation**
37
When is the diagnosis of **vaginal intraepithelial neoplasia (VAIN)** usually considered?
When an **abnormal pap** in a woman who is status **post-hysterectomy** or has **no cervical lesion**
38
MC type of vaginal cancer?
treatment
* **Squamous cell carcinoma**
* **Radiation** or **chemo radiation;** if lower 1/3 affected =\> remove groin nodes and if upper vagina is involved =\> surgery
39
**Vagina** is lined by what type of epithelium?
**Non-keratinizing** stratified squamous epithelium
40
Describe the NL flora of the vagina
**Lactobacilli** makes _lactic acid_ and _H202_ to keep the pH of the vagina at **(3.8-4.2)** and can protect against STIs.
41
What can alter NL flora of the vagina?
1. **ABX**
2. **Douching**
3. **Sex** (semen can increase to 7.2 for 6-8 hours and vaginal transudate has a pH of 7.4)
4. **Foreign bodies** (retained tampon)
42
**_Vaginal Discharge_**
* Inspect what?
* Use ______ to determine the vaginal pH.
* When collecting sample for **investigation of vaginal discharge** where do you take the sample from?
* Color, smell, texture, amount
* **Nitrazine paper** = pH
* Sample discharge from **posterior fornix** and place on slide
*
43
What is the most common cause of **vaginitis**?
**Bacterial vaginosis (BV),** which is often _polymicrobial_ but **Gardnerella vaginalis** is most common.
44
**_Bacterial Vaginosis_**
* RF
* SX
* **RF** = new/many sex partners, smoking, IUD, douching
* **Sx**=
* 1. Many asymptomatic
* 2. Thin, milky, fishy discharge, ESP after sex
45
Diagnosis of **Gardnerella vaginalis** as cause of vaginitis can be made with what 3 findings?
1. **Saline wet mount** = "clue cells" = epithelial cells covered w bacteria
2. 10% **KOH-positive whiff test**
3. **Vaginal pH \>4.5**
46
What is treatment for **Gardnerella vaginalis**?
## Footnote
Treat other partner?
* **500 mg Metronidazole BID x 7 days**
* No bc **not a STD**
47
**2nd** most common cause of vaginal infections and symptoms
* **Vulvovaginal candiasis** =
* [itching, burning, irritation, dysparenia]
* Often little to no discharge, but if present = white and clump
48
RF for vulvaginal candiasis
1. T2DM
2. ABX
3. Increased estrogen (OCP/pregnancy)
4. Immunosupressed
49
Diagnosis of **vuvlovaginal candidiasis** made via what 2 findings?
1. **10% KOH wet prep** = + for budding yeast (pseudohyphae)
2. **Vaginal pH \< 4.5**
50
Treatment for **vulvovaginal candidiasis**?
- **Diflucan**
- Vaginal application w/ **synthetic imidazoles** (miconazole, terconazole, etc.)
51
Symptoms **T. vaginalis**?
1. **50% are asymptomatic**
2. IF SX:
1. **Green-yellow "frothy" discharge**
2. **Strawberry cervix**
3. Dysparenia, irritation
52
How is diagnosis of T. vaginalis made?
1. **Saline wet mount** reveals motile trichomonads
2. **pH \>4.5**
3. **Strawberry cervix**
53
What is the treatment for **T. vaginalis**; treat partner?
1. **Metronidazole**
2. **YES** bc STD.
54
55
**pH in**
1. - Bacterial vaginosis
2. - Candiasis
3. - Trichomonas
1. \> 4.5 (basic)
2. \< 4.5 (acidic)
3. \> 4.5 (basic
