The vulva is prone to skin infections due to:
constant exposure to secretions, moisture, and friction.
it is also sensitive to hormonal influences.
DNA poxvirus spread through direct contact or shared items like towels or clothing:
MCV - Molluscum contagiosum virus
4 types - MCV-1 is MC
high incidence in children
virus gone when lesions are gone
Waxing and waning inflammatory skin dz with scaling red plaques with silvery scales:
psoriasis
Histological findings of psoriasis:
marked elongation of rete pegs (hyper-proliferative)
marked hyperkeratosis
loss of granular layer
vascular dilatation
non-specific skin condition that is a consequence of chronic pruritus and scratching:
lichen simplex chronicus
may lead to leathery, brownish appearance of skin
mb treated with anti-anxiety meds to stop scratching
histology of lichen simplex chronicus:
thickened epidermis
leukocyte infiltration of the dermis
elongated/widened/thickened rete ridges
skin condition that causes irritation, ulceration, erythema, soreness, burning, and raw areas - on the limbs, trunk, mouth, and vulva:
lichen planus
histology of lichen planus:
degeneration of basal cell layer
thickening of granular cell layer
infiltration of inflammatory cells into sub-epithelial CT
saw-tooth appearance of rate ridges
thickening of the skin of the vulva and peri-anal area which appears pale or white in color:
lichen sclerosus
Which of these is associated with the greatest risk of vulvar cancer -
lichen planus
lichen sclerosis
lichen simplex chronicus
lichen sclerosus - up to 5% of pts
histology of lichen sclerosis:
edematous degeneration of basal layer atrophy of epidermis disappearance of rete ridges dermis replaced by CT band-like lymphocyte infiltrates
Bartholin’s cysts are (common/rare), occur MC in the (young/old/all ages), and result from (hyperplasia/obstruction/atrophy) of the ducts.
common
all ages
obstruction
Bartholin’s cysts are lined by _________ epithelium or by epithelium that shows _________ __________. The predominant organism is:
transitional (normal)
squamous metaplasia
E. coli (infrequently gonococcal)
Bacterial STI’s:
Chalmydia (chl. trachomatis)
Gonorrhea (Neisseria gon.)
Syphilis (treponema pallidum)
Chancroid (haemophilus ducreyi)
Viral STI’s:
HSV 1 & 2 (herpes simplex) HIV HPV (human papilloma) Heb B & C MCV (molluscum contagiosum)
Fungal STI’s:
candidiasis
Parasitic STI’s:
lice (Pthirus pubis)
scabies (Sarcoptes scabieii)
Protozoal STI’s:
Trichomoniasis (Trichomonas vaginalis)
Smears from _______ lesions may reveal characteristic multinucleated giant cells.
Genital herpes (HSV)
the nuclei have a ground-glass appearance
mb nuclear inclusion bodies
gross appearance of MCV:
umbilicated erythematous papules
HPV strains responsible for 90% of genital warts:
6 & 11
HPV strains associated with 70% of cervical cancer:
16 & 18
Most easily recognizable sign of genital HPV infection:
genital warts
(condyloma acuminata)
most people who acquire HPV never develop sx
Histology of HPV:
acanthosis (diffuse epidermal hyperplasia)
hyperkeratosis
cytoplasmic vacuolation
spiral-shaped, gram neg highly mobile bacterium (assoc w/syphilis):
treponema pallidum
Syphilis infection may be characterized by a (painful/painless) (chancre/chankroid).
Painless
chancre
The 3 MC vaginal infections, accounting for 10M office visits per year:
bacterial vaginosis (BV)
trichomonas
candida
Vaginal infection characterized by no odor and low pH:
candida
Vaginal infection characterized by fishy odor and high pH:
BV
trichomonas
The discharge assoc w/candida has a characteristic ________ appearance.
cottage cheese
The discharge assoc w/trich has a ________ appearance.
frothy
Commonly, the only symptoms of BV are:
Histological findings:
discharge and odor
clue cells - epithelial cells coated with bacteria “shimmering”
Characteristic histo findings of trich:
flagellates
Signature characteristic of neisseria gonorrhea:
pathognomonic?
gram neg diplococci
NOT pathognomonic
Vulvar intraepithelial neoplasia (VIN) is characterized by:
the presence of hyper pigmented skin plaques
[varieties of colors - red, white, yellow, multi]
10-30% assoc w/a primary squamous neoplasm
More than 90% of all cases of VIN & assoc cancer contain DNA of which HPV strains?
