Vulval Conditions Flashcards

Question

Discuss lichen planus -Aietiology -Epidemiology -Examination findings -Histology -Treatment

Answer 1

1. Autoimmune condition. T cell targeting basal keratinocytes. Genetic component. -Lymphocytic attack with a cycle of cell damage and repair -3 types: erosive (Most common), hypertrophic, classic (rare) 2. Epidemiology -Peri and menopausal women affected (40-60) -Rarely associated with SCC -Affects 2% of women -Occurs in 25-55% of women with oral LP -10% overlap with lichen sclerosis 3. Examination -Classic purple plaques overlying lacy white lines -Erosions and fissures erythema -Involves vagina and cervix -Wickhams striae (Also seen in mucosa) -Extra genital involvement common - oral cavity -Loss of architecture and reabsorption of labia, agglutination 4. Histology -Lichenified inflammatory pattern -Epidermal hyperplasia, irregular saw tooth acanthosis -Hydropic degeneration of basal epidermal layer 5. Treatment -Potent steriods, topical tacrolimus, methotrexate, azathioprine, cyclosporine -Highly treatment resistant (cf Lichen sclerosis which response well) -Annual FU

Answer 2

1. Genetic, environmental, related to dysfunctional epidermal layer, irritants 2. Associated with other atopic illnesses 3. Examination -Excoriations -Ill defined erythema -Flexural lichenification -Occurs in labia majora 4. Histology -Scale crusts in stratum corneum -Epidermal spongiosum -Microvesicular formation in epidermis 5. Treatment -Hygiene, reduce triggers and test for allergins -Emollents -Topical steriods - ointments -Oral antihistamines -Treat superimposed infection -Avoid irritants (waxing, tight underwear, soaps,

Answer 3

1. Aeitiology -20% allergic - Type IV T cell mediated -80% irritant - due to skin irritation from prolonged exposure 2. Examination Allergic - difuse margins, tends to be asymetrical. Extreme pruitis Delayed onset worsening with multiple exposures Irritant - well dermarcated margins in area of contact. Waxy, shiny scale like appearence. Burning stinging pain Immediate onset 3. Histology simillar to atopic dermatitis -Scale crusts in stratum coreum -Epidermal spongiosum -Microvesicular formation in epidermis 4. Treatment -Avoid irritants, triggers, -Vulval hygiene -Oral antihystimines -Topical steriods - always use ointments not cream -Treat superimposed infection

Answer 4

1. Aietiology -Caused by itch scratch cycle. Caused by anything that causes itch -Vuvlval dermatoses, chronic illness causing pruritis, psych disorders, enviromental exposures causing itch 2. Examination -Vagina not affected -Erythematous lichenified plaques -Leathery skin, erosions, ulcers, fissures, pigmented skin 3. Histology -Lichenoid inflammatory pattern -Spongiosis from oedema in the epidermal layer -Acanthosis, hyperkeratosis, superficial dermal lympocyte infiltrate 4. Treatment -Eliminant irritants -Hygiene -Treat superimposed infection -Emollents, cool packs -Low potency steriods as first line. Consider PO steriods -Antihistamines

Answer 5

1. Chronic inflammatory skin disease 2. Affects 2% of population. Fhx common 3. Examination findings -Well demarkated bright erythematous plaques. Scalling uncommon. Often symetrical. Fissuring. -Frequently affects natal cleft -Look for psoriasis elsewhere on body 4. Treatment -Aim for control not cure -Avoid irritants, use emollients -Topical low potency steroids -Coal tar preparations for maintenance

