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Women's health > Vulvovaginal disorders > Flashcards

Vulvovaginal disorders Flashcards

1
Q

components of the Normal Flora

A
  1. Aerobes, anaerobes, and yeast
    - Anaerobes 10x > aerobes
    - Lactobacillus
    - Skin and GI tract flora
  2. Exempt from normal bactericidal immune activity
  3. Convert glycogen in vaginal mucosal secretions to lactic acid
    - Normal vaginal pH - 4.0 - 4.5
    - Postmenopausal - 6.5 - 7.0
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2
Q

what alters the vaginal flora?

A
  1. age - low estrogen lvls = less Lactobacillus; Estrogen replacement restores vaginal lactobacilli
  2. menses - mainly in first days; possibly 2/2 hormonal changes; Menstrual fluid may nourish bacteria
  3. abx - eradication of normal flora
  4. Changes in reproductive tract - hysterectomy, pregnancy
  5. Foreign substances
  6. Dec overall health
  7. Poor eating habits - esp sugary foods
  8. Meds - BC, abx, steroids
  9. Immunosuppression
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3
Q

how to restore vaginal flora

A
  • Avoidance of aggravating or predisposing factors
  • Antimicrobial regimen for treatment or prophylaxis of overgrowth
  • Probiotic dosing
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4
Q

MCC of Candidal Vulvovaginitis

A

Candida albicans - 90%

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5
Q

Candidal Vulvovaginitis
often associated with what other causes/conditions:

A
  1. Systemic disorder - DM, HIV, obesity
  2. Pregnancy
  3. Meds - abx, steroids, BC
  4. Chronic debilitation
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6
Q
  • Intense vulvar pruritus +/- excoriations
  • Thick, white, “cottage cheese” discharge
  • Usually with minimal odor
  • Vulvar erythema and possible edema
  • Burning sensation may follow urination
A

Candidal Vulvovaginitis

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7
Q

w/u for candidal vulvovaginitis

A
  1. Vaginal pH - mildly elevated (pH 4-5)
  2. Saline Prep
    - 1 drop vaginal discharge with 1 drop normal saline
    - Apply coverslip and examine under microscope
    - Candidiasis - branching filaments, pseudohyphae
  3. KOH Prep
    - 1 drop discharge w/ 10% aq KOH
    - Dissolves epithelial cells and debris and facilitates visualization of fungal mycelia
  4. Cx - gold standard for diagnosis
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8
Q

on microscopy you see budding yeast, pseudohyphae, dx?

A

candidiasis

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9
Q

tx for Candidal Vulvovaginitis

A
  1. Topical or oral antifungals, boric acid, gentian violet - Most respond to 1-3 days of topical azole creams or a single dose of fluconazole 150 mg PO
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10
Q

what is considered “complicated” in candidal vulvovaginitis?
tx?

A

4+ episodes/yr, severe sx, non-albicans, uncontrolled DM, HIV, steroids, pregnancy

  1. 7-14 d of topical therapy or 2 doses of oral fluconazole
  2. Cx to confirm dx
  3. Consider boric acid
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11
Q

Available OTC and rx
Less risk for systemic SE
Messy application
Weaken latex
May provide more rapid s/s relief

which type of antifungal tx?

A

Intravaginal antifungal creams

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12
Q

Available by rx only
Higher risk for systemic SE
More convenient
Overuse → resistance?
Delayed relief of symptoms
Cannot use in 1st trimester

which type of antifungal tx?

A

Oral antifungal therapy

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13
Q

Available OTC
Work better for non-candidal infections
Cannot use in pregnancy
Harmful if taken orally by mistake

which tx?

A

Boric acid intravaginal

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14
Q

Available OTC
Does not work well with other topical therapies
Caution in pregnancy - no studies
Discoloration of skin

which tx?