16, 18, 31, 45
Vulvar carcinoma represents ___% of all genital cancers in women, the majority >____ yrs.
3%
>60yrs
85% of vulvar carcinomas are:
SCC
The less common 15% of vulvar carcinomas are:
basal cell carcinoma
melanoma
adenocarcinoma
Vulvar tumors (assoc w/cancer) often reveal accumulation of:
p53 protein
[noted in papillary serous carcinoma]
T/F: Well differentiated vulvar carcinoma is typically positive for the presence of HPV.
FALSE!
Poorly differentiated reflects greater dysplasia, and is assoc with HPV.
Distal metastases of vulvar carcinoma typically involve:
lungs and liver
Why did adenocarcinomas of the vagina receive special attention?
Because of increased frequency of clear cell adenocarcinoma in young women whose mothers had been treated with diethylstilbestrol (DES) during pregnancy.
Histology of clear cell adenocarcinoma:
vacuolated clusters of tumor cells
gland-like structures
5th most deadly cancer in women, worldwide:
cervical cancer (1st in developing countries)
[8th MC cancer of women in the US/2nd worldwide]
Cervical cancer risks:
- early age of 1st intercourse
- multiple sex partners
- male partner w/multiple prior sex partners
- persistent detection of high-risk HPV (high viral load)
- presence of cancer-assoc HPV strains
- exposure to OCP
- tobacco use
- history of STI
- multiple births
CIN stands for:
and was developed to emphasize:
cervical intraepithelial neoplasia
the spectrum of cellular abnormalities in the development of cervical carcinoma; to standardize description, characterization, treatment
Mild dysplasia:
CIN1 LSIL (low-grade squamous intraepithelial lesions)
Moderate dysplasia:
CIN2
HSIL
Severe dysplasia:
CIN3 (carcinoma in situ)
HSIL
Term to describe cellular changes - enlarged nuclei, stains with a halo-like appearance:
koilocytosis
characteristic of ASC-US
atypical squamous cells of undetermined significance
Condition in which endometrial glands and stroma of the uterus are found and flourish outside the uterine cavity:
endometriosis
MC site - ovaries
Common symptoms and sequelae of endometriosis:
dysmenorrhea chronic pelvic pain dyspareunia infertility pelvic cysts
What is a “chocolate cyst”?
endometrioma - an ovarian cyst formed due to ectopic endometrial tissue that bleeds within the ovary. rupture may lead to peritonitis.
Ectopic endometrial tissue within the myometrium:
appearance:
adenomyosis
thick, spongy myometrial wall (muscular layer of uterus)
leads to uterine enlargement and irreg bleeding
Inflammation or infection of the endometrium:
endometritis
MC cause of endometritis:
childbirth related - d/t retained placental fragments or iatrogenic infx during delivery or abortion
non-childbirth related mb PID
Acute endometritis is characterized by:
micro-abscesses or neutrophils within the endometrial glands
majority of cases are poly-microbial
Gold standard for dx of endometritis:
endometrial biopsy
Chronic endometritis is characterized by:
plasma cells in the stroma
[lymphs, eos, & lymphoid follicles mb seen]
Etiology of chronic endometritis:
infx (typically w/PID)
intrauterine growths
foreign body
tissue damage d/t radiation
1/3 have no identifiable etiology
Infx of the upper genital tract not assoc w/pregnancy or surgery:
PID - pelvic inflammatory dz
aka salpingitis - bc infx of oviducts is MC, and most sequalae result from destruction of tubal architecture.
