Vulvar / Vaginal Disease

Ch 19, 23, 41
2009-2010 Academic Year
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 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 patients
evaluation in clinic and diagnosis.

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

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 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.

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 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.

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 Wet Mount (KOH)
Candidiasis (Yeast Infection)

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

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 Cevical Images
associated with vaginitis
Clumpy Cottage-cheese-like discharge
Consistent with Yeast infection

Frothy discharge consistent with

Trichomonas.

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 Dermatologic Conditions of Vulva
Squamous Hyperplasia
Lichen Sclerosis
Lichen Planus
Pemphigus
Bechets Syndrome
Crohn Disease
Acanthosis Nigricans

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 Squamous Cell Hyperplasia
Local thickening of epithelium
Associated with prolonged itch-scratch
cycle

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

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 Lichen Planus
Purplish, polygonal papules
Can be erosive
Vagina, vulva, mouth Lacy reticulated
pattern, scarring
Topical and systemic steroids

Ulcerated lesions

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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.
Crohns: slitlike knife-cut ulcers of vulva, edema
(often precedes GI sxs)
Acanthosis Nigricans: intertriginous areas, axilla,
nape of neck. Darkly pigmented velvety or warty
surface. Associated with insulin resistence.
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 Pemphigus oral lesions.
Bechets Syndrome
www.mdconsul.com
www.bestpractice.bmj.com

Acanthosis Nigricans
www.dermatologistsnyc.com

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 Vulvar Biopsy
When to biopsy
If you dont know what it is
If it is persistent despite treatment or recurrent
When in doubt, biopsy.

YOU ARE NEVER WRONG TO BIOPSY!!!

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