Vulvar / Vaginal Disease
Ch 19, 23, 41
2009-2010 Academic Year
MSIII Ob/Gyn Clerkship
Self-Directed Study
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
APGO Educational Topic 51:
• A. Define the risk factors for vulvar
neoplasms.
• B. Describe the indications for vulvar
biopsy.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Vaginitis
Inflammation 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.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Wet Mount (KOH)
Candidiasis (Yeast Infection)
Mycelial tangles of yeast pseudohyphae in KOH wet-mount preparation.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Cevical Images
associated with vaginitis
“Clumpy” “Cottage-cheese-like” discharge
Consistent with Yeast infection
Frothy discharge consistent with
Trichomonas.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Dermatologic Conditions of Vulva
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Squamous Hyperplasia
Lichen Sclerosis
Lichen Planus
Pemphigus
Bechet’s Syndrome
Crohn Disease
Acanthosis Nigricans
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Squamous Cell Hyperplasia
• Local thickening of epithelium
• Associated with prolonged itch-scratch
cycle
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Lichen Sclerosis
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Pruritus, Dyspareunia, burning
Most common in menopausal women
Skin is thin, inelastic, white, crinkled “tissue paper”
Potent topical steriods (0.05% Clobetasol)
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
•
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Lichen Planus
Purplish, polygonal papules
Can be erosive
Vagina, vulva, mouth
Topical and systemic steroids
Lacy reticulated
pattern, scarring
Ulcerated lesions
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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.
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
Pemphigus oral lesions.
www.mdconsul.com
Bechet’s Syndrome
www.bestpractice.bmj.com
Acanthosis Nigricans
www.dermatologistsnyc.com
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies
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!!!
2009-2010
USUHS MSIII Ob/Gyn
Clerkship Self Directed Studies