Vulval Conditions

Question 1

What are the differentials of vulval itch?

Answer 1

Candidiasis, trichomoniasis, pubic lice, scabies, vulval intra-epithelial neoplasia, atrophic vulvovaginitis, dermatitis, psoriasis, lichen sclerosis/planus/simplex chronicus

Question 2

What is lichen sclerosis?

Answer 2

Inflammatory scarring dermatoses of ano-genital skin

Question 3

Who tends to suffer from lichen sclerosis?

Answer 3

6-10x more common in women

2 peaks = prepubertal girls and postmenopausal women

Question 4

What tends to be the clinical course of lichen sclerosis?

Answer 4

Usually resolves in children but tends to be more chronic and relapsing in adults

Question 5

What are the symptoms of lichen sclerosis?

Answer 5

Itch = worse at night

Pain, dyspareunia, constipation (especially children)

Question 6

What are some red flag signs for vulval cancer?

Answer 6

Persistent ulcer, lump, weight loss

Question 7

What are some risk factors for lichen sclerosis?

Answer 7

21% linked with other autoimmune diseases (especially thyroid)
Smoking carries higher risk of developing complications

Question 8

Can lichen sclerosis have a psychosocial impact?

Answer 8

Yes

Question 9

What are the examination signs of lichen sclerosis?

Answer 9

White papules and plaques = figure 8 pattern on vulval and perineal skin, vagina not involved
Ecchymosis, erosions, fissures, architectural change

Question 10

How common is extra-genital skin involvement in lichen sclerosis?

Answer 10

Occurs in 10% of women with vulval disease

Question 11

What is the main differential of lichen sclerosis?

Answer 11

Lichen planus

Question 12

What are some features of lichen planus?

Answer 12

Affects genital skin and mucous membranes
Usually patients aged 50-60
Associated with autoimmune disease

Question 13

What are the symptoms of lichen planus?

Answer 13

Itch, pain, dyspareunia, discharge

May be oral, nail or hair involvement

Question 14

What are the other differentials of lichen sclerosis?

Answer 14

Vitiligo, mucous membrane pemphigoid, morphoea

Question 15

What is the main complication of lichen sclerosis?

Answer 15

Squamous cell carcinoma = up to 5% risk

Question 16

What is some general skin care advice for patients with vulval itch?

Answer 16

Wash gently once daily with soap substitute and try to avoid scratching/irritants
Apply emollients to relieve dryness and itching, and to act as barrier = Epimax is first line

Question 17

What is the treatment of lichen sclerosis?

Answer 17

General skin care

Super potent topical steroid = clobetasol propionate 0.05% (dermovate), 1/2 fingertip amount, 12 week regime

Question 18

What initial investigations are done for vulval itch?

Answer 18

High vaginal swab for infection and STI screen

Question 19

What are the symptoms of atrophic vulvovaginitis?

Answer 19

Itch, pain, mild thin white discharge, vaginal dryness, dyspareunia

Question 20

What are the signs of the atrophic vulvovaginitis?

Answer 20

Atrophy of labia, narrowing of vaginal opening, petechial haemorrhage

Question 21

What is atrophic vulvovaginitis associated with?

Answer 21

Low levels of oestrogen = tends to occur in postmenopausal women

Question 22

What are the symptoms of the genitourinary syndrome of the menopause?

Answer 22

Narrowing of the vaginal opening, labial atrophy, decrease in vaginal length, thinning of vaginal wall, urinary symptoms

Question 23

How is atrophic vulvovaginitis treated?

Answer 23

Vaginal oestrogen = can be taken with HRT

Perineal massage, lubricants, vibrator

Question 24

How can vaginal oestrogen be delivered?

Answer 24

Cream, oestring implant (lasts 3 months), pessary

Question 25

What are the benefits of vaginal oestrogen?

Answer 25

Doesn't cause endometrial hyperplasia/cancer with long term use and has little systemic absorption

Question 26

What may women with atrophic vaginitis develop?

Answer 26

Secondary vaginismus = body anticipates pain and tenses, increasing pain during sex further

Question 27

What are the differentials of vulval pain?

