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60 Cards in this Set
- Front
- Back
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Vulva contians the consists of |
labia majora, labia minora, clitoris, vestibule of the vagina, vaginal opening and bulbs of the vestibule |
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fourchette |
the inferior boundary of the vestibule of the vagina |
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The four main structures that open into the vestibule are |
urethra vagina 2 secretory ducts from bartholin's gland |
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Vulva and vagina berve innervations and sens to pain |
L1–2 and S2–4 nerve roots, is sensitive to noxious stimuli but the vagina is not sensitive to pain |
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Contact dermatitis |
Topical creams, soaps, perfumes and other toilet products irritate the vulva easily |
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Dermatoses |
predominant cause of vulvar problems If a dermatosis is suspected, check the skin on the body.
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Vestibular hypersensitivity |
Vestibular hypersensitivity (vulvar vestibular syndrome) is a distressing, reasonably common condition that gives superfi cial dyspareunia. Diagnosis is by an abnormal response to light touch, even by a cotton bud. |
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Pearly papules on vestibule |
(the equivalent of pearly penile papules) that look like tiny regular warts—they are normal |
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Candida albicans commensal |
Approximately 20% of women carry Candida albicans as genital flora but less than 5% suffer from repeated or intractable clinical candidiasis. |
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Itching and burning of the vulva and vagina |
Not all itching and burning of the vulva and vagina is Candida infection. Swabs should be taken for diagnosis before committing to treatment empirically. |
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Dermatitis classic presentaiton |
classically present with itching, burning and soreness initiated by scratching. |
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Causes of vulvar dermatitis |
• atopic dermatitis • irritant contact dermatitis • allergic contact dermatitis • seborrhoeic dermatitis • corticosteroid-induced dermatitis • psoriasis |
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Mx of vulvar dermatitis |
• Take an appropriate history, including atopy, skin diseases. • Check allergens and irritants (e.g. panty liners, soap, bubble bath, perfumed toilet paper, douches, perfumes, condoms, tea-tree oil). • Check for heat and friction (e.g. synthetic or tight underwear, tight denim jeans, sporting costumes/tights, sweating, vigorous activity—bicycle riding). • Check gynae–urological history (e.g. oestrogen status, faecal or urinary incontinence, vaginal discharge, ‘thrush’). • Check psychosexual history (e.g. dyspareunia, partnership issues, depression). • Carefully inspect the vulva plus the rest of the skin, scalp and nails. Look for lichenification. • Appropriate investigations: vaginal swab, PAP smear, perhaps patch testing and vulval biopsy for a rare, premalignant or suspected malignant condition. |
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White patches on vulva |
Lichen simplex (lichenifi cation) Lichen sclerosus Lichen planus Leucoplakia Cancer |
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Erosions and ulcers on vulva |
Herpes simplex virus Lichen sclerosus Lichen planus Cancer Various uncommon dermatoses Excoriated scabies |
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Intertrigo on vulva |
Atopic dermatitis Candida albicans Seborrhoeic dermatitis Tinea Erythrasma Psoriasis |
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Treatment of vuvlar dermatitis |
• Provide supportive education and counselling. • Correct underlying factors (e.g. tight clothes, incontinence, anal discharge, overused topical medications and cosmetics). • Treat any secondary infection. • Use aqueous cream moisturiser as cleanser. • Start with potent class III topical steroid (50-100time more ptoent that hyrocortision)and follow with 1% hydrocortisone. |
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Vulval psoriasis |
Psoriasis can affect the genital or perianal area (especially the natal cleft) and appears as a glazed, beefy red plaque without the classic scale seen elsewhere. There may be minimal or no sign of psoriasis on the skin of the body. The main symptom is itching. It is usual to take swabs to rule out infection. |
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Treating vulval psoriasis |
• Avoid irritants and use a soap substitute. • First apply a potent topical steroid (e.g. methylprednisolone aceponate)—continue until resolution of rash. • Second (when controlled) apply LPC 2% in aqueous cream bd, slowly increasing the strength up to 8%. If not tolerated, use ichthammol 2% in aqueous cream. Note: Maintenance with topical steroids— hydrocortisone 1% or resume potent agent for a flare-up. |
