EXAM #1: VULVAR & VAGINAL DISEASE

Question 1

What is the differential diagnosis for vulvovaginitis?

Answer 1

1) Bacterial vaginosis
2) Candida
3) Trichomoniasis
4) Atrophic vaginitis (elderly)

Question 2

What two causes of vulvovaginitis will cause an increase in vaginal pH?

Answer 2

1) Bacterial vaginosis

2) Trichomoniasis

Question 3

What is the wet mount finding that is pathognomonic for Bacterial Vaginosis?

Answer 3

Clue cells

Question 4

What are the findings that are diagnositc for Bacterial vaginosis?

Answer 4

1) Gray discharge
2) pH greater than 4.5
3) Positive whiff test
4) Clue cells on wet mount

Question 5

How is Bacterial vaginosis treated?

Answer 5

1) Oral metronidazole

2) Topical Clindamycin

Question 6

Why is Candidiasis more common in younger women?

Answer 6

Infection requires estrogen

Question 7

How will wet mount appear in Candidiasis?

Answer 7

Blastosphores or pseudohyphae

Question 8

What are the classic findings in Candidiasis?

Answer 8

1) Odorless cottage-cheese like discharge

2) pH between 4-5 (normal)

Question 9

What is the treatment for Candidiasis?

Answer 9

1) Vaginal application of an imidazole
2) Oral dose of fluconazole
3) Nystatin can be used in PREGNANCY

Question 10

How does a yeast infection that is positive for T. glabrata alter the treatment regimen?

Answer 10

• Resistant to all azoles; must treat with:
  1) Boric acid
  2) Gentian violet

Question 11

What are the clinical manifestations of Trichomoniasis?

Answer 11

1) Foul-smelling green-yellow discharge
2) pH greater than 4.5
3) “Strawberry cervix”

Question 12

How is Trichomoniasis identified on wet mount?

Answer 12

Mobile flagellates on wet mount

Question 13

If you are going to diagnose a patient with Trichomoniasis, what else do you need to screen them for?

Answer 13

STIs i.e. Chlamydia and N. gonorrhea

Question 14

How is Trichomoniasis treated?

Answer 14

Oral metronidazole (treat partner as well)

Question 15

What is atrophic vaginitis?

Answer 15

Atrophy of the vagina in elderly women due to decreased estrogen

Question 16

How is atrophic vaginitis treated?

Answer 16

Topical or oral estrogen

Question 17

What is Linchen Sclerosis? What is the classic presentation of Linchen Sclerosis?

Answer 17

• Thinning of the epidermis and fibrosis of the dermis of the vulva
• Presents with leukoplakia and “parchment-like” vulvar skin

Question 18

How is Linchen Sclerosis treated?

Answer 18

1) Biopsy to rule out neoplasia*
2) Treat any secondary infections (yeast)

*Long-standing linchen sclerosis can lead to vulvar carcinoma in elderly women

Question 19

What are the general care measures for Linchen Sclerosis?

Answer 19

1) Cotton underwear
2) No tight/occlussive clothing
3) No soap to vulva

Question 20

What is the initial pharmacologic treatment for Linchen Sclerosis?

Answer 20

1) Superpotent steroid ointment taper

2) Oral steroids

Question 21

What is Lichen Simplex Chronicus (LSC)? How does LSC classically present?

Answer 21

• This is hyperplasia of the vulvar squamous epithelium
• Presents with thick leathery vulvar skin
• Associated with chronic irritation and itching/ scratching

Question 22

How is LSC treated?

Answer 22

1) Discontinue any irritants
2) Oral antipruritic med (diphenhydramine) w/ moderate strength steroid cream
3) Trial of oral anti-depressant

Question 23

If LSC does NOT improve, what do you need to do?

Answer 23

Vulvar biopsy to rule out neoplasia

Question 24

What is Lichen Planus?

Answer 24

Cell-mediated immune response of unknown origin that causes a desquamative lesion of the vagina

Question 25

Aside from itching, what else is Lichen Planus associated with?

Answer 25

1) Insertion pain | 2) Profuse vaginal discharge

Question 26

How is Lichen Planus diagnosed?

Answer 26

Biopsy

Question 27

How is Lichen Planus treated?

