Disorders of the Vulva and Vagina Flashcards
(64 cards)
1
Q
Causes of vaginitis?
A
- bacterial vaginosis
- trichomonas
- candidiasis
2
Q
Normal cell structure of the vulva?
A
- keratinized squamous epithelium, hair follicles, sebaceous glands, sweat glands, apocrine glands
- occasionally contains breast tissue: may swell and become tender after delivery
3
Q
Normal cell structure and flora of the vagina?
A
- nonkeratinized squamous epithelium
- vaginal pH is 4.0-4.5 in premenopausal women
- vaginal flora - lactobacillus and other aerobic and anaerobic bacteria
- normal vaginal secretions: no odor
4
Q
How common are vaginal sxs?
A
- extremely common, account for over 10 million office visits/yr
- many women use OTC products (usually anticandidial tx) w/o ever seeing a provider
5
Q
What are the sxs of vaginitis?
A
- change in volume, color, or odor of vaginal d/c
- pruritus
- burning
- dyspareunia
- dysuria
- spotting
- erythema
- pelvic discomfort
6
Q
Can you determine etiology of vaginitis just by H and P?
A
- no, may mistreat condition
- impt that lab documentation of etiology of vaginitis is determined
- sxs are nonspecific
7
Q
PE of vagintis?
A
careful external exam of vulva:
- in bacterial vaginitis the vulva appears normal
- erythema, lesions or fissures may suggest a dermatitis of the vulva
- may be changes suggesting chronic inflammation
- may detect fb
- note characteristics of d/c
- check cervix for erythema and d/c
- check for vaginal trauma
- bimanual exam to check for cervical motion tenderness and uterine tenderness
8
Q
pH testing for vaginitis?
A
swab with pH swab or dry swab the wall of the vagina, not pooled secretions
- use narrow range pH paper or swab
- premenopausal women= 3.5-4.5
- trichomoniasis= 5.0-6.0
- bacterial vaginosis= greater than 4.5
- candidiasis= 4.0-4.5
- in pregnant women amniotic fluid raises pH
9
Q
Are bacterial cultures of the vagina helpful?
A
- NOPE!
10
Q
What are saline wet mounts for? What will be seen?
A
- eval in 20 min
- see clue cells - bacterial vaginosis
- trichomonads
- increased PMNs- cervicitis
11
Q
What is a KOH used for? What does it reveal? What otehr test is used along with this?
A
- destroys regular cells and reveals hyphae and budding of yeast
- amine test - smelling the slide immediately after adding KOH for fishy smell (BV or trich)
12
Q
What other tests are available for trich and BV?
A
- rapid antigen and nucleic acid tests
13
Q
What is the MC cause of d/c of women of childbearing age? What is the cause of this? Findings on exam?
A
- Bacterial vaginosis (40-50%)
- abnormality of normal vaginal flora: decrease in hydrogen-peroxidase lactobacilli and increase in primarily gram negative rods
- findings on exam:
fishy odor, clue cells, and thin, white/gray, fishy smelling d/c
14
Q
Usual complaint of a pt with BV?
A
- malodorous or copious d/c
- up to 75% of infections may be asx
15
Q
What is the amsel criteria for the dx of BV?
A
at least 3/4 criteria:
- homogenous, thin, grayish white d/c that smoothly coats the vaginal walls
- vaginal pH greater than 4.5
- positive whiff-amine test
- clue cells on saline wet mount, comprising at least 20% of epithelial cells
16
Q
Tx for BV?
A
- TOC: metronidazole oral 500 mg BID for 7 days (no alcohol), or intravaginal (gel) 5g qday for 5 days - clindamycin: oral 300 mg po BID for 7 days intravaginal: 2% cream 5g qday for 7 days ovules 100 mg intravaginal x 3 days clindesses 2%, single intravaginal dose of 5 g
- probiotics as adjunctive therapy may be helpful, sexual partners don’t need to be tx
17
Q
Recurrence rates of BV? How should these be tx?