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Lichen planus |
Genital lichen planus is relatively uncommon but may affect both the vulva and vagina and can occur in association with oral lesions. Vulvar lesions appear as whitish reticulated papules and plaques. A delicate white lacy pattern at the periphery of the lesion is a distinctive feature. Erosions may occur. |
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Symptoms of lichen planus |
pruritus, vaginal discharge, dyspareunia (if erosions) and postcoital bleeding. |
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DDx if vulvar lichenplanus |
include other causes of desquamative and erosive lesions, such as lichen sclerosus, pemphigus vulgaris, bullous and cicatricial pemphigoid and erythema multiforme |
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Tx of Lichen planus |
A biopsy is required to make the diagnosis. Treatment is diffi cult. Potent topical steroids provide symptomatic relief and there is a variety of treatment trials, including the encouraging topical cyclosporin |
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Lichen sclerosus |
uncommon chronic infl ammatory dermatosis of unknown aetiology (perhaps an autoimmune disorder) presents as well-defi ned white, fi nely wrinkled plaques that almost exclusively affect the anogenital skin, although they can occur anywhere on the body. Lichen sclerosus spares the vagina. It can run a chronic and complicated course with development of squamous cell carcinoma (SCC) in about 4% a concern. The differential diagnosis is atrophic vaginitis |
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genital pruritus + soreness + white wrinkled plaques = |
lichen sclerosus |
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Clinical features of Lichen sclerosus |
• Bimodal peak: prepubertal girls, perimenopause • Mean age of onset in adult women is 50 years • Pruritus is main symptom • Soreness, burning, dyspareunia |
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Examintion of Lichen sclerosus |
• Variable distribution • White wrinkled plaques • Purpuric and ulcerated areas • May show fi gure of 8 pale perianal and perivaginal area |
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Complications of untreated lichen sclerosus |
• Vulval atrophy and labial (even clitoral hood) fusion • Lifetime risk of SCC 2–6% |
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Mx of lichen sclerosus |
• Best in consultation with a dermatologist. • Confirm diagnosis by biopsy (tend to avoid in children). • Based on potent topical corticosteroids (e.g. betamethasone dipropionate 0.05% ointment or cream applied bd for 4 weeks, then daily for 8 weeks, with applicator—show patients where to apply, using a mirror). • Reduce to a potent topical steroid once daily for next 3 months, then reduce to hydrocortisone 1% ointment or cream applied daily for long term. • Lifelong surveillance with 6-monthly check-up. • A similar topical program is used in children. |
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Chronic vulvovaginal candidiasis |
This is different from acute candidiasis and remains difficult to treat because there may be a localised hypersensitivity to Candida. |
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Clincal features of CVC |
• Chronic vulval itch–scratch cycle • Burning, swelling—premenstrual exacerbation • Dyspareunia • Discharge not usually present • Aggravated by courses of systemic antibiotics |
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Mx of CVC |
• Swab—low vaginal—with each suspected episode, especially if discharge • Aim for symptom remission with continuous antifungal treatment: — topical vaginal antifungals (imidazoles or nystatin), or — daily oral antifungals (monitor liver function tests) until symptoms clear—ketoconazole 200 mg/day or fl uconazole 50 mg/day, or itraconazole 100 mg day (then weekly for 6 months) • Relieve itching with hydrocortisone 1% (do not use stronger preparations) • Use nystatin pessaries in pregnancy |
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Streptococal vulvovaginitis |
Swabs from the vulva or vagina can fi nd streptococcal species or Staphylococcus aureus, which are treated accordingly. Streptococcus infection may cause a vaginal discharge. It usually presents as an acute beefy red, sore vulva and vagina or a low-grade vulvitis |
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Tx of Strep vulvovaginitis |
phenoxymethylpenicillin 250 mg (o) 6 hourly for 10 days or oral antibiotic as indicated on sensitivity testing (e.g. amoxycillin or roxithromycin) • Topical mupirocin may help prevent recurrences |
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Tinea |