Answer 27

``` Acute = herpes, aphthous ulcers, shingles, trauma, Bartholin's cyst or abscess, dermatitis Chronic = vulvodynia, female genital mutilation, pudendal nerve dysfunction, lichen sclerosis/planus, vulval intraepithelial neoplasia ```

Question 28

What is vulvodynia?

Answer 28

Vulval discomfort, usually described as burning pain, occurs in absence of relevant findings or neurological disorder

Question 29

What are the classifications of vulvodynia?

Answer 29

Generalised or localised | Provoked, unprovoked or mixed

Question 30

What it usually required for vulvodynia to develop?

Answer 30

Usually requires a trigger in vulnerable individual

Question 31

What are the symptoms of vulvodynia?

Answer 31

Vulval pain during sex, burning/raw pain, feeling like there is a blockage

Question 32

What are the signs of vulvodynia?

Answer 32

High tone at introitus, tender on advancing speculum

Question 33

What are the differentials of vulvodynia?

Answer 33

Psychosexual issue, pudendal neuropathy, sacro-iliac joint problems, pelvic organ prolapse, skin conditions

Question 34

What is the management of vulvodynia?

Answer 34

Genital skin care and emollients Localised provoked pain = lidocaine 5% ointment Vaginal trainers and physiotherapy Unprovoked pain = tricyclics, gabapentin/pregabalin

Question 35

What should be covered in the subjective assessment of a patient with vulvodynia by the physio?

Answer 35

Presenting complaint, location and characteristic of pain, co-morbidities, psychogenic factors, surgery

Question 36

What should be covered in the objective assessment of a patient with vulvodynia by the physio?

Answer 36

Examination of joints and vagina, muscle testing, vaginismus, posture, body language and behaviour

Question 37

What treatments can the physio offer for vulvodynia?

Answer 37

Lumbar spine and/or pelvic girdle mobilisation techniques, posture, movement strategies, core stability exercises, manual handling and stretching, biofeedback, acupuncture

Question 38

What is female genital mutilation?

Answer 38

All procedures involving partial or total removal of external female genitalia or other injury to female genital organs for non-medical reasons

Question 39

Why is female genital mutilation practiced?

Answer 39

Insurance of virginity and chastity, cultural identity, religious beliefs (not supported by any doctrine)

Question 40

What is type 1 female genital mutilation?

Answer 40

Clitoridectomy = partial or total removal of clitoris and/or prepuce

Question 41

What is type 2 female genital mutilation?

Answer 41

Excision = partial or total removal of clitoris and labia minora, with or without excision of labia majora

Question 42

What is type 3 female genital mutilation?

Answer 42

Infibulation = narrowing of vaginal orifice with creation of covering seal by cutting and appositioning labia minora and/or labia majora, with or without excision of clitoris

Question 43

What is type 4 female genital mutilation?

Answer 43

All other harmful procedures to female genitalia for non-medical purposes

Question 44

What is the legal stance on female genital mutilation?

Answer 44

Illegal in UK to perform FGM, assist any girl to carry out FGM or assist a non-UK person to carry out FGM outside UK on UK resident

Question 45

What are the short term complications of female genital mutilation?

Answer 45

Haemorrhage, urinary retention, genital swelling, infection, sepsis

Question 46

What are the long term complications of female genital mutilation?

Answer 46

UTI (types 2 and 3), urinary stricture or fistula, dyspareunia or apareunia, PTSD, haematocolpos, HIV, hep B

Question 47

What are the obstetric complications of female genital mutilation?

Answer 47

Obstructed labour, postpartum haemorrhage, perineal trauma and sphincter injury, C-section, stillbirth

Question 48

What should be included in the examination of a patient with female genital mutilation?

Answer 48

Inspection of the vulva = needed to determine type of FGM

Question 49

How is type 3 female genital mutilation treated?

Answer 49

De-infibulation = ideally offer before first intercourse and pregnancy

Question 50

When should antenatal de-infibulation be offered?

Answer 50

Before last 2 months of pregnancy = can give under spinal if mother chooses to have C-section

Question 51

What should be done if female genital mutilation is identified?

Answer 51

Must explain UK law on FGM Report to social work if unborn child at risk Individual risk assessment done by midwife/obstetrician using FGM safeguarding risk assessment tool

Question 52

Do you have to report all pregnant women identified as having suffered female genital mutilation?

Answer 52

No = not mandatory to report all women but have duty to protect any children recognised to be at risk

Question 53

What are the acute differentials of painful genital lesions?

Answer 53

Ulceration = herpes, shingles, aphthous ulcers Lumps = Bartholin's abscess, abscess, furuncle/caruncle, hydradenitis supparative Trauma

Question 54

What are the chronic differentials of painful genital lesions?

Answer 54

Lichen sclerosis, lichen planus, vulval intraepithelial neoplasia, vulval cancer

Question 55

How can vulval cancer present?

Answer 55

May present with burning sensation in vulva associated with itching

Question 56

What may be seen on examination of vulval cancer?

Answer 56

Raised vulval ulcer = may have keratinisation in middle and indurated edges May have satellite lesions

Question 57

What investigations can be done for vulval cancer?

Answer 57

Lesion biopsy USS of groin if lymph node involvement MRI of perineum if lesion close to anus

Question 58

What area should be included in a biopsy for vulval cancer?

Answer 58

Area of epithelium where there is transition of normal to malignant tissue in biopsy

Question 59

Is vulval cancer common?

Answer 59

No = most common type is squamous cell carcinoma

Question 60

Where do vulval adenocarcinomas tend to occur?

Answer 60

In Bartholin's glands

Question 61

What are the precursors of vulval cancer?

Answer 61

HPV in young women | Lichen sclerosis in older women

Question 62

How is vulval cancer treated?

Answer 62

Mainstay is surgery = chemoradiotherapy can be used as adjuvant, may need reconstruction by plastic surgeons

Question 63

How long do you follow vulval cancer up for?

Answer 63

5 years post-treatment

Question 64

What vulval cancer lesions are suitable for wide local excision without groin node dissection?

Answer 64

Lesions confined to vulva/perineum with stromal invasion <=1mm

Question 65

What vulval cancer lesions are suitable for wide local excision and groin node dissection?

Answer 65

Lesion confined to pelvis, but >1mm depth of invasion

Question 66

How are vulval cancer lesions with obvious groin node involvement treated?

Answer 66

Chemoradiotherapy