Exam 21 - Gyn19 - Vulvitis And Vaginitis

Front 1

look at slide 5

Back 1

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Front 2

Normal appearance of physiologic vaginal discharge (normal secretions):

-White, ... viscosity.
-Clear.
-pH ≤ ...
-No significant odor.
-Lactobacilli present.
-Absence of mycelia, Trichomonas, etc.

Back 2

high
4.5

Front 3

Evalulation: the history

... have impaired cellular immunity generally b/c a hyperglucose environment is toxic to leukocytes. (cellular immunity is impaired in high glucose).

... – pts predisposed to fistula formation

Back 3

Diabetics
Crohn’s

Front 4

Examination of vaginal discharge:

Test pH
-< 4.5: ... or ....
-> 4.5: ... or ....

... of vaginal discharge rarely indicated.

-Wet prep.
-Mix discharge with 1 or 2 drops normal saline on clean slide, add cover slip.
-Look for hyphae under ... power.
-Look for leukocytes, clue cells, Trichomonas under ... power.

Back 4

Normal or candida
Bacterial vaginosis or Trichomoniasis
Cultures
lower
high

Front 5

When is a KOH prep indicated?

Back 5

if suspect candida and wet prep is unrevealing

Front 6

Amine (“whiff”) test:

-Add drop ... to slide or test tube with discharge in small amount saline.
-Strong amine (fishy) odor compatible with ....
-Indicated if ... is suspected but diagnosis not confirmed by other means.

Back 6

KOH
bacterial vaginosis
BV

Front 7

Yeast Vaginitis (Candida):

-usually an ... infection
-80-90% of the time, it is what organism?

Wet preparation (KOH):
-Branching filaments and blastospores.
-... – hyphae.
-... – spores only.
-pH 4.0-4.4 (normal)

Back 7

airborne
Candida albicans
C. albicans
C. glabrata

Front 8

look at slides 17-19

Back 8

ok

Front 9

Yeast vaginitis (candida):

Treatment:
-Local (cream/ointment/supp/tablet): clotrimazole, miconazole, terconazole.
-Oral: ...

Back 9

fluconazole (Diflucan)

Front 10

Chronic/Recurrent Candidiasis:

Risk factors:
-Exogenous estrogens.
-Chronic antibiotics.
-Chronic diseases, esp ....
-Immune compromise.

Therapy:
-Protracted therapy with oral antifungals (watch for ... toxicity).
-Antifungal prophylaxis during antibiotic therapy.

Back 10

diabetes
liver

Front 11

...: an STD

Clinical presentation:
-Malodorous discharge, frothy, yellow-gray or green.
-Dysuria.
-Vulvovaginal irritation.
-Asymptomatic in 20%-50% of women with the organism.

Risk factor:
-Sex that is not mutually monogamous.

Back 11

Trichomoniasis

Front 12

Trichomoniasis:

Microbiology:
-Protozoan.
-Unicellular, flagellated, motile.
-15 μm in size (slightly larger than a ...).

Diagnosis:
-Wet prep.
-Culture on Diamonds medium.
-Pap smear (low sensitivity and specificity).

Wet prep:
-... Trichomonads.
-pH ... 4.5.
-Large number of ....

Back 12

leukocyte
Motile
>
leukocytes

Front 13

look at slides 25-26

Back 13

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Front 14

Trichomoniasis treatment:

...
-Single dose of 2 gm orally +/- repeat dose in 2 d.
-500 mg bid orally x 7 days.
-Warn against ... consumption while taking.
-Treatment of male partner. (hangs out in prostate gland)
-Creams/gels available (Metrogel) but not as effective due to fact that Trichomonas can live in urethra, bladder, Skene’s glands, etc.
-95% cure rate with oral therapy.

Back 14

Metronidazole (Flagyl)
ETOH

Front 15

What should you suspect if you see clue cells (epithelial cells w/ fuzzy borders)?

Back 15

bacterial vaginosis

Front 16

Bacterial vaginosis:

-... absent or present in very low numbers. No one specific organism

Wet prep:
-... cells on microscopic examination: Vaginal epithelial cells with indefinite outlines/granular appearance due to bacilli attached to cell surfaces.
-Minimal inflammatory response (few ...).

Back 16

Lactobacilli
Clue
leukocytes

Front 17

look at slides 32-33

Back 17

ok

Front 18

Diagnosis of BV:

Clinical diagnosis (3 of 4 criteria):
-... cells on microscopic exam.
-pH ... 4.5
-Positive KOH “...” test – secondary to release of ....
-... discharge.