MC cause of PID infx:
BACTERIA
also mb viral, fungal, or parasitic
rate of infertility 2° to PID:
1 in 4
also 6-10x greater risk of ectopic pregnancy
MC GYN cancer in the US:
endometrial cancer (adenocarcinoma) 35K diagnosed each year
Risk factors for endometrial cancer:
nulliparity obesity (esp abd fat) DM / hyperglycemia HTN peak age - 55-65
Histology to differentiate endometrial adenocarcinoma from hyperplasia:
Glandular architecture is preserved but the tissue is confluent without intervening stroma
Benign smooth muscle tumors of the uterus:
leiomyomas (fibroids)
found in the myometrium of the corpus
Gross appearance of leiomyomas:
discrete well-circumscribed round firm gray-white vary in size
Histology of leiomyomas:
whorled pattern - characteristic
uniform muscle cell size/shape
oval nuclei
Histology of leiomyosarcoma:
greater density of cells more pleomorphism hyperchromatic some cells w/irreg nucleus spindle-shaped cells
T/F: leiomyosarcomas typically form from transition of leiomyomas.
FALSE
transition from the benign to the malignant is uncommon. leiomyosarcomas form independently.
PCOS can develop when the ovaries are stimulated to produce what?
Excessive amounts of male hormones [esp testosterone] by releasing excess LH from ant pituitary.
One of the MC female endocrine d/o’s and causes of infertility.
Sx of PCOS:
hirsutism acne disrupted menses infertility insulin resistance inc wt, cholesterol, trig, hyperglycemia inc incidence of DM
Hallmark lab finding of PCOS:
LH > FSH 3:1 or higher
PCOS found in ___% of women presenting with anovulation.
5-10%
Ultrasound finding in PCOS:
“string of pearls” sign
Over 90% of ovarian cancers are classified as ________ and arise from __________________.
epithelial
the surface of the ovary (or mb fallopian tubes)
Psammoma bodies are:
and are associated with:
small calcifications in the ovaries
ovarian serous cystadenocarcinomas (and other cancers)
Ovarian germ cell tumors often called dermoid cysts:
ovarian teratomas
contain skin, hair, sebum, teeth
The absence of one or both testes from the scrotum:
Cryptorchism
MC birth defect of male genitalia
3% full-term male births
30% premature males births
2/3 unilateral
In ___% of cases of cryptorchism, an undescended testis can be palpated in the inguinal canal.
90%
the remaining minority - in abdomen or nonexistant
2nd MC male birth defect, urethra that involves an abnormally placed urinary meatus:
hypospadias
ventral line
1st degree - cosmetic
1st/2nd degree - surgical repair
3rd degree - test hormones, endocrine, karyotype; intersex?
Rare male birth defect involving urethral opening on the dorsum of the penis:
epispadius
also occurs in females
some of urethra extending beyond external tissue
possibly small or bifid phallus
Condition where foreskin cannot be fully retracted over the glans:
phimosis
Condition where foreskin becomes trapped behind the glans:
paraphimosis
T/F: Both phimosis and paraphimosis are considered risk factor for development of penile cancer.
True
An abnormal enlargement of the vein draining the testicles:
Varicocele
present in ~15% of adult male pop.
largely post-pubertal
incidence increases w/age
98% of idiopathic varicoceles occur on the (left/right).
Left - due to testicular vein connecting to left renal vein at 90deg, vs right testicular vein draining directly into IVC at less than 90deg.
Accumulation of fluids around a testicle caused by fluid secreted by the tunica vaginalis:
Hydrocele
Etiology of hydrocele:
trauma hernia orchitis cancer lymphatic impairement - via chronic infx, parasite
PE to differentiate hydrocele from tumor:
transilluminate (hydrocele WILL transmit light)
Condition that occurs when the spermatic cord twists, cutting off the blood supply to the testicle:
Testicular torsion
MC underlying cause of testicular torsion:
congenital malformation know as “bell-clapper deformity”
typically surface rotates toward midline
In testicular torsion, ischemia may lead to necrosis in ____ hrs.
5-6 hours from onset of pain
may decompress spontaneously
absence of cremasteric reflex
Gonococcal urethritis is caused by:
Neisseria gonorrhoeae
GRAM-NEG DIPLOCOCCI!! :)
both intra- & extra-cellular
Non-gonococcal urethritis (NGU) is MC caused by:
Chlamydia trachomatis
gram-neg obligate intra-cellular bacteria
Triad of sx assoc w/reactive arthritis (Reiter’s syndrome):
- inflammatory arthritis of large jts (SI, knees, back)
- inflammation of the eyes (conjunctivitis, uveitis)
- urethritis in men / cervicitis in women; mucocutaneous lesions
T/F: Reactive arthritis is positive for rheumatoid factor.
