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Vulvar / Vaginal Disease Ch 19, 23, 41. 2009-2010 Academic Year MSIII Ob/Gyn Clerkship Self-Directed Study. Case Study.

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vulvar vaginal disease ch 19 23 41

Vulvar / Vaginal DiseaseCh 19, 23, 41

2009-2010 Academic Year

MSIII Ob/Gyn Clerkship

Self-Directed Study

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

case 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.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

questions to consider
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

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

apgo educational topic 35
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.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

apgo educational topic 51
APGO Educational Topic 51:
  • A. Define the risk factors for vulvar neoplasms.
  • B. Describe the indications for vulvar biopsy.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

vaginitis inflammation of the vagina vulva
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.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

wet mount normal saline
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.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

wet mount koh
Wet Mount (KOH)

Candidiasis (Yeast Infection)

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

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

cevical images associated with vaginitis
Cevical Imagesassociated with vaginitis

“Clumpy” “Cottage-cheese-like” discharge

Consistent with Yeast infection

Frothy discharge consistent with

Trichomonas.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

dermatologic conditions of vulva
Dermatologic Conditions of Vulva
  • Squamous Hyperplasia
  • Lichen Sclerosis
  • Lichen Planus
  • Pemphigus
  • Bechet’s Syndrome
  • Crohn Disease
  • Acanthosis Nigricans

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

squamous cell hyperplasia
Squamous Cell Hyperplasia
  • Local thickening of epithelium
  • Associated with prolonged itch-scratch cycle

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

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

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

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

Lacy reticulated

pattern, scarring

Ulcerated lesions

www.mdconsult.com

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

derm disorders of vulva that can be found on other parts of body
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.

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

slide15

Pemphigus oral lesions.

www.mdconsul.com

Bechet’s Syndrome

www.bestpractice.bmj.com

Acanthosis Nigricans

www.dermatologistsnyc.com

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies

vulvar biopsy
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!!!

USUHS MSIII Ob/Gyn

Clerkship Self Directed Studies