Vulvar things Flashcards

Question

What is management of Bartholin abscess?

Answer 1

I&D then word catheter for 4-6wks - culture abscess to r/o MRSA if abscess recurs, repeat I&D/word or marsupialization and add antibiotics.

Answer 2

E. Coli=most common. S. aureus, polymicrobial, GBS, Enterococcus. on exam: soft, tender, warm, or fluctuant mass recurrent abscess surrounding cellulitis pregnant immunocompromised MRSA+ signs of systemic infection. Bactrim DS 5-7d. Can add flagyl or augmentin.

Answer 3

Infectious: candiditis, scabies, pediculosis Dermatoses: atopic/contact dermatitis, lichen sclerosis, lichen planus, lichen chronicus Neoplasia: Paget’s disease, vulvar LSIL, HSIL, vulvar cancer Hormonal deficiencies: vulvovaginal atrophy Acute: infectious causes -> vaignal pH, saline/KOH, amine test Chronic: dermatoses (lichens), psoriasis, neoplasia-> biopsy

Answer 4

Infectious: recurrent vulvovaginal candidasis, herpes Dermatoses: lichen sclerosis/planus Neoplasia: paget’s, vulvar LSIL/HSIL, cancer Neurologic: postherpetic neuralgia, nerve compression Trauma: genital mutilation Pruritis: lichen planus or genitourinary syndrome of menopause (need pH, amine test) No pruritis: consider vulvodynia.

Answer 5

H&P - aggravating/alleviating, new things, severity/duration (acute vs chronic). If acute, rule out infections (BV, trich, candida, scabies). IF chronic, rule out (dermatoses and dysplasia). If pain, see if associated pruritis. I f pruritis + pain, dermatoses or vaginal atrophy. IF just pain, vulvodynia.

Answer 6

Atypical lesion (new pigmentation, bleeding, ulcerated, affixed) Concern for malignancy Lesion in immunosupcomprimsed Doesn’t respond to standard therapy or gets worsed Stable lesions that rapidly increase in size punch or excisional biopsy.

Answer 7

Range of symptoms: Mild erythema, swelling, scaling, fissures, erosions, ulcers. Typically associated rash. Chronic itching/burning Type 4 delayed hypersensitivity Treatment: vulvar care/removal of irritants, topical corticosteroids and oral antipruritic meds prn. AVOID topical antipruritic (benadryl) bc can cause allergic contact dermatitis.

Answer 8

chronic/intermittent prutitis w/ scratching/rubbing Erythematous scaling or lichenified plaques. ***Thick plaques w/ hyper and hypopigmentation. Erosions/ulcers develop from chronic scrapping*** Hx allergies, asthma or eczema. Ddx: clinical. Consider vaginal fungal culture to r/o candidas Treatment: vulvar care/hygiene, antipruritic meds, topical medium or high potency corticosteroid once or twice daily. How often to follow up on pts using high potency topical corticosteroids: schedule close interval follow up 4 wks post initiation. Additional visits based on pts response to therapy. Tx failures from use of low-potency or shorter than recommended use of high potency steroids

Answer 9

Chronic scarring affecting anogenital skin of postmenopausal woman and pre-pubertal girls. Exam w/ porcelain-white papules/plaques with area sof ecchymosis. Skin is thin, whitened, crinkled (cigarette paper) Involvement of mucutaneous junctions → introital narrowing. Involves superior vulva to perianal tissue to create “figure of eight” shape Fusion of labia minora, fissures. Ddx: Biopsy. Incr risk squamous cell carcinoma (2-5%). Tx=medium or high potency topical corticosteroids. Clobetasol propionate 0.05 ointment qhS x 4 weeks, alternate nights for 4 weeks then twice weekly for 4 weeks.

Answer 10

Monitor at 3 months. Then follow up 3-6 mo later. Biopsy any new growths. Do you need long-term maintenance therapy: long-term individualized topical corticosteroid to prevent scarring. Titrate to lowest dose needed. How do you treat resistant/poorly controlle cases? Intra-lesional corticosteroids injections. 10-20mg intralesionsal triamcinolone. If no response to intralesional corticosteroids? Topical calcineurin inhibitors (tacrolimus or pimecrolimus) What if calcineurin inhibitors fail? Refer to specialist.

