Title: Vulval Disease Lecture framework for obstetrics and gynaecology core trainees
1Vulval DiseaseLecture framework for obstetrics
and gynaecology core trainees
2Introduction
- These presentations were prepared by Caroline
Owen Consultant Dermatologist and David Nunns
Consultant Gynaecologist on behalf of the BSSVD
education group. - They are designed as a framework, to cover the
vulval disease component of the core curriculum
for obstetrics and gynaecology trainees, as set
out by the RCOG. - The clinical images have been omitted for patient
consent issues, and speakers are encouraged to
insert their own pictures where indicated. - The lectures are intended only as a guide and
resource.
3Lecture one - Objectives
- Assessment of vulval patient
- History, examination, investigations
- Treatment principles
- Emollients and topical steroids
- Overview of most common vulval dermatoses
- Eczema, psoriasis, candidiasis, lichen sclerosus,
lichen planus
4StratOG guidance on appropriate practitioners and
level of care for vulval conditions
Practitioner Roles and responsibilities Suggested conditions
GP Patient assessment (history, examination, swabs) Uncomplicated vulvo-vaginal infections and follow-up of vulval conditions e.g. lichen sclerosus
General gynaecology clinics Patient assessment (history, examination, swabs, biopsy) Treatment for common uncommon conditions Follow-up Referral for supra-specialist care Skin disease (e.g. lichen sclerosus) Vulvodynia Unifocal VIN Complicated infections (e.g. resistant to treatment)
Supra-specialist care (Vulval clinic) Assessment and management of uncommon and rare skin disease Uncommon conditions Vulval dermatoses (e.g. Lichen planus) Multifocal VIN Any patient with symptoms that do not respond to basic measures e.g. Vulvodynia
Gynaecological cancer team Level 4 care Patient assessment and treatment of premalignant and malignant vulval disease Liaison with the extended cancer team Vulval cancer VIN (all types including Paget's disease)
5Who sees vulval disease?
- GP
- Dermatology
- Gynaecology
- GUM
- Urology
-
- We all need to get good at it there is plenty
out there.
6Vulval disease
- 1. Assessment of the patient with a vulval
problem - 2. Treatment principles
- 3. Specific vulval dermatoses
- Eczema (irritant contact dermatitis, allergic
contact dermatitis, lichen simplex) - Psoriasis, recurrent candidiasis
- Lichen sclerosus, lichen planus
7Assessment of patient with vulval problem
- PC
- HPC
- PMH
- DH
- FH
- SH
- Good start but
8Vulval clinic history taking
- Need time box of tissues
- Have often had many appointments, investigations,
procedures already - Confused, wary, distressed
- Relationships may be under pressure
- May be struggling to conceive
- May not have spoken to anyone else
9 10Vulval clinic history taking
- Timescales
- Interventions that have helped or not
- Ask about sex
- Ask about urinary continence
- All topical applications
- Hygiene/washing routine
- Previous swabs, biopsies, investigations
11Vulval clinic - examination
- Good light
- Whole skin (including mouth)
- Be systematic
- mons pubis
- crural folds
- labia majora
- labia minora
- clitoris
- introitus
- fourchette
- perianal area
12Anatomy
13- Picture of a normal vulval
14Terminology
- Erythema
- Macule flat
- Papule raised lt0.5cm
- Nodule gt 0.5cm
- Vesicle blister lt 0.5cm
- Bulla blister gt 0.5cm
- Ecchymosis, purpura, petichiae bleeding/bruise
15Terminology cont
- Erosion loss of superficial epidermis
- Ulcer loss of epidermis /- dermis
- Glazed erythema red, shiny skin but intact
epidermis - Excoriation scratch
- Fissuring splits/cuts
- Lichenification thickening
- Atrophy thinning, wrinkling
- Fusion scarring, loss of vulval architecture
16- 2 images of LS, one adult, one child
17Vulval clinic - investigations
- Consider GUM screen/referral
- Viral and bacterial swabs (candida very common
without obvious clinical signs) - Patch testing (if suspect allergic contact
dermatitis) - Clinical photograph
- Biopsy
18Vulval biopsy
- As outpatient
- Local anaesthetic
- 4mm punch biopsy (usually)
- 50 vicryl rapide
- Site NOT eroded or ulcerated area
- Incisional/punch biopsy for rashes, excision for
lesions - Must document site and all clinical information
with differential for pathologists - If performing excision be confident of required
margins
194 mm punch biopsy
20- Picture of erosive LP to demonstrate site of
biopsy
21Treatment principles 1
- Complex patients need multidisciplinary team
- Dermatology
- GUM
- Urogynaecology
- Pathology
- Physiotherapy
- Psychosexual counselling
- GP
- Patient support groups
22Treatment principles 2
- Emollients emollients emollients