A
- recurrence rates are high
- may retx with same or different regimen
- women who have 3 or more documented cases of BV in 12 months be offered maintenace therapy - metronidazole gel for 7-10 days then 2x weekly dosing for 4-6 months
- not clindamycin b/c of toxicity
18
Q
2nd MC cause of vaginitis sxs? What are the etiologic agents?
A
- vulvovaginal candidiasis
- accounts for 1/3 of vaginitis cases (not an STI)
- primary etiologic agent: candida albicans, C. glabrata accounts for remainder
19
Q
Pathogenesis of vulvovaginal candidiasis?
A
- organism migrates from the anus to the vagina and colonizes there
- less common sexual or relapse from reservoir in vagina
- infection occurs when there is overgrowth of candida
20
Q
RFs for candidiasis?
A
- DM
- increased estrogen levels (OCP, pregnancy)
- immunosuppression
- abx use (up to 1/3 of women develop it)
21
Q
Dx of candidiasis?
A
- on speculum exam:
thick, white, sometimes cottage cheese d/c.
in severe cases a gray membrane, pH will be 4.0-4.5 - KPH wet mount slide (up to 50% negative)
- in rare cases cultures for candida are indicated:
in multiple recurrent or persistent cases not responsive to tx (may have resistant pathogen), women with normal pH, no visible pathogen on wet mount
22
Q
Education for pt to prevent candidiasis?
A
- keep external genital area clean and dry
- avoid irritating soaps, vaginal sprays, douches
- change tampons and sanitary napkins frequently
- wear loose cotton (rather than nylon) underwear that doesn’t trap moisture
- take abx only when rx and never take them for longer than necessary
23
Q
Tx of uncomplicated candidiasis infection?
A
this includes pts with mild to moderate signs/sxs, have probable infection with C. albicans, pt is healthy and not pregnant
tx:
- many OTC intravaginal txs available and highly effective, women may prefer oral tx:
fluconazole (diflucan) 150mgx1 dose - this can interact with many drugs, stays in vaginal secretions for 72 hrs
24
Q
Tx for complicated candidiasis infection?
A
this includes pts with severe signs/sxs, infection with other C. albicans (usually C. glabrata), pregnancy, DM, immunocompromised, debilitated, hx of verified (more than 4 infections a yr) of vaginal candidiasis
tx:
- fluconazole 150mg 2-3 doses 72 hrs apart, or topical therapy with clotrimazole/miconazole/terconazole for 7-14 days, or intravaginal boric acid tablets for 2 wks (fatal if swallowed) or flucytosine cream intravaginally qhs for 2 wks
25
What is the most common STI worldwide? What type of organism is this? Who does this infect? Sxs?
- Trichomonas vaginitis
- flagellated protozoan (causative agent = trichomonas vaginalis)
- females infections range from asx (50%) to acute, severe, inflammatory disease
- males are generally asx and infection resolves spontaneously 90% of the time (the remainder get typical urethritis sxs)
- women can acquire the infection from men or other infected women, but men can't acquire it from other men
26
Presentation of trichomonas vaginitis?
- malodorous, thin, green/yellow vaginal d/c (70%)
- burning, dysuria, frequency (urethra commonly involved also- presents like a UTI)
- pruritus, dyspareunia, pelvic discomfort
- post-coital bleeding
27
Dx of trichomonas?
- on speculum exam you may see green, malodorous, frothy d/c (less than 10%)
- will see strawberry cervix in 2%
- pH 5-6
- mobile T. vaginalis on wet mount (seen 60-70%)
- can do rapid antigen and nucelic amplification tests (usually available where prevalence is high)
- on males can do PCR test on urine or a urethral swab, trying to look for motile trich has very low yield
28
Tx of trichomonas?