A

Gentian Violet

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15
Q

inserted into vagina qhs using applicator
Cream or suppository; often also can use externally
Varying treatment lengths depending on medication - single-dose, 3 day, 7 day, 14 day

A

Vaginal Antifungal Therapy

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16
Q

MOA of Vaginal Antifungal Therapy

A

inhibit enzyme for cell membrane synthesis

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17
Q

which vaginal antifungal therapy increases permeability of cell walls

A

nystatin

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18
Q

SE and DDI of Vaginal Antifungal Therapy

A
  • SE - burning, itching, swelling, rash, discharge; rare - HA, cramps
  • DDI - rarely may potentiate warfarin
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19
Q

MOA of Oral Antifungal Therapy

A

inhibits enzyme for cell membrane synthesis

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20
Q

SE and DDI of PO antifungal therapy

A
  • SE - GI upset, abd pain, dizziness, HA, drowsiness, allergic rxn; Rare - dysrhythmia/palpitations (prolongs QT)
  • DDI - erythromycin, clopidogrel, warfarin, theophylline, sulfonylureas, thiazides, cimetidine, hepatotoxic drugs
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21
Q

new drug in triterpenoid class
Better long-term prevention of recurrent VVC than azoles
inhibits glucan synthase enzyme, used to make cell wall

A

Ibrexafungerp (Brexafemme)

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22
Q

SE and DDI of Ibrexafungerp

A
  1. SE - GI upset (N/V/D), abdominal pain
    - Rare - elevated AST/ALT, rash, back pain, vaginal bleeding
    - CI in pregnancy
  2. DDI - grapefruit, anticonvulsants, azole antifungals
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23
Q
  1. Most helpful in non-candidal infections
  2. Cannot be used in pregnancy
  3. 1 capsule intravaginally (PV) QHS x 7 d
  4. interferes with fungal metabolism
A

Boric Acid Intravaginal

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24
Q

Size 0 gelatin capsules filled with boric acid, which is about ? mg

A

600

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25
Q

SE and DDI of boric acid intravaginal

A
  1. SE - local irritation or inflammation
    - Toxic if taken internally
  2. DDI - not common
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26
Q

how to use gentian violet

A

Apply 1% topically QD x once (acute) or x 10-14 d (recurrent)

  1. May apply to clean tampon and insert
  2. Remove 3-4 hrs after tampon insertion
    - Should not use tampons for menstrual
    flow while performing this therapy
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27
Q

MOA of gentian violet

A

may inhibit protein synthesis

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28
Q

SE and DDI of gentian violet

A
  • SE - topical irritation, staining or
  • discoloration of clothing and skin
  • DDI - none known
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29
Q

tx for Recurrent cases of candidal vulvovaginitis

A

May use prophylactic antifungals for up to 6 months

  1. Azoles - PO 1x/week or PV 1-2x/week
  2. Boric acid - PV once every two weeks
  3. Gentian violet - PV/externally QD x 10-14 d, then PRN
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30
Q

prevention for Candidal Vulvovaginitis

A
  1. Keep vulvovaginal area dry - Avoid non-absorbent undergarments
  2. Control underlying systemic disease
  3. Avoid excessive glucose dietary intake
  4. DC complicating meds
  5. Consider prophylactic antifungals with abx
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31
Q

Overgrowth of abnormal bacterial flora
Often polymicrobial - Gardnerella vaginalis often present
Not considered STI, but rare in nonsexually active patients

A

Bacterial Vaginosis

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32
Q

Milky, homogenous, malodorous vaginal discharge, often with minimal inflammation
More noticeable after unprotected intercourse
“Fishy” smell, enhanced after KOH prep
Lack of vaginal mucosal inflammation on exam

A

Bacterial Vaginosis

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33
Q

BV is Associated with increased risk of ?

A

preterm delivery

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34
Q

w/u for BV

A
  1. Vaginal pH - usually elevated (pH 5.5 - 7)
  2. Saline Prep
    - 1 drop vaginal discharge with 1 drop normal saline
    - Apply coverslip and examine under microscope
    - BV - “clue cells” - epithelial cells covered with bacteria
  3. KOH Prep
    - 1 drop discharge with 10% aqueous potassium hydroxide
    - BV - fishy odor present or increased after KOH (“whiff test”)
  4. Can also do Gram stain and culture of discharge
    - Cx often not helpful - polymicrobial condition
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35
Q

tx for BV

A
  1. Metronidazole (Flagyl/Metrogel)
  2. Clindamycin (Cleocin)
  3. PO Tinidazole (Tindamax) - avoid in preg
  4. PO Secnidazole (Solosec) - avoid in preg
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36
Q

