Vulvar Workshop: Identification of Vulvar, Vaginal and Cervical Lesions REBECCA JACKSON MD

Vestibule

Skene’s duct opening

introitus For each slide: 1. What do you see Vulvar Issues 2. Would you biopsy and where? DERMATOSES INFECTIONS NEOPLASTIC 3. What do you think 1. Lichen sclerosis et 1. Herpes 1. Mole/ it is? atrophicus 2. Trichomonas 2. 2. 3. 3. VIN Appearance: 3. Contact 4. Mulluscom Thickened, well‐demarcated, contageosum 4. Squamous cell lighter than surrounding , 4. cancer excoriations 5. 5. Behcets disease 6. / 5. Paget’s Disease Lichen Simplex Chronicus (LSC) 6. Eczema 7. Condyloma Potential biopsy site The Scratch‐itch syndrome Other: epidermal inclusion cyst,

Lichen Simplex Chronicus •Scratch‐Itch Cycle .Relatively symmetric •Thickened skin, often Hint: she is .In pattern of panties incontinent excoriated wears .Redder than LSC incontinence •To treat successfully, pads must break scratch‐ .Stop vulvar irritants itch cycle: • Oral Benadryl .Bathe/wet and add emoliant • Mittens or socks on .TAC 0.1% Ointment hands at night • Medium Steroid (TAC .Biopsy if not sure of diagnosis 0.1% Ointment Appearance: sharply demarcated, red Contact Dermatitis Vulvar plaque, silver scale .Given how angry, may need Hint: lesions also present on topical anesthetic in addition to • No biopsy necessary if typical elbows, knees, steroid lesions elsewhere on body. crural folds .Lidocaine 2.5%/Prilocaine2.5% •When do have to biopsy, can be Cream (aka EMLA) difficult to differentiate from lichen simplex chronicus, especially in Otherwise: presence of scratching/rubbing .Lidocaine ointment

Hint: she is incontinent and has been applying perfume to her and pads

Vulvar Folliculitis Vulvar skin care

•Stop , waxing No soap! No lotion Free and clear detergent

Also avoid shaving, waxing, douching

UpToDate Lichen sclerosis Lichen sclerosis .Chronic and progressive .Loss of architecture .Increased risk of sq cell cancer so yearly exams, low threshold to re‐ .Whitening biopsy .Treatment: high potency topical .Symptoms: Predominantly steroid (eg clobetesol ointment itching 0.05% qhs 1‐2 months then taper to lowest effective dose—eg .Biopsy before treating twice weekly . Some evidence that treatment Appearance: severe decreases risk of cancer loss of architecture, whitened/splotchy . Early treatment may decrease white areas cosmetic deformity

Squamous cell Vulvar cancer and lichen sclerosis Appears as if there may also be LSC around anus. Question about Severely itchy vulvar lichen scratching, use of cleaning products sclerosus with scarring, loss etc. of vulvar architecture, and thick indurated areas of .

SCCA often presents in setting of years of untreated Lichen sclerosis Don’t push too Finish biopsy with Vulvar Biopsy hard, just get pickups and through skin 1. Alcohol/betadine for cleansing scissors Molluscum contageosum 2. Punch biopsy (4mm) 3. Topical anesthetic (lido/prilo 2.5/2.5)—wait 5 min •Pearly appearance, dimple in center 4. 1‐2 cc 1% lidocaine (with or without epi) using… 5. syringe (not PPD syringe) • HIGHLY infectious 6. Suture removal kit (pick‐ups and scissors) • Caused by poxvirus 7. Gauze/silver nitrate for hemostasis •Treatment options: expectant, cyro, curettage, podophyllotoxin cream,

imiquimod Hint: whole family has this but in child it is on arms/legs. In adults, its in genital area

Hint: very tender and associated with painful lymphadenopathy, fever and malaise. Primary HSV Behcet’s Disease

