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MRCOG PART 2 SBAs and EMQs

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Essay 317 - VIN

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		Posted by Naheed M. Tue Feb 2, 2010 12:37 pm
N.M I will ask the patient about the onset, the severity and if the problem has been recurring (HPV). Is it localized to vulval area or generalized body itching. I wil ask her the associated complains such as bleeding, pain, ulcer, cyst, vesicular rash, or mass . I will ask her about any medical illness such as diabetes, HIV positive status, urinary and gastrointestinal conditions such as urinary incontinence/leakage or crohn’s disease). I will as her any history of fever. Any history of acute infectious illness such as herpes, recurrent shingles or abnormal foul smelling vaginal discharge. I will ask her about last menstrual period, if menopausal since when and what is her cervical smear history. I will assess through history if she is exposed to the multiple sexual partners (though unlikely at her age but it should be excluded) and thereby sexually transmited infections. I will ask her if she has any kind of allergies or dermatologic conditions such as eczema, contact dermatitis. She should be asked about history of scabies in family or at work place. I will ask about any lesion at her breast (pagets disease) or under breast skin folds(candida). I will ask her the use of clothing (tight undergarments or silk clothing), any scented soap creams or talcum which may cause the complain. I will ask her about her sexual history and use of latex condoms. I will assess how much her quality of life ( sexual, social and psychological) is affected with this problem. I will ask her about smoking and her socioeconomic conditions. I will perform general and local examination. I will examine if there are scratch marks or rash on the body areas. Any kind of lesions at other body parts such as limbs and abdomen (lichen sclerosis) .I will check if mucous membranes of mouth and throat show any kind of lesions (lichen planus). I will inspect the local vulval and vagivnal area for presence of any rash, lesion or mass. I will perform Perspeculum examination to check the condition of cervix, vagina and any evidence of abnormal vaginal discharge under good light. I will collect the swabs and send for laboratory testing if clinically suspicious for infections such as HPV, candida, trichomonas, threadworm, and herpes. As pruritis can be associated with vulval neoplastic conditions (VIN or other benign and malignant vulval lesions) so excision biopsy should be taken to exclude such conditions. If cervix looks suspicious she should be sent for smear (if due)or colposcopy (if indicated on examination) as VIN can be associated with CIN. It can be assocaiated with multicenteric disease so other suspicious areas if present e.g on vagina, perineum or anus should be biopsied. Nonspecific tests should be performed if indicated such as FBC (leucocytosis for infections) CRP, urinalysis and midstream urinary culture and sensitivity. The treatment of VIN is controvercial as the natural history of the disease course is unknown and variable. The treatment options can be expectant, medical and surgical and choice of the option depends upon severity/grade of lesion and patient’s choice. Expectant treatment can be successful as VIN is associated with spontaneous regression. However woman should be informed of importance of follow-up. Follow up is very necessary in the cases of VIN because it is associated with higher risk of recurrence, can be multicenteric (vulva, vagina, cervix, perineumand anal canal) disease and carries the risk of progression (6%) to high grade lesion and rarely to carcinoma. Medical treatment includes new topical ointment , imiquimod which is not licensed in UK and is still under evaluation. Topical 5-fluorouracil has not been proven beneficial. Mainstay treatment for VIN is surgical. widelocal excision or laser ablation with Nd-YAG or CO2 can be used. Woman should be provided with psychological support and reassurance. Long term follow up is essential so patient should be counselled well verbally along with written leaflet information.
		Posted by F N. Tue Feb 2, 2010 03:07 pm
A 53 year old woman has been referred to the gynaecology clinic with a 6 months history of a burning sensation and itching in the vulval area. (a) Discuss your clinical assessment and investigation [10 marks ]. (b) She is found to have vulval intra-epithelial neoplasia. Discuss the available treatment options and justify your plans for follow-up [ 10 marks ]. I will ask her about the onset and progression and severity of associated symptoms like itching as it might have significant psychological impact on her life.Previous history of valval disorder like lichen sclerosis and any treatment might increase her risk of valval malignancy.history of intake of drugs like steroids might predispose her to valval dystrophies.I will ask about her cervical smears as VIN may be associated with CIN.any history of autoimmune disorders may increase her risk further.history of recent weight loss,lethargy,loss of apetite and abnormal bowe habits might be suggestive of malignancy.History about her life style habits is important as smoking and malnutrition is associated with valval neoplasis.History of any comorbid conditions like Diabetes,hypertension and cardiac disease is important to check her suitability for surgery in case of malignancy. I will do a general,systemic and local examination.I will look for any abdominal masses or palpable inguinal lymph nodes if i am suspecting malignancy.I will do local valval examination to look for any abnormal and suspicious skin changes.I will also note whether the changes are multifocal as it might affect the recurrence rate and will be difficult to treat.I will also do speculam examination to assess cervix and vagina as VIN might coexist with CIN and VGIN (cervical and vaginal intraepthelial neoplasia.)I will also do a bimannual pelvic examination to exclude any pelvic masses. I ill check her FBC to exclude anemia,i will do baseline U&Es and LFTs and renal functions if i am suspectind malignancy.If on clinical examination there is evidence of abnormal changes i will take valval biopsy either punch or excisional.there is a role of colposcopy and biopsy if there is suspicion of CIN or VGIN. CT/MRI of abdomen and pelvis will be helpul to look for inguinal/femoral lymph nodes and metastatic disease. B: Vulvar intraepithelial neoplasia is a chronic disorder caused by high-risk types of human papillomavirus (HPV), most commonly HPV type 16 (HPV-16). The treatment options are conservative medical and surgical.The choice of treatment depends on the age of the patient,grade of the disease,comorbid conditions and patients wishes. Low grade VIN can be managed expectantly as most of these lesions resolve spontaneously.However in older ladies with coexistent CIN even treatment of low grade lesions may be an option. Medical therapy usind topical florinated steroids and interferons and 5 floruracil may be tried for symtomatic relief however there role is unclear in treatment of VIN and they can cause skin irritation. CO2 Laser therapy is another option especialy for multifocal disease however it cause skin scarring.It can be a preferred treatment option in young patients,in whom valvectomy and wide local incision might not be suitable. Surgery can be by wide local excision,skinning with skingrafts..The role of crotherapy to treat VIN is unclear.Patients with vulvar intraepithelial neoplasia require long term follow up, Spontaneous regression occurs in less than 1.5% of patients, and the rate of recurrence after treatment is high and the risk of invasion may be higher than previously thought.
		Posted by SYAMALRANJAN S. Tue Feb 2, 2010 09:44 pm
SRS (a) Discuss your clinical assessment and investigation [10 marks ]. Careful history taking which includes other associated symptoms such as vulval soreness, discharge, presence of swelling, pain, chronology of symptoms and aggravating or relieving factors if any. I will also enquire any other body area(like breasts, limbs, axilla,groin) skin problems suggestive of skin disorders,fungal infections. Severity of presenting symptoms and effects on quality of life are enquired. Menstrual history(menopause, last menstrual period, cycle regularity ) , obstetrical history, sexual history(numbers sexual partners, dyspareunia), contraceptive history (using barrier method) might give clue with the sexually transitted infections particularly human papilloma virus infection. I will ask about drug history particularly immunosuppressive drugs, previous and current treatment history, lifestyle(smoking, drug abuse), personal hygienic habits (soap, deodorant related to allergy, contact dermatitis). I will review cervical smear history Iwill enquire medical history and family history suggestive of diabetes mellitus. Urinary (dysuria, voiding problems), associated perianal symptoms (scratching, bleeding , mass) are relevant for assessing vulval problems. Psychological status needs to be observed. I will examine her general health(anaemia, cachexia). I will also note upper limbs, lower limbs, breasts (if any symptoms suggest) skin lesions(contact dermatitis , fungal infections). Iwill carefully examine vulva (rash, scratching , ulceration, swelling, discharge) groin (palpable inguinal nodes) including perianal skin. Introitus , vagina , cervix are examined. Good light source with a colposcope at low magnification is preferable. Bacteriological swabs are taken from vulval area if suggestive of infection and sent for microscopy and culture. I will take biopsy from representative area if suspicious features. Urine for glycosuria and urinary tract infection and if relevant, diabetes screening. (b) She is found to have vulval intra-epithelial neoplasia. Discuss the available treatment options and justify your plans for follow-up [ 10 marks ]. Expectant treatment is an option because of possibility of spontaneous regression but needs clear explanation, strict regular follow up, if necessary repeated biopsy ( depending upon severity of symptoms , suspicious features). Excision biopsy is an option of small localized area. Wide excision or skinning vulvectomy with skin grafting for multifocal disease. This should be planned for high risk women or those with evidence of progression on subsequent biopsy. However, the presence of symptoms (itching) may make surgical excision beneficial. More radical surgery is not justified CO2 laser vapourisation may be an effective treatment although depth of treatment for adequate treatment is unknown and difficult to control in vulva (reported to be successful in 90% of cases but depth of tissue destruction limits its usefulness). Treatment is required to a depth of 1mm for non-hairy skin and 2mm for hairy skin. Extensive treatment may cause sufficient skin damage requiring skin grafting. Topical fluoridated steroids may be used for symptoms relief. Topical 5-flurouracil is irritant and ineffective. Topical alpha-interferon may be of benefit but remains under evaluation. Topical imiquimod (immunomodulator) may be useful but remains experimental at present. Multidisciplinary involvement including plastic surgeon , clinical psychologist, support group ( for physical and psychosexual morbidities)are required. I will provide written information. Recurrence rates are high ( 15-45%) after surgery or laser ablation and also having multicentric in nature (such as cervix, vagina, vulval, perianal involvement). Therefore long term close follow up and repeated biopsy if suspicious changes. If there is small chance of recurrence of VIN , GP care is advised but any new symptoms or changes then specialist referral and review is suggested.
