2009-2010

Vulvar / Vaginal Disease Ch 19, 23, 41

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Case Study

63 yo GP3 postmenopausal woman, not on hormone replacement therapy, presents to clinic with complaints of vulvar pruritus. The patient has concerns as she is a diabetic and does not want to have an infection. Please discuss this patient’s evaluation in clinic and diagnosis.

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Questions to Consider

1. How would this change if she were 22?

– Decreased risk of malignancy 2. Differentiate bacterial vaginosis and yeast infection by history.

– BV – fishy odor, yellowish frothy discharge – Yeast – white clumpy discharge, pruritus 3. What if you see lesions? What if you see lesions in a 33 yo vs. an 80 yo?

– Increased risk of malignancy with age – In a 33 yo, differential diagnosis includes infection and neoplasm 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

APGO Educational Topic 35:

• A. Diagnose and manage a patient with vaginitis.

• B. Interpret a wet mount microscopic examination.

• C. Describe dematalogic disorders of the vulva.

• D. Evaluate a patient with vulvar symptoms.

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APGO Educational Topic 51:

• A. Define the risk factors for vulvar neoplasms.

• B. Describe the indications for vulvar biopsy.

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Vaginitis

Inflammation of the vagina (+/- vulva) • Evaluation of Vaginal Discharge – Whiff Test: KOH on slide or speculum with vaginal discharge produces “amine” or fishy odor with BV or Trichomoniasis.

– Wet-Mount: Vaginal discharge on slide, mixed with normal saline or mixed with KOH. Evaluated under microscope.

– Characteristic of discharge, pH also helpful.

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Wet Mount (Normal Saline)

Microscopic view (high power) of a Trichomonad in a saline wet-mount preparation. The organisms are usually motile in this type of preparation.

Trichomonas Bacterial Vaginosis Microscopic view of clue cells in a saline wet-mount preparation. Note the irregular or serrated cell walls.

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Wet Mount (KOH)

Candidiasis (Yeast Infection) Mycelial tangles of yeast pseudohyphae in KOH wet-mount preparation. 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Cevical Images

associated with vaginitis

“Clumpy” “Cottage-cheese-like” discharge Consistent with Yeast infection Frothy discharge consistent with Trichomonas.

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Dermatologic Conditions of Vulva

• Squamous Hyperplasia • Lichen Sclerosis • Lichen Planus • Pemphigus • Bechet’s Syndrome • Crohn Disease • Acanthosis Nigricans 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Squamous Cell Hyperplasia

• Local thickening of epithelium • Associated with prolonged itch-scratch cycle 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Lichen Sclerosis

• Pruritus, Dyspareunia, burning • Most common in menopausal women • Skin is thin, inelastic, white, crinkled “tissue paper” • Potent topical steriods (0.05% Clobetasol) 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Lichen Planus

• Purplish, polygonal papules • Can be erosive • Vagina, vulva, mouth • Topical and systemic steroids Lacy reticulated pattern, scarring Ulcerated lesions 2009-2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies www.mdconsult.com

Derm disorders of vulva that can be found on other parts of body

• Several dermatologic findings can also affect vulva/vagina.

–

Pemphigus

: autoimmune blistering disease of vulva/vagina, conjunctival areas.

– –

Behcets

: ulcerations of genitals, mouth, ocular lesions.

Crohn’s

: slitlike “knife-cut” ulcers of vulva, edema (often precedes GI sx’s) –

Acanthosis Nigricans

: intertriginous areas, axilla, nape of neck. Darkly pigmented velvety or warty surface. Associated with insulin resistence.

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Pemphigus oral lesions.

www.mdconsul.com

2009-2010 Bechet’s Syndrome www.bestpractice.bmj.com

Acanthosis Nigricans www.dermatologistsnyc.com

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Vulvar Biopsy

• When to biopsy – If you don’t know what it is – If it is persistent despite treatment or recurrent – When in doubt, biopsy.

YOU ARE NEVER WRONG TO BIOPSY!!!

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