MOA of nitroimidazoles

A

binds to and deactivates enzymes

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37
Q

best nitroimidazoles for pregnant pts

A

PO metronidazole or clindamycin

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38
Q

SE of Nitroimidazoles

A

dizziness, HA, false lab results (LFTs and TG)

  • GU - dark colored urine, local irritation (vaginal)
  • GI - abdominal pain, GI upset, dry mouth, glossitis, altered taste
  • Rare - neurotoxicity, anaphylaxis, serotonin syndrome
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39
Q

DDI of nitroimidazoles

A

alcohol (up to 3 days after use), disulfiram (up to 2 weeks before/after use), anticoagulants, phenytoin, lithium

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40
Q

MOA of clinda

A

binds to ribosomes blocking protein synthesis

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41
Q

SE of clinda

A

C. diff and pseudomembranous colitis, local irritation (vaginal)

  • GI - abdominal pain, GI upset, altered taste
  • Rare - blood dyscrasias, hepatotoxicity, anaphylaxis, polyarthritis
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42
Q

DDI of clinda

A

macrolides, neuromuscular drugs, antiperistaltic drugs

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43
Q

how to prevent BV

A

Avoidance of factors altering nml vaginal flora

Under investigation:
1. Probiotic supplements - oral or intravaginal
1. Boric acid with EDTA suppositories
1. Microbiome transplant
1. Acidifying vaginal douches - Vaginal douching not recommended

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44
Q
  1. Unicellular flagellate protozoan
  2. Most prevalent non-viral STD in the US - Rarely transmitted outside of sexual activity
  3. Associated with perinatal complications and increased HIV transmission
A

Trichomonal Vaginitis

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45
Q
  • Profuse, extremely frothy, greenish, at times foul-smelling vaginal discharge
  • possible vulvar pruritus, urinary sx
  • generalized vaginal erythema with multiple small petechiae - “strawberry cervix;” edema/tenderness of labia minora, vestibule
A

Trichomonal Vaginitis

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46
Q

w/u for Trichomonal Vaginitis

A
  1. Vaginal pH - elevated (pH >5-5.5)
  2. Saline Prep
    - 1 drop vaginal discharge with 1 drop normal saline
    - Apply coverslip and examine under microscope
    - Trichomonas - actively motile trichomonads
  3. Other tests - can give false + results
    - Immunochromatographic rapid test - 10 minutes
    - Nucleic acid probe - 45 minutes
    - Pap smears may reveal infection
    - Cx - most sensitive and specific method
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47
Q

tx for trichmonal vaginitis

A
  1. metronidazole OR secnidazole OR tinidazole
  2. Resistant - tinidazole
  3. Partner should also be treated! Also screen for other STIs - G&C, HIV, syphilis
48
Q

Gonorrheal Vulvovaginitis Mc infects glands of ?

A

cervix, urethra, vulva, perineum, anus

49
Q

?% of Gonorrheal Vulvovaginitis are asx

A

80-85%

50
Q

w/u and tx for gonorrheal vulvovaginitis?

A
  • Dx - nucleic acid probe or culture of discharge; G- diplococci within leukocytes
  • Tx - ceftriaxone + doxycycline/azithromycin (chlamydia)
  • Partner should also be treated!
51
Q

s/s of Chlamydial Vulvovaginitis

A

often asx
May see mucopurulent cervicitis, dysuria, and/or postcoital bleeding
Can progress to PID or lymphogranuloma venereum

52
Q

w/u and tx for Chlamydial Vulvovaginitis

A
  • Dx - Cx, immunoassay, nucleic acid
  • Can be found on Pap smear as well
  • Tx - doxycycline (preferred), azithromycin; Usually also receive tx for gonorrhea
  • Partner should also be treated!
53
Q

causes of Noninfectious Vaginitis

A
  • Topical irritants - sanitary supplies, spermicides, feminine hygiene supplies, soaps, perfumes
  • Allergens - latex, antimycotic creams
  • Atrophy - s/p menopause or premature ovarian failure
  • Excessive sexual activity
  • Poor hygiene, stress, sweat, heat
54
Q

s/s of Noninfectious Vaginitis?
tx?

