Vulva, Vagina, Cervix - Dobson Flashcards by Andrew Herrmann

Vagina is itchy, red, swollen, with a thick white discharge

Diagnostic test?
pH?

Candidiasis

KOH test - pseudohyphae or pseudospores

Normal pH (4.0 - 4.5)

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Vulvovaginal candidiasis - what can be assumed?

Causes?

Disturbance in microbial ecosystem or neutrophils or T-helper cells

DM, antibiotics, pregnancy, OCPs, immunodeficiency (cancer, transplant, HIV), burns, indwelling catheter

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Painful vesicles w/ purulent exudate on vulva that become ulcers rimmed by inflammatory infiltrate, fever, headache, myalgia, tender inguinal LNs

Viral inclusions w/ ground-glass appearance

HSV-2 genital herpes

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2 ways HSV-2 can be transmitted

Sexual, perinatal

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Describe HSV-2 infection and recurrences

Replicate in skin/mucous membranes at entry, causing infectious virions and vesicular lesions
Viruses spread to LUMBOSACRAL GANGLIA (sensory neurons) and lie dormant
Infection recurs in immunocompetent or immunocompromised for various reasons

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Immunocompromised + HSV recurrence…potential presentations

Meningitis, hepatitis, pneumonitis

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Baby is born with lymphadenopathy, splenomegaly, encephalitis, necrotic foci throughout body

Prognosis?

Neonatal HSV-2 (TORCH infection)

Poor (high mortality rate)

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Things that can trigger HSV recurrence in immunocompetent person

Stress, trauma, hormones, temperature extremes, UV radiation

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Men vs. women - symptomatic w/ HSV?

Men - ALWAYS

Women - 1/3

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Yellow, frothy vaginal discharge, pain, painful urination, painful intercourse (dyspareunia)

What to expect on full exam?

Trichomonas vaginalis

Fiery red vaginal/cervical mucosa (inflammation) (STRAWBERRY CERVIX)

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Large, flagellated ovoid protozoan

Trichomonas vaginalis

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Thin, green-gray, malodorous (fishy) vaginal discharge, no inflammation

Bacteria type?

Test?

Gardnerella vaginalis

Gram-negative bacillus

Whiff test (enhances fishy odor)

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Pap smear = squamous cells covered in shaggy coating of coccobacilli

Clue cells – Gardnerella vaginosis

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Pregnant woman presents w/ thin green-gray fishy vaginal discharge. Dx?

Caution?

Gardnerella

Risk of premature labor

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Female presents for routine Pap smear. Results show small gram-negative obligate intracellular bacteria.

What else can be seen in the cells?

Chlamydia trachomatis

Elementary bodies and reticulate bodies

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Men vs. women - symptomatic w/ Chlamydia?

Women - asymptomatic

Men - urethritis or asymptomatic

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Chlamydia - risk?

PID (spread to uterus and fallopian tubes)

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Pearly, dome-shaped papules w/ dimpled/umbilicated center; cytoplasmic viral inclusions

Bug?

Molluscum contagiosum

Poxvirus

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Molluscum contagiosum - kids vs adults

Kids (2-12) - direct contact/shared articles - trunk, arms, legs

Adults - sexually transmitted - genitals, lower abdomen, buttocks, inner thighs

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What is PID?

Infection beginning in the vulva/vagina that spreads upward into the rest of the female genital system, causing mucosal inflammation and exudate and healing and scarring

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Pelvic pain, adnexal tenderness, fever, vaginal discharge

PID

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Causes of PID (3)

N. gonorrhea, Chlamydia, post-abortion infections (polymicrobial)

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Severe acute inflammation of the mucosal surfaces of the genital tract, exudate w/ phagocytosed gram-negative diplococci w/in neutrophils

N. gonorrhea

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First typical place of spread from the vagina/cervix of gonococcal infection

Complication? Explain findings

Fallopian tubes (endometrium is skipped)

Acute salpingitis (tubal mucosa infiltrated diffusely by neutrophils, plasma cells, and lymphocytes), causing SLOUGHING OF PLICAE and PURULENT EXUDATE

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Next potential complication of gonococcal infection after salpingitis Findings

Ovary (salpingo-oophoritis) Pus accumulation (tubo-ovarian abscesses or pyosalpinx (tubal lumen))

First chronic complication of gonococcal PID Explain Complication of this complication

Chronic salpingitis Denuded tubal walls adhere to one another and fuse/scar, causing gland-like spaces and blind pouches Infertility or ectopic pregnancy

Second chronic complication of gonococcal PID (after chronic salpingitis) Explain

Hydrosalpinx Accumulation of tubal secretions, causing distention of the tubes

How does PID of other organisms differ from gonococcal PID? Results?