• May be prolonged systemic • Apthous ulcers of illness with severe genital ulcerations and neurologic mouth, eye, genitalia, involvement recurrent • All patients with first • Autoimmune disease episode of genital herpes • Can affect multiple should receive antiviral organs therapy • Treatment: steroids, • Acyclovir 400 tid or 200 5x/d or valacyclovir 1g bid immunosuppression x 7‐10d Symptoms: painful lesion; Appearance: Squamous cell Behcet’s oral ulcers cancer (within background of lichen sclerosis)

Potential biopsy site

VIN: Vulvar Squamous intraepithelial cell cancer neoplasia

• Red macular lesion

• Well‐demarcated

• Not in a contact dermatitis distribution

Potential biopsy site VIN: Vulvar intraepithelial neoplasia HSIL of vulva

Brown macular lesion

VIN can have many appearances

Potential biopsy site

Vulvar melanoma Lichen planus

Biopsy all irregularly shaped hyper‐ pigmented lesions of the vulva Erosive lichen planus Oral lichen planus • Erosions (white arrow); Reticulate pattern of striae (black arrow) • Affects skin, mouth, hair, vulva • SX: burning, , , usually not itching. Leads to and scarring • Treatment: high potency topical steroid (eg clobatesol 0.05%) daily for 2‐3 mos then taper to lowest effective dose erosion (white arrow) with nd surrounding straie (black • 2 line: tacrolimus arrow). • if severe, oral prednisone

Lichen simplex Lichen sclerosis Lichen Planus chronicus Chronic Itching>>burning, Soreness>>itching, Symptoms Syphilis scratching/rubbing dysuria dyspareunia Involves No No Yes; and oral • ? Primary syphilis Thickened, excoriated, Thin, white, loss of Bright red, ulcerations, • Usually asymptomatic Key features sometimes discolored architecture reticulate lace pattern • Nontender, indurated base, 1. Vulvar skin care 1. Vulvar skin care 1. Vulvar skin care ulcerated top 2. Clobatesol 0.05% 2. Stop scratch (gloves, 2. Clobatesol 0.05% • 3‐6 wks then heals ointment qhs for 1‐ benedryl) ointment qhs for 2‐3 Treatment 2 mos then taper to spontaneously 3. 1 month TAC 0.1% mos then taper to minimum to bid. Decrease and minimum to maintain maintain stop when itch gone effectiveness effectiveness Condyloma Acuminata Conylomata lata

• Secondary syphilis • Papular grey masses, weeping. • Not vegetative like condy acuminata

VIN: Vulvar intraepithelial neoplasia Vaginal Issues CYSTS INFECTIONS OTHER • Raised white plaques 1. Bartholin Cyst 1. Herpes • Similar to condyloma—this 2. Embryologic remnant 2. Trichomonas 1. Vaginal is why biopsy so important! cysts adenosis 3. Candidiasis 3. Epidermal inclusion 2. cyst 4. BV 4. Skene’s gland cyst 5. Syphilis 5. Urethral diverticulum 6. Bartholin Potential biopsy site abscess Wet mount abnormalities Normal

• Normal epithelial cells (not clue cells) • Lactobacillus • No or few WBC’s

Yeast Trich

• Don’t diagnosis in • Spaghetti (hyphae) and absence of motility meatballs (budding given the relationship yeast) harm that can occur • Note casts of dead cells in background (KOH) • Can get NAAT if suspect DIV: Desquamative What conditions inflammatory have parabasal cells?

• Sheets of white cells • Some parabasal cells (immature squamous cells). • Smaller than sqaumes, much larger than wbc)

Answer: DIV, . In DIV, also lots of WBCs. Not so in . (DIV= Desquamative inflammatory vaginitis

Yeast

Budding yeast

Very small, often shiny (refractive) BV Vulvovaginal Candidiasis

Clue cells Can have significant Note fissures and satellite Moth eaten edges lesions caused by studding of non‐lactobacillus bacteria

