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NOTE:  Information Reviewed 9/04.  There are very good articles on your reading list.

VULVAR DISEASE - Rose Mary Russell, Women's’ Health NP

TERMS

    1. Vulvodynia-chronic vulva discomfort
      1. vulvar vestibulitis
      2. dysesthetic vulvodynia
    2. Vulvar dystrophy-broad term to describe various epithelial changes
    3. 1987-ISSVD International Society Studies of Vulvar disease
      1. nonneoplastic
      2. intraepithelial neoplasms - spuamous cell CIS
      3. nonsquamous intraepithelial neoplasia

INCIDENCE OF VIN

    1. 40 Y.O. AND YOUNGER
    2. incidence of associated cancer
    3. History/Of HPV
    4. Pigmented and multifocal
    5. etiology, HPV
    6. prognosis- may regress
    7. histology- uniform cells
      • Relationship to HPV
      • Over 60 viruses
      • more that 1 can coexist
      • type depends on site

ANATOMY

    1. Hart’s Line - marks the border of the vestibule. Vestibule includes urethra, skenes, Bartholin's gland & minor vestibular glands
    2. Labia minora have sebaceous glands, look yellow cobblestone
    3. Vulvar vestibule - nonkeratinized sq. epithelium. Lateral to Hart’s line is papillated keratinized epithelium of lateral labial minora.
    4. Vestibule contains many small gland openings. This area may normally produce mucous. Acetowhite

 

TIPS
(must r/o vaginitis)

    1. Acetowhite - acetic acid 5%. Common household vinegar
      1. Not normal for hairy surfaces to turn acetowhite
      2. apply to non-hair bearing surface of vulva
        • mucous surface can be looked at immediately
        • keratinized skin is more impermeable, wait 10-15 min.
        • hyperkerantinized will turn + l; wart
        • caution-any area of hyperkeratosis will also turn + acetowhite
        • not all warts turn white
        • biopsy is necessary
    2. KOH (10-20%) specimen from border
      • if keratinized skin is going to be examined, wait 10-15 min. for cell to dissolve
      • start with power at 10X and low light
      • superficial fungi exhibit branching with yeast buds
      • Candida, exhibit pseudohyphae with yeast buds
    3. Saline prep
      1. don’t press cover slip, distort or immobilize specimen ie. trichomonas
    4. pH
      1. normal pH is 3.5 - 4.2
      2. avoid lubricant or wet speculum

HISTORY

    1. use OLD CART method of inquiry
      1. include time of day symptoms ^
      2. relationship to menses cycle
      3. quality- burning, irritation, raw.
      4. quantity - effect on ADL
    2. prior infection. h/o HPV, abnormal, raw
    3. previous inflammatory dermatoses
    4. sex health hx. -partners relationships, hx of abnormal pap
    5. substance abuse
    6. hygiene-method of bathing, laundry
    7. type of clothing
    8. type of exercise
    9. medications
      1. carefully ask time frames
      2. length of self treatment
      3. improvement followed by return of s/s several days later
    10. note the patients wording-dry and irritated may be used interchangeably, refers to vagina for everything when describing
    11. diet recall- foods high in calcium oxalate, ie. dk green veg, spinach, choc, rhubarb, ^ cellulose foods
    12. fam h/o diabetes, Crohn’s (cutaneous fistula may resemble a Bartholin's cyst)
    13. HIV

PHYSICAL EXAMINATION

    1. Temp
    2. System as indicated by hx and drugs
    3. Examine groin, inner thighs, buttocks, evaluate for adenopathy
    4. Examine vulva; include clitoral hood, glands, urethra; Observe for leukoplakia, bleeding, hyperkeratosis, color, lesions, odor, edema, atrophy
    5. Obtain secretions; scales from borders of areas that are flaking
    6. Culture as necessary
    7. Normal amount of daily vag. secretions 1.6g q 8 hrs
    8. Assess vestibule for pain with moisten cotton tip applicator
    9. Presence of aceto white-use magnifying glass
    10. Consider FBS, HIV, wood’s lamp, cultures

PUNCH BIOPSY AND COLPOSCOPY

    1. Biopsy

      1. may use topical anesthetic, EMLA, a topical eutectic mixture, 30 min. prior followed by local 2% lidocaine. Dermal punch 3 mm.
        • gentle rotation, taking in edge of lesion
        • snip off base
        • silver nitrite sticks are usually sufficient to control bleeding (more caustic) Monsel’s solution.
    2. Excisional - refer
    3. Colposcopy
      • microscopic evaluation of tissue
      • acetic acid applied prior to visualization
      • refer

