Vaginal and vulvar disorders

Question 1

Vulvar itching + dyspareunia
Postmenopausal
Thinning of the epidermis and sclerosis/fibrosis of dermis
High risk of squamous cell carcinoma

Answer 1

lichen sclerosus

Question 2

PE: Porcelain-white plaque with red/violet border with epidermis “parchment-like”

Answer 2

lichen sclerosus

Question 3

how do you treat lichen sclerosus?

Answer 3

Steroid ointments to reduce itching

Question 4

Itch-scratch cycle

Hyperplasia of vulvar squamous epithelium from chronic irritation or scratching
– totally benign

Answer 4

lichen simplex chronicus

Question 5

PE: leukoplakia, thick and leathery

Answer 5

lichen simplex chronicus

Question 6

how do you treat lichen simplex chronicus?

Answer 6

Steroid ointments to reduce itching

Question 7

Females of reproductive age
Duct gets blocked – cystic dilation from mucus plug, STI (gonorrhea)

Answer 7

bartholin’s duct cyst and abscess

Question 8

how do you treat a bartholins duct cyst and abscess?

Answer 8

Drainage of infected cyst or abscess, antibiotics, excision

Question 9

Burning, rawness, irritation, dryness, hyperpathia (pain provoked by very light touch)

Vulvar pain syndrome = vulvar pain in absence of relevant visible physical findings = vulvodynia (2 types)

Answer 9

vestibular disease (vestibulitis)

Question 10

Pure (without concomitant vulvovaginitis) or complicated (with recurrent vulvovaginitis) With or without continuous vulvar pain
20-30 years

Answer 10

localized vulvodynia (vestibulodynia)

Question 11

Primary – pain since first attempt
Secondary – pain after initial period of pain-free intercourse

Answer 11

localized vulvodynia (vestibulodynia)

Question 12

Clinical criteria:
1 Introital pain on vestibular or vaginal entry
2 Vestibular tenderness (from cotton-tip application at site)

Biopsy not required

Answer 12

localized vulvodynia (vestibulodynia)

Question 13

How do you treat localized vulvodynia (vestibulodynia)

Answer 13

Start with simple measures and re-evaluate every 3 months:
Pelvic floor PT with biofeedback, vulvar hygiene, topical application of lidocaine cream, soothing oils, estrogen if menopausal
After 3 months of no improvement: oral or topical treatment with TCA, pregabalin, gabapentin

Still no improvement = surgical therapy by vulvar vestibulectomy with vaginal advancement

Question 14

Constant pain and burning
60s, HTN
Unknown etiology with pain involving larger area

Answer 14

generalized unprovoked vulvodynia

Question 15

Definitive diagnosis with exclusion of other causes
Cotton swab test is negative

Answer 15

generalized unprovoked vulvodynia

Question 16

how do you treat generalized unprovoked vulvodynia

Answer 16

Oral TCA (amitriptyline)
Initial relief expected after a few weeks
Topical local anesthetics

Question 17

Vaginal irritation, pain, pruritus, unusual or malodorous discharge

Inflammation and infection of vagina from infection, allergic reaction, vaginal atrophy, friction
Normal pH <4.5
Predominant organism: lactobacillus

Answer 17

vaginitis

Question 18

PE: inspection, speculum, bimanual

LABS: gonorrhea, chlamydia, yeast, vaginosis, trich, pH
pH >4.5 = trich and BV

Answer 18

vaginitis

Question 19

Intense vulvar pruritus, white cheesy vaginal discharge, vulvar erythema, burning with urination

Answer 19

candidiasis

Question 20

Candida albicans and may be associated with systemic disorder, pregnancy, medication, chronic debilitation
Prevent with nonabsorbent undergarments, keep area dry, control underlying metabolic diseases

Answer 20

candidia

Question 21

Wet prep: pH will be normal and pseudohyphae (c. albicans)

Gold standard: culture of vaginal discharge

Answer 21

candida

Question 22

how do you treat candida?

