Vulvar Vaginal Disease Ch 19 23 41 2009

Vulvar / Vaginal Disease Ch 19, 23, 41 2009 -2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Case Study 63 yo GP 3 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. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

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. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

APGO Educational Topic 51: • A. Define the risk factors for vulvar neoplasms. • B. Describe the indications for vulvar biopsy. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

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, p. H also helpful. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

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. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

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. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

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. 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

Pemphigus oral lesions. www. mdconsul. com Bechet’s Syndrome www. bestpractice. bmj. com Acanthosis Nigricans www. dermatologistsnyc. com 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies

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!!! 2009 -2010 USUHS MSIII Ob/Gyn Clerkship Self Directed Studies