		Posted by L S. Tue Feb 2, 2010 10:15 pm
A 53 year old woman has been referred to the gynaecology clinic with a 6 months history of a burning sensation and itching in the vulval area. LS: (a) Discuss your clinical assessment and investigation [10 marks ]. From history, I would determine if this is her first episode or has had similar symptoms in the past. If has occurred before, did it resolve spontaneously. Severity of her pruritus determined and did it lead to traumatic ulceration enquired. Use of local irritant (perfumed soap, deodorants), tight clothes or any urinary leakage which can cause inflammatory dermatosis enquired. Menstrual history and if she is menopause, does her symptom start after menopause. Drug history and any history of allergies enquired. Sexual activity and if her partner has symptoms asked. Past surgical history on vulva enquired. Her cervical smear history checked and note if any premalignant condition to genital tract previously. Past medical history on diabetes and ulcerative colitis or Crohns enquired. On examination, all skin and mucous surfaces (mouth) to exclude systemic disease. I would examine the rest of the genital tract, including cervix, vagina, perineum and anal opening to exclude malignancy or associated pelvic pathology. Abnormality of anatomy of vulva like fusion or atrophy of labia inspected and noted. Hyperpigmentation of her vulval noted as can be associated with inflammatory dermatosis. I would look for any ulcers, if seen its site, size, depth, tenderness and number noted as solitary non-tender ulcers usually caused by syphilis or malignancy. Multiple ulcers can be due to herpes, Crohns or Behcets disease. Ulcers which are indurated may indicate malignancy or vulval intraepithelial neoplasia (VIN). Investigations include infection screen, colposcopy and biopsy. Swabs are taken for bacteriological and viral cultures over lesions seen. Good light source using the colposcope to examine the vulva for VIN and taking representative biopsies. Vulval biopsy should be taken as it’s important to confirm diagnosis and exclude malignancy and done using outpatient disposable punch biopsy over suspicious lesion seen. (b) She is found to have vulval intra-epithelial neoplasia. Discuss the available treatment options and justify your plans for follow-up [ 10 marks ]. Treatment options can be expectant, medical and surgical. Expectant management can be employed once malignancy has been excluded and there are no high risk factors like other immune-suppression or other genital tract malignancies as spontaneous regression may occur. She can be followed up with repeated biopsies of suspicious lesion or if suspicious changes occur over lesions. This is because natural history not well understood and the disease can be multi focal. Topical fluoridated steroids may be given for symptom relief once invasive disease excluded. Topical 5-fluorouracil is highly irritant and has high failure rate. Chemical dermatitis caused by this drug can take up to 6 weeks to heal. The value of topical alpha interferon is still unproven. Surgical treatment if small lesion excision biopsy can be carried out. If larger lesions or multi- focal, skinning vulvectomy with skin grafting may be required. This mode if treatment has limited value due to its high recurrence rate. Surgery is usually reserve for high risk group or if evidence of disease progression on subsequent biopsy. However presence of pruritus can make surgical excision beneficial. CO2 laser vaporization may be effective but depth of tissue destruction for adequate treatment limits its usefulness. Extensive laser may cause skin damage needing grafting. This disease has high recurrence rate. Difficulties in predicting its risk and disease progression to malignancy makes it important to have a close follow up with repeated biopsy. This condition is usually associated with cervical intraepithelial neoplasia, therefore I would recommend cervical screening.
		Posted by H H. Wed Feb 3, 2010 03:20 am
I will ask her regarding how her symptoms are affecting her quality of life. Will ask of severity of itch and if affecting her activity and sleep. Will ask if her symptoms are associated with vaginal discharge (candida). Will ask regarding change in colour of affected area or any ulceration. Will ask regarding her sexual history , dyspareunia,bleeding during intercourse and history of sexualy transmitted disease. Will ask of her last pap smear and how was the last smear(associated CIN). Will ask regarding her medical history ,diabetes, auto immune disease and if taking medications like immunosuppressive agents. Will ask of personal or family history of malignancy anywhere. Will ask if has allergy to synthetic material in underwear. Will ask regarding any previous treatments of her condition including surgical treatment. Will ask regarding her social history,smoking, alcohol intake and any support at home. I will examine her for BMI ,BP , routine general and abdominal examination and then locally for inspection of vulval area for discouleration, white areas ,scratching, ulceration, scally lesions of psoriasis or discharge. Will do speculum examination to inspect the cervix and take swabs if there is discharge. Investigations will include FBC, fasting blood sugar and auto antibodies screen. If there is discharge will do swabs( high vaginal swab, endocervical swab,uretheral /rectal swab and pharyngeal swab) Will refere her to colposcopy(with in 2-4 wk maximum) where toulidine blue can be applied to detect abnormal violet areas, at same time the cervix is examined as there might be an associated CIN associated . A vulval biopsy is taken from suspicious areas to detect pathology. The patient is approached in a sensitive manner and told that it is a precancerous condition and that treatment can take long duration. Consevative management include following the patient with only symptomatic treatment as some cases revert to normal. Medical treatment include topical application of of 5 floro uracil or trichloroacetic acid. Allergic skin reactions can occur and irritation and it can be painful. Laser ablation of the affected area can be another option. It is more cosmotic than surgical management, but the depth of penetration can not be guaranteed and need expert centers. For resistant, recurrent lesions or wide lesions, skinning vulvectomy can be done, however recurrence can still occur in the new skin,and it can lead to disfigurement and psycho sexual problems. Proper counselling should be done before attempting such treatment. Follow up for progession or recurrence after treatment should be done every 6 months. Suspicios areas are biopsied. Patient is put in the care of a psycho sexual counseler and given support. Her GP is notified of her problem and that she will need sensitive support. Patient is better dealt with at an oncology center for regular follow up and management of malignancy should this occurs,the Mcmillan nurse is of great help.
		Posted by Bee N. Wed Feb 3, 2010 07:21 am
Bee A 53 year old woman has been referred to the gynaecology clinic with a 6 months history of a burning sensation and itching in the vulval area. (a) Discuss your clinical assessment and investigation [10 marks ]. (b) She is found to have vulval intra-epithelial neoplasia. Discuss the available treatment options and justify your plans for follow-up [ 10 marks ]. A) I will inquire about the onset and severity and timing of itch as local irritants used in bathing may be implicated as cause. I will ask about any visible lesions around the area and if associated with bleeding. Papules can be associated with lichen planus. Redness and pain/tenderness with dermatitis. Red lesion can also suggest pagets disease. I will ask about similar symptoms in other skin areas as this may be a local complaint of a more generalised skin problem. I will ask about urinary symptoms such as urine incontinence as urine can be irritative when in constant contact with skin. I will ask about recent change of soaps or antiseptics which could have caused some form of irritation especially in areas where they are not ready washed off with water. I will enquire about any vaginal discharge to rule out infective processes such as candidiasis.I will ask for any past history of thyroid problems or alopecia that may suggest autoimmune disease as in lichen sclerosis. I will ask how this symptoms have impacted on everyday life and her genaral state of health. I will take a smear history as VIN is often in assoiciation with CIN. I will take a social history to find out if she smokes. This may contribute to recurrence of VIN after treatment. I will take history of allegy to find out if patient suffers from Atopy. I will then ask if she has had previous investigation by biopsy or treatment to her vulva. Examination will involve the whole body skin looking for alopecia and other areas affected by skin lesions. The flexor compartment are notorious for Lichen planus. This will also involve mucous membranes e.g oral cavity. I will examine the thyroid gland if history suggests thyroid involvement. I will the look for lymph node enlargement especially the inguinal region in case of and infective or malignant process at the vulva. I will then examine the vulva looking for raised lesions,colour and location. Lichen sclerosis is associated with thinning of vulval skin with involvement of the perineum in figure of eight fashion and may involve fusion of the labia minora. Pagets disease may be red lesions and lichen planus a white raised papular lesion. I will do a spesulum examination to look for vaginal discharge and to examine the cervix. Investigations will include colposcopic examination of the vulva where punctation and mosaicism may be found. When stained with acetic acid, the areas with VIN to be biopsied will appear white. If thyroid problems are suspected, I will do a thyroid function test. If discharges are found, I will take swab for culture and sensitivity. If smear test isnt up to date, I will take a smear test. If allergy is suspected I will refer to dermatologist to test for specific skin allergy/sensitivity testing. B) The options of treatment will involve counselling,expectant, medical or surgical treatment. The patient will be informed this is not cancer and only a premalignant condition. It is associated with HPV. The patient can be managed expectantly with repeat biopsy in 6 month. Management can be with fluorouracil. This can cause irritation. Surgical treatment would include laser ablation of lesions. This achieves a depth of destruction considered satisfactory. Excision of the lesion can also be carried out especially if localised to a region. If in multiple regions, skinning vulvectomy can be done with skin grafting. Surgical excision can be problematic due to need for further excision secondary to recurrence. This can cause significant disfiguration and narrowing of the introitus. Cryotherapy, electrocautery and cold coagulation are usually not very effective form of treatments. The patient is followed up in clinic with further biopsy at colposcopy if needed due to the high rate of recurrence( Approx. 20-30%).It will also be an opportunity to encourage ceasation of smoking which will encourage recurrence as well as address any complaints or fall out as already mentioned as a result of treatment carried out.
		Posted by Bindi J. Wed Feb 3, 2010 08:27 am
BJ: History should be taken to exclude if she is menopausal and since when. History of dyspareunia, dryness and vulvar soreness should be taken for atrophic vulvitis. Urogenital symptoms and bleeding also support atrophic vulvitis. History of intense itching specially at night and itching in perianal area are pointers to Lichen sclerosis. History of change in shower gel and personal hygiene should be taken. History of any suspicious lesions on the vulva should be obtained and if change in colour of the vulvar skin. Medical History for skin conditions should be obtained. History of atopic or autoimmune conditions should be taken. History of local application of any medications on vulva should be obtained. History of vulvar hygiene should be obtained sensitively. History of Cervical screening should be obtained. It is important to know the effect of vulvar symptoms on her quality of life. Examination of skin lesions elsewhere on the body. Per abdominal examination should be done for any masses. Vulvar examination should be done to look for pallor, rugation and petichiae for atrophic vulvitis. The classic appearance of porcelain white plaques on vulva and perineum in a figure of eight pattern, with fissuring and erosions support the diagnosis of Lichen Sclerosis. Signs of inflammation like erythema and tenderness should be looked for contact dermatitis. Vesiculation, crusting and edema should be looked for Allergic dermatitis. Lichenification, exaggerated skin markings and excoriation marks should be looked for Lichen simplex chronicus. Flat topped violaceous papules on the body skin with typical Wickham stria in mucous membranes are suggestive of Lichen Planus. Investigation should include cervical screening if not done in the last 5 years. Skin swabs to exclude secondary infection. Urine analysis should be done for leucocytes and nitrites. Tests for autoimmune conditions like Thyroid function tests. Patch test should be done for allergic dermatitis. The confirmatory investigation is histopathology of biopsy specimens. The woman should be told sensitively that it is a premalignant condition and course of nature of the condition is not fully understood. If the lesion is superficial she should be offered carbon dioxide Laser treatment. It has a success rate of 90%. Surgical treatment should be reserved if she develops symptoms of progressive condition on subsequent biopsy. She can be offered skinning vulvectomy or wide local excision with a skin graft later on. Medical treatment has a limited role. 5Flurouracil can be offered but has a limit success rate. It is associated with chemical dermatitis. Role of immunomodulators is still experimental. Referral to a counsellor may help as she is likely to be psychologically upset. She should be provided with written information. It is important to tell her that the disease has a risk of progression. It is difficult to predict the severity and progression and hence she needs a close follow up. She will be followed up clinically for change in symptoms or any suspicious lesions.