False
seronegative for RF
positive for HLA-B27
Reactive arthritis assoc. rash on the soles of feet:
keratoderma blennorrhagica
80-20 rule for HSV:
HSV 1 - 80% oral / 20% genital
HSV 2 - 20% oral / 80% genital
Approx US pop. positive for HSV 1 by 4th decade?
HSV 2?
1 - 65%
2 - 25%
Characteristic histological finding in HSV:
Latent in:
Multinucleated giant cells
HSV 1 - trigeminal ganglia
HSV 2 - sacral ganglia
Histopathology of syphilis:
Treponema pallidum spirochetes
Gross - keratotic lesions, granuloma
Genital warts are caused by:
HPV - 6 & 11
It is estimated that ____ new cases of HPV-assoc penile cancers are dx in the US each year.
95% are:
> 1000
SCC
HPV prevalence in penile cancer:
Predominant strain:
40%
16 - 63%
The MC solid tumor affecting males aged 20–35 yrs:
primary testicular cancer
showing a progressive inc over the past 2 decades
Testicular cancer classifications/prevalence:
Seminoma - 35%
Embryonal carcinoma - 20%
Teratoma - 5%
Mixed cell types - 40%
Avg age of dx of seminoma:
40 years old
MC - mass felt on self-exam / 10-14% have no palpable mass
Blood tests in seminoma reveal:
PLAP (placental alk phosphatase) - 50%
hCG mb elevated
serum alphafetoprotein - not classically elevated
Microscopic eval of seminoma usu reveals:
sheet-like or lobular pattern of cells fibrous stromal network abundant clear to pink cytoplasm abundant glycogen prominent nuclei w/ 1 or 2 lg nucleoli prominent nuclear membrane
Germ cell tumor that occurs in the ovaries and the testes:
Embryonal carcinoma
Avg dx at 31 yrs
10% of testicular germ cell tumors
20-66% of pts have mets at dx
Serology of embryonal carcinoma:
mb elevated hCG & AFP
Histopathology of embryonal carcinoma:
sheets of cells primitive tubules crowded, pleomorphic nuclei primitive epithelial cells nuclear atypia, overlapping prominent nucleoli mitoses common
Encapsulated tumor with tissue or organ components resembling normal derivatives of all three germ layers:
Teratoma
while tissue found is “normal” it is often present in an unexpected location
Review three layers of germ cells:
Mesoderm: immature cartilage
Endoderm: G.I. lining cells/glands
Ectoderm: epidermis with keratin
An inc in the # of prostatic stromal & epithelial cells, resulting in formation of lg, discrete nodules in the periurethral region of the prostate:
BPH
when sufficiently large, nodules compress urethral canal, causing obstruction
T/F: Elevated PSA in BPH reveals an increased risk of cancer.
False.
BPH may elevate PSA levels, d/t organ volume, inflammation, and UTI, but does not increase cancer risk.
A normal prostate is ___ cm in diameter:
3-4 cm
BPH is extremely common in men over ____.
50
Gross appearance of BPH:
enlarged prostate gland
multiple nodules of varying sizes
nodes vary from solid to cystic
partial to complete urethral obstruction
Histopathology of BPH:
glandular > stromal tissue
glands well-differentiated
corpora amylacea - small laminated pink concretions
Histopathology of prostatitis:
numerous small dark blue lymphocytes in stroma, btw glands
T/F: Most prostate cancers are aggressive, fast growing, with lots of symptoms.
False. Although it is one of the most prevalent cancers in men, many remain asx, undergo no therapy, & die of other causes.
However, more aggressive prostate cancers acct for more cancer-related deaths in US men than any other cancer except lung.
95% of prostate cancers are found to be:
adenocarcinoma
T/F: prostatic hyperplasia is a premalignant lesion.
False
