Transcript vulva talk screeners

The Vulva
Terminology
Normal Anatomy
Normal Anatomy
Symptoms your patients will tell you
about
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Pruritus (itch). General or just one spot
Soreness: stinging / burning / pain
Difficulty with sex
Lumps
Causes of pruritus vulvae and/or pain
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Candida albicans infection
Irritant contact dermatitis
Seborrhoeic dermatitis
Psoriasis
The three lichens:
-Lichen simplex
-Lichen sclerosus
-Lichen planus
Candida albicans – vulvovaginal
Candida albicans – vaginal
Irritant contact dermatitis
• Erythema
• Oedema
• Fissuring
Soap, water, rubbing
Irritant contact dermatitis
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Burn-like
Glazed erythema
Superficial erosions
Oedema
Faecal and urinary incontinence
Seborrhoeic dermatitis
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Usually patient has it at other sites also
Mons pubis and flexures
May or may not be scaly
Mild or absent symptoms
Seborrhoeic dermatitis
Causes of pruritus vulvae
• Candida albicans infection
• Irritant contact dermatitis
• Seborrhoeic dermatitis
• The three lichens:
Vulval psoriasis
Vulval psoriasis
Causes of pruritus vulvae and /or pain
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Candida albicans infection
Irritant contact dermatitis
Seborrhoeic dermatitis
Psoriasis
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• Lichen simplex
• Lichen sclerosus
• Lichen planus
Lichens
• All three cause similar skin change
• The skin becomes thickened, pale, with
increased skin markings [grooves]and fissures
Lichen Simplex
• Chronic irritation causes the skin change
• Remove the irritant and the skin recovers
Lichen simplex
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Perineum - ?Candida
Skin thickening
Fissuring
Skin coloured
Dyspigmentation
common
Lichen simplex
• Unilateral, labium major
• Due to rubbing because
of intense itch
• Well-demarcated
• Skin thickening
• Increased skin markings
• Skin coloured
• Dyspigmentation
common
Lichen sclerosus
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Probably an immune system disease
Itch: nil to very severe
Soreness: nil to very severe
Altered anatomy from tissue destruction
Dyspareunia / apareunia because of
symptoms or changed anatomy
The Itch of lichen sclerosus
• Mainly the labia minora, clitoral hood and/or
perineum
• Perianal in 50%
• Extragenital in 15%
Who gets Lichen Sclerosus
• Most are 50 years or older but children and
teenagers may be affected
• May have other associated autoimmune
conditions
– 25% thyroid antibodies;
– 10% psoriasis
LS and VIN
• Lichen Sclerosus is associated with pre
malignant change
• VIN, Vulval Intraepithelial neoplasia
• VIN untreated may become SCC
Lichen sclerosus
• Distribution: figure of 8
with wings
– Usually bilateral
• Colour – white,crinkly
(‘cigarette-paper’)
• Sclerosis – firm
Lichen sclerosus
• White, like vitiligo
• Anatomic change
– Loss of labia minora
Lichen sclerosus
• Distorted clitoral hood
and labia minora
• Postinflammatory white
areas
• Postinflammatory
brown pigmentation
Lichen sclerosus
• Resorption of labia
minora
• Fissures in the labial
sulcus and onthe
perineum
Lichen sclerosus
• Flattening of clitoral
hood
• Resorption of labia
minora
• Haemorrhages
Lichen sclerosus
• Flattening of clitoral
hood
• Resorption of labia
minora
Lichen sclerosus
• Severe introital
narrowing
• Splitting of posterior
forchette
Lichen sclerosus
• Bridging / fusion /
agglutination of left and
right labia
• Ulceration
Lichen sclerosus
• Distortion of labia
minora
• Ulceration
• Haemorrhage
Lichen sclerosus
• Ulcer right labium
minor
Lichen sclerosus
• Hyperkeratosis
– Consider biopsy
LS in a teenager
Psoriasis + lichen sclerosus
• Psoriasis less
symptomatic but more
impressive
• Psoriasis ‘outside’
• Lichen sclerosus ‘inside’
• Psoriasis does not alter
anatomic features
Lichen sclerosus: treatment
• Ultrapotent topical steroid, usually clobetasol
ointment
• Once daily until clear (one to three months)
• Then alternate days for the same duration