- all women even if asx should be tx if there is an infection
- all partners involved need to be tx and must abstain from sex until finishing abx and are asx
- non-preg females and males:
tinadazole (Tindamax) or metronidazole (flagyl)- 1 time dose of 2 grams (4-500mg pills)
- pregnant females: 2 g dose of metronidazole
- nursing females: 2 g dose of flagyl but pump breast milk and discard for 24 hrs after taking
- HIV pts: 7 day course of either med BID
29
Why do recurrent infections of trichomonas occur? Tx?
- usually due to return to sexual activity too soon and reinfection
- may tx with metronidazole 2g dose again or use 7 day course of 500 mg BID of either drug
- if above fails - can tx with 2 g a day for 5 days
- if still refractory - culture to see if resistant strain
- in general there isn't a 2nd line abx, desensitization is recommended if pt allergic
30
Cause of genital herpes? How common in US? What outbreak is the worst?
- caused by HSV 1 and 2
- among the most ubiquitous of human infections
- HSV-2 affecting 26% of adult females and 18% adult males in US (approx 50 mill)
- much higher in certian pops
- Primary outbreak is the worst episode and recurrent outbreaks are generally less severe
31
Sxs of genital herpes?
- painful genital ulcers and itching
- dysuria
- tender inguinal lymphadenopathy
- may have systemic sxs like HA and fever
32
Dx of genital herpes?
- PE: multiple vesicle on an erythematous base, vulvar swelling, lymphadenopathy
- dx should be confirmed by viral cell culture (Tzanck smear) or PCR
33
Management of genital herpes - primary infection?
- needs to be started w/in 72 hrs for 7-10 days:
acyclovir 400mg TID or 200mg 5x a day
famcyclovir 250mg TID
valocyclovir 1000mg BID
34
Management of genital herpes - recurrent outbreak?
- acylovir: 800 mg BIDx 3 days
- famcyclovir: 1000mg BIDx 1 day
- valocyclovir: 500 mg BIDx 3 days
35
Suppressive therapy for herpes simplex?
- acyclovir 400 mg BID
- famcyclovir 250 mg BID
- valocyclovir 500 mg 1x a day
36
What is the most common viral STI in US? Etiologic agent?
- codylomata acuminata (anogenital warts)
- HPV - serotypes 6 and 11
- as many as 50-75% of sexually active people infected with HPV during their lifetime
- women account for 67% of the affected pop.
37
Clinical manifestations of genital warts?
- pruritus, burning, pain
- bleeding, vaginal d/c
- may have no sxs
- when very large can interfere with defecation and coitus
38
Tx success for genital warts? Indications for tx?
- must inform pt that prolonged tx with frequent f/u is necessary
- clearance of warts is 35-100% but latent HPV can still exist and 20-30% have recurrence
- spontaneous regression occurs up to 40% of cases
indications:
- alleviation of bothersome sxs
- cosmetic
- b/c of obstruction, dyspareunia, or psychological distress
- to decrease risk of transmission
39
When should a bx be recommended for genital warts?
if:
- dx is uncertain
- lesion has suspicous features (irregular or unusual pigmentation)
- pt is postmenopausal or immunocompromised
- lesion is refractory to medical therapy
40
Diff types of tx for genital warts?
chemical destruction:
- podophyllin: must not be used in pregnancy
- trichloracetic acid: highly caustic, can be used in pregnancy
- 5-FU gel is injected into lesions
immunologic:
- imiquimod (aldara): externally applied cream
- interferon alpha - systemic therapy
surgery:
- cryotherapy: liquid nitrogen, or probe cooled with nitrous oxide
- laser therapy: done in operating room with anesthesia
- excisional: knife or scissors, requires anesthesia
41
Can vertical transmission of genital warts occur?
- yes, HPV can manifest in young children as:
| mucosal, conjunctival or laryngeal disease, juvenile-onset respiratory papillomatosis (JRP) is most severe although rare
42
Presentation of mulloscum contagiosum?