A
  • Varying degrees of pruritus, irritation, burning, erythema, and vaginal discharge
  • remove offending agent; Atrophy - lubricants, moisturizers, HRT or ospemifene (a SERM); Warm sitz baths; Topical steroid therapy (minimal duration)
55
Q

CAM Treatment of Vaginitis

A
  1. Intravaginal therapies - white vinegar, herbals (oregano leaf, goldenseal root, echinacea), povidone iodine, tea tree oil suppositories
  2. Probiotic supplementation
  3. Daily oral supplements - green tea, cat’s claw, milk thistle, grapefruit seed extract, garlic
56
Q

MC type of HSV

A

60% - HSV type 2

57
Q

s/s of herpes genitalis

A

vesicles that become painful erosions or ulcers surrounded by an erythematous halo

  1. Prodrome - tingling, itching, burning, flu-like symptoms
  2. +/- inguinal lymphadenopathy
  3. +/- urinary symptoms (dysuria, urinary retention)
58
Q

w/u for herpes genitalis?

A

viral culture, PCR, DFA, Tzanck smear

59
Q

tx for herpes genitalis

A
  1. Initial - antivirals for 7-10 days
    - Valacyclovir, Famciclovir, Acyclovir
  2. Recurrent - antivirals for 1-5 days
  3. Prophylaxis - re-evaluate need periodically

Prevention - barrier contraception, suppressive antivirals

60
Q

MCC of Condyloma Acuminatum?

A

HPV 6 and 11

61
Q
  1. white exophytic or papillomatous growth
    - Tend to coalesce and form large cauliflower-like masses
    - May also see flat lesions with granular surfaces
  2. Can affect vagina, cervix, vulva, perineum, perianal areas as well as other areas of body
A

Condyloma Acuminatum

62
Q

w/u for Condyloma Acuminatum

A
  1. Before tx, should do Pap and colposcopy
    - bx to r/o neoplasia
    - screen for STIs
63
Q

tx for Condyloma Acuminatum

A
  1. Provider - topical application of bichloracetic acid, trichloroacetic acid, podophyllin; cryotherapy, electrosurgery, simple excision, laser
  2. Pt - topical podofilox, imiquimod, topical interferon, or sincatechins
  3. Recurrence after treatment is common!
64
Q

Benign epithelial tumors caused by poxvirus
Size varies - up to 1 cm
Often multiple and contagious
microscopy: numerous inclusion bodies in cell cytoplasm

dx?
tx?

A

Molluscum Contagiosum

Tx - desiccation, freezing, curettage, chemical cauterization, topical imiquimod; Frequently cause scarring; May choose to observe

65
Q

STI caused by Treponema pallidum

A

Syphilis

66
Q

the 4 types of Syphilis

A
  • Primary - lone painless ulcer (chancre) +/- LAD
  • Secondary - generalized rash, malaise, F
  • Latent - asx w/ positive serology
  • Tertiary - systemic involvement (e.g. cardiac, neural)
67
Q

tx for Syphilis

A
  1. PCN (benzathine penicillin)
    - If pregnant - still use PCN (desensitization for PCN-allergic pts)
  2. Primary, secondary, or < 1 yr latent
    Benzathine PCN G x 1 dose
    - PCN allergic, nonpregnant women - doxy
  3. > 1 yr latent, tertiary, CV
    Benzathine PCN G x 3 wk
    - PCN allergic, nonpregnant women - doxycycline x 4 wk
68
Q

Located near vaginal orifice
Secrete mucus for lubrication

A

Bartholin’s Glands

69
Q

problems with Bartholin’s Glands

A
  1. Infection - important cause of obstruction
  2. Other causes - inspissated mucus, congenital narrowing
  3. Postmenopausal - may reflect cancer; Consider bx of lesion
70
Q
  • Pain, tenderness, dyspareunia
  • Difficulty walking with adducted thighs
  • Usually will have fluctuant, tender mass
  • If cystic only - swelling with no pain or minimal discomfort
  • Systemic signs of infection are unlikely
A

