1
Q
Discuss Batholin’s cyst and abscess
-Role of Batholins gland
-Pathophysiology of cyst and abscess formation
-Common infective microbes (8)
-Management (4)
A
- Role of Batholin’s gland
-Mucous producing to keep vulva moist
-Small amount of mucous for lubrication during intercourse 2. Pathophysiology
-Cyst forms from blockage of Batholins duct. Usually by friction caused by sexual intercourse
-Abcess forms if Cyst infected. Abcess 3 x more common than cyst - Common bacteria in Batholin’s abcess
-Neisseria gonorrhoea, Stap Aureus, Sterep Faecalis, E. Coli, Pseudomonas aeruginosa, Chlamydia trichamonas.
-Bacteroides fragilis. Clostridium perfringes - Management
- Conservative with antibiotics - not definitie management
- Word Catheter
3.I&D and Marsupialization - Excision of gland
NB: No difference in recurrence rates with Word vs Marsupilization
2
Q
Discuss Benign Mullerian cysts
-Aeitology
-Sx
-Anatomical location
-Ix
-Management (2)
- Complications
A
- Persistance of glandular tissue
- Asx, dypareunia, vaginal discomfort
- Anywhere along the Mullerian tract.
- TVUSS or MRI
- Management
-Conservative - yearly surveillance
-Surgical excision - Complications
- malignant transformation, recurrence, infection
3
Q
Discuss Gartners duct cyst
-Aeitology
-Sx
-Anatomical location
-Ix
-Management (2)
- Complications
A
- Persistance of mesonephric ducts
- Asx, dysparunia, vaginal discomfort
- Anterior lateral wall of upper third of vagina
- TVUSS/CT/MRI
- Management
-Yearly surveillance
-I&D or marsupilisation if large - Complications
-Infection, malignant transformation, recurrence
4
Q
Discuss Skene’s gland
-Aeitology
-Sx
-Anatomical location
-Ix
-Management (2)
- Complications
A
- Obstruction of Skenes duct
- Urethral pain, recurrent UTI, Voiding Sx, dypareunia
- Lateral to urethral meatus
- TVUSS/MRI
- Management
-Conservative - antibiotics and analgesia
-Surgical - aspiration, marsupilisation, gland excision - Complicaiton
-Urethral diverticulum
-Recurrence
5
Q
Discuss epidermal inclusion cysts
-Aeitology
-Sx
-Anatomical location
-Ix
-Management (2)
- Complications
A
- Entrapemnt of fragments of the epidermis
- Asx, labial discomfort
- Labia majora
- Clinical diagnosis
-non tender, mobile 5mm mass with cheese like discharge - Management
-Surveillance
-I&D - Complications
-Infection, recurrence
6
Q
Discuss hidradenoma papillferum cysts
-Aeitology
-Sx
-Anatomical location
-Ix
-Management (2)
- Complications
A
- Blockage of sebaceous gland
- Asx, labial discomfort
- Between labia majora and minors
- Clinical dx
- Excision under LA
- Complicatins: Infection, recurrence
7
Q
Discuss mucinous cysts of the labia
-Aeitology
-Sx
-Anatomical location
-Ix
-Management (2)
- Complications
A
- Obstruction of the vestibular glands lined by mucinous cells
- Asx, labial discomfort
- Labia minora, and vestibule. Often lateral
- Clinical dx
- Management
-Surveillance as may occasionally show squamous metaplasia
-Excision if large or expanding - Complications: Infection, recurrence
8
Q
Discuss cysts of the canal of Nuck
-Aeitology
-Sx
-Anatomical location
-Ix
-Management (2)
- Complications
A
- Patent processus vaginalis
- Asx, discomfot
- Labia majora, mons pubis
- Clinical Dx
- Surgical resection and ligation of the neck of the processus vaginalis
- Complications: Inguinal hernia, recurrence
9
Q
Discuss female genital mutilation (cutting)
-Definition
-Types (4)
-Epidemiology
A
- Defintion
-All procedures that involve partial or total removal of external genitalia or other injury to female genital organs for non-medical reasons - Types
Type 1 - excision of all or part of the clitorus
Type 2 - Excision of all or part of the clittorus and labia minor/majora
Type 3 - Removal of the external genitalia and narrowing of the vaginal opening (Infibulation)
Type 4 - pricking, piercing of the clitoris or labia, scraping of the vaginal tissu or introduction of substances to cause vaginal bleeding or narrowing - Epidemiology
-200 million women affected
-3 million girls at risk every year
-80% are type 1 and 2
-15% are type 3
10
Q
Discuss FGM in NZ in terms of the law (4)
A
- No evidence that it is practiced in NZ
- Ilegal to perform under 1996 Crimes Act
- Ilegal to arrange/encourage/assist/convince another person to have FGM overseas
- Imprisonment up to 7yrs
- Mandatory reporting for children at risk
11
Q
Discuss the complications of FGM
-Short term (8)
-Long term (8)
A
- Short term complications
-Haemorrage - most common complication (clittoral artery)
-Infection - sepsis, HIV
-Pain
-Shock - septic, haemorragic, neurological
-Chronic infection from poor healing
-Urinary retention
-Injury to proximal organs, bladder, urethra, bowel
-Injury to girl while imobilising - soft tissue, fracture - Longterm complications
-Urinary issues: UTI, obstruction, incontinence, hydronephrosis, fistulation