Answer 22

fluconazole

Question 23

“Fishy” vaginal discharge more noticeable after unprotected intercourse

Milky, homogenous, malodorous, nonirritating discharge

Worse after sex and menses

Answer 23

bacterial vaginosis

Question 24

MCC of symptomatic bacterial infection in reproductive-aged women

Amsel’s criteria – 3 of the 4 must be met:
Homogenous gray-white vaginal discharge
Fishy odor when KOH is applied (whiff)
Presence of clue cells >/= 20%
Vaginal pH >4.5

Answer 24

bacterial vaginosis

Question 25

how do you treat bacterial vaginosis?

Answer 25

Metronidazole, clindamycin

Question 26

Prolonged vulvar irritation with pruritus, local discomfort, slight bloody discharge Asymmetric, irregular borders, large size, open sore that doesn’t heal, red or white ulcerative/raised crusted lesion Enlarged lymph nodes in groin

Answer 26

vulvar cancer

Question 27

>50, multiple sexual partners (early age at 1st sex, smoking, immunocompromised) Long-standing lichen sclerosus HPV are risks for:

Answer 27

vulvar cancer

Question 28

Squamous lesions –Benign: LSIL (treated like anogenital warts) –Premalignant: HSIL (HPV 16 + 18), dVIN (vulvar dermatoses, precursor for majority of vulvar cancers)

Answer 28

vulvar cancer

Question 29

Early = non-neoplastic epithelial disorders Late = mass, exophytic growth, firm/ulcerated area in vulva Biopsy any atypical vulvar lesions → Skin punch specimens Colposcopy can help identify areas to biopsy and treatment

Answer 29

vulvar cancer

Question 30

how do you treat vulvar cancer?

Answer 30

Radical local excision, lymphadenectomy Radiation, chemo, both

Question 31

Vulvar warts + abnormal pap smear Generally asymptomatic isolated or multifocal, loss of epithelial cell maturation and often accompany HPV infection

Answer 31

preinvasive disease of vagina

Question 32

Colposcope examination of vagina with directed biopsy in---

Answer 32

preinvasive disease of vagina

Question 33

how do you treat preinvasive disease of vagina?

Answer 33

Surgical excision or CO2 laser ablation, vaginectomy if multifocal disease

Question 34

Ulcerative, exophytic, direct invasion of bladder/rectum may occur **Postmenopausal vaginal bleeding/postcoital bleeding** Vaginal discharge, vaginal mass, urinary symptoms, constipation, pelvic pain Abnormal bleeding

Answer 34

vaginal cancer

Question 35

Smoking, HPV, multiple sexual partners, history of lower genital tract neoplasia >60 lead to risk of

Answer 35

vaginal cancer

Question 36

MCC: Squamous cells Secondary is much more common than primary (from cervical) Also adenocarcinomas (young), melanomas

Answer 36

vaginal cancer

Question 37

Iliac lymph nodes inflamed Biopsy is definitive CT or MRI to check for metastasis May need IV pyelogram, cystoscopy, proctosigmoidoscopy, CT scan Most common site = posterior wall of upper ⅓ of vagina

Answer 37

vaginal cancer

Question 38

how do you treat vaginal cancer?

Answer 38

Surgery, radiotherapy, chemotherapy

Question 39

hernia of bladder causing soft anterior fullness

Answer 39

cystocele

Question 40

herniation of terminal rectum into posterior vagina, “collapsible pouch-like” fullness

Answer 40

rectocele

Question 41

vaginal vault hernia containing small intestine, posterior vagina, deeping of rectouterine pouch

Answer 41

enterocele

Question 42

Multiparous women, vaginal birth, genetic predisposition, advancing age, prior pelvic surgery, connective tissue, increased intra-abdominal pressure are risks for

Answer 42

pelvic organ prolapse

Question 43

how do you treat a pelvic organ prolapse?

Answer 43

Supportive - high fiber diet, laxatives, weight reduction + limitation of straining and lifting, pelvic muscle training, pessaries Surgical measures - vaginal or abdominal hysterectomy, restoring apical support, reserved until after completion of childbearing Refer