Vulvovaginal Candidiasis Complicated VVC (vulvo‐vag candidiasis) CRITERIA FOR “COMPLICATED” VVC TREATMENT .Severe signs/sx .Start with: 2‐3 doses of sequential fluconazole 150 mg 72 hours apart .Non‐albicans candida (eg glabrata) .If severe sx: add low potency steroid/anti‐fungal combo (eg .Pregnancy, poor control DM2, nystatin/triamcinolone) immunosuppression • .Glabrata: If fails above: 600 mg 85‐95% C. albicans, next is C. glabrata .Recurrent (>=3/yr) verified boric acid capsules qhs x 2wks • Culture if recurrent or resistant (caution: FATAL IF SWALLOWED) Trichomonas Trichomonas • Diagnosis: motile trich on wet mount or NAAT vaginal swab • Anareobic so need to keep wet and look at quickly • NAAT 98% sensitive and specific • Treatment: Flagyl 2gx1 or tinidazole 2gx1 “strawberry ”

• Frothy greenish discharge (more tolerable and effective but more Keep trich alive by $). dunking qtip in a few • Sexually transmitted: must treat partner too cc of saline in test • Increases risk of HIV, PID, PTD • Resistance rare—usually failure to tube until make slide • Can cause significant vulvitis or can be asymptomatic treat partner or to take treatment (more commonly asx in men than women) • Metrogel not effective

Bacterial Vaginosis Vulvovaginal atrophy • Loss of labial and vulvar fullness, loss of • Caused by lack of lactobacilli which produce ruggae, pallor acid, allowing overgrowth of other bacteria • Narrowed introitus • Increases risk of HIV, Gc/CT, PID, HSV, post‐ • Prominent urethra op infection, PTD, PROM • No partner treatment necessary • 50% say QoL is affected, only 20% get • Recurrence very common (30‐50%) care • New treatment (only compared with placebo): Secnidizole granules 2g x1 • Treatment: Topical cream or Estring Vaginitis summary

Bacterial Vaginosis Trichomonas Vaginitis Candidal Vaginitis Vulvovaginal Atrophy Desquamative inflammatory vaginitis (DIV) Itching, malodorous Itching, dysuria, Symptoms Itching, discharge Dryness, discomfort Treatment: discharge excessive discharge • Persistent, copius, purulent‐appearing Vaginal pH > 4.5 > 4.5 < 4.5 >5 discharge, possibly dysparunea, possibly 2% clindamycin cream 4 Thin, homogeneous, Yellow, green, frothy, Cottage cheesy, curd‐ spotted vagina, cervix Discharge None to 5 grams (by vaginal white/grey adherent like Wet mount: Whiff test Positive Positive Negative Negative . Ph>4.5 applicator) qhs 4‐6 wks Clue cells Trichomonas, WBCs > Hyphae, Parabasal cells, Wet prep . (PMNs/epith > 1:1 in at least 4 hpfs on wet Or No WBCs 10/hpf pseudohyphae, spores decrease lactobacilli prep) 10% hydrocortisone 1. Metronidazole 2 g PO .Increase parabasal cells (>10% total) 1. Metronidazole 1. Fluconazole Topical hormonal x 1 (or 500 mg BID x cream 3‐5g (by vaginal 500mg PO BID x 7 150mg PO x 1 or therapy 3x per wk : .Loss of normal vaginal lactobacilli 7 days) or days or gel 5g 2. 3‐7 day cream, 1. Premarin cream applicator) qhs 4‐6 wk Treatment 2. Tinidazole 2g po x1 •Diagnosis of exclusion QHS x 5 days or suppositories: 2. 10‐25 mcg Vagifem **Treat partner and 2. clindamycin 300 Clotrimazole, tablets abstain 7 days mg BID x 7 days miconazole etc 3. Estring

