Vulvar / Vaginal Disease Ch 19, 23, 41 2009-2010 Academic Year

Vulvar / Vaginal Disease Ch 19, 23, 41

• 2009-2010 Academic Year

• MSIII Ob/Gyn Clerkship

• Self-Directed Study

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.

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

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.

APGO Educational Topic 51:

• A. Define the risk factors for vulvar neoplasms.

• B. Describe the indications for vulvar biopsy.

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.

Wet Mount (Normal Saline)

Wet Mount (KOH)

Cevical Images associated with vaginitis

Dermatologic Conditions of Vulva

• Squamous Hyperplasia

• Lichen Sclerosis

• Lichen Planus

• Pemphigus

• Bechet’s Syndrome

• Crohn Disease

• Acanthosis Nigricans

Squamous Cell Hyperplasia

• Local thickening of epithelium

• Associated with prolonged itch-scratch cycle

Lichen Sclerosis

• Pruritus, Dyspareunia, burning

• Most common in menopausal women

• Skin is thin, inelastic, white, crinkled “tissue paper”

• Potent topical steriods (0.05% Clobetasol)

Lichen Planus

• Purplish, polygonal papules

• Can be erosive

• Vagina, vulva, mouth

• Topical and systemic steroids

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.

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!!!