The vagina and vulva

Question 1

What epithelium lines the vagina?

Answer 1

Squamos

Question 2

What is found posterior to the vagina?

Answer 2

upper 1/3 is the pouch of douglas and lower 2/3s is the rectum

Question 3

What is the lymph drainage from the vagina?

Answer 3

inguinal lymph nodes - femoral - external iliac- mets spread

Question 4

What symptoms are linked to the vulva?

Answer 4

Pruritis, soreness, burning, superficical dyspareunia

Question 5

Which infections can occur at the vulva?

Answer 5

Candidiasis +/- vaginal discharge, diabetes, systemic disease. Vulval warts- condylomata acuminate. pubic lice, scabies, HSV, syphillis, donovanosis

Question 6

What is donovanosis?

Answer 6

Bacterial infection with klebsiella granulomatis causing ulcerative genital lesions.

Question 7

Which derm diseases are seen at the vulva?

Answer 7

Eczema and psoriasis

Question 8

Which condition is thickening of the skin of the vulva with scaling that arises secondary to repetitive scratching or rubbing seen?

Answer 8

Lichen simplex

Question 9

What treatment can be given to relieve lichen simplex?

Answer 9

Emollients, steroid creams, antihistamines and pt advised to avoid soap contact.

Question 10

In which condition is erythematous, inflammed, scaly, well-demarcated, lichenified, firm, rough plaques, exaggerated skin lines with hyperpigmentation and maybe a cutaneous horn seen?

Answer 10

Lichen simplex

Question 11

In which condition is white thickening of the skin of the vulva seen?

Answer 11

Lichen sclerosis

Question 12

Which condition presents with thin vulval epithelium (due to loss of collagen) with lesions that appear small, flat and of a white/ivory colour?

Answer 12

Lichen sclerosis

Question 13

In which condition is the affected vulva skin unbearably itchy (pruritis vulvae) and/ or vulvodynia (sore) sometimes with bruises, blood blisters and ulcers appear after scratching or on their own?

Answer 13

Lichen sclerosis

Question 14

Which conditions are associated with lichen sclerosis?

Answer 14

Autoimmune disease, thyroid disease and vitiligo

Question 15

Which vulval disease is associated with a lack of collagen?

Answer 15

Lichen sclerosis

Question 16

What percent of patients are at risk of developing vulvar carcinoma which presents with a slowly-growing lump or sore that doesn’t heal?

Answer 16

5%

Question 17

Which rash of the vulva is chronically recurrent and is due to inflammation?

Answer 17

Lichen planus

Question 18

Which disease of the vulva is characterised by small, flat- topped, many sided (polygonal) bumps/papules- purplish in colour that can grow together into rough scaly plaques on the skin.

Answer 18

Lichen planus

Question 19

Which condition of the vulva has flat topped lilac or violet spots a few millimeters in diameter on the skin?

Answer 19

Lichen planus

Question 20

Apart from the vulva, what else can lichen planus affect?

Answer 20

Hair, nails, mucous membranes

Question 21

Where is donovanosis commonly found?

Answer 21

It is an STI commonly found in tropical, and subtropical areas such as Southeast India, Guyana and New Guinea

Question 22

How is candidiasis commonly seen in?

Answer 22

Patients with diabetes, pregnant women, women using antibiotics and those with compromised immunity.

Question 23

What are bartholins glands and what is their function?

Answer 23

2 glands behind the labia minora which secrete lubricating mucus for coitus.

Question 24

What infection is commonly seen when the ducts of bartholins glands become blocked and form cysts/abscesses?

Answer 24

Staph a and e.coli

Question 25

How are bartholins cysts treated?

Answer 25

Incision, drainage and marsupialization

Question 26

What is marsupialization?

Answer 26

Surgical technique of cutting into a cyst and suturing the edges of the slit to form a continuour surface from the exterior to the interior of the cyst, the cyst remains open and can drain freely. This is used to treat a cyst that a single draining would not be effective for and complete removal of the surrounding structure would be undesirable.

