Vulvar Lesions
CAPT Mike Hughey, MC, USNR
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 1
Bartholin Gland
• Normally not seen nor felt
• If enlarged, can be a
painless cyst or painful
abscess
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 2
Bartholin Duct Cyst
Video
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 3
Bartholin's Abscess
•
Must be drained
•
Simple I&D
•
Marsupialization
•
Word Catheter
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 4
Don’t Confuse it with These:
Inclusion Cyst of the Vulva
Right Vaginal Wall Cyst
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 5
Skene's Gland
•
Each side of urethra
•
Normally neither seen nor
felt
•
May become swollen and
tender, particularly with GC
or chlamydia
•
Culture
•
I&D if pointing
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 6
Skenitis
• Will need I&D
• Culture for GC, Chlamydia
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 7
Herpes Vulvitis
•
Prodrome of itching or
tingling
•
Multiple, small, painful
blisters
•
Shallow ulcers filled with
gray material
•
Crusts over in 7-10 days
•
Recurrences in 50%
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 8
Herpes Vulvitis Treatment
•
Spontaneous resolution in 10
days
•
Zovirax 200 mg PO Q 4 hours
while awake #50
•
May need to place Foley
cather
•
Recurrences are not as severe
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 9
Molluscom Contagiosum
•
Multiple, 1-2 mm raised,
painless lesions
•
Dome-shaped with central
dimple
•
Contain cheesy-white
material
•
Sexually transmitted
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 10
Molluscom Contagiosum Treatment
Video
•
Cryosurgery (just the
lesion)
•
Bichloracetic acid (just
the lesion)
•
Dermal curette (AgNO3
to base)
•
Electrocute the lesion
(local anes.)
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 11
HPV (Condyloma)
•
Clinical warts
•
Flat warts
•
Soak vulva in vinegar,
Exam under 7x power,
Red-free light filter
•
No specific treatment
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 12
Tinea Cruris (Jock Itch)
• Raised, reddened intertrigenous
lesion
• Dx: visual, but may obtain
KOH scrapings
• Rx: (BID x 2-3 weeks)
-Monistat
-Lotrimin
-Diflucan
-Nizoral
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 13
Runner’s Rash
• Chafing from running, walking
or other exercise
• Lubricate with vaseline
• Avoid cotton underwear
• Local treatment
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 14
Vulvar Dystrophy - Hypertrophic
• Skin too thick
• Sx: Itching
• Dx: Biopsy
• Rx: Steroid Cream
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 15
Vulvar Dystrophy - Lichen Sclerosis
•
Skin too thin
•
Sx: Itching
•
Dx: Biopsy
•
Rx: Testosterone Cream or
Clobetasol
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 16
Paget's Disease
•
Slow-growing malignancy
•
Exzematoid lesion
-dry, crusty skin
-moist, weepy
-contact bleeding
•
Looks like yeast, but isn’t
cured with anti-fungal Rx
•
Confirm by Bx, treat with local
excision
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 17
Vulvar Hematoma
•
Straddle injury
•
Foley/Ice/Rest
•
Completely resolves in 2-3 weeks
•
Try not to drain them
–
–
–
–
Unnecessary
Bleeding point elusive
Risk infection
Spontaneous drainage in half
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 18
Primary Syphilis Appearance
•
Painless solitary ulcer
•
LNs enlarged, firm, nontender
•
Positive RPR, VDRL
•
Positive Darkfield
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 19
Primary Syphilis Treatment
•
Benzathine PCN G, 1.2
M in each buttock
(2.4 M total)
•
TTCN, 500 mg PO QID
x 14 days
•
Doxycycline 100 PO
BID x 14 days
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 20
Condyloma Lata Diagnosis
•
Secondary syphilis
•
Raised, painless flat lesions
•
Resemble condyloma, but
smooth surface
•
Positive VDRL
•
Positive darfield of surface
scrapings
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 21
Condyloma Lata Treatment
•
Same as Primary Syphilis
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 22
Chancroid Appearance
•
Tender, red papule filled
with pus
•
Grayish, necrotic base
•
Jagged, irregular margins
•
No induration (contrast
syphilis)
•
Tender inguinal LNs in
50%
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 23
Chancroid Diagnosis
•
Hemophilus ducreyi
•
Hard to culture
•
Gram-neg coccobacillus in
clusters around
Polymorphonucleocytes
•
"School of Fish
Appearance"
•
History, physical, exclude
other ulcerative diseases
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 24
Chancroid Treatment
•
Azithromycin 1 g PO
•
Ceftriaxone 250 mg IM
•
Ciprofloxacin 500 mg PO
BID for 3 days
•
Erythromycin base 500 mg
PO QID for 7 days.
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 25
Lymphogranuloma Venereum (LGV)
•
Ulceration of the vulva, rectum
or groin
•
Pain with walking, sitting, or
BMs
•
Hard tender masses (bubos)
arise in the inguinal area
•
Untreated, extensive scarring in
the rectum and vagina
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 26
LGV Diagnosis
•
Chlamydia trachomatis serotype
culture from a bubo
•
Acute/convelescent serum
complement fixation test
•
History of exposure
•
Visual appearance
•
Prevalence in the population.
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 27
LGV Treatment

Doxycycline 100 mg orally
twice a day for 21 days, or

Erythromycin base 500 mg
orally four times a day for 21
days.

Zithromax? (Probably with
multiple doses over several
weeks)
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 28
Granuloma Inguinale Appearance
•
Chronic ulcerative disease
•
Clean, granulomatous, sharplydefined
•
Multiple, confluent ulcers
•
Beefy red base which bleeds
easily
•
Pseudobuboes in the groin
•
Confirm with biopsy (Donovan
Bodies)
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 29
Granuloma Inguinale Treatment
•
Minimal scarring when treated
early
•
Extensive scarring when treated
late
•
3 Weeks of:
– Bactrim DS BID
– Doxycycline 100 mg BID
– Ciprofloxacin 750 mg BID
– Erythromycin base 500 mg QID
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 30
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 31