		Posted by ASB -. Wed Feb 3, 2010 08:40 am
ASB (a) I would ask if there are associated manifestations like vaginal discharge , dysuria , abnormal vagial bleeding. Ask her if she noticed any vulval changes like colour change, masses or ulcers . Drug history including previous treatment of her problem and their effect. Enquiry about recent use of local medication or new personal care products ( e.g soaps or sprays). Menestrual history including regularity of cycle , LMP and presence of intermenstrual or postcoital bleeding . History of medical disorders particularly for diabetes. Examination include careful inspecion and palpation of the vulva under good light source with spread and inspection of labia as well as hair bearing areas . Palpation of groin for evidene of lymphadenopathy. Speculum examination for vaginal discharge and visualization of cervix. Investigations include colposcopic examnation of the vulva with addition of acetic acid to help recognise abnormal areas . Biopsy is indicated for any suspicious area. (b) Wide local excision refers to excision of an individual lesion with one centimeter margin followed by closure of defect by reapproximation. Removal of epidermis with small amount of dermis help ensure the absence of invasive disease. Skinning vulvectomy is suitable for multifocal lesion or large lesions . It involve removal of vulval skin while preserving subcutaneous tissue . closure is by reapproximation or split thickness skin graft . Laser vaporisation refers to tissue destruction rather than excision using laser . It may offer cosmotic advantage over skinning vulvectoy . Topical treatment ( 5-flurouracil or imiqimod ) aim at preserving vulval anatomy specially in young patients . For low grade VIN ,no treatment with frequent follow up may be appropriate due to high rate of regression . Because recurrence rate is high following treatment ( at least one third of cases ) , regular follow up is required every 6 month for 2 years after treatment and then annually .
		Posted by Sarika N. Wed Feb 3, 2010 10:13 am
A 53 year old woman has been referred to the gynaecology clinic with a 6 months history of a burning sensation and itching in the vulval area. (a) Discuss your clinical assessment and investigation [10 marks ]. Patient should be asked for associated diacharge as could be sign of infection, especially Candida associated with burning sensation. Specific questions regarding postcoital bleeding in association with menopausal symptoms could indicate atrophic changes during perimenopause or postmenopause. Associated symptoms of burning sensation on passing urine can indicate UTI. Changing of soap can be suggestive of allergic reaction. Smelly discharge can be associated with infection and the sexual history should be enquired. Past medical history of Diabetis, as patient can be prone to infection and thrush, psoriasis , as can affect vulva and perianal area should be enquired. Clinical assessment include examination: presence of white, thin skin can be suggestive of Lichen sclerosis, Lichen planus should be excluded by examining the mucose membraines, genital warts should be biopsied.Other features to look to exclude malignancy: swelling, polyp or lump, colour changes, elevation or irregularity of surface, fungating mass, ulser with raised edges, enlarged groin nodes. Presence of red, inflamed area can be suggestive of allergy, infection or atrophic changes should be noticed. Swabs from the area and vagina should be done if infection suspected. Examination of vulva, vagina and cervix should be performed, recent smear history should be noted. If VIN suspected colposcopy should be done and biopsy including the borders of the affected areas should be taken. VIN is associated with HPV virus and abnormal smears. (b) She is found to have vulval intra-epithelial neoplasia. Discuss the available treatment options and justify your plans for follow-up [ 10 marks ]. The treatment will depend on grade of VIN. Low grade disease can be observed regularly some authors suggest annually to avoid transformation. VIN3 should be treated by wide local excision or laser vaporisation, Recurrence have been described more after laser., may be associated with difficulty to remove HPV. Management is more conservative in view of low invasive potential and physical and phychological scarring. Patient should be explained the condition and the principles of monitoring.
		Posted by SRABANI M. Wed Feb 3, 2010 01:45 pm
SM a. A detailed history of her present complaint is very important . Apart from burning sensation & itching any other symptom like dyspareunia, dysuria, voiding difficulty should be asked about. Chronology of symptoms should be asked. Itching in the perianal area should also be asked. Any family history of malignancy should be asked. Her smear test results & whether any other premalignant disease (like cervical intraepithelial neoplasia) she has got or not should be asked. Her menstrual history is also important including postcoital bleeding or intermenstrual bleeding.History of HPV infection or HIV infection in this lady is very important.Any existing medical condition like diabetes should be asked as well. On clinical examination , lesions may be multifocal & have variety of appearances VIN mainly affects labia minora & perineum & hence these area should be examined carefully. It may also involve cervix, vagina, perineum,anal .canal & natal cleft ( Multicentric intraepithelial neoplasia).Scratching of perineal skin may cause breakage of the skin & ulceration.Any lesion in the trunk or limb should be looked at( present in lichen sclerosus).Diagnosis should be made by examining vulva with a good light source such as colposcope. Biopsy should be taken from the lesion. VIN is graded 1-3 in increasing severity of abnormal cell maturation and stratification. HPV typing & HIV testing should be done. b. There is no national guideline for management of Vulval intraepithelial neoplasia.She should be managed very sensitively..Current treatments for VIN are suboptimal in terms of their poor clinical response rates, high relapse rates and associated physical & psychological morbidities. VIN should be observed . VIN3 should be treated by local excision or laser vaporisation.Recurrence is common after surgical excision & even more common in laser ablation. A topical immunomodulator called immiquimod may be used in management of women with VIN., it still remains experimental at present..Conservative surgery is currently the basis of treatment.Lesions in perineum & anal canal may require an initial colostomy prior to skin grafting.Treatment should involve multidisciplinary team which comprises a gynaecologist, colorectal & plastic surgeon,stoma nurse & probably a psychologist. As recurrence rate is very high in this clinical condition, long term follow up is essential.Recurrence of 39 % after surgical excision & 70% after laser ablation have been reported.
		Posted by fluffy F. Wed Feb 3, 2010 04:36 pm
from fluffy a) History of a recent cervical smear done , as cervical intraepithelial neoplasia( CIN ) is associated with higher risk of vulval intraepithelial neoplasia( VIN). Allergy history- to detergents , soaps used recently which can cause itching at the vulva. Sexual history - a sexual history will help to identify those at risk of sexually transmitted diseases such as genital herpes and syphilis.History of painful ulcers are suggestive of herpes genitalis and painless are usually syphilitic ulcers.Medical history - of behcets disease , crohns disease ,diabetes which can also present with vulval lesions with itch and burning sensation.Past surgical history- surgeries on the vulva or cervix will be relevant . Menstrual history - menopausal women with atrophic vulva and itch. Examination- General examination, a cachexic patient is suggestive of ongoing malignancy compared to a generally well healthy looking person.Examination of oral cavity for ulcers , suggests herpetic ulcers or behcets disease.Examination for significant lymphadenopathy ,suggestive of chancroid.Examination of the abdomen for any pelvic masses suggestive of malignancy.Examination of the vulva for any pigmentation, scratch marks, ulcers and indurations suggestive of a inflammatory lesion.Examine for evidence of infection at the vulva, for abscess , pus discharge which usually occurs in diabetics. Any vulval growth, friable , painless and bleeds on touch suggests malignant vulval lesion. Investigations , swabs from the vulval area for sent for culture and sensitivity. If lesions are suggestive of genital herpes , polymerase chain reaction can be done for higher sensitivity and specificity.If lesions are seen at the vulva, colposcopy and a directed biopsy done to rule out malignancy.A cervical smear should be done if not yet done recently. If suspected syphilis, dark ground microscopy for treponema pallidum. b) Treatment options are expectant care as VIN can regress on its own once diagnosis is confirmed . but this is limited to asymptomatic women who agree for repeated biopsies if new changes are seen.Medical - with potent steroids for relieve of the symptoms but malignancy should be ruled out. Laser with carbon dioxide may be effective but the depth of clearance is still doubtfull.Surgery - small lesions can be excised and sent for biopsy- excision biopsy with adequate margin clearance. followup - as VIN can progress to maligant lesion in 20-30 % of cases , she should be assesed 6 monthly with colposcopy evaluation for new lesions. Advice for regular cervical smears as VIN is usually associated with CIN as well.
		Posted by Shamita S. Wed Feb 3, 2010 11:54 pm
ANS (A) Assesment should preferably be done in a combined clinic ,so as to save the woman from repeated examinations..History of the itching and burning to be taken in detail as to its frequency and its effect on her life,itching anywhere else in the body,any associated change noticed or felt in the skin of the vulva ,if there is any associated vaginal discharge or bleeding and the nature of the same .Other causes of itching to be enquired like atopy ,allergies to soap ,irritants fungal infections .A history of psoriosis to be asked for like scaly plaques on scalp and knees and eelbows in the past ,A family history of psoriosis to be asked for.History of smoking to be asked for as smoking causes increased chance of VIN .A change in sexual partners to be asked for as HPV is associated with multiple sexual partners and is causative of VIN .Drug history of intake of immunosuppresive drugsto be taken as in women with renal transplants Menstrual history to see if the patient has attained menopause.Examination to be done under good strong light with patient in appropriate position to loook for skin colour change for evidence of inflamation or any pigmentary change ,texture of the skin to look for abnormal thickness (atrophy or hypertrophy),tenderness or any underlying mass .Examination of the labia minora ,the vestibule ,urethral opening vaginal opening ,perineal skin and anal epithlium to be done thorougly as VIN tends to extend from labia minora to the perineal area.The cervix to be seen per speculum for ny evidence of crevical lesion.A general examination to be carried on for any other lesions to rule out lihen plannus Investigations would include pap smear from the cervix as CIN or even Ca CX could be causative of VIN ,colposcopy, and inspection of the cevix, vagina and vulva for intraepithelial lesions , application of lugols iodine and identification of abnormal areas ,punch biopsy of suspicious areas .exicional biopsy is needed in hyperkeratotic ,pigmented lesions (B) Natural history of VIN is not fully understood it is very slowly progressive as well as multifocal and the risk of invasive disease is small after VIN. Spontaneous regression may occur ,so in the absence of high risk factors and low grade VIN patient may be closely observed with rrepeat examination and biopsy. Surgical treatment is for high risk women who have single lesion ,those which show evidence of progression on subsequent biopsy ,the presence of severe symptoms would make surgical treatment beneficial .It would involve wide local exicision with a1 cm margin of healthy tissue and HPE of the same . Some would require more radical surgery with skin grafting , should the patient require skinnig vulvectomy it would lead to pshyosexual morbidity and hence patient to be reffered for proper councelling. CO2 laser is successful in 90% but the depth of destruction and loss of tissue for bioposy limits its use Medical treatment with 5FU causes sever chemical dermatitis and has a high failure rate even after 5-6 wks of use.The value of interferon is unproven. whatever modality of treatment opted for this patient needs close follow up as it has a tendency for recurrance
		Posted by drvimaladkm@yah K. Thu Feb 4, 2010 03:50 am