Question 27

What is the name of the surgery which can treat an introital tear?

Answer 27

Fentons procedure

Question 28

What causes introital damage?

Answer 28

Over tightening due to incorrect perineal repair or extensive scar tissue. Commonly follows childbirth

Question 29

What are the symptoms of VIN?

Answer 29

Puritis, pain and change in appearance of the skin- popular, white areas

Question 30

What type of VIN is most usually seen?

Answer 30

HPV 16-18.

Question 31

What type of lesion is seen in VIN, hpv 16-18?

Answer 31

A warty, basaloid lesion

Question 32

The other type of VIN- the differentiated type, commonly develops more often in women with what condition?

Answer 32

Lichen sclerosis. It is also keratinizing.

Question 33

Which type of VIN is the major cause of vulval cancer in women over 45?

Answer 33

Differentiated type

Question 34

How do you treat VIN?

Answer 34

Alleviate the pain and itching and with high grade VIN: local incision, laser therapy, topical immunomodulators such as imiquimod (also used to treat genital warts and acitinic keratinosis)

Question 35

What is the pathology of 95% of vulval carcinomas?

Answer 35

squamous cell carcinomas

Question 36

What is the pathology of 5% of vulval carcinomas?

Answer 36

Melanomas, BCC, adenocarcinomas, sarcomas

Question 37

What are the causes of vulval carcinoma?

Answer 37

VIN, de novo, lichen sclerosis, immunosuppression, smoking and pagets

Question 38

What are the clinical features of vulva cancer?

Answer 38

Pruritis, bleeding, discharge and a mass

Question 39

On examination of a vulval carcinoma, what is likely found?

Answer 39

Ulcer/mass/hard enlarged immobile inguinal nodes

Question 40

How does vulval cancer spread via lymph?

Answer 40

superficial inguinal nodes to deep inguinal nodes to femoral- externam iliac

Question 41

How is stage 1 vulval cancer described?

Answer 41

Its a tumour less than 2cm with no nodal involvement 1a- stromal invasion -<1mm 1b- stromal invasion >1mm

Question 42

How is stage 2 vulval cancer described?

Answer 42

Tumour more then 2cm with no nodes

Question 43

How is stage 3 vulval cancer described?

Answer 43

Spread beyond vulva, periuneum to urethra, vagina, anus. Nodes only affected unilaterally

Question 44

How is stage 4 vulval cancer described?

Answer 44

Tumour is in rectum, bladder, bone or distant mets. Nodes are affected bilaterally

Question 45

What is the treatment for vulval cancer?

Answer 45

Stage 1a- wide local excision, no lymphadenectomy Other stages- wide local excision and groin lymphadenectomy Radiotherapy is used on large tumours to shrink down

Question 46

Which carcinoma of the vagina is commonly seen is late teenage years and is related to children of women who were given DES during pregnancy in the 1950s?

Answer 46

Clear cell adenocarcinoma

Question 47

What are the symptoms of primary vaginal carcinoma and who is it seen in?

Answer 47

Older women and its squamous with bleeding, discharge, a mass and maybe an ulcer common symptoms.

Question 48

What is the treatment for primary vaginal carcinoma?

Answer 48

Vaginal radiotherapy. radical surgery.

Question 49

Where does secondary vaginal cancer usually originate?

Answer 49

Cervix, endometrium and vulva

Question 50

What type of discharge is commonly associated with TV?

Answer 50

Offensive, yellow/green, frothy discharge Vulvovaginitis Strawberry cervix

Question 51

What type of discharge is associated with BV?

Answer 51

Offensive, thin, white/grey, 'fishy' discharge | Next question

Question 52

What type of discharge is associated with candida?

Answer 52

'Cottage cheese' discharge Vulvitis Itch

Question 53

In which two conditions is cervical excitation found?

Answer 53

Ectopic and PID