Less mucosal involvement, more deeper tissue layer involvement Involvement of serosa, broad ligaments, pelvic structures, and peritoneum

What immune deficiency increases the risk for disseminated gonococcal infection?

Complement 6-9 (MAC) deficiency

Men vs. women - symptomatic w/ gonorrhea?

Women - often asymptomatic (unless PID) | Men - urethral discharge

Most common diseases of the vulva are what?

Cutaneous disorders (dermatoses) and superficial infections

Vulva - opaque, white plaque-like epithelial thickening, producing pruritis and scaling Causes

Leukoplakia Squamous cell hyperplasia, neoplasias, (inflammatory dermatoses)

Post-menopause, smooth white patch/plaques that coalesce into parchment-like skin around the vulva. Any risk? If?

Lichen sclerosis Slight risk of squamous cell carcinoma - IF SYMPTOMATIC

Lichen sclerosis - histology (5)

Hyperkeratosis, THIN EPIDERMIS, basal cell layer degeneration, sclerosis of superficial dermis, band-like lymphocytic infiltrate

Cigarette paper, butterfly, or figure 8 pattern of skin plaques on vulva

Lichen sclerosis

Complications of lichen sclerosis (besides SCC)

Atrophic labia minora, clitoral hood fusion (phimosis), vaginal orifice constriction

How does squamous cell hyperplasia (lichen simplex chronicus) differ from lichen sclerosis? (3)

- From rubbing/scratching to relieve itchiness - THICKENING of epidermis - Mitotic activity (maybe)

How to know that squamous cell hyperplasia is not neoplastic?

No cellular atypia

Multifocal warty growths on the vulva, vagina, cervix, perineal, or perianal areas. Papillary, exophytic, tree-like cores of stroma covered by thick squamous epithelium. Cause?

Condyloma acuminatum HPV 6 or 11

Condyloma acuminatum - characteristic finding

Koilocytic atypia - nuclear enlargement, hyperchromasia, cytoplasmic perinuclear halo

Broad-based, elevated plaques in the anogenital region, inner thigh, or axilla. Lymphadenopathy, mild fever, malaise, weight loss Cause?

Condyloma lata 2º syphilis

2 types of vulvar carcinomas

- HPV-related | - Non-HPV

HPV-related vulvar cancers Typically in who?

- Basaloid - Warty Younger women

Non-HPV vulvar cancer Typically in who?

Keratinizing squamous cell carcinoma Older women

HPV-related vulvar carcinoma develops from what? Cause?

Classic VIN (precursor) HPV 16

Risk factors for HPV infection? Thus, these are also risk factors for what cancers?

Young at 1st intercourse, multiple partners, male partner w/ multiple partners HPV-associated vulvar carcinoma and cervical carcinoma

Risk factors for non-HPV vulvar carcinoma Precursor?

Long-standing Lichen sclerosus or squamous cell hyperplasia Differentiated VIN

TP53 - which VIN?

Differentiated (non-HPV)

Vulva - White or pigmented lesion w/ epidermal thickening, nuclear atypia, increased mitoses, and no cellular maturation

Classic VIN

Exophytic or indurated vulvar mass with small, tightly-packed cells that lack maturation and resemble basal layer epithelium. Foci of central necrosis Came from what?

Basaloid vulvar carcinoma Via Classic VIN

Exophytic, papillary vulvar mass w/ prominent koilocytic atypia (halo, large hyperchomatic nuclei). Came from what?

Warty vulvar carcinoma Via Classic VIN

Vulva - Squamous basal layer atypia, normal differentiation of superficial epidermal layers

Differentiated VIN

Vulva - leukoplakia, nests and tongues of malignant squamous epithelium w/ prominent central keratin pearls

Keratinizing squamous cell carcinoma (vulva)

Risk factors for developing carcinoma from VIN

Long duration, severe extent of disease, poor immune status

Differentiated VIN may be first mistaken as what?

Dermatitis or leukoplakia

Risk factors for metastasis of vulvar cancer

Primary tumor size, invasion depth, lymphatic involvement

Erythematous, pruritic, ulcerated, map-like vulvar rash on labia majora Prognosis?

Extramammary Paget Disease Good w/ excision, but can recur

Intraepithelial proliferation of large malignant vulvar epithelium, PAS+, cytokeratin 7 positive, keratin+, S100-. Glandular differentiation

Extramammary Paget Disease

Extramammary Paget Disease vs. Paget Disease of Breast... Underlying cancer?

Breast - YES Vulva - NO

2 uteri, 2 vaginas - why?