Clinical assessment is done with history. Severity of her symptoms affecting her quality of life to be assessed. Any dampness, associated discharge per vagina, its duration, nature, whether offensive, blood stained , post coital bleeding, bleeding per rectm to be elicited. Prior H/O recurrent vesicular eruptions or ulcerations (as in HPV 16 & 33) and treatment taken to be asked. Previous or current H/O of any other genital malignancy and treatment with radiation to be noted. H/O any associated autoimmune disorders like thyroidits with antibodies to be enquired by symptoms of hypothyroidism such as weight gain, lethargy, intolerance to cold. H/O allergies, skin conditions like psoriatic lesions to be found out. H/O exposure to drugs like Diethylstilbestrol to be asked. Family H/O malignancy to be asked. Her menstrual details with last menstrual period or duration of menopause to be noted. Her details of cervical screening to be reviewed. Clinical examination may reveal thin or thickened ,varied colored irregular surfaced lesions with indistinct or sharp edges (as in Paget’s disease).There may be some excoriations in the vulval region. Whether vagina is involved or any adhesions of labia and extent of the lesion to be noted. Application of 5% acetic acid may show mosaic or punctate lesions with irregular edges. Usually multifocal lesions are found in vulval intraepithelial lesions. Cervical smear to be done if due. Colposcopic examination of cervix & vagina is required to rule out CIN or VAIN(vaginal intraepithelial lesions) or carcinoma in situ. Multiple punch biopsy or excision biopsy with histology is done to confirm the diagnosis. B)Treatment options for VIN are expectant line of management as some lesions may regress spontaneously along with biopsy of suspected lesions and regular follow up. Co2 laser vapourisation of the lesions may destroy the lesions sometimes with dense scarring requiring skin grafting. Medical treatment with floridated steroids gives some relief of symptoms like itching. 5-Flurouracil application is ineffective. Surgical treatment with excisional biopsy of the lesions may be done when lesions are small and single. But in multifocal lesions skinning vulvectomy may be required followed by skingrafting. Patient is helped with support groups. These patients need long term follow up is required as natural course of malignancy potential is not certain as in CIN. VDKM
		Posted by Seham S. Thu Feb 4, 2010 05:07 am
SE-SA (a)Detailed history about onet of symptoms and its severity during these last 6 months.Presence of other complain like redness,swelling or crusting. I would ask her if she felt swelling or induration at site of itching. Iwould ask about vaginal discharge,its characteristics (colour,odour,consistency) .Urinery symptoms like frequency,dysuria and wetness sensation for incontenence and related contact dermatitis.History of allergy and atopy. I would ask her about her last menestrual period and if she is on HRT .Sexual activity and use of barrier method and if she complain of superficial dysparounia.I would ask her about general health and medical diseases like diabetes millitus and immunocompromised state and use of immunosuppressive drugs.I would ask her if she had lichen sclerosis before and if she recieved treatment and for how long. I will review her last cevical smear result as some cases of VIN is associated with CIN .I would ask about smoking,personal habites like douching,use of perfumes or deodorants for allergic causes. I would ask her how much symptoms are distressing and if it affect her quality of life . Examination include inspecion of vulva for redness ,oedema. swelling,whitich areas , crusting or fusion of labia minora. Inspection of peri-anal area for other lesions. Speculum examination for discharge and cervical abnormalities. Palpation of inguinal region for lymph nodes if malignancy is suspected. Investigation include HVS which can be taken during speculum examination if infection is expected. If there is suspected lesion , addition of 5% acetic acid may show white area . colposcopy could be done which may show punctation or mosaicism in case of VIN . Biopsy from suspicious lesion should be done to confirm or exclude malignancy. (b) Treatment options include expectant managment as some cases of VIN may regress spontaneously and follow up by biopsy is recommended.Small localised lesion could be treated by local excision and multifocal lesion is treated by skining vulvectomy with skin grafting. Laser vaporisation is another option and may be effective although depth of destruction for adequate treatment is unknown and difficult to control in vulva.Extensive laser treatment may requir skin graft. Medical treatment as topical flouridated steroids may be used for symptom relief once invasive disease is excluded by biopsy.Topical alpha-interferon may be effective but remain under evaluation. 5-flurouracile is not effective. natural history is not known but malignant potential is less than CIN. Malignant changes is more common in older patient so follow up by repeated biopsied should be recommended.Recurrence after surgical treatment or laser is high (15-40%) so close follow up by repeated biopsies is recommended
		Posted by Jan I. Thu Feb 4, 2010 06:38 am
JAN A) As several vulval conditions are associated with autoimmune diseases I would start with a general clinical assessment which would include looking for any signs suggestive of hyperthyroidism (including tremor, exopthalmus or a goitre) that may indicate Grave’s Disease, signs of hypothyroidism (including lethargy and brittle nails/hair) suggestive of Hashimoto’s Disease or skin changes associated with vitiligo. I would inspect flexor surfaces and mucus membranes for any lesions suggestive of lichen planus or for cutaneous evidence of eczema that may also be responsible for the vulval itching. I would assess for any abdominal masses or pelvic lymphadenopathy that may indicate malignant vulval disease with local or secondary spread. I would examine the vulva to establish the distribution of the itching and whether it was associated with any visible lesions. General atrophy to the vulva and vagina may indicate atrophic vaginitis. Lichen Sclerosis (LS) would be associated with white thinning skin changes and may have caused adhesion of the labia minora, a narrowed introitus and also involve the perianal area in a ‘figure of 8’ appearance. The presence of blue papular lesions may represent Lichen Planus and these may also be present inside the vagina. I would look for any scaly areas that may represent eczema or psoriasis. I would confirm that the itching was not focally associated with a mole that may represent a malignant melanoma. I would perform a swab of any abnormal discharge as this may represent superinfection of lesion that may require antibiotic treatment I would look for multifocal areas of thickening, redness or altered pigmentation that may represent vulval intraepithelial neoplasia (VIN) or Paget’s disease of the vulva. I would inspect the cervix to confirm no overt suspicious cervical lesions and perform a smear test if VIN is suspected as this is associated with cervical intrapithelial neoplasia (CIN). Application of acetic acid will cause characteristic aceto-white colour changes in VIN that may help to confirm the diagnosis. Any ulceration or suspicious lesion of the vulva would be an indication for biopsy to rule out squamous cell carcinoma or confirm the diagnosis and this can be performed with local anaesthetic and aseptic technique. Thyroid function tests should be performed to confirm suspected thyroid disease or to screen for this if LS is suspected. If vulval malignancy is suspected than an MRI scan should be arranged to asses local and nodal spread. B) Treatment should be guided by the degree of VIN and by patient choice once fully counselled. With low grade VIN (VIN I) conservative management is as option as spontaneous regression can occur. Repeat biopsy is necessary every 6 months to rule out disease progression or transformation into squamous cell carcinoma of the vulva and this should ideally be at a dedicated vulvoscopy clinic run by a practitioner with a special interest in vulval pathology. The patient should re-present sooner for assessment and biopsy if any suspicious features develop including ulceration or raised lesions. Symptomatic relief can be provided with the use of fluorinated steroid ointment and anti-histamines. The value of alpha-interferon treatment is still under evaluation. Hormone replacement therapy has not been shown to be of benefit with regards disease regression of symptom relief. Laser destruction of the affected areas is also an option but this should be carefully discussed, especially with large areas, as this can cause significant scarring and disfigurement which may affect the patient’s body image and sexual function. The depth of treatment of this modality is variable & unpredictable. Regular follow up will be necessary at 6 monthly intervals (initially) as there is a risk of recurrence and/or malignant transformation that may require subsequent treatment. Surgical management by wide local excision or vulvectomy is an option. Wide local excision is effective, especially with focal single lesions as they can be effectively removed and excision margins confirmed. This would be recommended treatment for VIN II – III. Repeat vulvoscopy will be necessary at 6 months to confirm no recurrence though this can be reduced to annually if no evidence of VIN is found with clear excision margins. The risk of recurrence after excision is approximately 25%. Vulvectomy is a large operation carrying significant physical and psychlogical morbidity and would only be considered for VIN III displaying significant sinister cellular changes or carcinoma-in-situ. As with wide local incision repeat vulvoscopy would be necessary at 6 months given the risk of recurrence.
		Posted by Ulduz A. Thu Feb 4, 2010 08:25 am
UA a)I will ask her about onset,aggravating and relieving .I will ask her how much it is affecting her quality of life.If she had any treatment and how much it was effective.Any associated bleeding,abnormal vaginal discharge enquired.Presence of any warts,skin changes asked.Gynecological history,presence of any genital tract malignancies,treatment asked.Smear history will be asked.Social history as smoking required.Medical conditions as diabetes,skin disease as psoriasis,eczema,contact dermatitis inquired.Patient will be asked about use of perfumes,soups,deodorants in vulval area.Use of syntetic underwear can cause itching and burning sensation.Presence of urinary incontinence asked in a sensitive manner. General examination performed to reveal skin scratches,rash,inguinal lympadenopaty.Abdominal masses should be ruled out.Presence of warts(CIN),ulcerations(herpes) noted.Any skin changes,white,wrinkly,atrophic appearance of lichen sclerosis noted. Swabs taken from all areas where abnormal discharge noted.FBC,CRP/ESR to rule out inflamatory conditions. Urinanalysis done if urinary symptoms are present.Any soreness,pruritis ruled out.If STIs suspected appropriate tests to be done.Colposcopy and excisional biopsy needed from all abnormal looking areas.Careful cervical examination and biopsy needed to rule out cervical neoplasia.If lymphadenopathy present,imaging studies as CT/MRI performed for pelvic assessment. b)Natural history of the disease is unknown.Treatment options depend on patiens choices,grade of VIN,presence of any medical conditions.VIN 1 can be treated conservatively because of chance of self-resolution.But patient should be informed about high risk of recurrence and she should be warned to notify if any changes appear.VIN 2-3 can be treated by local exision or laser vaporization.Recurrences are common(39% after local excision and 70% after laser ablation).As a medical treatment topical immunomodulator Imiquimod may be used in women with VIN but still is experimental.5-flururacil and interferon has no benefit. UA a)I will ask her about onset,exagerating and relieving factors of itching and burning.I will ask her how much it is affecting her quality of life.If she had any treatment and how much it was effective.Any associated bleeding,abnormal vaginal discharge enquired.Presence of any warts,skin changes asked.Gynecological history,presence of any genital tract malignancies,treatment asked.Smear history will be asked.Social history as smoking required.Medical conditionsas diabetes,skin disease as psoriasis,eczema,contact dermatitis inquired.Patient will be asked about use of perfumes,soups,deodorants in vulval area.Use of cintetic underwear can cause itching and burning sensation.Presence of urinary incontinence asked in a sensitive manner. General examination performed to reveal skin scratches,rash,inguinal