Tinea causes an annular spreading rash with an active border that spreads from the labia to the thigh (see tinea cruris, Chapter 114, pages 1126–7). A problem is the development of tinea incognito from the application of topical steroids. This lacks central clearing but the active margin can be seen. Skin scrapings are necessary for diagnosis. Treatment is with a topical imidazole (avoid nystatin) or oral agents if resistant or extensive |
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Pruritus vulvae CAUSES of an itchy vagina |
• candidiasis (rash, cottage cheese discharge): — broad-spectrum antibiotics — diabetes mellitus — contraceptive pill • poor hygiene and excessive sweating • tight clothing • sensitivity to soaps, bubble baths, cosmetics and contraceptive agents • overzealous washing • local skin conditions: — psoriasis — dermatitis/eczema (uncommon cause) • post-anal conditions (e.g. haemorrhoids) • infestations: — threadworms (children) — scabies — pediculosis pubis • infections (other than candidiasis): — Trichomonas — urinary tract infection — genital herpes, genital warts • menopause: due to oestrogen defi ciency • topical antihistamines • vulval carcinoma • psychological disorder (e.g. psychosexual problem, STI phobia) |
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General advice to patients with an itchy vagina |
• Attend to hygiene and excessive sweating. • Avoid overzealous washing. • Take showers of no more than 5 minutes duration. • Avoid water too hot (lukewarm preferable). • Avoid toilet soap—use a soap alternative (e.g. aqueous cream, Cetaphil lotion) and wash it off with water only. • Use soap alternatives (e.g. Dove, Neutrogena) for rest of body. • Pat the skin dry after the shower (avoid harsh drying). • Keep the genital area dry and wash thoroughly at least once a day. • Do not wear tight pantyhose, tight jeans or tight underwear, or use tampons. • Do not use vaginal douches, powders or deodorants. • After the toilet, wipe gently with a soft, non-coloured, non-perfumed toilet paper or baby wipe (e.g. Dove). • Apply a good moisturiser (e.g. Hydraderm or 5% peanut oil in aqueous cream). |
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General treatment for an itchy vagina |
• For pruritus, apply cool moisturising cream (kept in refrigerator) when there is an urge to scratch. • Apply prescribed steroid ointment to the rash. |
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Vulvovaginitis |
Vulvovaginitis is the most common gynaecological disorder of childhood. It can affect women of any age but is particularly common in girls, especially between the ages of 2 and 8 years. It is a type of dermatitis of the vulva and the vagina. |
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Mild vulvovaginitis Sx |
• discomfort and soreness • vulval itching • redness • discharge—usually a slight yellow discharge on the underwear • dysuria |
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Causes of vulvovaginitis |
• thin vaginal mucosa (the normal prepubescent state) • dampness from synthetic fi bre underwear, tight clothing, wet bathers, obesity • lack of hygiene • frequent self-handling, especially with irritation • irritants (soap residue, bubble baths, antiseptics, chlorinated water) • ‘sandbox’ vaginitis: girls sitting and playing in sand or dirt may develop irritation from particulate matter trapped in the vagina |
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Managment of vulvovaginitis |
• Explanation and reassurance to parents • Avoidance of the above causal factors, especially wet bathers, synthetic underwear, bubble baths, perfumed soaps and getting overweight • Attention to good, supervised toileting practice • Attention to bathing and drying • Regular warm baths (rather than showers) It is worth soaking the child in a warm shallow bath containing half a cup of white vinegar. Alternatively, bicarbonate of soda (10 g/10 L water) can be used. Soothing creams such as soft paraffi n creams and nappy rash creams such as zinc and castor oil cream should be applied three times daily as a short-term measure. If a powder is required, use zinc oxide (e.g. Curash). |
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Moderate/persistent vulvovaginitis IMPORTANT CAUSES |
• ‘Sandbox’ vaginitis • Skin disorders, especially atopic dermatitis and lichen sclerosus (look for skin problems elsewhere on body) • Foreign body: consider if a bloody, malodorous vaginal discharge • Candidiasis—uncommon but consider if antibiotic therapy or possibility of diabetes • Sexual abuse (uncommon but must not be missed) • Pinworm infestation (Enterobius) (see Fig. 15.5 in Chapter 15) • Sexually transmissible organisms—usually postpubertal |
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Examining moderate/persistent vulvovaginitis |
Aspirate vaginal secretion with a medicine dropper for appropriate cultures. A Pap smear is advisable for a persistent problem since a sarcoma is a possibility. A rectal examination may be performed to try to feel for suspected foreign bodies in the vagina |
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Taking a swab |