-Menstural issues: amenorrhoea, dysmenorrhoea, haematocolpos, endometriosis, retrograde menstruation
-Infection - abcesses, HIV, PID
-Dermatological - neurinoma, keloid scarring, ulcers
-Mental health: PTSD, depression, anxiety
-Sexual issues: Dysparenunia, reduced sexual pleasure, vaginismis
-Infertility - PID or inability to have intercourse
-Childbirth issues: Retained fetus in miscarriage, difficult D&C, Difficult to manage labour: VE, IDC, Intrapartum procedures, Prolonged / obstructed labour, PPH, perineal tears, fistula formation, HIE, Increased CS
12
Q
Discuss management in pregnancy for women with FGM
-Antenatal (4)
-Intrapartum (5)
-Postpartum (1)
A
- Antenatal care
-Identify and counsel
-Assess type and ability to VE
-Ref for deinfibulation - second trimester if required
-Cousel on increased risks and management of FGM in labour
-Offer defibulation in second trimester if required - Intrapartum care
-FGM not a reason for CS
-Deinfibulation in first or second stage if required
-Low threshold for epis given scar tissue
-Suture skin edges together
-Reinfibulation - illegal - Post partum
-Deinfibulation cares
13
Q
Discuss defibulation
1. Prepocedure counselling (4)
2. Procedure (7)
3. Post porocedure (7)
A
- Pre-procedure cares
-Counselling re what to expect post procedure
-Change to urination flow and menstural flow
-Avoid intercourse til healed
-Will not cause prolapse
-Reinfibulation is illegal - Procedure
-Anaesthetic LA or GA
-Infiltrate midline with LA
-Elevate anterior skin away from underlying structures
-Incise scar tissue posterior to anterior
-Extend excision until external urethral meatus is visible
-Avoid involvement of clitoral stump (pain and bleeding)
-Over sew skin edges with fine dissolvable subcut suture - Post procedure care
-Analgesia
-Offer smear
-Counsel hygiene cares, suture cares, infection risk
-Avoid sexual intercourse until healed
-Discuss legal status of FGM in NZ
-Refer for social support if required
-FU 6 weeks
14
Q
How should you respond to a parent who wants to take their daugther back to home country for FGM (6)
A
- Explain illegal to perform on person in NZ or to take a child overseas for that purpose
- FGM is considered violation of human rights
- In new country FGM doesn’t have same positive value and may cause prejudice or disadvantage marriage
- Resaerch shoes countries where FGM is prevalent many communities want it to end
- Research shows that where FGM is prevalent men prefer to marry uncut women
- Explain health implications for women
15
Q
Discuss VAIN
-Defintion
-Classification
-Risk factors
-Incidence
A
- Vaginal intra-epithelial lesion. Doesn’t involve tne basement membrane. Premalignant condition
- Classification
LSIL - Previously VAIN I
HSIL - Previously VAIN 2 & 3. 2-12% chance of invasive cancer - Risk factors
-Persistent infection with oncogenic HPV
-Often seen in conjunction with CIN
-Immunosupression and smoking - Rare
16
Q
Discuss management of VAIN
A
- If LSIL - observation with FU colposcopy
- Excision
- local if single lesion
-Vaginectomy if widespread disease - Laser vaporisation
-Better if multifocal, if LSIL in young women
-Must rule out cancer - 5 Fluorouracil - greater recurrence
- Imiquimod - consider in you women, OK to try in HSIL
-Better HPV clearence cf laser. Same recurrence rates as laser - Close long term FU
17
Q
Discuss VIN (Vulval intraepithelial neoplasia)
-Definition
-Classification
-Incidence
-Risk factors (4)
A
- Defintion
-Chronic vulval skin disorder characterised by dysplastic squamous epithelia - Classification
Vulvar LSIL - HPV associated, not thought to be precancerous
Vulvar HSIL - usual. HPV associated
-Graded like CIN
-Most common 90% of VIN
-Potential for malignancy 4-6%
-Causes 20% of SCC of vulva
-Affects younger women
Vulvar HSIL - differentiated - not HPV assoicated
-Makes up 10% of VIN
-Associated with Lichen sclerosis and planus
-Potential for malignancy - 85% within 2-4yrs
-Affects older women
-Develops into cancer faster than uVIN - Incidence 2.8:100,000
- Risk factors
-Oncogenic HPV 16, 18, 31
-Lichen sclerosis
-Smoking
-Immune suppression
18
Q
Discuss clinical evaluation of VIN
-Sx (3)
-Examination
-Investigations (2)
A
- Symtpoms
-Pruritis, pain, asx (40%) - Examination
-variable appearence of lesions, hyperkeratosis, white, red, brown, erythematous - Investigations
-Vulvoscopy and colposcopy with 5% acetic acid
-Punch bx
19
Q
Describe the histological findings of VIN
-uVIN
-dVIN
A
- uVIN
-Dysplastic, vacuolated cells with mitoses throughout epithelium
-p16 positive on immunohistochemistry - dVIN
-Dysplastic cells adn mitoses confined to basal layer
-p53 positive on immunochemistry staining
20
Q
Discuss excision as management for VIN
-Indication
-Method
-Advantages
-Disadvantages