lympadenopaty.Abdominal masses should be ruled out.Presence of warts(CIN),ulcerations(herpes) noted Swabs taken from all areas where abnormal discharge noted.FBC,CRP/ESR to rule out inflamatory conditions.If STIs suspected appropriate tests to be done.Colposcopy and excisionalbiopsy needed from all abnormal looking areas.Careful cervical examination and biopsy needed to rule out cervical neoplasia.If lymphadenopathy present,imaging studies as CT/MRI performed for pelvic assessment. b)Natural history of the disease is unknown.Treatment options depend on patiens choices,grade of VIN,presence of any medical conditions.VIN 1 can be treated conservatively because of high chance of self-resolution.but patient should be informed about high risk of recurrence and she should be warned to notify if any changes appear.VIN 2-3 cana be treated by local exision or laser vaporization.recurrences are common(39% after local excision and 70% after laser ablation).As a medical treatment topical immunomodulator called imiquimod may be used in women with VIN but still is experimental.5-flururacil and interferon has no benefit. UA a)I will ask her about onset,exagerating and relieving factors of itching and burning.I will ask her how much it is affecting her quality of life.If she had any treatment and how much it was effective.Any associated bleeding,abnormal vaginal discharge enquired.Presence of any warts,skin changes asked.Gynecological history,presence of any genital tract malignancies,treatment asked.Smear history will be asked.Social history as smoking required.Medical conditionsas diabetes,skin disease as psoriasis,eczema,contact dermatitis inquired.Patient will be asked about use of perfumes,soups,deodorants in vulval area.Use of cintetic underwear can cause itching and burning sensation.Presence of urinary incontinence asked in a sensitive manner. General examination performed to reveal skin scratches,rash,inguinal lympadenopaty.Abdominal masses should be ruled out.Presence of warts(CIN),ulcerations(herpes) noted Swabs taken from all areas where abnormal discharge noted.FBC,CRP/ESR to rule out inflamatory conditions.If STIs suspected appropriate tests to be done.Colposcopy and excisionalbiopsy needed from all abnormal looking areas.Careful cervical examination and biopsy needed to rule out cervical neoplasia.If lymphadenopathy present,imaging studies as CT/MRI performed for pelvic assessment. b)Natural history of the disease is unknown.Treatment options depend on patiens choices,grade of VIN,presence of any medical conditions.VIN 1 can be treated conservatively because of high chance of self-resolution.but patient should be informed about high risk of recurrence and she should be warned to notify if any changes appear.VIN 2-3 cana be treated by local exision or laser vaporization.recurrences are common(39% after local excision and 70% after laser ablation).As a medical treatment topical immunomodulator called imiquimod may be used in women with VIN but still is experimental.5-flururacil and interferon has no benefit. UA a)I will ask her about onset,exagerating and relieving factors of itching and burning.I will ask her how much it is affecting her quality of life.If she had any treatment and how much it was effective.Any associated bleeding,abnormal vaginal discharge enquired.Presence of any warts,skin changes asked.Gynecological history,presence of any genital tract malignancies,treatment asked.Smear history will be asked.Social history as smoking required.Medical conditionsas diabetes,skin disease as psoriasis,eczema,contact dermatitis inquired.Patient will be asked about use of perfumes,soups,deodorants in vulval area.Use of cintetic underwear can cause itching and burning sensation.Presence of urinary incontinence asked in a sensitive manner. General examination performed to reveal skin scratches,rash,inguinal lympadenopaty.Abdominal masses should be ruled out.Presence of warts(CIN),ulcerations(herpes) noted Swabs taken from all areas where abnormal discharge noted.FBC,CRP/ESR to rule out inflamatory conditions.If STIs suspected appropriate tests to be done.Colposcopy and excisionalbiopsy needed from all abnormal looking areas.Careful cervical examination and biopsy needed to rule out cervical neoplasia.If lymphadenopathy present,imaging studies as CT/MRI performed for pelvic assessment. b)Natural history of the disease is unknown.Treatment options depend on patiens choices,grade of VIN,presence of any medical conditions.VIN 1 can be treated conservatively because of high chance of self-resolution.but patient should be informed about high risk of recurrence and she should be warned to notify if any changes appear.VIN 2-3 cana be treated by local exision or laser vaporization.recurrences are common(39% after local excision and 70% after laser ablation).As a medical treatment topical immunomodulator called imiquimod may be used in women with VIN but still is experimental.5-flururacil and interferon has no benefit. UA a)I will ask her about onset,exagerating and relieving factors of itching and burning.I will ask her how much it is affecting her quality of life.If she had any treatment and how much it was effective.Any associated bleeding,abnormal vaginal discharge enquired.Presence of any warts,skin changes asked.Gynecological history,presence of any genital tract malignancies,treatment asked.Smear history will be asked.Social history as smoking required.Medical conditionsas diabetes,skin disease as psoriasis,eczema,contact dermatitis inquired.Patient will be asked about use of perfumes,soups,deodorants in vulval area.Use of cintetic underwear can cause itching and burning sensation.Presence of urinary incontinence asked in a sensitive manner. General examination performed to reveal skin scratches,rash,inguinal lympadenopaty.Abdominal masses should be ruled out.Presence of warts(CIN),ulcerations(herpes) noted Swabs taken from all areas where abnormal discharge noted.FBC,CRP/ESR to rule out inflamatory conditions.If STIs suspected appropriate tests to be done.Colposcopy and excisionalbiopsy needed from all abnormal looking areas.Careful cervical examination and biopsy needed to rule out cervical neoplasia.If lymphadenopathy present,imaging studies as CT/MRI performed for pelvic assessment. b)Natural history of the disease is unknown.Treatment options depend on patiens choices,grade of VIN,presence of any medical conditions.VIN 1 can be treated conservatively because of high chance of self-resolution.but patient should be informed about high risk of recurrence and she should be warned to notify if any changes appear.VIN 2-3 cana be treated by local exision or laser vaporization.recurrences are common(39% after local excision and 70% after laser ablation).As a medical treatment topical immunomodulator called imiquimod may be used in women with VIN but still is experimental.5-flururacil and interferon has no benefit. UA a)I will ask her about onset,exagerating and relieving factors of itching and burning.I will ask her how much it is affecting her quality of life.If she had any treatment and how much it was effective.Any associated bleeding,abnormal vaginal discharge enquired.Presence of any warts,skin changes asked.Gynecological history,presence of any genital tract malignancies,treatment asked.Smear history will be asked.Social history as smoking required.Medical conditionsas diabetes,skin disease as psoriasis,eczema,contact dermatitis inquired.Patient will be asked about use of perfumes,soups,deodorants in vulval area.Use of cintetic underwear can cause itching and burning sensation.Presence of urinary incontinence asked in a sensitive manner. General examination performed to reveal skin scratches,rash,inguinal lympadenopaty.Abdominal masses should be ruled out.Presence of warts(CIN),ulcerations(herpes) noted Swabs taken from all areas where abnormal discharge noted.FBC,CRP/ESR to rule out inflamatory conditions.If STIs suspected appropriate tests to be done.Colposcopy and excisionalbiopsy needed from all abnormal looking areas.Careful cervical examination and biopsy needed to rule out cervical neoplasia.If lymphadenopathy present,imaging studies as CT/MRI performed for pelvic assessment. b)Natural history of the disease is unknown.Treatment options depend on patiens choices,grade of VIN,presence of any medical conditions.VIN 1 can be treated conservatively because of high chance of self-resolution.but patient should be informed about high risk of recurrence and she should be warned to notify if any changes appear.VIN 2-3 cana be treated by local exision or laser vaporization.recurrences are common(39% after local excision and 70% after laser ablation).As a medical treatment topical immunomodulator called imiquimod may be used in women with VIN but still is experimental.5-flururacil and interferon has no benefit. UA a)I will ask her about onset,exagerating and relieving factors of itching and burning.I will ask her how much it is affecting her quality of life.If she had any treatment and how much it was effective.Any associated bleeding,abnormal vaginal discharge enquired.Presence of any warts,skin changes asked.Gynecological history,presence of any genital tract malignancies,treatment asked.Smear history will be asked.Social history as smoking required.Medical conditionsas diabetes,skin disease as psoriasis,eczema,contact dermatitis inquired.Patient will be asked about use of perfumes,soups,deodorants in vulval area.Use of cintetic underwear can cause itching and burning sensation.Presence of urinary incontinence asked in a sensitive manner. General examination performed to reveal skin scratches,rash,inguinal lympadenopaty.Abdominal masses should be ruled out.Presence of warts(CIN),ulcerations(herpes) noted Swabs taken from all areas where abnormal discharge noted.FBC,CRP/ESR to rule out inflamatory conditions.If STIs suspected appropriate tests to be done.Colposcopy and excisionalbiopsy needed from all abnormal looking areas.Careful cervical examination and biopsy needed to rule out cervical neoplasia.If lymphadenopathy present,imaging studies as CT/MRI performed for pelvic assessment. b)Natural history of the disease is unknown.Treatment options depend on patiens choices,grade of VIN,presence of any medical conditions.VIN 1 can be treated conservatively because of high chance of self-resolution.but patient should be informed about high risk of recurrence and she should be warned to notify if any changes appear.VIN 2-3 cana be treated by local exision or laser vaporization.recurrences are common(39% after local excision and 70% after laser ablation).As a medical treatment topical immunomodulator called imiquimod may be used in women with VIN but still is experimental.5-flururacil and interferon has no benefit.
		Posted by Ulduz A. Thu Feb 4, 2010 08:41 am
Sorry,for previous answer.Kindly mark.Thanks. UA a)I will ask her about onset,aggravating and relieving factors.I will ask her how much it is affecting her quality of life.If she had any treatment and how much it was effective.Any associated bleeding,abnormal vaginal discharge enquired.Presence of any warts,skin changes asked.Gynecological history,presence of any genital tract malignancies,treatment asked.Smear history will be asked.Social history as smoking required.Medical conditionsas diabetes,skin disease as psoriasis,eczema,contact dermatitis inquired.Patient will be asked about use of perfumes,soups,deodorants in vulval area.Use of cintetic underwear can cause itching and burning sensation.Presence of urinary incontinence asked in a sensitive manner. General examination performed to reveal skin scratches,rash,inguinal lympadenopaty.Abdominal masses should be ruled out.Presence of warts(CIN),ulcerations(herpes) noted.Atrophic ,wrinkly,white areas of lichen sclerosis noted.Soreness of skin,pruritis are noted. Swabs taken from all areas where abnormal discharge noted.FBC,CRP/ESR to rule out inflamatory conditions.Urinanalysis done if appropriate.If STIs suspected appropriate tests to be done.Colposcopy and excisional biopsy needed from all abnormal looking areas.Careful cervical examination and biopsy needed to rule out cervical neoplasia.If lymphadenopathy present,imaging studies as CT/MRI performed for pelvic assessment. b)Natural history of the disease is unknown.Treatment options depend on patiens choices,grade of VIN,presence of any medical conditions.VIN 1 can be treated conservatively because of chance of self-resolution.but patient should be informed about high risk of recurrence and she should be warned to notify if any changes appear.VIN 2-3 cana be treated by local exision or laser vaporization.recurrences are common(39% after local excision and 70% after laser ablation).As a medical treatment topical immunomodulator imiquimod may be used in women with VIN but still is experimental.5-flururacil and interferon has no benefit.