Treatment of recurrent vaginitis Trichomonas Bacterial Vaginosis Candidal Vaginitis Bartholin Glands Vaginitis Usu due to inadequate Common: 30% within Can’tNormally be seennot seen or feltnor feltwhen normal treatment of pt or Incidence 3 mons, 50% within 6 Less than bv (~25%) partner; resistance is mos Posterior aspect of vulva rare If enlarged, can be a painless cyst or painful abscess 1. Metronidazole gel 1. Fluconozole 150mg day 1. Re‐treat patient and If enlarged: painless= cyst, painful 2x per wk x 4‐6mos 1,4,7 (or cream for 7‐14 partner with =abscess Treatment 2. Oral 500 bid x7d days) then weekly metronidazole or (try #2 if #1 then boric acid fluconazole for 6 mos tinidazole 2g fails) 600mg PV qhs x21 2. If cyclic recurrence (eg To differentiate from peri‐anal or 2. 500 mg bidx7d day then gel 2x/wk with menses or sex), vulvar abscess, palpate mass with 3. 2g qd x7d x 4‐6 mos treat episodically one finger in vagina, one externally Skene’s Glands , Can’t Normallybe seen notor feltseen when nor felt normal Each side of urethra If enlarged, can be a painless • AKA Epidermal inclusion cyst, cyst or painful abscess sebaceous cyst If enlarged: painless= cyst, painful • Firm, non‐pigmented lesions in =abscess hair‐bearing areas

When enlarged, cysts/ will appear midline

Bartholin Duct Cyst Vulvar abscess Bartholin abscess Vulvar abscess Difficult to differentiate from vulvar abscess

To differentiate from peri‐ anal or vulvar abscess, palpate mass with one finger in vagina, one externally

Bartholin's Abscess Word Catheter Placement

Must be drained Leave in for 3‐4 wks for epithelial tract to form Simple I&D, Marsupialization or Word Catheter Most important: Incision within vagina (within hymeneal ring if possible). Never out on vulva (pain, poor cosmetic result) Vaginal Wall Cyst Vaginal cyst Right Vaginal Wall Cyst • Most benign, asx • Gartner’s duct cyst • Embryologic remnants • Embryologic remnant of • Mullian=paramesone mesonephric duct (near the round phric ligament of ) • Wollfian=mesonephr • Arise high in vagina ic =Gartner’s cyst • When cysts become large, they • Usually asymptomatic can appear in the midline and don’t require Prolapsing Mullerian cyst treatment

Vaginal Inclusion Cyst Vaginal Adenosis

• Usually due to obstetric injury • Persistent Mullerian columnar in the anterior wall and • If asymptomatic: no upper 1/3 of vagina treatment • Manifestation of maternal DES • If symptomatic simple exposure excision (cystectomy) • Red, granular patches • Precursor of clear cell adenocarcinoma Urethral Caruncle Urethral Diverticulum

soft pink or red, sessile or • Outpouching of urethra in pedunculated, lesions mid/distal urethra protruding from the • Symptoms: frequency, urgency, dysuria, post‐void urethral meatus. dribbling, dyspareunia • Treatment: conservative vs excision Compression results in expression of milky discharge from urethra

Purulent-.jpg Skene’s gland cyst Cervicitis

• Skene’s ducts lateral to • Cervix friable and red urethra • Q‐tip within os to determine if pus coming from • inside cervix. Yellow q‐tip = cervical mucopus If obstruct, cyst or abscess • Diff diagnosis: GC, CT, Trich, HSV, BV can form • Workup: wet mount, test for GC/CT/trich, do • Often asymptomatic or can pelvic exam to r/o PID have urinary hesitancy, • Treatment: If <25yo or sexual RF, treat dribbling presumptively with Azithro 1g or doxy 100 bid • If symptomatic, treat via for 7 days. If low risk, wait for test results to treat excision Cervical ectropian

• Associated with young age, pregnancy. Decreased on OCP. • Can have bothersome discharge. If so, try OCP vs .

Exophytic nabothian cyst Cervical

• Can be white, clear, red, blue or purple. • If unsure it’s a Nabothian, stick a needle in it. Mucus return confirms Nabothian Prolapsing or polyp

Endometriosis Conclusions . Biopsy important .Lesions not always classic appearing .VIN can appear quite benign .To guide treatment (high potency vs medium potency steroids)

.Vulvar skin care important: .NO SOAP! .Many women are self‐treating with a variety of products .Must break scratching cycle: socks/mittens at night, benedryl