Answer 6

1. Aetiology -Intraepithelial adenocarcinoma of the anogenital or axillary skin -Primary -cutaneous in origin probably apocrine cells -Secondary - metastatic disease 2. Epidemiology -Usually >50yrs. Peak age 65 -More common in Caucasians 3. Examination findings -Asymetrical unilateral pink/red scaly plaques -Slow growing nodules in late stage -Irregular poorly defined margins -Itchy (70%), red and beefy appearance -Well demarcated and multifocal 4. Histology -Presence of Paget cells in epidermis -Epidermal hyperplasia 5. Treatment -WLE with 2cm margins -Radical vulvectomy -High recurrence rates -Consider imiquimod, laser therapy, radiotherapy -Long term FU 6. 5 yr survival 75-95%

Answer 7

1. Aietiology -Unknown 2. Clinical presentation -More common in perimenopausal women -Pain, copiois vaginal discharge, no erosions -Diagnosis of exclusion 3. Examination findings -Normal architecture. -Vulva not involved -Thinned sensitive erythemaotous oedematous vestibule -Vaginal ecchymtic rash -Cervix - erosive lesions -Vaginal pH >4.5 -Saline wet mount - increased number of parabasal inflammatory cells 4. Treatment -Intravaginal clindamycin or glucocorticosteriods 4/52 5. Recurrence rate 50%

Answer 8

1. Vulvar pain secondary to a specific disorder -Infection, inflammation, neoplasia, neurological, trauma, iatrogenic, hormonal deficiencies 2. Vulvodynia - vulvar pain of at least 3 months with no clear cause. -Can be localised or generalised -Can be provoked or spontaneous or mixed -Can differ by temporal pattern 3. Women can have both 1 and 2

Answer 9

1. Increased number of nerve and pain fibres 2. Pro-inflamatory state with increased T and B cells, IL6, TNF 3. Can be idiopathic 4. Can be triggered -70% chronic candidiasis -Abuse -Surgery -Postpartum

Answer 10

1. Patient education and reassurance -Explore beliefs and fears -Personal hygiene and vulval cares 2. Pain modification -Topical lignocaine -Topical Gabapentin or amytriptyline cream -Systemic amytrip or gabapentin, pregabalin 3. Physical therapy -PT in high pelvic floor resting tone -Diaphragmatic breathing -TENS -Dilators 4. Psychological therapy -If psychological distress -Pain coping strategies, CBT, relaxation techniques 5. Botox -RCT don't support use 6. Vestibuloectomy -If pain recalcitrant to other therapies -For loacalised and provoked vulvodynia -85% improvement. Equivalent outcomes with CBT at 30months

Answer 11

1. Epidemiology -Common vulvular pain disorder - 6-8% prevalence -25% lifetime risk -Younger women -Provoked most common 2. Related to peripheral nerve bundles in the vestibule 3. Associated factors -Recurrent Candidiasis, OCP, Vaginismis, pelvic floor hypertonus, other pain syndromes, psychosocial factors 4. Symptoms -Pain present with provacation - sex, tampons, bike riding. -Persists after stimulis -Pain free intervals at other times -Afterburn - allodynia following SI

Answer 12

1. More common in perimenopausal and post menopausal women 2. Clinical features -Pain is long lasting and persists after cessation of stimulus -Involves the whole vulva -Chronic discomfort, worse during the day -Pain not exaccerbated by touch -Can be associated with intersitial cystisis -On examination vulva appears normal 3. Best managed as chronic pain with multi-modality treatment

Answer 13

1. Characteristics -Shorter in duration -Milder pain -No or 1 associated factor -No co-existing chronic pain -Little central sensitization 2. Common causes -Pelvic floor overactivity mainly following peripheral inflammatory mechanisms 3. Diagnosis -Clinical -Cotton swab test -Swabs for micro and culture

Answer 14

1. Women should be offered deinfundibulation during pregnancy to improve obstetric outcomes (Reduced PPH/CS/OASIS injury) 2. DeInfundibulation can be offered either as AN or intrapartum 3. Managing FGC/M should include MDT and be culturally sensitive with trauma informed care 4. Women with infundibulation should be offered deinfundibulation 5. Women should be counselled about the risks and benefits of deinfundibulation regarding anatomical changes and risks and unknown benefits of clitoral reconstruction