If the discharge is profuse and offensive, take an introital swab (do not take a vaginal swab). Infective vulvovaginitis in girls is almost always due to a Group A beta-haemolytic streptococcus. Treat with an appropriate antibiotic. |
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Treatment of vaginal dermaititis |
Most cases of vulval dermatitis will respond to short courses 1% hydrocortisone ointment or cream, provided aggravating factors are removed. |
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Labial adhesions (labial agglutination) |
Labial fusion is caused by adhesions considered to be acquired from vulvovaginitis after which sometimes the medial edges of the labia minora become adherent. The adhesions are certainly not present at birth. Labial fusion is regarded as a normal variant and usually resolves spontaneously in late childhood. Provided the child is able to void easily, no treatment other than reassurance is needed. |
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Treating significant labial adhesions |
• <18 months—using EMLA cream. Separate with a blunt instrument. This can be distressing for the child and is followed by a high risk of recurrence. • >18 months—separate adhesions under general anaesthetic followed by application of Vaseline and/or oestrogen cream. However, these measures are not generally recommended. |
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Vulvodynia |
Vulvodynia describes the symptom of pain (burning, rawness or stinging) and discomfort, where no obvious cause can be found. NO ITCH.
- vestibular hypersens. - infections (HSV) - dermatitis |
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Vestibular hypersensitivity definition |
Vestibular hypersensitivity is severe vulvar or vestibular pain on touch or entry into the vagina. |
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Vestibular hypersensitivity causes |
In many instances the cause of the primary condition is not apparent and a history of possible sexual abuse or other psychological provoking factors should be diplomatically elicited
most common cause of dyspareunia in premenopausal women |
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young + nulliparous + dyspareunia Diagnostic triad |
VVS |
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Clinical features of VVS |
• Delayed diagnosis (average 2–3 years)4 • Sexually active women in 20s and 30s • Pain provoked by intercourse, tampon insertion, tight underwear • Superfi cial ‘entry’ dyspareunia • Sexual dysfunction • Tender vestibule on light pressure • Erythema (usually minute red spots) around Bartholin’s duct openings (consider Candida) |
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Dx VVS |
Inappropriate tenderness to light touch with a cotton bud. |
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Mx of VVS |
50% GO AWAY on their own
• Investigate underlying cause and treat it • Patient education, counselling and support • Physiotherapy—rehabilitation of pelvic fl oor musculature by increasing awareness and increasing elasticity of the tissues of the vaginal opening • Reassure that the condition is self-limiting • Encourage use of oil-based lubricants • Use bland emollients or 2% lignocaine gel prior to intercourse • If Candida present, treat with fl uconazole 150 mg (o) weekly for 6 weeks Options • Biofeedback technique • Tricyclic antidepressants (start low, e.g. amitriptyline 10–20 mg nocte) • Gabapentin • Intralesional therapy: — triamcinolone — interferon • Vestibulectomy (last resort): — excise tender vestibular tissue |
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Dysaesthetic vulvodynia |
The typical patient with this neuropathic pain problem is a middle-aged to elderly woman who presents with a constant burning pain of the labia. It typically builds up during the course of the day. Examination is often unrewarding. The underlying cause may be pudendal neuralgia (may be secondary to pudendal nerve block), referred spinal pain or simply unknown. |
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What needs to be excluded before a dysaesthetic vulvodynia dx |
HSV |
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Tx of dyaesthetic vulvodynia |
antidepressants and gabapentin |
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Bartholin's cyst |
A Bartholin’s gland swelling follows obstruction of the duct and presents as a painless vulval swelling at the posterior end of the labia majora, close to the fourchette. A simple, non-infected cyst can be left alone and may resolve spontaneously. If it becomes infected an abscess may result, causing a painful, tender, red vulval lump. |
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Tx of bartholin cyst |
It may resolve with antibiotics or discharge spontaneously. Otherwise drain and perform a micro and culture. The usual organism is E. coli. If the cyst persists and becomes large, a surgical marsupialisation procedure, which allows permanent drainage, can be performed |