A
Excisional (WLE) - gold standard
1. Indication:
-If single unifocal lesion in location that won’t distort function
-If multifocal lesions recalcitrant to other treatment
2. Method
-0.5-1cm margins and 4mm depth
-Aim primary closure or flap
3. Advantages:
-Lowest recurrence rate - 25%
-Complete excision
-Can review histology and check margins
4. Disadvantages:
-Surgical risks - infx, haemorrhage, GA
-Dysparenunia
-Slow recovery
21
Q
Discuss ablative management of VIN
-Indication
-Method
-Advantages
-Disadvantages
A
- Indication
-Widespread multifocal disease
-High risk GA
-Young women with no suspicion of invasion - Method
-CO2 or cryotherapy
-1mm depth on hair free surfaces, 3mm in hairy areas - Advantages
-Better cosemsis
-Reduced dyspareunia
-voids anaesthetic
-Can be performed in pregnancy - Disadvantages
-HIgh recurrence rate 40%
-No histo or assessment of invasion
-Can cause hypertrophic scarring
22
Q
Discuss topical management of VIN
-Indication
-Method
-Advantages
-Disadvantages
A
- Indication
-Widespread or multifocal disease
-For lesions where high risk of anatomical distortion and impaired function
-When invasion is not suspected
-High risk anaesthetic patients - Imiquimod 5% 3 x weekly for 16 weeks
- Advantages
-Avoids atomical distortion
-Non invasive
-Avoids surgical risks
-Able to be applied by patient - Disadvantages
-No histo or invasion info
-Recurrence risk 50%
-Can cause local pain and irritation
-Avoid in pregnancy
23
Q
Discuss the follow - up for VIN (4 points)
A
-6 monthly surveillance for 5 yr then annually
-Long term recurrence risk = 30% regardless of classification
-Recurrence more common if smoker (quit), larger multi focal lesions, immunosuppressed, positive margins
-Progression to cancer usually within 10yrs of Dx
24
Q
Discuss lichen sclerosis
-Aietiology (5)
-Epidemiology (3)
-Examination findings
-Histology
-Treatment
A
- Aeitiology
-Multifactorial, autoimmune, genetic, hormonal, infection - Epidemiology
-Mean age 55
-2/3 cases > 50 but can occur in children
-Associated with autoimmune conditions
-Associated with dVIN - 2% progression - Examination findings
-Thin crinkly skin, figure of 8, white atrophic epidermis, purpura, sclerotic thickened dermis, loss of architecture (fusion of clitoral hood, resorption of labia)
-Only impacts vulva. Never vagina.
-Less extra genital involvement cf lichen planus - Histology
-T cell mediated
-Lichenified inflammatory pattern, epidermal atrophy, hyperkeratosis, hydropic degeneration of basal epidermal
layer - Treatment
-Confirm dx with Bx
-Consider autoimmune screen
-Potent topical steroids. Clobetasol 0.05% or Betamethasone 0.05% BD for 1/12, OD 1/12 then maintenance. (steroids reduce risk of progression to dVIN)
-Long term FU for dVIN 6-12 monthly
-Encourage self monitoring for change/ non healing
25
Discuss lichen planus
-Aietiology
-Epidemiology
-Examination findings
-Histology
-Treatment
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
26
Discuss atopic dermatitis (Eczema)
-Aeitiology
-Epidemiology
-Examination findings
-Histology
-Treatment
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,
27
Discuss contact dermatitis
-Aietiology
-Examination
-Histology
-Treatment
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
28
Discuss lichen simplex chronus
-Aietiology (4)
-Examination
-Histology
-Treatment
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
29
Discuss psoriasis
-Aietiology
-Epidemiology
-Examination findings
-Treatment
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
30
Discuss Paget's disease of the Vulvar
1. Aetiology
2. Epidemiology
3. Examination findings
4. Histology
5. Treatment
6. Prognosis
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%
31
Discuss desquamative inflammatory vaginitis
-Aitieology
-Clinical presentation
-Examination findings
-Treatment
-Recurrence risk
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%
32
Discuss the classification of vulval pain and vulvodynia (2 groups)
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
33
Discuss the aeitology of vulvar pain (4)
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
34
Discuss the management of vulvar pain (5)
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
35
Discuss localised provoked vestibulodynia
-Epidemiology
-Aietoiology
-Assoicated factors (4)
-Symptoms
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
36
Discuss unprovoked vulvodynia
-Epidemiology (1)
-Clinical features (6)
-Management
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
37
Discuss uncomplicated vulvodynia
-Characteristics cf complicated vulvodynia (5)
-Common causes
-Diagnosis
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
38
What are the recommendations for FGM/C by RANZCOG (5)
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
