Obgyn Vulvar And Vaginal Dz And Neoplasia

Front 1

What should be next step when a vulvar lesion is seen or suspected?

Back 1

punch biopsy

Front 2

Lichen sclerosus

Back 2

- often chronic vulvar pruritis
- very thin, whitish epithelial area, ("onion skin" or "cigarette paper")
- often responds to topical steroids

Front 3

areas most commonly affected by lichen sclerosus

Back 3

labia majora and minora, clitorus, periclitoral epithelium and perineal body
- may have perianal halo of atrophic, whitish epithelium forming a figure of 8 confirmation
- if severe, there may be loss of normal anatomy and stenosis of the vaginal introitus

Front 4

etiology of lichen sclerosus

Back 4

unknown, but family history, autoimmune disorders including thyroid disorders and class II HLA are associations

Front 5

histological appearance of lichen sclerosus

Back 5

lichenoid pattern with band of chronic inflammatory cells (mostly lymphs), upper dermis has a zone of homogeneous, pink-staining, collagenous-like material beneath the epidermis due to cell death
- obiteration of boundaries between collagen bundles --? "hyalinized" or "glassy" appearance

Front 6

hyperkeratosis

Back 6

increase in the number of epithelial cells -- may be seen in acanthotic areas of lichen sclerosus
- in patients with a mix of acanthosis and typical lichenoid-- the acanthosis should be treated first with 2-3 weeks of toprical steroids

Front 7

tx of lichen sclerosus

Back 7

topical steroid (clobetasol)
- ameliorates sx but does not usually completely resolve lesions
- may need indefinite intermittent treatment
- acanthotic lesions typically resolve within 6 mo if tx given
- lichen sclerosus doe not increase likelihood of cancer

Front 8

therapeutically resistant acanthosis may be a sign of ..?

Back 8

squamous cell carcinoma

Front 9

lichen simplex chronicus

Back 9

"the itch that rashes"
- most patients develop this disorder secondary to an irritant dermatitis, which progresses to lichen simplex chronicus as a result of the effects of chronic mechanical irritation from scratching the irritated area
- itching leads to epidermal thickening or hyperplasia and an inflammatory cell infiltrate, which leads to increased sensitivity and more itching--cycle

Front 10

h/o of vulvar itching and/or burning that is temporarily relieved by scratching or rubbing with a washcloth

Back 10

lichen simplex chronicus

Front 11

tx of lichen simplex chornicus

Back 11

skin irritants may include laundry detergents, scented toilet paper etc-- need to get rid of these sources to break the cycle
- empiric tx with benadryl or hydroxyzine hydochloride to inhibit nightime unconcious itching, topical steroid cream
- if areas of significant hyperkeratosis then give hydocortisone, triamsinolone or betamethasone
- if no relief after 3 mo-- bx lesions

Front 12

appearance of lichen simplex chronicus on exam

Back 12

skin of labia majora, minora and perineal body is diffusely red with some areas of hyperplastic or hyperpigmented plaques of red or reddish brown
- bx usually not warranted unless there is no sx relief after 3 months of tx

Front 13

lichen planus

Back 13

DESQUAMATIVE lesion of the vagina or sometimes vulva that involves whitish, lacy bands (wickham striae) of keratosis near the reddish ulcerated lesions

Front 14

sx of lichen planus

Back 14

chronic vulvar burning and/or pruritis and insertional dypareunia, and profuse vaginal discharge

Front 15

dx of lichen planus

Back 15

- may bx if there is atypical appearance-- lesions will NOT show atypia
- vaginal discharge will show lots of acute inflammatory cells (PMNs) but no bacteria
- this along with history and exam that shows patchy redness and wet prep that shows lots of WBCs

Front 16

tx for lichen planus

Back 16

topical steroid or intravaginal 1%hydrocortisone douches
- more likely to recur than lichen simplex chronicus

Front 17

psoriasis

Back 17

autosomal dominant disorder that affects 2% of the population
- slightly raised round or oval patches with a SILVER PLAQUE OVER AND ERYTHEMATOUS BASE
-acanthotic pattern may be seen histologically
- tx: UV light and corticosteroid topically

Front 18

two categories of vulvar dermatitis

Back 18

1. eczema (a. exogenous , b. endogenous)
2. seborrheic dermatitis

Front 19

endogenous vs exogenous eczema

Back 19

exogenous- irritant and allergic contact dermatitis
endogenous - atopic dermatitis-often also on flexor surfaces of of knees and elbows


--cannot tell the difference on bx because they all have spongiotic pattern (intercellular edema within the epidermis--widening space between cells)

Front 20

sborrheic dermatitis

Back 20

chronic inflammation of the sebaceous glands
- pale red to yellowish pink lesions that may be covered by an oily appearing, scaly crust

Front 21

tx for vulvar dermatitis

Back 21

- remove offending agent
- perineal hygeine
- 5% aluminum acetate solution several times/day--> drying
- topical corticosteroid like betamethasone
- benadryl at night initially to break cycle

Front 22

vulvar vestibulitis

Back 22

acute and chronic inflammation of the vestibular glands, just underneath the vaginal introitus
- should suspect this in all patients with new onset insertional dyspareunia
- unknown etiology

Front 23

what should be suspected in all patients with new onset insertional dyspareunia?

