2009-2010usuhs msiii ob/gyn clerkship self directed studies vulvar / vaginal disease ch 19, 23, 41...

2009-2010 USUHS MSIII Ob/GynClerkship Self Directed Studies

Vulvar / Vaginal DiseaseCh 19, 23, 41

2009-2010 Academic Year

MSIII Ob/Gyn Clerkship

Self-Directed Study


Case Study

63 yo GP3 postmenopausal woman, not on hormone replacement therapy, presents to clinic with complaints of vulvar pruritus. The patient has concerns as she is a diabetic and does not want to have an infection. Please discuss this patient’s evaluation in clinic and diagnosis.


Questions to Consider

1. How would this change if she were 22?– Decreased risk of malignancy

2. Differentiate bacterial vaginosis and yeast infection by history.– BV – fishy odor, yellowish frothy discharge– Yeast – white clumpy discharge, pruritus

3. What if you see lesions? What if you see lesions in a 33 yo vs. an 80 yo?– Increased risk of malignancy with age– In a 33 yo, differential diagnosis includes infection and

neoplasm


APGO Educational Topic 35:

• A. Diagnose and manage a patient with vaginitis.

• B. Interpret a wet mount microscopic examination.

• C. Describe dematalogic disorders of the vulva.

• D. Evaluate a patient with vulvar symptoms.


APGO Educational Topic 51:

• A. Define the risk factors for vulvar neoplasms.

• B. Describe the indications for vulvar biopsy.


VaginitisInflammation of the vagina (+/- vulva)

• Evaluation of Vaginal Discharge– Whiff Test: KOH on slide or speculum with

vaginal discharge produces “amine” or fishy odor with BV or Trichomoniasis.

– Wet-Mount: Vaginal discharge on slide, mixed with normal saline or mixed with KOH. Evaluated under microscope.

– Characteristic of discharge, pH also helpful.


Wet Mount (Normal Saline)Microscopic view (high power) of a Trichomonad in a saline wet-mount preparation. The organisms

are usually motile in this type of preparation.

Trichomonas

Bacterial Vaginosis

Microscopic view of clue cells in a saline wet-mount

preparation. Note the irregular or serrated cell walls.


Wet Mount (KOH)

Mycelial tangles of yeast pseudohyphae in KOH wet-mount preparation.

Candidiasis (Yeast Infection)


Cevical Images associated with vaginitis

“Clumpy” “Cottage-cheese-like” dischargeConsistent with Yeast infection

Frothy discharge consistent withTrichomonas.


Dermatologic Conditions of Vulva

• Squamous Hyperplasia

• Lichen Sclerosis

• Lichen Planus

• Pemphigus

• Bechet’s Syndrome

• Crohn Disease

• Acanthosis Nigricans


Squamous Cell Hyperplasia• Local thickening of epithelium

• Associated with prolonged itch-scratch cycle


Lichen Sclerosis• Pruritus, Dyspareunia, burning• Most common in menopausal women• Skin is thin, inelastic, white, crinkled “tissue paper”• Potent topical steriods (0.05% Clobetasol)


Lichen Planus• Purplish, polygonal papules• Can be erosive• Vagina, vulva, mouth• Topical and systemic steroids

Ulcerated lesions

Lacy reticulatedpattern, scarring

www.mdconsult.com

http://www.mdconsult.com/


Derm disorders of vulva that can be found on other parts of body

• Several dermatologic findings can also affect vulva/vagina.– Pemphigus: autoimmune blistering disease of

vulva/vagina, conjunctival areas.– Behcets: ulcerations of genitals, mouth, ocular

lesions.– Crohn’s: slitlike “knife-cut” ulcers of vulva, edema

(often precedes GI sx’s)– Acanthosis Nigricans: intertriginous areas, axilla,

nape of neck. Darkly pigmented velvety or warty surface. Associated with insulin resistence.


Pemphigus oral lesions.www.mdconsul.com Bechet’s Syndrome

www.bestpractice.bmj.com

Acanthosis Nigricanswww.dermatologistsnyc.com

http://www.mdconsul.com/

http://www.bestpractice.bmj.com/


Vulvar Biopsy

• When to biopsy– If you don’t know what it is– If it is persistent despite treatment or recurrent– When in doubt, biopsy.

YOU ARE NEVER WRONG TO BIOPSY!!!

2009-2010usuhs msiii ob/gyn clerkship self directed studies vulvar / vaginal disease ch 19, 23, 41...

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