Case 1 Case Studies in Vulvovaginal Disease Leah Moynihan, RNC, MSN Women & Infants Hospital of Rhode Island Division of Urogynecology & Reconstructive Pelvic Surgery Disclosures I have no relevant financial relationships to disclose Atrophic vulva Lichen simplex chronicus Lichen sclerosus Contact dermatitis Case 1 71yo female with hx urinary incontinence, new to your office, also long hx vulvar itching Has used OTC creams (Vagisil, Cortaid) and been treated by gyn for yeast Not sexually active due to partner issues, last time 10 yrs ago it was very painful Wears pads, washes vulva with soap and water several times daily due to odor Lichen sclerosus Whitened, shiny, thickened, hyperkeratotic skin Loss of vulvar architecture Commonly seen around vulva and perineum Diagnosis based on appearance or biopsy 1
Treatment: Lichen sclerosus Super potent topical corticosteroids Halobetasol 0.05% ointment Clobetasol 0.05% ointment Betamethasone 0.05% in augmented vehicle ointment Case 2 Treatment pearls: Lichen sclerosus Biopsy not necessary unless suspicious lesion or no response to treatment Abnl apperance can resolve with tx Treatment is indefinite Patient education Stop the irritants Vaginal estrogen prn Dyspareunia Vulvodynia Atrophic vaginitis Vulvar vestibulitis Case 2 Vulvodynia 21yo with complaint of pain with sex x3 months Menarche at 14, started OCPs at 18, only uses pads with menses, cannot tolerate tampons Now having burning vulvar pain all the time, skin feels raw, pain worse with urination Sometimes has vaginal discharge, wears liners Urine cultures negative but antibiotics help pain On exam, tender to q-tip at 5-7 o clock introitus, pelvic floor tender, mild vulvar erythema Vulvar pain, usually burning, not caused by infection Vestibulitis is old term not truly inflammatory disorder Erythema may be present Classified by site, generalized or localized, and provoked, unprovoked, or mixed Other pain syndromes common 2
What s your diagnosis? Syphilis Chancroid Herpes simplex Vulvar cancer Debra L. Birenbaum MD Case 3 54yo with urge incontinence x 5 years, last seen 2 yrs ago, urge incontinence so bad that she sleeps on trash bags and wears diapers Two hrs late for visit, mentions having a bump down there for 2 mos, tried to pop it, accidentally shaved it, now will not heal Has to leave soon for another appt Vulvar Cancer Reasonable to test for other possible causes but do not delay biopsy Final diagnosis: FIGO Stage IB and AJCC Stage pt1bn0(i+) squamous cell carcinoma of the left vulva Radiation discussed but declined Case 3 On exam, she has an ulcer-like lesion, 1cm diameter, raised, painless, no lymphadenopathy Case 4 85yo with Alzheimers, presents with daughter for c/o vulvar vs vaginal pain, itching and burning with voiding, sitting, walking Has been treated with fluconazole, antibiotics, triamcinolone ointment Leaks urine with urge Wears pull up all the time, showers 3x per week, only uses water to wash vulva in shower Also with recurrent and resistant UTIs in past 3
Case 4: Exam General: WA, well-developed thin elderly female, alert when I entered the room but fell asleep during history, easily rousable External genitalia: mild erythema of bilateral labia majora but no skin breakdown. The perineum is dry. Vulva: tender to qtip at 6 o'clock introitus, unclear if tender elsewhere (pt couldn't answer yes/no), no mass/lesion Urethra: nontender, uncomfortable with catheter, PVR 130cc Vagina: atrophic, no discharge, no lesions, no prolapse Case 4: Treatment Answer: All of the above? Manage the chaos Stop fluconazole after yeast cx negative Stop flomax as PVR is within nl limits Gabapentin 6% cream BID to vulva Hydroxyzine 10mg at bedtime Start cephalexin 250mg bedtime for UTI suppression Case 4: Review records Problems began after multiple courses of antibiotics for UTI, which led to C diff Urinary retention noted during hosp for C diff, managed with foley then Flomax from urology Fluconazole suppression q 3 days given based on symptoms of vulvar itching Case 4 Follow Up UTI is causing vulvar symptoms UTI symptoms in elderly can be different Now on rotating antibiotic suppression, discussed D-Mannose and high potency cranberry supplement What s your diagnosis? Contact dermatitis Vulvodynia Atrophic vaginitis All of the above Case 5 35yo G0 with c/o vulvar itching for last 6 months, also with urge incontinence Itching/scratching wakes her from sleep Hx lichen planus of scalp Wears menstrual pads for leakage Has self-treated with OTC yeast creams Washes vulva with soap and water several times/day 4
Case 5 Case 6 Fructer et al, 2017 17yo G0 c/o burning with urination since age 13, also pain with full bladder Symptoms started after diagnosed with Crohn s disease and started mesalamine, Crohn s now in remission Subsequently diagnosed with vulvodynia No hx sexual activity or abuse Symptoms are daily, wax and wane in intensity What s your diagnosis? Atropic vaginitis Lichen simplex chronicus Yeast infection Cellulitis Case 6: Exam findings Erythema (6 o clock introitus, mild) Urethra: no lesions Vulva: no masses or lesions, tender to q-tip only in periurethral area Bladder: nontender, no masses Vagina: pelvic floor soft, nontender Bimanual: no adnexal mass or fullness, uterus nl All urethral, vaginal, and urine cultures negative Lichen simplex chronicus Variant of eczema Irritants can trigger (pads, urine) Eliminating triggers alone not enough High potency steroid ointment Soak and seal What treatment would you recommend first line? Antibiotic Physical therapy Amitriptyline Pentosan polysulfate sodium Cystoscopy with hydrodistension 5
Case 6: mixed symptoms Features of painful bladder vs non-infectious urethritis and vulvodynia Tried PT first line with improvement Added amitriptyline and topical lidocaine Now following anti-inflammatory diet Herpes simplex virus Lichen sclerosus flare Contact dermatitis Vulvodynia Case 7 82yo with known lichen sclerosus, calls with acute vulvar pain Uses clobetasol ointment and Aquaphor regularly, no new products Notes dysuria, burning vulvar pain No prior STIs, not sexually active currently Herpes simplex virus (HSV) Use of high potency topical steroid can increase risk of HSV outbreak Likely recurrence, not primary outbreak If HSV culture negative, consider serology This pt s culture was (-), serology positive Treat for HSV while waiting for result Case 7: Exam Case 8 85yo seeing you for pessary check, has urinary incontinence all the time, wears diapers Pt has dementia and cannot provide history, notes from SNF include med list and recent labs (normal, no recent UTIs) Aide mentions seeing spots of blood in adult diaper that morning (pt is s/p hyst) 6
Case 8: Exam Resources International Society for the Study of Vulvovaginal Diseases (ISSVD, www.issvd.org) Vulvovaginal Disorders Algorithm (http://vulvovaginaldisorders.com/) National Vulvodynia Association (www.nva.org) From UpToDate Reproduced with permission from: Rodriguez MI, Obstet Gynecol Surv 2012 Irritant dermatitis Yeast infection Vulvar cancer Lichen sclerosus Irritant dermatitis Urine leakage is most common cause, incontinence products also contribute Treatment challenges with dementia If in SNF, provide peri-care instructions If at home, relative may be able to help Discontinue irritants (is leakage treatable?) Improve skin barrier function Consider vag estrogen 7