Lecture 8: Benign and Malignant Conditions of the Vulva and Vagina

Question 1

Androgen insensitivity syndrome (46,XY) is most commonly inherited how?

Answer 1

X-linked recessive

Question 2

Which disease is characterized by severe pruritic raised yellow retention cysts in the axilla and labia majora and minor resulting from keratin-plugged inflammation of apocrine glands?

Answer 2

Fox-Fordyce disease

Question 3

What is the most common type of genital cyst?

Answer 3

Epidermal inclusion cyst = mobile, nontender, spherical, and slow growing

Question 4

Sebaceous cysts of the vulva are most commonly found where and contain what?

Answer 4

• Inner surface of labia minora and majora
• Contain a cheesy sebaceous material

Question 5

What is the most common benign solid tumor of the vulva; what are its growth characteristics?

Answer 5

• Fibromas
• Slow growing, most range from 1-10cm
• CAN become gigantic (250 lbs!!!!)

Question 6

Which condition of the vulva is assoc. w/ 1-4mm erythematous dots that are extremely tender and is characterized by severe introital dyspareunia and occasional vulvar pain?

Answer 6

Vulvar vestibulitis (vestibular adenitis)

Question 7

What is the treatment for labial agglutination?

Answer 7

Estrogen cream and massagetoseparatethelabia majora

Question 8

Vuvlvar hematomas most often arise following what; how are they managed?

Answer 8

• Arise following trauma i.e., bike injuries (straddle injury), birth trauma or sexual assault
• Close observation and occasional surgical exploration may be warranted

Question 9

Atrophic vaginitis is due to what; managed how?

Answer 9

• Due to loss of estrogen
• Tx w/ topical estrogen and may consider oral estrogen to prevent recurrence

Question 10

Treatment for lichen simplex chronicus?

Answer 10

Moderate strength steroid ointments w/ anti-pruritic agents

Question 11

Biopsy of lichen sclerosis will show what 2 major characteristics?

Answer 11

• THIN epithelium
• Loss of rete ridges and inflammatory cells lining the BM

Question 12

What is seen with lichen planus and what are the sx’s?

Answer 12

• Purplish, polygonal papules that may appear in an erosive form
• Sx’s: vulvar burning, severe insertional dyspareunia
• Tx: topical and systemic steroids

Question 13

Transverse vaginal septums are most commonly found where in the vagina and may only become apparent when?

Answer 13

• Upper and middle thirds of the vagina
• May only become apparent when intercourse is impeded

Question 14

Mullerian agenesis characterizd by absence of the uterus but sparing of the fallopian tubes is known as what?

Answer 14

Rokintansky-Kuster-Hauser Syndrome

Question 15

What is the most common vulvovaginal tumor?

Answer 15

Bartholin’s Cyst

Question 16

Bartholin’s cysts are typically (uni-/bilateral); how does size dictate symptoms and when must you biopsy?

Answer 16

• Typically unilateral swelling
• <3cm is usually asymptomatic
• Need to biopsy in women 40+ y/o to rule out a Bartholin’s carcinoma!

Question 17

What are 2 treatment options for bartholin’s gland abscess?

Answer 17

• Word catheterization: left in for 4-6 wks which promotes an epithelialized tract for drainage of glandular secretions
• Marsupialization: creates a new duct opening by everting the cyst wall onto the epithelial surface where it is sutured w/ interrupted absorbable sutures

Question 18

What is the most frequently reported symptom of vuvlar cancer?

Answer 18

Long history of chronic vulvar pruritus

Question 19

What is VIN III usual-type vs. differentiated-type?

Answer 19

• Usual-type: assoc w/ HPV (16/18), smoking, and immunocompromised states; younger (35-65 y/o)
• Differentiated-type: is NOT assoc. w/ HPV or smoking –> more commonly w/ vuvlar dermatologic conditions, such as Lichen Sclerosus; older (55-85 y/o)

Question 20

Paget’s disease of the vuvla is most common in whom and what are the signs/sx’s?

Answer 20

• Postmenopausal white females
• Itching and tenderness are common —> well-demarcated and eczematoid in appearance w/ fiery red background w/ white plaque-like lesions

Question 21

How is VIN type III managed clinically?

Answer 21

• Local superficial surgical excision is mainstay of tx; 5mm margins are typically adequate
• Can do skinning vulvectomy
• Laser therapy is useful for small lesions on clit, labia minora or perianal areas

Question 22

What is the management for SCC of the vulva?

Answer 22

• Radical vulvectomy and regional lymphadenectomy

or

• Wide local excision of the 1’ tumor w/ inguinal LN dissection +/- pre-op radiation, chemo, or both

Question 23

What do the lesions of verrucous carcinoma of the vuvla look like; what kind of tx is contraindicated?

Answer 23

• Lesions are cauliflower-like and can be confused w/ condyloma
• Radiation = contraindicated because it may induce anaplastic transformation

Question 24

What is tx for Batholin’s gland carcinoma?

Answer 24

Radical vulvectomy and bilateral lymphadenectomy w/ post-op radiation

Question 25

When is the diagnosis of vaginal intraepithelial neoplasia (VAIN) usually considered?

Answer 25

When an **abnormal** **pap** in a woman who is status **post-hysterectomy** or has **no** demonstrable **cervical lesion**

Question 26

What is the main method of treatment for carcinoma of the vagina?

Answer 26

**Radiation** or **chemoradiation**

Question 27

When collecting sample for investigation of vaginal discharge where do you take the sample from?

Answer 27

Sample discharge from **posterior fornix** and place on **slide**

Question 28

Diagnosis of *Gardnerella vaginalis* as cause of vaginitis can be made with what 3 findings?

Answer 28

- Saline **wet mount** reveals presence of **"clue cells"** - **10% KOH-positive whiff test** - Vaginal **pH \>4.5**

Question 29

What is treatment for *Gardnerella vaginalis?*

Answer 29

**Metronidazole** **BID x 7 days**

Question 30

Sx's and characteristics of the discharge assoc. w/ vuvlovaginal candidiasis?

Answer 30

- Vulvar **itching**, **burning**, irritation/**dyspareunia** - Often little to no discharge, but if present is **white adherent** and **clumpy (cottage cheese-like)**

Question 31

Diagnosis of vuvlovaginal candidiasis made via what 2 findings?

Answer 31

- 10% KOH wet prep-**positive** for **budding yeast** - Vaginal **pH \<4.5**

Question 32

Treatment for vulvovaginal candidiasis?

Answer 32

- **Diflucan** - Vaginal application w/ synthetic **imidazoles** (miconazole, terconazole, etc.)

Question 33

What is the vaginal discharge like w/ symptomatic *T. vaginalis?*

Answer 33

**Green-yellow "frothy"** discharge

Question 34

How is diagnosis of *T. vaginalis* made?

Answer 34

- Saline wet mount reveals **motile trichomonads** - **pH \>4.5** - **Strawberry cervix**

Question 35

What is the treatment for T. vaginalis; must also evaluate for what?

Answer 35

- **Metronidazole** - Is an **STD**, so test pt for **STI's** and have **partners** evaluated too!