Bartholin Gland Disease

71
Q

tx for Bartholin Gland Disease

A
  1. Drainage of cyst or abscess
    - 1st line - marsupialization or insertion of Word catheter
    - Simple aspiration or I&D - temporary relief
  2. Excision - if recurrent or postmenopausal
  3. abx - if significant inflammation
    or signs of systemic illness
72
Q

Benign, chronic, inflammatory disorder
MC non-neoplastic epithelial vulvar disorder

A

Lichen Sclerosus

73
Q

causes of lichen sclerosus

A

Multifactoral

  1. Vit A def, autoimmune, excess of elastase, dec 5-alpha-reductase
  2. > 60 years
    - Childhood pts → 50% have spontaneous resolution at adolescence
74
Q

s/s of Lichen Sclerosus

A

pruritus (MC)
May see vulvar pain, dyspareunia, asx white lesions

75
Q

Typical characteristics and progression of Acute Lichen Sclerosus:

A
  1. Erythema and edema of vulvar skin
  2. Development of white plaques - lichenification and hyperkeratosis
  3. Uniting of white plaques
  4. Intense pruritus → scratch–itch cycle
  5. Telangiectasias and subepithelial hemorrhages 2o scratching
  6. Erosions, fissures, and ulcerations
76
Q

Typical characteristics and progression of Chronic Lichen Sclerosus:

A
  1. Thin, wrinkled, white skin (“cigarette-paper”)
  2. Agglutination of anterior bilateral labia minora → cover the clitoris → phimosis
  3. Contraction of the vulvar structures → introital stenosis
  4. Involvement of the perianal region
  5. Some women develop islands of hyperplastic epithelia within the atrophic lichen sclerosus epithelium
77
Q

complications of lichen sclerosus

A
  1. High rate of SCC (3-5%)
    - bx indicated for all new lesions
    - Cancer mainly in pts who continue to suffer itching or who neglect treatment
78
Q

goals of lichen sclerosus therapy

A
  1. Stop itch-scratch cycle
  2. Minimize dermal inflammation
  3. Improve vulvar hygiene
    - Avoid tight undergarments
    - Daily cleansing with mild soap
    - Drying skin with hair dryer
79
Q

tx for lichen sclerosus

A
  1. Clobetasol propionate 0.05% (Dermovate)
    - intralesional injection for refractory areas with thickened, hypertrophic plaques (monthly x 3 months)
  2. Adjunct - oral antihistamines QHS, topical emollient
  3. 2nd-line - tacrolimus cream, retinoids (topical or oral), phototherapy
  4. Surgery - for introital narrowing causing dyspareunia or invasive SCC
  5. Refractory - oral acitretin (retinoid), MTX, laser/UVA therapy
    - Surgical undermining of affected skin (Mering procedure)?
80
Q

tx that are no longer used for lichen sclerosus

A
  1. Topical testosterone cream - Less effective than steroids; virilization
  2. Topical progesterone cream
  3. Intralesional alcohol injection
  4. Vulvectomy
81
Q

Emerging/Investigational therapies for lichen sclerosus

A
  1. Silk underpants
  2. Tretinoin, cyclosporine, adalimumab
  3. Cryotherapy and/or focused US
  4. Platelet-rich plasma
82
Q

prognosis of lichen sclerosus

A
  1. Chronic disease - recurs when tx stopped
  2. Steroids resolve symptoms in most patients - Can reverse skin changes in 50%
83
Q
  • Benign epithelial thickening and hyperkeratosis
  • Chronic irritation (perfumed pads, chronic infection)
  • 26-75% association w/ atopic disorders (hyperplastic dystrophy, squamous cell hyperplasia)
  • Chronic pruritus leads to rubbing and scratching which becomes involuntary over time
A

Lichen Simplex Chronicus

84
Q
  1. Lichenified, scaly, localized plaque
    - Initially may present as red papules that later coalesce
    - +/- excoriations, hypopigmentation, or hyperpigmentation
    - Can develop secondary cellulitis
    - Patients usually complain of itching
A

Lichen Simplex Chronicus

85
Q

w/u for Lichen Simplex Chronicus

A

bx

  • Required to rule out intraepithelial neoplasia or invasive CA
  • Absence of dermal inflammatory infiltrate distinguishes from lichen sclerosus
86
Q

mgmt for Lichen Simplex Chronicus

A
  1. General vulvar hygiene
  2. Sitz baths and topical lubricants
  3. Oral antihistamines
  4. Topical medium-potency steroids (fluocinolone, triamcinolone)
  5. Intractable cases -
    - steroid injection
    - Oral antidepressants (TCA such as amitriptyline)
87
Q
  1. Mucocutaneous dermatosis
    - Skin - sharply marginated flat-topped papules
    - Mucous membranes - less sharply marginated white plaques
  2. Rare to find on vulva
    - Erosive lesions (more common) or leukoplastic lesions
    - May have introital stenosis or vaginal adhesions

dx?
tx?