Failure of mullerian duct fusion

Red, granular areas on the vaginal wall that are abnormal from the surrounding pale-pink mucosa Common cause?

Adenosis - residual glandular (endocervical) epithelium DES exposure

Vaginal adenosis - rare complication?

Clear cell carcinoma

Submucosal, fluid-filled lesions along the lateral wall of the vagina

Gartner duct cysts - residual wolffian ducts

Nearly ALL primary vaginal carcinomas are what type? Cause?

SCC - HPV 16

Most common cause/risk of vaginal SCC

Previous cervical/vulvar SCC

Vaginal SCC - precursor

VaIN

Vaginal SCC - most common location

Posterior wall @ jxn with ectocervix

Vaginal SCC - lymph drainage

Lower 2/3 = inguinal LNs | Upper 1/3 = iliac LNs

Infant/child, polypoid round bulky mass of grape-like clusters emerging from vagina Spindle-shaped cells, desmin+

Sarcoma botryoides (embryonal rhabdomyosarcoma)

2 cell types of cervix

``` Outer = Squamous Inner = Columnar, mucus-secreting Junction = TZ ```

SC junction (TZ) movements

Repro years = out onto cervix | Old age = up into canal

Dominant bacteria of cervix Describe (physio/micro)

Lactobacilli Squamous cells become glycogenated (menarche) --> energy for lactobacilli --> lower vaginal pH --> suppress other bacteria

Things that can disrupt lactobacilli

Things that increase pH -- bleeding, sex, douching, antibiotics

Common causes of acute cervicitis

Gonococcus, Chlamydia, Mycoplasma, HSV

Pap test - acute cervicitis

Shedding of atypical-looking squamous cells due to reparative/reactive changes

Irregular vaginal spotting or bleeding + growths in endocervical canal

Endocervical polyps

Small bumps to large polypoid masses within endocervical canal; loose stroma covered in mucus-secreting glands

Endocervical polyps

Most important, crucial risk factor for cervical cancer or precursor

High risk HPV

Most HPV infections are (asymptomatic/symptomatic) and (eliminated/persistent)

Asymptomatic and eliminated via the immune system

_____ increases the risk of the development of cervical cancer precursor from HPV

Persistent infection

What do HPVs infect? (2)

- Immature basal cells of squamous epithelium | - Immature metaplastic squamous cells at SC jxn

HPV infection REQUIRES what?

Damage to surface epithelium -- allows access to immature cells below

Why is the cervix the most vulnerable to HPV?

Has the most coverage of immature squamous cells

HPV viral proteins - fxns

E6 - degrades p53, increases telomerase | E7 - degrades RB and p21

Which HPV viral protein interaction is DEFINITIVE for HIGH-RISK types?

E6 binding p53

Is HPV infection enough to cause cervical cancer? Explain

NO Co-carcinogens = CIGARETTE smoking, infections, hormone changes, dietary deficiencies

Name of cervical cancer precursor Types?

SIL (squamous intraepithelial lesion) ``` LSIL = mild dysplasia (lower 1/3) HSIL = moderate to CIS (more than lower 1/3) ```

Most cases of LSIL _____ | THUS, LSIL is NOT treated as _____

Regress spontaneously NOT Premalignant

ALL HSIL cases are considered _____ ALL are due to what? MOST stem from what?

High risk for progression to carcinoma HPV (high risk) LSIL

SIL morphology (5) These are synonymous with ____

- Nuclear enlargement - Hyperchromasia - Coarse chromatin granules - Variation in nuclear size and shape - Cytoplasmic halos KOILOCYTIC ATYPIA

2 major types of cervical carcinoma

SCC, Adenocarcinoma

Exophytic or infiltrative mass, nests and tongues of malignant squamous epithelium, invades underlying stroma

SCC

Exophytic or infiltrative mass, proliferation of glandular epithelium w/ malignant endocervical cells and mucin-depleted cytoplasm

Adenocarcinoma

5 stages of cervical cancer

``` 0 = CIS (HSIL) 1 = Cervix only 2 = Upper vagina 3 = Pelvic wall, lower vagina 4 = Beyond pelvis, bladder/rectum, and/or metastasis ```

Majority of cervical cancers are in women who did not _____

Have regular screenings

Most common consequence of cervical cancer (w/ examples)

Local invasion - ureteral obstruction, pyelonephritis, uremia, kidney failure

LSIL vs HSIL - level of CELLULAR replication/growth How to measure this?

LSIL - low HSIL - high Ki-67 and p16 = actively dividing cells = HSIL (if above lower 1/3)

Vulva, Vagina, Cervix - Dobson Flashcards

(97 cards)