Name the 3 Autoimmune Vulvar Diseases
Lichen Slerosis
Lichen Planus
Behcet’s Disease
Name the 5 Vulvar Diseases Specific to “Older Women”
Lichen Sclerosis
Lichen Planus
VIND (differentiated)
Vulvar Cancer (unrelated to HPV)
Vulvodynia
- Autoimmune/Genetic
- Assoc w/ Hypothyroidism/HLA
- Koebner’s phenomenon
- CHRONIC
- Assoc w/ SCC
Lichen Sclerosis
- Pruritis
- Anal discomfort
- Nevi
- Sharp/Demarcated white plaques
- Cellophane/Wax paper
- FRAGILITY
- “figure 8”
What is the dx & treatment & SE of tx?
Dx: Lichen Sclerosis
Tx: Super high potency steroid ointment: Clobetasol Ointment
SE: atrophy, dermatitis, rosacea
- Hx of atopy
- Triggered by sweating, hygiene, liners, topical meds, tight clothes
- Weeks to months of burning & pruritus
- “itch that rashes”
- Anxiety/Depression
Lichen Simplex Chronicus
- Poorly marginated red scaling papules/plaq
- Initially–> weeps, excoriations, crusts
- Chronic–> lichenification/callus, HYPOpigmentation w/ moisture
How is it diagnosed?
Tx?
Lichen Simplex Chronicus
Dx: Punch biopsy
Tx:
- Topical Hydrocortisone cream
- Antihistamine, SSRI daily
- Loose clothes, no liners, no aggressive hygiene, ↓ stress
- Bath soaks / Lubricants
- 50-60 y/o
- Introital irritation (superficial dyspareunia)
- BURNING (no pruritus)
- Vag discharge
- PE: agglutination of labia minora, introital narrowing, fusion of vestibule, adhesions
Dx? What else do you expect on PE? Tx?
Lichen Planus
PE:
(non-erosive) Lacy white fern like / white striae
(erosive) Deep vag erythema, erosions, PURULENT vag secretions
1st line Tx: Hydrocortisone cream/suppository
VINU
(vulvar intraepithelial neoplasia usual type)
What are the 3 types of HPV?
What age group?
What 3 RF?
- 16, 18, 31
- Younger women
- RF: Smoking, immunosuppression, multiple sex partners
Dx? How is dx made? Tx?
- Burning & Prutitus
- Raised/Flat grey, white, red, black lesions
VINU
Dx: Coposcopy/PAP are mandatory bc/ assoc w/ high grade CIN, Biopsy pigmented lesions
Tx: Off label uses, 5FU cream -Efudex), Interferon, Imiquimod cream, surgery w/ CO2 laser(standard of care), Gardasil vaccination
FU time for VINU
Vulvar inspection at 6 months and 12 months
–> then annually
- Women >70
- Lower 1/3 of epithelium (inflammation)
- Assoc w/ squamous cell hyperplasia
Dx? Tx?
VIND
Tx: surgical excision
Comorbidities: DM2, obese, HTN
Bimodal: 20-40 / 60-70
Vulvar Cancer
Younger: HPV related
Older: chronic irritation, VIND, SC hyperplasia
- Pruritus + Cauliflower lesion
Vulvar Cancer: SCC
Pruritus + raised dark lesion over labia minora/clitoris
Vulvar Cancer: Malignant Melanoma
Pruritus + raised lesion, ulcerated center, rolled borders
Vulvar Cancer: basal cell carcinoma
Vulvar Cancer
Staging system?
Tx?
Staging: FIGO
Tx: complete surgical removal of tumor + inguinal node dissection
Radiation if spread to lymphnodes
Exposure to bacteria, virus, heavy metals, chemicals results in: aphthous ulcers, genital lesions, ery nodosum, palpable purpura, uveitis
Dx? How is it dx? Tx?
Behcet’s Disease
Dx criteria: recurrent oral aphthae 3x in 1 year + two of the following: recurrent genital ulcers, uveitis, skin lesions, + pathergy test
Tx: Temovate ointment, Intra-lesional Triamcinolone, systemic corticosteroids if refractory
- Acute painful unilateral labial swelling, painful sitting/walking, drainage
- Tender fluctuant labial mass, cellulitis, abscess
Dx? Tx?
Bartholin Cyst (less painful) or Abscess (more painful)
Tx: I&D + Word catheter & culture the purulent drg for MRSA, E. coli, STIs
Empiric abx: Bactrim, Aug, Cephalo, Doxy
Sits baths 3 days after I&D
NO INTERCOURSE till cath removed
Marsupialization (if severe/recurrent)
- Pelvic floor dysfunction
- Mood/Anxiety disorder
- BURNING
- Introital pain w/ intercourse
- Pain/erythema limited to vestibule
Dx? PE? Tx?
Vulvodynia
PE: Use Q-tip to palpate and single digit exam to feel for spasm/tenderness of pelvic floor
Tx: avoid scented products, intercourse
Sits baths + petroleum jelly
Couples counseling, SNRI
Pelvic floor PT
Topical lidocaine/estrogen