- multiple, 1-2 mm raised, painless lesions
- dome shaped with central dimple
- contains cheesy-white material
- can be sexually transmitted
- tx: cryosurgery, bichloracetic acid, dermal curette but will clear on own eventually
43
When does atrophic vaginitis occur? What can be done to tx this?
- can occur in women of any age who experience a decrease in estrogenic stimulation of urogenital tissue
- estrogen stimulation:
maintains a well epithelialized vaginal vault, it acts on receptors in the vagina, vulva, urethra, and trigone of bladder
- maintains the collagen content of epithelium
- keeps epithelial surfaces moist
- maintains optimal genital blood flow
- maintains acidic vaginal pH (w/o estrogen pH would be over 5)
44
Main RFs of atrophic vaginitis?
* *- natural menopause
* *- bilateral oophorectomy
- spontaneous premature ovarian failure
- ovarian failure due to radiation, chemo or surgery
- premenopausal meds with anti-estrogenic effect
- post-partum reduction in estrogen prod. during lacatation
- prolactin elevation
- amenorrhea secondary to suppression of hypothalamic pituitary axis b/c of chronic tx with glucocorticoids
45
Clincal manifestations of atrophic vaginitis?
- vaginal dryness, burning or itching
- decreased lubrication during sex
- dyspareunia
- vulval or vaginal bleeding (post-coital bleeding)
- vaginal d/c
- pelvic pressure or vaginal bulge
- urinary tract sxs - freq., dysuria, and hematuria
46
PE findings of atrophic vaginitis?
- pale, smooth or shiny vaginal epithelium
- loss of elasticity
- sparsity of pubic hair
- introital narrowing
- fusion or resorption of labia minora
- friable, unrugated epithelium of vagina
- shortened, narrowed and poorly distensible vaginal vault
47
Common presentation and findings of pt with atrophic vaginitis?
- 2 yrs since natural menopause
- loss of labial and vulvar fullness
- pallor of urethral and vaginal epithelium
- narrow introitus
- minimal vaginal moisture
- loss of urethral meatal turgor
48
Tx for atrophic vaginitis? Most effective tx?
- indicated if sxs are causing a woman distress
- for vaginal dryness: replens, vagisil, K-Y (use 1-2x a wk)
use lubricants for intercourse: watersoluble (k-y), silicone (Pjur eros)
oil based: elegance women's lubricant
- sexual activity itself may improve vaginal fxn
vaginal estrogen therapy:
most effective, CIs: estrogen dependent tumor
- assoc with urinary tract benefits, usually start with vaginal estrogen therapy: cream, tablet, ring
SE: irritation, bleeding or breast tenderness
- some women need systemic therapy (refer)
- SERM:
ospemifene (osphena)
SE: hot flushes, thromboembolism, endometrial cancer
49
```
lichen sclerosis:
etiology
PP
dx
sx - hallmark?
```
- etiology: may be genetics or autoimmune
- pp: intense inflammatory rxn
- 2 peaks: prepubertal girls and postmenopausal women
- dx: bx
- 4% risk of cancer occurring
-sxs:
vulvar pruritus is hallmark and may be so intense as to interfere with sleep, pruritus ani, painful defecation, anal fissures, dyspareunia
50
Exam findings of lichen sclerosis?
- chronic inflammation
- well-demarcated white, finely wrinkled, atrophic patches
- labia minora often shrink and adhesions of labia majora may cover clitoris
51
Tx for lichen sclerosis?
- clobetasol propionate 0.05% cream for 6-12 wks (topical steroids)
- then for maintenance therapy apply 1-3x/wk
52
How common are bartholin gland disorders? Why is a good DDx needed?
- 2-3% of women develop cysts or abscesses of Bartholin glands
- carcinoma and benign tumors are rare
- many vaginal and vulvar lesions mimic bartholin gland disorders need a good ddx
53
How big are bartholin duct cysts? Sxs? Tx?