Answer 27

1) Topical steroid cream | 2) Intravaginal hydrocortisone/ suppository

Question 28

What is Psoriasis?

Answer 28

Excessive keratinocyte proliferation causing salmon-color plaques with silver scale *Autosomal dominant

Question 29

When Psoriasis is suspected in the vagina, what is the clinical clue to the diagnosis?

Answer 29

Psoriasis in other areas

Question 30

How is Psoriasis treated?

Answer 30

1) Topical coal tar followed by UV light | 2) Topical steroid "Betamethasone"*

Question 31

What are the two types of eczema?

Answer 31

1) Exogenous= irritant and contact dermatitis | 2) Endogenous= atopic dermatitis

Question 32

How is exogenous eczema treated?

Answer 32

Remove the offending agent

Question 33

What is Seborrheic Dermatitis?

Answer 33

Chronic inflammation of the sabecous glands in the vagina

Question 34

How does Seborrheic Dermatitis present?

Answer 34

- Pale red to yellow-pink | - Oily appearing and scaly crust

Question 35

How is vulvar dermatitis treated?

Answer 35

1) Remove offending agent 2) Good perineal hygiene 3) Aluminum acetate solution 4) Topical corticosteroids 5) Oral antipruritic agents

Question 36

What are sebaceous cysts?

Answer 36

- Blockage of the sebaceous gland duct resulting in a cysts - Small nodular mass with a cheesy sebaceous material inside *Treatment is excision

Question 37

What is a cyst of the Canal of Nuck?

Answer 37

Hydrocele i.e. fluid collection in the round ligament of the uterus that inserts into the labia majora *Treatment is excision

Question 38

What are the premalignant conditions of the vulva?

Answer 38

1) Pagets Disease | 2) Vulvar Intraepithelial Neoplasia (VIN)

Question 39

What are the clinical manifestations of Paget's Disease?

Answer 39

Erythematous, pruritic, ulcerated vulvar skin *More common in women over 60

Question 40

How is Paget's Disease diagnosed?

Answer 40

Biopsy

Question 41

How is Paget's Disease treated?

Answer 41

Wide local excision

Question 42

What is VIN?

Answer 42

Vulvar Intraepithelial Neoplasia - Precursor to vulvar carcinoma - Often high-risk HPV related

Question 43

How is VIN diagnosed? What major diagnoses are you trying to differentiate between?

Answer 43

Colposcopy and biopsy *Need to rule out melanoma

Question 44

How is VIN treated?

Answer 44

1) Laser excision 2) Wide local excision 3) Follow-up frequently b/c of high recurrence rate Colposcopy every 6 months until disease free for 2 years; then annual

Question 45

What is the most common cell-type of vulvar cancer?

Answer 45

Squamous cell carcinoma (85-90%)

Question 46

Where is vulvar cancer typically found?

Answer 46

Labia major

Question 47

What are the risk factors for Vulvar Cancer?

Answer 47

1) Post-menopausal 2) CIN, VIN, HPV 3) Smoking 4) Immunosuppression 5) Hx. of cervical cancer

Question 48

How is vulvar cancer diagnosed?

Answer 48

Biopsy

Question 49

How is vulvar cancer treated?

Answer 49

1) Wide local excision plus ipsilateral inguinal lymph node dissection 2) Pelvic radiation if positive mets to nodes

Question 50

What is VAIN?

Answer 50

Vaginal Intraepithelial Neoplasia *This is the precursor to vaginal carcinoma

Question 51

How is VAIN diagnosed?

Answer 51

1) PAP smear 2) Colposcopy 3) Biopsy

Question 52

What is the treatment for VAIN?

Answer 52

1) Local resection 2) Laser ablation (no sample for pathology) 3) 5-FU (chemotherapy cream w/ a lot of adverse effects)

Question 53

What is the proper follow-up for VAIN?

Answer 53

Colposcopy every 6 months until disease free for 2 years; then annual

Question 54

What is the most common type of vaginal cancer?

Answer 54

SCC *Associated with extension from the cervix

Question 55

What is clear cell adenocarcinoma associated with?

Answer 55

In utero exposure to DES

Question 56

What is the treatment for Stage I or II vaginal cancer?

Answer 56

Surgical resection

Question 57

What is the treatment for Stage III or IV vaginal cancer?

Answer 57

Radiation