		Posted by Dr Dyslexia V. Thu Feb 4, 2010 02:14 pm
X a) History of the onset progressiveness and associated symptoms are important such as itching which decreases quality of sleep and what are her current coping methods. Has she attained menopause and what is her estrogen status is important which includes if she is on hormone replacement therapy. Associated symptoms such as urinary leakage frequency or dysuria, post coital bleeding, dysparunia since menopause could point to atrophic vulvoganitis. The usage of panty liners, detergents, lubricants or douching should be ascertained as it could point towards contact dermatitis. History of atopy such as allergic dermatitis, hay fever, asthma and rhinitis could point towards dermatitis. History of auto immune disease and involvement of lesion elsewhere in the body could point towards lichen sclerosis or lichen planus. History of recently acquired sexually transmitted disease or chrohn’s disease or psoriasis could indicate a vulval counterpart of the following conditions lesion. History of recent cervical smear should also be taken to the association of VIN(Vulval Intraepithelial Neoplasia) to CIN. Examination of the vulva should be done with good lighting and to ascertain its appearance, its extension, depth and presence of lymph nodes should be done. Appearance of porcelain white plagues involving perineum and perianal skin and texture of parchment like characteristics with figure of 8 distribution could indicate lichen sclerosis. Appearance of red raw area with non specific erosion involving vestibule and vagina is suggestive of vulval lichen planos. Investigations should include a cervical smear if not done recently. A high vaginal swab or endocervix swab to ascertain etiology of such as candidiasis or chlymadia in behcet’s disease. The most useful tool would be a directed biopsy of the lesion to ascertain the diagnosis. b) The treatment of VIN would include expectant, medical, and surgical management. Spontaneous regression could occur in VIN changes and typically reserved for young women who are followed up with repeated biopsies in presence of suspicious changes in the lesion. Usage of topical fluoridated steroids could be used if invasive disease are excluded. Other topical modalities include 5 flurouracil or topical alpha interferon been used but randomized clinical trial results are still pending. Laser CO2 could be used on the lesion but it causes scarring of the skin which sometimes require grafting. The multi focal nature of VIN makes it difficult to treat and it requires high vigilance as it could evolve to vulval carcinoma.
		Posted by Preethi A. Thu Feb 4, 2010 09:36 pm
The Differential diagnosis include Lichen sclerosis, Vulval Intraepithelial Neoplasia(VIN), Vulval carcinoma, Pagets disease, Basel cell carcinoma, Melanoma of the Vulva. A detailed history about previous episodes, diagnosis and treatments along with the success of these can indicate lichen sclerosis .Smoking and previous HPV infections are risk factors for VIN and need to be inquired. History of mass or bleeding from vulva need to asked to rule out vulval carcimonas. Dysparunia , problems of bladder or bowel functions can help to assess the progression of the disease. Examination of the Vulva and cervix need to be done. Presence of pale skin with epidermal atropy and loss of rete ridges indicate lichen sclerosis esp with typical figure of ‘8’ lesions. Presence of a mass and margin of involvement need to be looked for. Palpation of the inguinal canal for any nodal involvement helps in staging. Investigations include Colposcopy at low magnification and full thickness biopsies. The biopsy is best done including normal areas along with the lesions . Cervix need to be visualised as cervical lesions can co exist . CT or MRI of the pelvis may be indicated to identify pelvic lymph nodes if there is any doubt about nodal involvement. (b) Surgery remains the first line treatment for VIN,however it is associated with high recurrence rates and potential for malignancy even with extensive surgery. Surgery can cause urethral ,sexual and anal dysfunction especially in midline lesions. Counselling and support groups help to address these issues. 5 % imiquimod is a immune modulator which stops viral replication and promotes cell mediated immunity and is helpful in treating HPV related VIN. The side effects include irritation ,burning and redness . Lazer vapourisation helps in preserving urethral,anal and sexual functions however has a high relapse rate around 70%. 5-flurourasil and photodynamic therapy have also been useful in treatment of VIN. Counselling including psyco sexual counselling can help to overcome the distortion of self image found in some of these patients. Due to the high rate of recurrence and the potential for malignancy, she needs to be followed up regularly. This can be every 6 months with careful examination of the vulva and biopsies if any suspicious lesions are identified. Inguinal lymph nodes need to be looked for at the time of examination and recorded.
		Posted by Green K. Fri Feb 5, 2010 10:23 am
Green: a) Severity of symptoms and the effect on the quality of life. Presence of superficial dyspareunia, sleep disturbance due to itchiness or pain would reflect the severity of her symptoms. Occurrence of exacerbation of symptoms at night is suggestive of lichen scerosus. Symptoms occurring when in contact with a certain perfume or skin cleanser is suggestive of contact irritant dermatitis. Age of menopause as atrophic dermatitis is common after menopause with worsening severity with time. Presence of ulceration or bleeding over the vulva may suggest vulval carcinoma or skin excoriation due to intense scratching. Presence of malaise, loss of appetite or loss o weight may suggest malignancy. Presence of urinary incontinence may suggest irritant dermatitis due to prolonged contact with urine. Past history of skin disorders such as allergic dermatitis. Past history of autoimmune disorders such as lichen planus which may affect the vulva. Current treatment and the response to treatment. Previous Pap smears and results. Examination of the skin to look for presence of well circumscribed flat top violaceous lesions and Wickham striae over the buccal mucosa would suggest presence of lichen planus. Presence of red raw vulva with non specific erosions with involvement of the vagina is suggestive of lichen planus of the vulva. Vulval examination would be done to look for features of atrophy such as pallor and loss of rugation to suggest atrophic vulvitis. Presence of porcelain-white plaques on the vulva, perineum and perianal skin with \"cigarette paper\" texture would be suggestive of lichen sclerosus. Absence of any lesion on the vulva with demonstrable tenderness to the top of a cotton swab would suggest vulvodynia although itchiness is not typical. Presence of inguinal lymph nodes may suggest either secondary infection of the vulval or malignancy. Demonstration of leaking of urine on coughing may suggest presence of urinary incontinence. Investigation would involve multiple punch biopsy and histoplathological assessment of the lesion under local anesthesia. b) Surgical excision of the entire lesion under general anesthesia. This would remove the lesion and reduces the chance of recurrence. The radicality of the procedure depends on the extend of the lesion. Multiple lesions or areas where lesion is difficult to remove are treated with laser ablation. Other possible mode of treatment include topical chemotherapy such as 5 Florouracil. Long term follow up is needed with the gynae oncologist to assess changes which may require repeated biopsies if any abnormalities are detected. Total duration of follow up is unclear as there is always a small chance of recurrence and progression to vulval carcinoma. Follow up by a GP may be an acceptable option of the gynae oncologist is satisfied with the outcome of the primary treatment. In such cases, patient would be adviced to report any new symptoms and patient referred urgenty so that early assessment can be made.
		Posted by Ida I. Fri Feb 5, 2010 10:03 pm
a) She should be asked regarding the severity of her symptoms and if it has impaired her day to day activities. Her menstrual history needs to be obtained to ascertain her menopausal status, as atrophic vaginitis can present the same way. She also needs to be asked if she has any vaginal discharge that could suggest vaginal candidiasis. A history of of dysuria or frequency would suggest urinary tract infection. She also needs to be asked if she has a history of using any vaginal wash or soaps that could induce dermatitis in the area. A drug history, as well as a detailed past medical history has to be obtained to see if she has been taking any form of drugs that could induce such a lesion or if she is immunocompromised. A family history of the same complaints is also relevant, as benign vulval lesions such as lichen planus and lichen sclerosis has a genetic predisposition. A detailed sexual history is also relevant to ascertain a sexually transmitted and infective cause. A thorough examination of her vulva and perineum needs to be done to look for any obvious vulval lesions. Presence of rubbery edema with \'cigarette-paper scarring\' would be suggestive of lichen sclerosis, and the presence of a bluish coloured rash is suggestive or lichen planus. A multifocal lesion with variable colour is suggestive of vulval intraepithelial neoplasia (VIN). The rest of her body, especially her arms and legs, needs to be inspected for the presence of the same lesion. Her abdomen needs to be palpated, especially for inguinal nodes.She would need a speculum examination to look for any lesions in the vagina or the cervix. Investigations should include a high vaginal swab to exclude any infections in the vagina, such as vaginal candidiasis. She needs a pap smear to exclude CIN or cervical cancer, as VIN can be present concurrently with the latter and the former. Urine microscopy is necessary to exclude any urinary tract infections. She would need a biopsy of the lesion for a histopathological diagnosis, so that the appropriate treatment can be administered. b) As VIN is a pre-malignant condition, treatment for her, especially in her age group, should be definitive. Some lesions can spontaneously regress, thus she can be offered expectant management if she wants to. This would involve close follow up with repeated skin biopsies. However, this is more feasible in younger women, as prognosis is much better. She can be given topical medications, such as flouridated steroids, for symptom relief. 5- flourouracil is of no benefit, as it is not shown to be effective, and it can irritate the skin. Topical alpha interferon can be offered, however, its benefit still remains under evaluation. Laser vaporisation with CO2 laser may be effective. However, it has been shown to cause more pain and prolonged healing. Moreover, it can be difficult to control the depth of tissue damage, resulting in more tissue being destroyed than necessary. Wide local excision can be both diagnostic and therapeutic. Excision of the lesion should include about 2 to 3 mm of normal tissue for the lesion to be effectively treated and to ensure a clear surgical margin. If the lesion is extensive, she may require a vulvectomy with skin grafting. She would require long term follow up as recurrent rates of VIN are considerably high, even after laser treatment and wide excision. This is especially so if she is immonocompromised. She would need close follow up with repeated skin biopsies to look for recurrence of the disease or malignant change.
		Posted by R S. Sat Feb 6, 2010 03:59 am
R S: a. Vulval pruritus can result from various conditions. Presence of vaginal discharge with or without offensive odour indicates infection (vulvovaginitis).Contact dermatitis from polyster clothes, soaps or perfumes should be ruled out. Presence of burning micturition, lower abdominal pain and frequency indicate urinary tract infection. Medical history of DM or chronic disease increase liability for infection. Histories of autoimmune diseases are explored as it’s linked with lichen sclerosis. History of previous cervical smears and their results are explored to see if the woman is up to date with her screening as premalignant or malignant conditions might present. Smoking, positive family history and menopause are all risk factors for developing neoplasia. Menstrual history including duration of menopause, menopausal symptoms and whether she is on HRT or not. Pruritus can accompany genital atrophy. Additional symptoms are also explored like vaginal spotting or postcoital bleeding as they may indicate infection or malignancy. Drug history, previous treatment and response to treatment are also looked for. Local inspection of vulva and perineum may reveal atrophy, lesions, ulcers, papule or abnormal areas. Narrowing of interoitus may reflect lichen sclerosis while well demarcated elevated area goes with lichen planus. Regional lymphadenopathy should be rules out. Vagina and cervix are also examined to rule out associated pathology or infection. Urinalysis, high vaginal and endocervical swabs are taken to to exclude urinary tract or lower genital tract infection. Colposcopy may reveal area of mosiasim or punctuation which reflect neoplasia. Exisional biopsy of apparently abnormal area with histopathological examination can give accurate diagnoses. Cervical smear is mandatory if the woman is not up-to-date with the screening programme. b. Not all women with VIN will develop vulval cancer; therefore, women with VIN I can be managed expectantly or conservatively. Women with VIN II & III will need local excision. In addition, all abnormally looking skin areas should be excised like lichen planus and lichen sclerosis. Skining vulvectomy with or without skin flap is another option. Alternatively, laser ablation can be applied. The disease can be multifocal so colposcopy directed treatment is recommended. Patient is fully counseled about treatment options and prognosis which is general good if no other neoplastic disease is present. Follow up should be done in joint vulval clinic. Cervical, vaginal and vulval colposcopy is repeated after 6 months then annually to detect recurrence. The patient is educated about importance of compliance with follow up.