APPROACH TO EVALUATION

    1. Vulvar lesion that do not disappear within several weeks either spontaneously or therapeutically must be referred.
    2. Documentation is imperative and critical

 LESIONS AND DISEASES

HSV

S: Reports flu like symptoms, pain, itching, UTI symptoms, vaginal discharge, sores on labia, anus, perineum, buttocks, thighs, dyspareunia

O: Vesicles, ulcers, pustules, tender adenopathy, 70% will have lesion in vagina

P:

        1. Viral collection from fluid of vesicle if possible
        2. Sitz bath TIC 20 min
        3. Lidocaine @% gel every 2 hrs prn pain
        4. Acyclovir 200 mg 5X/day X 5 days
        5. Air dry perineum
        6. Literature/no sex
        7. RTC 2 weeks

Syphilis

S: Reports painless sore

O: Primary - red, round, firm ulcer with granular base with well-formed edges. Secondary- moist, mucus lesions which resemble herpes. Moist cutaneous lesions called condyloma lata, appear flat and gray. Adenopathy, maculopapular rash.

P:

        1. Serum test RPR, FTA-ABS
        2. Pen g 2. mil units IM. Allergy - Doxycycline 100 mg BID x 14
        3. STD teaching
        4. RTC PRN

Condyloma Acuminata

S: Report new bump: itching, generalized pruritus, last pap

O: Warty, flesh colored, sharp and pointed, cauliflower, + acetowhite

P:

        1. Perform Pap
        2. Aldara (imiquimod 5%)
          • Apply thin layer to warts and rub in 3X/week at bedtime, max 16 weeks
        3. TCA 30% or Podophyllin 25 - 40%
          • apply weekly up to 4 weeks
        4. Condylox home treatment
        5. STD, reg. paps, decrease smoking
        6. RTC weekly if no improvement, refer for laser or cryo.

Candidiasis

S: Reports burning, itching, discharge, dyspareunia, vulvar edema, h/o diabetes, high carbohydrate diet, use of AB, frequent intercourse, h/o steroids, HIV

O: Vag pH 4.0 - 4.7 KOH mycelia, pseudohyphae, spores, +lactobaccilli, G. Glabrata- no pseudohyphae; pap may reveal 50% of asymptomatic women, satellite lesions.

P:

        1. Azoles preps are preferred
        2. oral, fluconazole 1 150 mg po 1 X
        3. recurrent- review risk factors
        • tx partner
        • yogurt
        • 2 week course of oral azole
        • premenstrual, use of po/vag tx.
        • RTC prn 2 weeks

 

Bartholin's Gland Infection

S: Reports unilateral bump. Reports active sex, recent trauma, new sexual partner leading to infections, fever, complaints of pain with intercourse, warmth, tender to touch, difficulty walking, sitting. H/O Crohn’s disease.

O: Erythema, edema, lymph nodes palpable, size of cyst < 4 cm., possible purulent exudate from mass.

P:

        1. If small, <1 cm, non-tender, no redness, no tx.
        2. If recent? sex relationship, do cervical cultures.
        3. Bedrest
        4. Analgesics
        5. Sitz bath TID
        6. If <2 cm. red, warmth, adenopathy, may tx with Doxycycline 100 MG 1 po BID and Flagyl 500 mg 1 po QID. Age factor.
        7. If > 2 cm. I & D, guaze and Word catheter
        8. RTC 2 wks prn

Contact Dermatitis

S: Reports itching, rash, bath preps, tight clothes

O: Skin red, inflamed, edematous, vesicles or bullae if severe, weeping, crusting and lichenification. Tissue scraping to r/o fungi, wet mts. neg.

P:

        1. Remove causative agent.
        2. If vesicles or bullae are present use Burrows solution 1?20 dilution QID
        3. May use hydrocortisone 1% sparingly TID
        4. Antihistamines for sleep at HS
        5. RTC 2 weeks/prn
Intertrigo

S: Reports chafing, itching, burning

O: Early- Erythematous or white from maceration

Later- Linear fissuring, cracking, thickening and hyperkeratosis, and hyper pigmentation. No papules/pustules

P:

        1. KOHL prep to r/o fungal infections
        2. Culture lesions for bacterial
        3. FBS
        4. Dry environment
        5. Wt. Loss
        6. 1% hydrocortisone for pruritis
        7. If secondary infection, antifungals or AB
        8. Miconazole BID
        9. RTC prn

NONNEOPLASTIC EPITHELIAL DISEASES

    1. Presence of keratin
    2. Depigmentation
    3. Relative avascularity

 

Lichen Sclerosus

S. Reports itching, familial linkage, edema, superficial ulcers, burning, area feels different.

O: All ages, appearance of clitoris, prepuce, labial majora, minora, edema, scarring, color, appearance of tissue paper of skin.