Back 23

vulvar vestibulitis

Front 24

dx of vulvar vestibulitis

Back 24

physical exam before speculum insertion - touch over glans (4 and 8 oclock with a wet cotton tip)-- brings out pain

Front 25

tx for vulvar vestibulitis

Back 25

eliminate environmental factors, temporary sexual abstinence, cortisone or lidocaine jelly
- may surgically excise the glands
- low dose TCAs or fluoxetine
- calcium citrate to remove oxalic acid crystals from the urine

Front 26

sebaceous or inclusion cysts

Back 26

small, smooth nodular masses arising from the inner suface of labia majora and minora that contain cheesy sebaceous material

Front 27

hidradenoma

Back 27

rare lesion arising from the sweat glands of the vulva
- almost always benign
- usually on inner surface of labia majora
- tx = excision

Front 28

vaginal intraepithelial dysplasia (VIN) 1

Back 28

mild dysplasia, low grade lesion that is limited to the lower epidermis
- occurs most often in condyloma acuminata
- likely not a cancer precursor
- dx by bx
- tx = same as for condylomas

Front 29

VIN 2 and 3 = VIN usual type

Back 29

high-grade, HPV related lesions
- true neoplasia with high predilection for progression to severe neoplasia and carcinoma if untx
- Almost 60% of women with VIN3 will also have CIN (10% of women with CIN 3 will have VIN or VAIN)

Front 30

risk factor for VIN

Back 30

smoking

Front 31

presentation of VIN

Back 31

vulvar pruritis, chronic irritation and raised mass lesions

Front 32

VIN usual type three categories histologically

Back 32

warty, basaloid, or mixed
- all have atypia in the lower 1/3 to 1/2 of the epithelial layer

Front 33

tx of VIN usual type

Back 33

completely remove all involved areas of skin- wide local excision or laser ablation
- non surgical options- corticosteroids, 5-FU, and imidazoquinolones (imiquimod)

Front 34

VIN, differentiated type

Back 34

- VIN - caricinoma in situ
- hyperkertotic plaque, warty papule or and ulcer seen primarily in older women
- often associated with SCCs or lichen sclerosis
- not HPV related
- short VIN stage before progression to cancer

Front 35

paget disease of vagina/vulva

Back 35

- extensive intraepithelial disease that grossly appears as fiery red background mottled with whitish hyperkeratotic areas
- histo- large pale cells of apocrine origin
- associated with skin cancer
- associated with higher incidence of internal cancer especially breast and colon

Front 36

tx for paget disease of vagina/vulva

Back 36

- wide local excision or simple vulvectomy
- recurrences more common than with VIN --> wider margins

Front 37

vulvar carcinoma

Back 37

5% of gyn malignancies
- usually occurs in postmenopausal women 70-80 and presents with pruritis
- may have red or white ulcerative exophytic lesion (usually on posterior 2/3 of labia majora)
- associated with smoking

Front 38

where does vulvar carcinoma metastasize to?

Back 38

regional lymph nodes including inguinal and femoral nodes
- anterior 1/3 of vagina may go to deep pelvic nodes

Front 39

Staging of vulvar cancer

Back 39

0 - carcinoma in situ
1- tumor confined to vulva/perineum <2 cm
I A- stromal invasion < 1mm
I B- stromal invasion > 1 mm
II tumor confined to vulva/perineum > 2 cm
III - tumor of any size which invades lower urethra, vagina, anus and/or unilateral lymph nodes
IV A- tumor invades ipper urethra, bladder, rectal mucosa, or is fixed to bone or bilateral LNs
IV B- distant metastasis including pelvic LNs

Front 40

tx of vulvar cancer

Back 40

mostly surgical although trying to avoid radical vulvectomy with b/l LN dissections if possible
- post op radiation for people with 2 or more positive nodes
- chemo of limited value

Front 41

most common non-squamous cell carcinoma of the vulva?

Back 41

melanoma (3-4% of melanoma in females occurs on genitals)
- appears as raised, irritated pigmented pruritic lesions

Front 42

how should any new bartholin mass in a woman > 40 be treated?

Back 42

excision, although cancer is unlikely
- bartholin cancer requires radical vulvectomy and b/L lymph node dissection, with reccurrences common

Front 43

inclusion cysts

Back 43

- usually on the posterior lower vaginal surface and arising from imperfect approximation of vaginal tears during childbirth or episiotomies
- often cheesy content
- excise if sx

Front 44

VAIN

Back 44

vaginal intraepithelial neoplasia
- 3 types
1. VAIN 1- involves basal epithelial layers
2. VAIN 2- involves upper 2/3 of vagina
3. VAIN 3- involves more of vag epithelium -- CIS

Front 45

what % of patients with VAIN have either vulvar or cervical ca?

Back 45

50-66%

Front 46

what % of women who undergo hysterectomy for CINIII ultimately develop VAIN?

Back 46

1-2%, which is why some say pap smears of vaginal cuff should be done yearly

Front 47

dx and tx of VAIN

Back 47

dx- colpo and bx of lesions
tx- VAIN 1 and 2- no tx needed
VAIN 3- laser ablation, local excision, and 5-FU cream. If fail these then vaginectomy

Front 48

staging and tx of vaginal cancer

Back 48

nonsurgical staging.
radiation = mainstay of tx

Front 49

tx of vaginal clear cell carcinoma

Back 49

usually this is confined to upper 1/2 of vagina so tx = hysterectomy, pelvic node disection, + radiation after

Front 50

sarcoma botryoides

Back 50

aka embryonal rhabdomyosarcoma- rare tumor that presents a mass of grape-like polyps protruding from the introitus of ped's patient
- may present with bloody d/c
- tx = combination chemo to shrink tumor then surgical resection