		Posted by Lilantha W. Sat Feb 6, 2010 11:00 am
(a) I ask how these symptoms affect her quality of life. Any aggravating factors will be asked as the onset of symptoms may relate to use of new skin cleansers, perfumes or panty liners is suggestive of allergic contact dermatitis. If the onset is related to unprotected sexual intercourse with a new partner, risk of sexually transmitted infection such as herpes should be suspected. Presence or absence of ulcers, papules, warts, vaginal discharge or urinary incontinence will be asked as these may reveal possible aetiology. Vulval itchiness associated with creamy white discharge suggests candidosis. The last menstrual period would enable duration for which she has been menopaused and this will aid suspicion of atrophic vulvitis, particularly in the presence of vaginal dryness and ssuperficial dysparunia. Past history of chicken pox may be related to unilateral itchiness, burning sensation and pain in herpes zoster. History of eczema, psoriasis and atopic dermatitis in the rest of the body may be the underlying cause of these symptoms. Personal history of colonic adenocarcinoma increases the risk of developing pagets disease whereas; cervical carcinoma increases the risk of vulaval neoplasis. Therefore, smear history will be asked. Smoking, immunosuppressant therapy and immune deficiency increase the risk of developing vulval neoplasia. Treatment history and its response will be noted. General examination may reveal presence of any skin disease or inguinal lymphadenopathy. Inspection of vulva would reveal pale, thin vulval skin with loss of normal rouge in atrophic vulvitis. Co-existing vaginal atrophy would support this diagnosis. Presence of white plaques in figure of eight pattern with fissuring and erosions is classical of lichen sclerosis. Fusion of labia minora with narrow introitus may also be found. Red, warm, oedematous vulva may be found with candidosis and allergic dermatitis. Ulceration can be a feature of herpes or vaginal carcinoma. Flat topped violaceous papules with Wickham striate characteristic of lichen planus. Multi focal areas of skin thickening and altered pigmentation are suggestive of vulval intraepithelial neoplasia (VIN). Well demarcated, hyperpigmented vulval or vaginal lesions are susceptive of melanoma. Eczematous weeping lesions with velvety appearance are found in pagets disease. Speculum examination may reveal vaginal atrophy and cervical lesion. Vulval colposcopy is required to make a reliable clinical diagnosis. Application of acetic acid on the suspected area would stain it white in VIN and it may also reveal punctation and mosaicism. Mapping punch biopsies or excision biopsies are necessary to confirm the diagnosis. Lymph node biopsy is important in the presence of inguinal lymphadenopaty, if vulval cancer/melanoma is suspected. Cervical smear or colposcopy and biopsy can be obtained if index of suspicion for cervical cancer is high. (b) Treatment options available are conservative, medical and surgical. Treatment decisions are best taken at multi disciplinary setting. Patient is counselled about prognosis and any uncertainties of diagnosis and treatment. Written information should be given to the patient. Treatment for VIN1 is usually observation or conservative as it is non-specific inflammatory change and is not pre-malignant. However, untreated VIN2 and VIN3 can progress into vulval cancer in about 80%, therefore, every 4-6 months follow-up in a specialised vulval (oncology) clinic would be ideal. Therefore, appropriate referral should be made. Vulval colposcopy is required at each visit. If suspicious lesions are found, repeat biopsy is indicated. Medical therapy is not very effective. Treatment with 5 flurouracil can be beneficial. Immomodulation therapy with Imiquimod is under investigation which appears effective. Laser ablation is rarely recommended due to high recurrence rate and poor functional outcome. Immunisation against specific HPV serotypes may prevent disease development. The aim of surgical treatment is to minimise symptoms and side effects of VIN and to exclude development of vulval carcinoma. Hence, small, painful lesions are best excised surgically. It is difficult completely excise large lesions. Even if excised, recurrence is common with consequent poor functional outcome. For resistant recurrent disease or widespread disease, skinning vulvectomy can be done, however, skin closure is done with plastics procedure to minimise disfigurement. Psycho-sexual problems are common following the treatment and will require proper counselling and additional help from patient support groups.
		Posted by S S. Sat Feb 6, 2010 01:56 pm
A. I will ask about the severity of the symptoms and it\'s effect on the quality of life. It is also important to know if it is a recurrent problem, hence could be HPV or new onset. It is also important to know whether she is menopausal as atrophic changes may cause pruritus. Other associated symptoms should be enquired about like Ulcers (malignancy, STI, lichen sclerosis), discharge ( malignancy, STI) and rashes (drug erruptions). Dyspareunia is present in postmenopausal and in lichen sclerosis. Dysuria is associated with infection and lichen sclerosis. Also enquire about urinary incontinence as urine will irritate the vulval skin. I will ask about lesions elsewhere in the body which may be fixed drug erruptions, lichen sclerosis. A history of smoking ( risk of VIN), Diabetes and immunosuppresant use (Risk of infection) should be taken. A history of smear test is noted. A general physical examination is done to note lesions in other parts of the body. Vulva is examined for rashes, ulcers, signs of inflammation, discharge and discolouration. examination may be normal. A speculum and vaginal examination is done to identify abnormality in cervix(inflammation, ulceration, irregularity), uterus and adenexa. Prolapse and urinary incontinence noted, if any. B. Investigations depend on the history and exam findings. A biopsy should be taken if there is suspicion of malignancy or lichen sclerosis. If this is the case, colposcopy is indicated as CIN and VaIN are associated with VIN or vulval cancer. A cervical smear should be taken if she is due for one. Swab from ulcer or discharge should be taken for bacteriology and virology. Blood sugar should be done. If urinary symptoms are present then urine sent for microscopy and culture. Other blood investigations like full blood count, urea and electrolytes and liver functions also checked as indicated as pruritus is also associated with renal and liver diseases.. C.Treatment depends on the grade of VIN and patient\'s wishes. VIN I is usually thought to be due to chronic inflammmation. It usually resolves over time hence an expectant policy can be adopted. She is adviced to return urgently if symptoms worsen rapidly or new symptoms develop like ulcer or a growth. VIN II and III could be precancerous. Treatment options are medical or surgical. 5FU can be used topically however it is usually not well tollerated and ther is high recurrence rate. Immiquimod an immune modulator can be applied locally but leads to soreness. Surgical options are either excision or laser ablation for solitary small tumour or skinning vulvectomy followed by vascular graft for large or multiple lesion. She will need annual follow up because of increased risk of vulval cancer. Counselling should also be offered to her as this may affect her psychosexually. If she is a smoker she should be adviced to stop it as it is a risk factor for vulval cancer.
		Posted by tahira jabeen J. Sat Feb 6, 2010 10:37 pm
tj a) i will take detailed history,regarding her symptoms,severity of symptoms.impact of this on her life.as this can lead to sigificant psychological morbidity. patient will be enquired about other associated symptoms like,vaginal discharge,p/v bleeding as if it associated with other cervical pathology like CIN.if she has any skin discolorarion ,rashes,or lacy lesions or white discolouration as can happen with lichen sclerosis or lichen plannus. her past medical history for her fitness for surgery if needed or any auto immune disorder like chrons disease ,pagets disease,as it can be associated with VIN.her drug history as immunosupressio n can predispose to vulval dytophies.her sexual history as multiple sexual partners can expose her to HPV which can expose her to VIN development.& to know if she is sexually active as it can effect her management.history of last pap smear .her social history like smoking as it is risk factor for VIN . i will examie patient thoroughly to see her general health.then local examination of vulva noting colour,texture of skin as white patches can be due to lichen sclerosis.arrowing of etroitus also suggestive of lichen sclerosis.if any erythema ca n be due to local irritation or candidal infection.if any lesion to palpate it .also will examine groin lymph nodes if susopision of neoplasia.sepeculum examine to see vagina & cervix if any suspicisious lesion should have urgent refferal for colposcopy if suspecting VIN. investigations will be base line FBC,LFT,UREA,electrolytes,CXR for her fitn ess for surgeryif required for treatment in case of malignancy. high vaginal swabfor direct microscopy & cu;ture & sensitivity,pap smear if n ot done .if any suspicios area on cx for colposcopy.if any lesion on vulva direct biopsy of lesion should be taken at edge of lesion to determine the depth involved. if lymph node involved or palpable needs MRI pelvis.sentinal node mapping in case of vulval malignancy. b) pt is confirmed to have VIN treatments available are conservative if its small there are chances of regression so patient can be managed conservatively.but need careful,regular assesment. ist line of treat met is surgery.surgery can be mutilating if it is multifocal as adequate margins are to be obtained.surgical excision can lead to icreased morbidity if lesion involves mid line structure.so other modes of treat ment like laser treatment will be considered.pt needs psychological support as surgery can lead to sexual dysfunction,poor self imaging..pt can have laser ablation of lesion specially if mid line structures are involved.. other option is medical treatment.imiquamod is immune response modifier will inhiibit HPV REPLICATION .its effective in VIN treatment.smoking may hinder its effect. its side effects are burning ,irritation,erythema. 5 floruracil can also be used HPV vaccines have role i n treatment specially one covering type 16 .&18. it is about effective in 97 % cases.
		Posted by tahira jabeen J. Sat Feb 6, 2010 11:18 pm
tj pt needs follow up as 40% lesion reccur .if untreated about 80% will progress to invasive ca in 10 years.relapse rate is high if multiple lesions .
		Posted by M E. Sun Feb 7, 2010 04:16 am
SAM a) I will ask if this is her first episode of burning and itching in the vulval. If there were previous episodes, whether there was spontaneous resolution. I will ask if she is still menstruating or her age of menopause and the use of HRT, since conditions like lichen sclerosus tyically occur in the post menopausal patient. Presence of associated symptoms of per vaginal bleeding, presence of lumps on the vulva or a foul smelling discharge, since these are more common in patients with vulval intraepithelial lesion(VIN). Presence of dyspareunia can occur with lichen planus secondary to stenosis. I will enquire about the presence of lesions elsewhere on the body. Presence of lumps on the breast in Paget\'s disease. Lesions on the flexor surfaces of the upper limb or in the mouth are seen with lichen planus. History of urinary incontinence and usage of pads or topical vaginal medication can cause irritation. Medical history of medical conditions such as ulcerative cloitis, thyroid disease, hepatitis C is associated with lichen planus. History of allergies.. Presence of pathology on cervial smears. History of smoking, since this increases the risk for VIN. On examination on the skin for lesions especially on the flexor surface of the upper limbs and scalp for lesions, usually present with lichen planus. Examination of the mouth for Wickham striae also seen with lichen planus. Examination of the thyroid for enlargenment. Through examination of the genital system. Thin white parchment like lesions with sparing of the vaginal is found with lichen sclerosis. Presence of white, rough lumps in the vulva is seen with VIN. Involvement of the vagina and cervix can also be found. Examine labia minora to check for fusion as seen in lichen sclerosis or presence of stenosis in the introitus in lichen planus. Examination of the anus for involvement. For cases in which VIN is suspected, colposcopic guided biosy is performed. 5% acetic acid is used to aid identifcation and these areas should be biopsied to exclude malignancy.Toluidine can also be used for staining. b)Once invasive disease has been excluded, topical fluoridated steroidscan be used for symptomatic relief. It is however ineffective in curing VIN.It causes local irritation and assocaited with poor compliance. Topical alpha interferon may be of benefit. CO2 Laser ablation to the affected area can be done under colposcopic guidance as an out patient precedure. It is assocaited with better cosmesis than excision. However no tissue is obtained for biopsy for presence of concurrent invasive disease. The procedure is painful and associated with prolonged healing.. Grafting may be required for extensive burns Wide local excision is diagnostic and therapeutic. There is no current guideline for margin size. Patient should have follow up visits every six months. There is a high recurrence rate 20-40% after surgical excision or laser treatment. The risk of progression to invasive disease is 5-10% . Repeated biopsies are required if new lesions develop.