Colposcope - white lesions with fissures, erythema or paleness, punctation usually absent. Loss of rete pegs and vascularity.

P.

        1. BX is required. Corticosteroid cream, 2% testosterone cream is no longer recommended.
        2. High-potency steroid such as clobetasol 0.05% BID x2 mo. This is a consult or referral. Temovate cream, high potency steroid.
        3. RTC 2 weeks or prn.

Squamous Cell Hyperplasia

S: Age less that 50, itching, burning, no familial pattern

O: + acetowhite, raised white or pink lesions, thick white plaques or lichenification, vulva can appear dusky red, hypopigmentation may be present. Some degree of hyperkeratosis. Fissures and excoriations.

P.

        1. R/O fungal and vaginitis
        2. Eliminate aggravating factors
        3. Punch bx before tx.
        4. Antihistamines at HS note: Zyrtec is best for pruritis.
        5. Mid potency steroids ie. Triamcinalone p.p1% BIC. Most lesions respond in 2-4 weeks. May repeat X 1. No long therapy.
        6. 1% hydrocortisone cream BID X 14 days

Lichen Planus

S: Report itching, burning, c/o vulvovaginitis symptoms on mucosal surface of vulva. Dyspareunia, painful erosive areas. Bleeding on contact, stenosis of introitus.

O: White raised lesion with reticular, lacy pattern. Erosive reddened area bordered by reticular white epithelium. External labia has appearance of lichen sclerosus + acetowhite. Look in mouth.

P:

        1. BX
        2. Mid-potency steroids may control itching 1-2 weeds for itching
        3. Antihistamine. Zyrtec, otc benadryl cheaper and effective.
        4. RTC prn

 

Vulvar Neoplasm-Melanoma

S: Postmenopausal, asymptomatic, brown, black, raised or flat. Affects clitoris and labia majora. Usually no symptoms.

O: Important prognosis indicator is depth of invasion. Seen on vulvar exam

P:

        1. Refer.
        2. Large excisional bx.

Vulvar Intraepithelial Neoplasm

S: Pruritus, vulvar burning, pain, discharge, bleeding, may report urethra, vaginal and anal symptoms

O: white, dk, red, ulcerated, raised warty, or nodular lesions. Labia mayora most common site, minora, clitoris and perineum. Adenopathy.

P:

        1. BX and colposcopy
        2. Refer

 

Vulvodynia (Vulvar Pain Syndrome)

S: Various levels of burning, stinging, pain, dryness, irritation, rawness. No pruritus. May report long term hx.

0: Common organic causes: contact dermatitis, yeast, trich, HPV HSV

P:

        1. Wet preps,  Tricyclics - Amitriptyline 10 mg. BID
        2. SSRI
        3. Pain that is refractory consider MRI, CT scan for sacral tumor or nerve root cysts.

Vulvar Vestibulitis

S: Burning, dysuria, frequency, h/o repeated yeast infections or HPV, h/o of frequent self tx., severe pain with touch or attempting intercourse.

0: With cotton tip applicator-pain at Barth glands, also, vulvar vestibule, marked erythema, symptoms >6 months.

P:

        1. wet prep, topical steroids, estrogen. Antibiotics, antifungals agents offer no effect
        2. laser, cryotherapy has limited effect.
        3. recombinant interferon (for HPV) may reduce symptoms 50%. No long term effect.
        4. Surgical incision - 60% improvement
        5. Urinary calcium oxalate. Low oxalate diet. 200mg calcium/950 mg. citrate. 2 tabs TID. Inhibits calcium oxalate-crystal formation.

Paget's Disease

S/O:vulvar pruritis, older women, red/tan scaly lesion

P: Bx.  10% have adenocarcinoma

        1. examine breast
        2. tx. vulvectomy

Other:

EPIDERMAL CYSTS OF VULVA: cysts <1 cm., white top, firm, to palpation. If squeezed will extrude sebaceous contents. May leave alone or squeeze contents out; may need to use large bore needle to open. If inflamed, I&D.

ACROCHORDON: soft nodule, may be wrinkled, color same as surrounding skin. May remove for cosmetic purpose.

 

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