• Then once or twice per week long-term or
PRN
• Explain to patient precisely where to apply the
ointment
Lichen planus
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Less common
More painful
Just as destructive
More likely to be seen on other parts of the
patient
• Two types: cutaneous and mucosal
Lichen planus: cutaneous type
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Violaceous plaques
Wickham’s striae
Labia majora
Irregular distribution
Lichen planus: mucosal type
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May be very itchy
More often very painful
Very tender to touch
Destructive – loss of clitoral hood, labia minora
May cause introital narrowing
More likely to involve vagina (unlike lichen sclerosus)
May also affect oral mucosa
– Buccal mucosa, inner lips, tongue
– Desquamative gingivitis
Erosive lichen planus
• Red glistening painful
mucosal patch
• Loss of labia minora
Erosive Lichen Planus
Erosive lichen planus
Erosive lichen planus
• Mucosal disease may
result in
postinflammatory
pigmentation
Erosive lichen planus
• Destruction of tissue
• Introital narrowing
• Eaten-away appearance
Erosive lichen planus: treatment
• Topical clobetasol daily
– May be required daily long-term
• Topical calcineurin inhibitors, e.g.,
pimecrolimus cream
• Oral prednisone
• Methotrexate
• Often symptoms respond better than signs
Plasma cell Vulvitis
• Much less common
• Much less destructive
• Often asymptomatic
Plasma cell vulvitis
• Deeper red than LP
– Haemorrhagic
• More internal
• More patchy
Plasma cell vulvitis
• May extend
periurethrally
• Contact bleeding
Plasma cell vulvitis: treatment
• Topical antibiotic
– Clindamycin cream
– Metronidazole cream
• Hydrocortisone cream
Symptoms your patients will tell you
about
• Pruritus (itch). General or just one spot
• Soreness : stinging / burning / pain
• Difficulty with sex
Lumps that might not cause
symptoms
• Frightening things
• Not so frightening things
Pre malignant and Malignant lesions
• Vulval intraepithelial neoplasia, VIN
• Invasive squamous cell carcinoma
• Melanoma
Vulval intraepithelial neoplasia
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This is a pre malignant lesion
Mild or no symptoms but does have signs
Two types: Usual and Differentiated
Usual VIN = HPV related
Differentiated VIN = Lichen sclerosus or lichen
planus related
– more likely to become an aggressive SCC
HPV
• Human Papilloma Virus
• Low risk and High risk, but HrHPV types are
associated with cancers in many parts of the
body: cervix, vagina, vulva, anal canal, mouth.
• Sexually transmitted
• Vaccine
• ENT surgeons now very interested
VIN
VIN
VIN
VIN
+ Lichen sclerosus
Invasive squamous cell carcinoma
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Arises within VIN [HPV or lichen sclerosus]
Irregular, hard nodule, often ulcerated
May be multifocal
Often aggressive
Invasive squamous cell carcinoma
Invasive squamous cell carcinoma
Melanoma
• Rare
• Not related to fair skin or sun exposure
• Mild or no symptoms
Vulval melanoma
Melanoma
Less frightening things
• You will often notice lumps or bumps
• Ask about them
• The patient may be waiting to see if you think
its abnormal.
Sebaceous Cyst
Vaginal Wall prolapse
Prolapse
Varicosities
Genital Warts
Others
• Urethral caruncle
• Bartholin’s cyst
• Asymmetrical labia
Bartholins cyst
Urethral caruncle
It’s a very private area
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Our perception of our vulva is effected by:
Culture
Religion
Age
Education
Marital status
Sexual experiences
Facebook
Vulval Disease
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Most women present late, and very distressed
They often feel guilt or ashamed
They always feel embarrassed
They worry it’s an STI
If there is a lump they think it’s a wart
Results of surveys of the impact of vulva
disease are alarming
Vulval disease
• Any one of the conditions I have discussed
today, even the most innocuous will disrupt
their sex lives no matter their age.
• Patients can become very socially isolated and
their relationships severely altered.
• There is usually something we can do to help
Vulva Sign