		Posted by K I. Sun Feb 7, 2010 07:59 pm
a) Clinical assessment will include a detail history history. History of the symptoms; onset of symptoms, severity of symptoms, any associated symtoms like abnormal pv bleeding,pv discharge, vaginal dryness,symptoms of menopause, and how the symptoms is affecting her quality of life. Detail gynae and obstetrics history including LMP, prev smear test,parity. Family history of any gynae or other malignancies.History of other medical condition, esp skin condition like psoriasis or dermatitis. Any allergies to medications or anything in general.Use of pantiliner,cream,bath soaps,detergent. Examination will include general examination including looking at other skin parts of the body for any sign of allergic reaction or skin diseases.Abdominal examnination for any palpable masses or lymphadenopathy esp the ingunal region.Vulval inspection for any rash, ulcers, bleeding, fusion of labia. Investigation will include swabs for any area that is suspicions of any infection, and biopsy of any suspicious area to outrule malignancy, as it can be difficult clinically to differenciate between a benign and malignant lesion. b) Treatment options for VIN includes conservative management where only symptomatic relief is offered. this can be the option if there is low grade of VIN as it can resolved on its own with time. But it is very inportant to follow up the patient in the clinic to detect futher progression. Medical management will include topical chemotherapy e.g. 5-florouracil (5-FU) or bleomycin for 6 to 10 weeks. This has the advantage of avoiding surgery, but is not consistently successful e.g. patient compliance. Laser ablation is another option to avoid surgery but can be painful and no tissue for histology will be available. Surgery will be the ideal treatment, involving wide local excision, as it will have tissue for histology and will remove the lesion and lower the riskof recurrence. Follow up is very important whatever the choice of treatment as to avoid not detecting progression and compliance of patient for treatment.
		Posted by Nadira N. Mon Feb 8, 2010 12:06 pm
A) I will ask her about the associated symptoms of pain and discharge,presence of ulcer or mass .I will ask her about her last menstrual period ,vaginal dryness ,dysparunea and other menupausal symptoms such as hot flushes.History of diabetes mellitus should be asked as glycoseurea can cause soreness and erythema in the area of contamination.History of urinary conditions which can cause soreness should also be asked such as urinary incontenance ,pyurea and heamaturea.Fecal incontenace ,fissure in ano and haemorrhoids should also be asked.Deficancy states such as chronic anemea and causative factors like menorrhagia, malabsorption syndrome or postgastrectomy syndrome should be excluded.Psychological factors are also important as they may present as skin disease and psychoneurosis of of sexual basis can prsesent in vulver skin.Skin sensitivity to various chemical constituents should be excluded like bath soaps and use of antiseptics.Use of tight fitting clothes and nylon can also cause skin allergy.Skin conditions like psoriasis and seborrhoeic dermatitus and scabies which are generalised skin disorders may present to be more obvious in vulva than elsewhere.Report of her last pap smear should be reviewed as CIN is associated with VIN.History of smoking and multiple sexual partners is important in assessing the risk for VIN and microinvasive disease.Second step is full physical examination to exclude any extra genital lesions especially in the mouth and ear and on the hands and feet.The vulva is examined carefully but appearance of vulva itself may not be diagnostic.Per speculum examination is required to assess the condition of vagina and cervix and to collect the swabs for trichomonas vaginalis and candida albicans.Blood test for CBC,OGTT , achlorhydria and test for vitamin B12 and folate deficianies should be asked and skin senstivity tests .Biopsy is diagnostic ,it is best taken with 4 or 6mm keyes punch under local anesthesia .Knife biopsies do not reach the deeper layers.Cytology is generally useless as the cancer cells are not desquamated. B) VIN1 which is never visible macroscopically can be managed expectantly while larger grades which are always visible need treatment.The best treatment for a clearly defined lesion is by wide local excision of the affected area with atleast 5 mm margin of normal skin with end to end approximation of the deficit.If there are multicenteric lesions , a skinning vulvectomy with split-thickness skin graft can be done.Topical 5-fluorouracil has been used but it is painfull and in effective .Topical gamma interferon may give better results .Radiotherapy is not indicated.CO2 laser ablation is effective but great expertise is required to control the depth of excision .The depth of less than 1mm in non hairy and less than 3mm in hairy areas is required.General anesthesia may be required for larger lesions.Post laser vulva should be kept clean and dry and anagesia should be used.In case of extensive area involved vulva,perinium and perianal area colostomy may be needed.Recurrance rate is 15 to 43% ,these are probably new lesions arising in unstable epithelium.These may require repeat excision over the course of many years.Before treatment patient should be informed about the possibility of recurrance, future risk of invasive disease and follow up for indefinite time.Sexual dysfunction is a consequence of vulvar surgery.
		Posted by Nadira N. Mon Feb 8, 2010 12:12 pm
A) I will ask her about the associated symptoms of pain and discharge,presence of ulcer or mass .I will ask her about her last menstrual period ,vaginal dryness ,dysparunea and other menupausal symptoms such as hot flushes.History of diabetes mellitus should be asked as glycoseurea can cause soreness and erythema in the area of contamination.History of urinary conditions which can cause soreness should also be asked such as urinary incontenance ,pyurea and heamaturea.Fecal incontenace ,fissure in ano and haemorrhoids should also be asked.Deficancy states such as chronic anemea and causative factors like menorrhagia, malabsorption syndrome or postgastrectomy syndrome should be excluded.Psychological factors are also important as they may present as skin disease and psychoneurosis of of sexual basis can prsesent in vulver skin.Skin sensitivity to various chemical constituents should be excluded like bath soaps and use of antiseptics.Use of tight fitting clothes and nylon can also cause skin allergy.Skin conditions like psoriasis and seborrhoeic dermatitus and scabies which are generalised skin disorders may present to be more obvious in vulva than elsewhere.Report of her last pap smear should be reviewed as CIN is associated with VIN.History of smoking and multiple sexual partners is important in assessing the risk for VIN and microinvasive disease.Second step is full physical examination to exclude any extra genital lesions especially in the mouth and ear and on the hands and feet.The vulva is examined carefully but appearance of vulva itself may not be diagnostic.Per speculum examination is required to assess the condition of vagina and cervix and to collect the swabs for trichomonas vaginalis and candida albicans.Blood test for CBC,OGTT , achlorhydria and test for vitamin B12 and folate deficianies should be asked and skin senstivity tests .Biopsy is diagnostic ,it is best taken with 4 or 6mm keyes punch under local anesthesia .Knife biopsies do not reach the deeper layers.Cytology is generally useless as the cancer cells are not desquamated. B) VIN1 which is never visible macroscopically can be managed expectantly while larger grades which are always visible need treatment.The best treatment for a clearly defined lesion is by wide local excision of the affected area with atleast 5 mm margin of normal skin with end to end approximation of the deficit.If there are multicenteric lesions , a skinning vulvectomy with split-thickness skin graft can be done.Topical 5-fluorouracil has been used but it is painfull and in effective .Topical gamma interferon may give better results .Radiotherapy is not indicated.CO2 laser ablation is effective but great expertise is required to control the depth of excision .The depth of less than 1mm in non hairy and less than 3mm in hairy areas is required.General anesthesia may be required for larger lesions.Post laser vulva should be kept clean and dry and anagesia should be used.In case of extensive area involved vulva,perinium and perianal area colostomy may be needed.Recurrance rate is 15 to 43% ,these are probably new lesions arising in unstable epithelium.These may require repeat excision over the course of many years.Before treatment patient should be informed about the possibility of recurrance, future risk of invasive disease and follow up for indefinite time.Sexual dysfunction is a consequence of vulvar surgery.
		Posted by AFSHEEN M. Tue Feb 9, 2010 06:54 am
A 53 year old woman has been referred to the gynaecology clinic with a 6 months history of a burning sensation and itching in the vulval area. (a) Discuss your clinical assessment and investigation [10 marks ]. (b) She is found to have vulval intra-epithelial neoplasia. Discuss the available treatment options and justify your plans for follow-up [ 10 marks ]. a) I will ask about severity of itching and effect on quality of life. I will ask about associated vaginal discharge and its characteristics,superficial dyspareunia or urinary and fecal incontinence. I will ask about history of dysuria,urgency, frequency or hematuria to exclude urinary tract infections.i will ask about any postmenopausal bleeding ,if postmenopausal or postcoital/irregular vaginal bleeding, if pre/perimenopausal.I will ask about history of medical disorders such as diabetes,skin disorders or previous history of hysterectomy.I will enquire about smoking,history of cervical cancer and most recent cervical smear test.I will also ask about any allergies or recent use of new bath creams, lotions. I will asess general health and fitness of the patient and examine her abdomen for any palpable masses.I will examine the vulva and perineum under good lighting for signs of atrophy,any swelling,abnormal vaginal discharge or abnormal/suspicious areas of altered color and texture.I will look for signs of labial fusion and vaginal narrowing.I will perform the speculum to visualise cervix, polyps or abnormal discharge andperform a bimanual examination to assess size, position of uterus and adnexal fullness. I will perform a FBC, CRP if UTI suspected; and U&Es and LFTS as baseline in the presence of medical conditions, such as diabetes.I will perform a urinalysis +/_ midstream sample of urine to exclude UTI.Depending upon examination findings, I will perform a colposcopy and vulvoscopy with application of acetic acid ,to identify abnormal mosaicism and puctation.I will also perform a full thickness vulval biopsy of all suspicious areas,under local or general anesthesia, as guided by history and examination. b) VIN has an uncertain clinical course, multifocal nature and high recurrence rate;thereby making treatment more challenging. If the patient is fit, surgery with local excision may be best suited.However, may need large area removal, if multifocal disease, with myocutanous flaps to improve physical and psycolological morbidity. Medical treatment with potent steroids is also an option, once invasive disease excluded. CO2 laser can be helpful but adequate depth for effective treatment is not known. It can also cause burns and scarring, requiring skin grafting; also has high recurrence rate. Expectant management is an option, however needs multiple repeat biopsies to exclude cancer. The choice of teatment depends upon patient fitness and choice, whether multifocal disease and expertise available. I will organise a close follow up due to high recurrence rate, especially with CO2 laser treatment.Individual follow up plans will depend upon severity of disease, procedure performed and facilities available.