- most common large cyst of vulva: 1-3 cm size
- most are asx:
tx not necessray in women less than 40 unless infected or sx
- in women older than 40, bx and drainage is performed to exclude carcinoma
- if cyst is large and not resolving then it can be tx with techniques described for tx an abscess
54
Clinical manifestations of bartholin duct abscess?
- swelling of bartholin gland w/ exquisite pain
- occurs in 2% of women
- on exam: erythematous, warm, tender, and usually fluctuant
- there may be surrounding cellulitis
- infection: usually polymicrobial, STIs less likely but should be tested for in pts who are at higher risk of STIs
Rise in MRSA as etiologic agent
55
Tx of cyst or abscess?
- I&D: lanced at or behind hymenal ring
- place a word cath into cavity: left in place for at least 4 wks
- marsupialization: done under local anesthesia, longer procedure, reserved for pts who fail 1-2 placements of word catheter, complications: hematoma, scarring, and dyspareunia
56
What is a cystocele? Causes?
- prolapsed bladder
- bulging of bladder into vagina
- occurs when supportive tissues and muscles b/t bladder and vagina weaken and stretch - bladder bulges into vagina
- causes:
childbirth
repetitive straining for BM
constipation
chronic or violent coughing
heavy lifting
obesity
57
Tx of cystocele?
- graded - depending on severity
tx:
- watchful waiting, avoid heavy lifting or straining
- kegels to strengthen pelvic muscles
- pessary: silicone medical device placed in vagina that supports vaginal wall and hold bladder in place
- anterior vaginal wall repair (colporrhaphy)
58
What is paget's disease?
- intraepithelial adenocarcinoma
- extramammary disease may involve genital, perianal, and axillary areas: may be an indication of underlying malignancy
- lesions are brick red, scaly, velvety eczematoid plaque with sharp border
- S/S: itching, burning, bleeding
- cellular origin unclear
59
Tx of paget's?
- primary: excision with more than 3 mm border from visible margin
- recurrent disease may be tx with:
radiotherapy
laser
photodynamic therapy
5-FU
imiquimod
- local recurrence rate 31-43%
60
How common is vulvar cancer? RFs?
- 4th MC gyn cancer
- represents 5% of malignancies of female
genital tract
- RFs:
HPV infetion (60%)
smoking
lichen sclerosis
vulvar or cervical intraepithelial neoplasia
immunodeficiency syndromes
prior hx of cervical cancer
Northern European ancestry
61
Clincal manifestations of vulvar cancer?
- unifocal vulvar plaque, ulcer or mass
- in 10% of cases the lesion is too extensive to determine the site of origin
- lesions are multifocal in 5% of cases
- a 2nd malignancy: usually cervical CA is found in up to 22% of pts with vulvar malignancy
- pruritus is common complaint
- many pts are asx: need to inspect
62
Histological types of vulvar cancer?
- squamous cell: over 90% - keratinizing, differentiated or simplex type - more common
may have warty appearance, predom. assoc with oncogenic strains of HPV (found in younger women)
- verrucous carcinoma: variant of squamous cell
- melanoma: 2nd most common vulvar CA
- basal cell carcinoma: 2%
- extramammary paget disease: less than 1%
63
Mode of spread of Vulvar cancer?
- direct extension to adjacent structures
- lymphatic embolization to regional lymph nodes: can occur early
- hematogenous dissemination: occurs late in the disease
64
What is VAIN? Cause? Tx?
- vaginal intraepithelial neoplasia - carcinoma: this is a reason why PAPs should be cont. after hysterectomy
- vaginal squamous cell atypia w/o invasion
- consistently assoc with prior or concurrent neoplasia elsewhere in lower genital tract
- 50-90% of pts with VAIN had or currently have either intraepithelial neoplasia or carcinoma of cervix or vulva
- HPV (types 6, 11)assoc with 80% of VAIN cases
-tx:
laser ablation
local excision
5-FU intravaginal
vaginectomy and skin graft