Answer 11

Scarring inflammatory disorder. sx=dyspareunia, burning, soreness, itching, incr vaginal discharge Affects perimenopausal/menopausal Up to 70% have oral involvement Types: Classical (white, reticulate, lacy, fernlike striae), hypertrophic (least common, white thick), Erosive (Deep, painful erosions and extend to labia minora - can cause oblieration of vaginal space. INVOLVES VAGINA. Eval of oral cavity recommended) - refer to oral specialist. Ddx: clinically. Vaginal discharge w/ predominance of inalmamtory cells and parabasal/basal cells. Incr vaginal pH (5-6). Biopsy is non-specific Treatment: prognosis for remission is poor. High-potency topical corticosteroids: twice daily use w/ tapering. How often to follow up? 2-3 mo. How to treat resistance disease? Topical calcineurin inhibitors. How to treat if vaginal involvement: if erosive w/ vaginal involement, intravaginal corticosteroids (hydrocortisone acetate suppositories inserted twice daily and tapered off). 80% pts will have improvement. Can use vaginal dilators to prevent scarring/obliteration. How to treat extensive vaginal disease? High-dose hydrocortisone inserts.

Answer 12

Vulvar LSIL/HSIL: warty, basaloid, mixed - associated w/ genotypes of HPV and risk factors (smoking, immunocompromised) Differentiated: NOT assoc w/ HPV. assoc w/ vulvar dermatoses. If have lichen sclerosis, likely to be associated with SCC. New terminations: usual type is now vulvar HSIL. flat lesions assoc w/ basal atypia are LSIL (condyloma or HPV effect).

Answer 13

Visual assessment. Biopsy if needed - only if not responding to usual therapy. Determine extent of disease if persistent pruritis/pain and if symptomatic despite treatment Apply 3-5% acetic acid to vulva using soaked gauze pads. - COLPO! WLE if cancer suspected bc risk invasion (Include gross margins of 0.5-1cm around tissue w/ visible disease. If critical area lesion, refer to specialist. - If occult invasion not a concern, vulvar HSIL (VIN usual type) treated w/ : - excision - laser (1mm in non-hair bearing and 3mm in hair-bearing areas) - topical imiquimod 5%.

Answer 14

Treatment of vulvar HSIL when cancer NOT suspected. Need 0.5-1cm margin of normal appearing skin to be treated. Need to destroy cells through entire thickness of epithelium.

Answer 15

Exophytic, ulcerative, indurated, poorly-defined borders

Answer 16

-- just know basics. An indwelling bladder catheter is placed. The incision can be marked with a skin-marker to plan the extent and axis of the excision. The shape of the excision should be elliptical, running in long axis parallel to neighboring structures to be preserved we start posteriorly so that venous oozing from the incision does not affect visualization in the direction of travel. The excised portion of the incision is grasped with a toothed forcep or Allis clamp and consistent tension is applied, allowing the operator to elevate and stretch the skin (figure 4). The epidermis, dermis, and underlying adipose tissue are dissected from the underlying perineal tissues using scissors, scalpel, or electrocautery.

Answer 17

A vaginal wet mount preparation is a test where a sample of vaginal discharge is observed by wet mount microscopy. - The swab collected sample is placed on a clean glass slide and mixed with either 0.9% saline or 10% potassium hydroxide (KOH). - Saline preserves cell membranes and allows observation of motile trichomonads, and vaginal epithelial cells coated with bacteria (clue cells), and white blood cells (WBCs). - If a yeast infection is suspected, the addition of 10% KOH will hydrolyze trichomonads, cells, and bacteria to provide a clearer view of yeasts and pseudohyphae. In many cases of BV or trichomoniasis infection, addition of KOH to the vaginal discharge will produce a strong amine or fishy odor.

Answer 18

rare, accounts for 5-10% melanoma in women. - BRCA2 AT INCREASED RISK - avoid lots of sun exposure, need regular physical exams. - eval w/ colposcopy. can do biopsy.

Answer 19

Cryotherapy, TCA, surgical removal. Imiquinod=immune response modifier. Applied 3x/week until warts are gone. HPV, increased # sexual partners, on oCPs, smoking

Vulvar things Flashcards

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