A

Lichen Planus

  • Initial - topical hydrocortisone foam for vagina (Colifoam)
  • Secondary - higher potency topical steroids or topical tacrolimus
  • Severe - systemic steroids
  • Introital stenosis or adhesions - vaginal dilators or surgical release
88
Q

Dark vulvar lesions

A
  1. Melanosis / Lentigo - darkly pigmented flat lesion; mistaken for melanoma
  2. Vulvar melanoma - only 1-3% of vulvar cancer - extremely aggressive
  3. Capillary hemangioma
    - Childhood - small strawberry hemangiomas or large cavernous; often become static or regress after 18 months
    - Senile - small, dark blue, asx papules
    - excision (if repetitive bleeding is an issue), laser, cryotherapy
  4. Other lesions - vaginal neoplasia, Kaposi’s sarcoma, dermatofibroma, SKs, vulvar varicosities
89
Q
  1. Varicose veins involving the vulvar anatomy
    - May be aggravated during pregnancy
    - Rare outside of pregnancy - May signify underlying vascular dz, pelvic tumor
  2. Rupture can cause profuse hemorrhage
  3. Can have phlebitis or thrombosis of a vulvar varicosity causing pain and tenderness

dx?
tx?

A
  • Vulvar Varicosities
  • seldom necessary unless there is a complication; Supportive compression undergarments during pregnancy; If persistent postpartum - sclerosing agent
90
Q

Vulvar intraepithelial neoplasia (VIN) often associated with multifocal lower genital tract disease
May involve vagina, vulva, cervix, perineum, perianal areas

A

Preinvasive Vulvar Disease

91
Q

Preinvasive Vulvar Disease has a strong association with ?

A

HPV (90% of lesions)
Also associated with HIV

92
Q

what increases risk of high-grade lesions of preinvasive vulvar disease

A

smoking

93
Q
  1. white, hyperkeratotic papules
  2. Discrete or diffuse, single or multiple, flat or raised
  3. vary in color from white to velvety red or black
  4. pruritus (60%); Often asx!

dx?
w/u?

A
  • Preinvasive Vulvar Disease
  • inspection of vulva with colposcopy (+/- green filter) followed by bx of suspicious lesions
94
Q

tx for preinvasive vulvar disease

A

Based on bx

  • Wide local excision
  • Laser ablation
  • Topical 5-fluorouracil or imiquimod
  • Superficial vulvectomy
95
Q

f/u for Preinvasive Vulvar Disease

A
  • Thorough pelvic exam with colposcopy every 3-4 months until patient is disease free for 2 years
  • After 2 years - pelvic exam every 6 months
96
Q
  • Intraepithelial neoplasia (adenocarcinoma in situ)
  • < 1% of all vulvar malignancies
  • MC Caucasian women in 60s-70s
  • May be extensive but MC confined to epithelial layer - Often extends to perirectal, buttocks, thighs, inguinal, mons
A

Extramammary Paget’s Disease

97
Q
  • pruritus, vulvar soreness
  • Pruritic, slowly spreading velvety-red discoloration - Initial lesion may be confused with other chronic vulvar lesions
  • Eventually becomes eczematoid with maceration and development of white plaques
  • “Red Velvet Cake” appearance

dx?
w/u?
tx?

A
  1. Extramammary Paget’s Disease
  2. bx
  3. wide local excision
98
Q

prognosis of extramammary paget’s disease

A

High chance for recurrence

  • multiple local excisions of recurrent disease after tx of primary disease
  • If invasive, (-) node metastases - good prognosis
  • If invasive, (+) node metastases - almost always fatal
99
Q

MCC of Vulvar Cancer

A
  1. SCC
  2. 2nd MC - malignant melanoma (5%)
  3. MC cause in younger women - HPV
  4. MC cause in older women - chronic inflammation
100
Q

vulvar cancer is MC in who?

