Vulvar Lesions CAPT Mike Hughey, MC, USNR

Bartholin Gland Normally not seen nor felt If enlarged, can be a painless cyst or painful abscess

Bartholin Duct Cyst Video

Bartholin's Abscess Must be drained Simple I&D Marsupialization Word Catheter

Don’t Confuse it with These: Inclusion Cyst of the Vulva Right Vaginal Wall Cyst

Skene's Gland Each side of urethra Normally neither seen nor felt May become swollen and tender, particularly with GC or chlamydia Culture I&D if pointing

Skenitis Will need I&D Culture for GC, Chlamydia

Herpes Vulvitis Prodrome of itching or tingling Multiple, small, painful blisters Shallow ulcers filled with gray material Crusts over in 7-10 days Recurrences in 50%

Herpes Vulvitis Treatment Spontaneous resolution in 10 days Zovirax 200 mg PO Q 4 hours while awake #50 May need to place Foley cather Recurrences are not as severe

Molluscom Contagiosum Multiple, 1-2 mm raised, painless lesions Dome-shaped with central dimple Contain cheesy-white material Sexually transmitted

Molluscom Contagiosum Treatment Cryosurgery (just the lesion) Bichloracetic acid (just the lesion) Dermal curette (AgNO3 to base) Electrocute the lesion (local anes.) Video

HPV (Condyloma) Clinical warts Flat warts Soak vulva in vinegar, Exam under 7x power, Red-free light filter No specific treatment

Tinea Cruris (Jock Itch) Raised, reddened intertrigenous lesion Dx: visual, but may obtain KOH scrapings Rx: (BID x 2-3 weeks) -Monistat -Lotrimin -Diflucan -Nizoral

Runner’s Rash Chafing from running, walking or other exercise Lubricate with vaseline Avoid cotton underwear Local treatment

Vulvar Dystrophy - Hypertrophic Skin too thick Sx: Itching Dx: Biopsy Rx: Steroid Cream

Vulvar Dystrophy - Lichen Sclerosis Skin too thin Sx: Itching Dx: Biopsy Rx: Testosterone Cream or Clobetasol

Paget's Disease Slow-growing malignancy Exzematoid lesion -dry, crusty skin -moist, weepy -contact bleeding Looks like yeast, but isn’t cured with anti-fungal Rx Confirm by Bx, treat with local excision

Vulvar Hematoma Straddle injury Foley/Ice/Rest Completely resolves in 2-3 weeks Try not to drain them Unnecessary Bleeding point elusive Risk infection Spontaneous drainage in half

Primary Syphilis Appearance Painless solitary ulcer LNs enlarged, firm, non- tender Positive RPR, VDRL Positive Darkfield

Primary Syphilis Treatment Benzathine PCN G, 1.2 M in each buttock (2.4 M total) TTCN, 500 mg PO QID x 14 days Doxycycline 100 PO BID x 14 days

Condyloma Lata Diagnosis Secondary syphilis Raised, painless flat lesions Resemble condyloma, but smooth surface Positive VDRL Positive darfield of surface scrapings

Condyloma Lata Treatment Same as Primary Syphilis

Chancroid Appearance Tender, red papule filled with pus Grayish, necrotic base Jagged, irregular margins No induration (contrast syphilis) Tender inguinal LNs in 50%

Chancroid Diagnosis Hemophilus ducreyi Hard to culture Gram-neg coccobacillus in clusters around Polymorphonucleocytes "School of Fish Appearance" History, physical, exclude other ulcerative diseases

Chancroid Treatment Azithromycin 1 g PO Ceftriaxone 250 mg IM Ciprofloxacin 500 mg PO BID for 3 days Erythromycin base 500 mg PO QID for 7 days.

Lymphogranuloma Venereum (LGV) Ulceration of the vulva, rectum or groin Pain with walking, sitting, or BMs Hard tender masses (bubos) arise in the inguinal area Untreated, extensive scarring in the rectum and vagina

LGV Diagnosis Chlamydia trachomatis serotype culture from a bubo Acute/convelescent serum complement fixation test History of exposure Visual appearance Prevalence in the population.

LGV Treatment Doxycycline 100 mg orally twice a day for 21 days, or Erythromycin base 500 mg orally four times a day for 21 days. Zithromax? (Probably with multiple doses over several weeks)

Granuloma Inguinale Appearance Chronic ulcerative disease Clean, granulomatous, sharply- defined Multiple, confluent ulcers Beefy red base which bleeds easily Pseudobuboes in the groin Confirm with biopsy (Donovan Bodies)

Granuloma Inguinale Treatment Minimal scarring when treated early Extensive scarring when treated late 3 Weeks of: Bactrim DS BID Doxycycline 100 mg BID Ciprofloxacin 750 mg BID Erythromycin base 500 mg QID