Culture diagnosis is unreliable, has no role; Gardnerella vaginalis found in up to 60% of normal vaginal cultures.

Back 18

Clue
>
whiff
amines
Homogeneous

Front 19

If you have an elevated pH, what are your 2 diagnoses?

What is the treatment for both?

Back 19

BV or trichomoniasis
Flagyl (metronidazole)

Front 20

Pregnancy and BV:

Should all symptomatic women be treated if indicated?

It’s best to avoid treatment in the ... trimester.

Back 20

yes
first

Front 21

Inflammatory Vulvitis:

All that itches is not ...!

...:
-Avoid irritant and tx with low-potency topical steroid (0.025%-0.1% hydrocortisone).

Seborrheic dermatitis.

...:
-Erythematous vulvar patches with or without scales (generally without).
-Multifocal. Usually not limited to vulva.

Back 21

yeast
Contact dermatitis
Psoriasis

Front 22

.../...:

-Grossly normal exam but erythema of vestibule noted if looked for carefully.
-Pain on contact with vestibule (cotton swab testing of vestibule).
-Dyspareunia, coitus impossible in some cases.
-Treatment – no one modality works for everyone therefore many tx options (some controversial): stop all previous tx, vegetable oil, interferon or steroid injections, biofeedback, psychological support, tricyclic antidepressants (pain management doses), empiric weekly or monthly oral antifungal, vestibulectomy.

Back 22

Vestibulitis/Vulvodynia

Front 23

Ulcerative Lesions of the Vulva (Non-STI):

... disease:
-Vulvar ulcers, oral/buccal ulcers, iritis.
-Treat with ....

... disease:
-Vulvovaginitis due to fistula(s).
-Pyoderma gangrenosum.
-Erythema nodosum.
-Abscess.
-Treatment – abx and ... correction of fistula.

Back 23

Behçet’s
prednisone
Crohn’s
surgical

Front 24

Vulvar Dystrophies:

... epithelial cell disorders of the vulva.
-Lichen sclerosis. (common)
-Squamous cell hyperplasia.
-Vulvar intraepithelial neoplasia (VIN).
-Sebacious cysts. (most common)
-Condyloma.
-Nevi.

When in doubt, check it out (...!); don’t miss a vulvar ... (SCC, melanoma).

Back 24

Nonneoplastic
biopsy
malignancy

Front 25

look at slide 41

Back 25

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Front 26

...:

-Usually postmenopausal; 10-15% occurs in children.
-Non-specific, patchy, thin, white, parchment-like labial skin.
-Does not involve vagina or labia majora.
-Atrophic destruction of labia ... may cause introital stenosis.

Back 26

Lichen Sclerosis
minora

Front 27

Lichen Sclerosis:

Diagnosis: clinical vs biopsy (I strongly recommend ... to exclude malignancy and confirm diagnosis).

Biopsy findings:
-Hyperkeratosis, loss of rete pegs, thin epithelium, underlying collagenization, presence of neutrophils.

Treatment:
-... (0.05%). –make sure it’s not atrophy (will make it worse)

Back 27

biopsy
Clobetasol ointment

Front 28

...:

-Clinical findings: Gray, pink or white firm patches, thickened, hyperkeratotic areas, pruritus.
-Diagnosis via biopsy: Increased cellular elements, parakeratosis, hyperkeratosis, chronic infiltrates, acanthosis.
-Treatment – topical or subcutaneous (via injection) steroid.

Back 28

squamous cell hyperplasia

Front 29

...:

-White, red or pigmented lesions.
-May be pruritic.
-Associated with HPV, other lower genital tract neoplasia.
-... potential.
-Treatment:
*Surgical: wide local excision, vulvectomy, laser ablation.
*Medical: imiquimod, topical 5-fluorouracil.

Back 29

Vulvar Intraepithelial Neoplasia
Premalignant

Front 30

look at slide 46

Back 30

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Front 31

...:

-Symptoms: pain, tenderness.
-Signs: unilateral swelling of posterior labium majus, redness in overlying skin, labial edema.
-Treatment: warm soaks, antibiotics, incision and drainage with Word catheter placement, marsupialization, or surgical excision of the gland (rare).
-Suspicious for ... if postmenopausal.

Back 31

Bartholin gland cyst/abscess
adenocarcinoma

Front 32

look at slide 48

Back 32

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