A
  • MC in poor and elderly
  • Uncommon overall - 4% of GYN cancers
  • infrequent medical exams
  • 10% - DM
  • 30-50% - obese, HTN or other CV disease
101
Q

s/s of vulvar cancer

A
  1. Vulvar pruritus and/or mass - >50% pts
    - Bleeding or vulvar pain also possible
    - 20% - asx; mass found on exam
    - 25% have seen physician and received tx w/o bx done
  2. SCC - 65% in labia, 25% clitoris or perineum
  3. > ⅓ midline or BL vulva
  4. Varies from large, exophytic, cauliflower-like lesion to small ulcers to elevated red velvety tumor - Exophytic lesions may become very large, necrotic, and become infected
102
Q

tx for vulvar cancer

A
  1. remove all tumor wherever possible
    - Wide radical local excision with inguinal LN excision; (+) LN metastasis - radiation
    - Imaging depends on presentation
    - Pelvic exenteration - if involvement of anus, rectum, rectovaginal septum, proximal urethra or bladder
    - Chemotherapy - depends on cancer extent and type
103
Q

f/u for vulvar CA

A
  1. Every 3 months for 2 years - 80% of recurrences in 1st 2 yrs
  2. Every 6 months thereafter
104
Q

Most Vaginal Intraepithelial Neoplasia (VAIN) are where?

A

in the upper ⅓ of the vagina

105
Q

s/s of preinvasive vaginal disease

A
  1. History similar to cervical neoplasia (CIN)
  2. May present as abnormal cytology or as a visible lesion
    - Condylomatous lesions usually associated with dysplasia
    - Lesions usually on vaginal ridges; may be raised, have spicules
106
Q

w/u for preinvasive vaginal disease

A

colposcopy and biopsy

  • 3-5% acetic acid solution used to identify areas
  • May be difficult to do colposcopy of vaginal cuff
107
Q

tx for preinvasive vaginal disease?

A
  • VAIN I: regresses; do not require tx
  • VAIN II/III: surgery / CO2 laser; topical 5-FU
  • Hysterectomy if CIS of cervix extends to upper ⅓ of vagina
  • hard to resolve w/ only one tx modality/session; close monitoring q 4-6 mo
108
Q

MC type of cancer to cause vaginal cancer?

A

SCC - 85%

109
Q

when is vaginal CA considered primary?

A

no cervical involvement/minimal involvement

109
Q

MC form of vaginal malignancy is extension of ?

A

cervical cancer

110
Q

RF for vaginal CA

A

similar to cervical neoplasia

  1. Smoking
  2. Hx of HPV infection or lower genital tract neoplasia
  3. Multiple sexual partners
  4. In-utero DES - risk of primary vaginal adenocarcinoma
111
Q

May be exophytic or ulcerative
involves posterior wall of upper ⅓ of vagina

which type of vaginal CA?

A

SCC

112
Q

MC primary vaginal cancer in young patients?

A

adenocarcinoma

113
Q

MC form is highly aggressive tumor in infancy or early childhood with polypoid, edematous “grape-like” masses at vaginal introitus
May also see in older pts - upper anterior vaginal wall

which type of vaginal CA?

A

sarcoma

114
Q

Rare - MC arise from anterior surface and lower ½ of vagina

which type of vaginal CA?

A

melanoma

115
Q

s/s vaginal CA

A
  • MC asx and found on exam
  • MC sx - postmenopausal and/or postcoital bleeding
  • vaginal discharge, vaginal mass, urinary sx possible
  • Pain or leg edema if advanced tumor present
116
Q

w/u, mgmt, prognosis for vaginal CA?

A
  • Dx - Colposcopy and bx
  • hysterectomy, vaginectomy, lymphadenectomy
  • Localized - pelvic exenteration
  • 5-yr survival - 77% stage I, 45% stage II, 31% stage III, 18% stage IV; Melanomas - highly malignant, do not respond well to therapy

Women's health (15 decks)

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