- Topical steroids
- Lubricants
- Dilators (Amielle comfort or Fenmax)
23Emollients Emollients Emollients
- Moisturisers
- Vital active treatment
- Repairs skins barrier
- Prevents penetration by allergens and irritants
and bacteria - Reduces itch and makes skin feel more comfortable
- Soap substitute leave on moisturiser
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27Emollients
- Lotions
- light, spread easily, cooling but not very
moisturising - Creams
- Heavier than lotions but not as moisturising as
ointments - Ointments
- Do not contain any water, thick and can be
difficult and greasy to apply but very good at
moisturising
28Emollients
- Light
- E45
- Double Base
- Ung Merck
- Diprobase cream
- Greasy
- Epaderm
- Hydromol ointment
- Emulsifying ointment
- 50/50 white soft paraffin/liquid paraffin
- Aqueous, too light use only as soap substitute
(need to wash off)
29- THE BEST EMOLLIENT IS
- THE ONE THE PATIENT
- WILL USE
30Topical steroids
- Very effective
- Very safe
- Underuse a MUCH greater problem than overuse
31Topical Steroids
- Steroids are produced naturally by the body
- Anti-inflammatory
- Allow skin a chance to repair
- Side effects very rare, steroid atrophy extremely
rare
32Topical steroids
- Can use on broken skin
- Can use longer than 7 days
- Ignore the word sparingly
- Can use potent and superpotent steroids on vulva
(and often need to) - Better to reduce frequency than go up and down
steroid ladder
33Topical Steroids - guidelines
- Dont use more than twice daily
- Must use with regular emollients
- Stop using them once completely clear but
continue with moisturisers - Start again if necessary
- Use mirror to demonstrate correct site
34Vulval disease
- Dermatoses
- General dermatological dermatoses
- Eczema psoriasis
- Infections
- Candidiasis
- STIs
- Specific vulval dermatoses
- Lichen sclerosus, lichen planus
- Lesions
- Benign
- Bartholin cyst
- Epithelial (sebaceous) cyst
- Angiokeratoma
- Malignant
- VIN/SCC
- BCC/melanoma
35Vulval Eczema
- Very common
- Look for signs of eczema elsewhere
- Defect in barrier function of skin
- Often atopic
- Always itchy
- Often worse at night
- Eczema dermatitis
- Irritant contact dermatitis / allergic contact
dermatitis
36 37- 2 images of vulval eczema demonstrating
excoriations and fissures
38- Vulval eczema with fissuring in crural folds
39Vulval eczema - treatment
- Emollients emollients emollients
- Avoid soap
- Loose cotton underwear
- Topical corticosteroids
- Consider irritants and allergens (wetwipes)
- Pre-disposes to candidiasis (impaired barrier
function) swab to check
40- Irritant contact dermatitis chapped, damaged
skin, can happen to anyone - Water, abrasives
- Soap, shampoo
- Wool/synthetic clothing
- Cold weather
- Allergic contact dermatitis more common in
those who already have eczema - Caused by a true allergic reaction to a specific
substance (allergen) - Previous contact (often prolonged) with substance
is needed to start the allergic reaction - Lasts forever
- Diagnosed on patch testing
- Consider if previously controlled eczema flares
or start to react to topical treatments
41- 2 images of vulval eczema and lichen simplex
42- Images of lichen simplex on vulva and leg
43 44Vulval psoriasis
- Appearances often deceptive
- Look for signs of psoriasis elsewhere
- May have family history
- Often sore
- Can be psychologically disabling
45- 4 images of psoriasis plaque, flexural, vulval
46Vulval psoriasis - treatment
- Explain diagnosis
- Loose cotton clothing
- Emollients
- Refer to dermatology (options are topical
steroids/topical Vitamin D analogues/Immunomodulat
ors/combination therapies - Trimovate/Alphosyl HC/ Curatoderm/Protopic
- May need systemic therapy
47Vulvovaginal candidiasis
- Common
- Difficult to diagnose clinically
- Pain, itch, dyspareunia, swelling
- Take a swab
- Albicans in 80 -92
- Non-albicans (e.g. glabrata) in the rest
- Often associated with eczema
- Recurrent if gt6 episodes in one year
48- Image of typical vulval candidiasis
49- 2 images of dry fragile vulva with satellite/
perifollicular superficial peeling often seen in
VVC
50Vulvovaginal candidiasis - treatment
- Emollients long term
- Topical steroid at night during acute phase
- Oral fluconazole as stat treatment AND then
maintenance therapy (usually weekly) - Relapse very common if treatment stops
- Consider stopping OCP/HRT (related to
oestrogen) - No need to treat asymptomatic partners
- Maintenance fluconazole therapy for recurrent
vulvovaginal candidiasis. Sobel et al NEJM 2004
351876-883
51- Before and after treatment pictures of VVC
showing significant swelling of vulva before
therapy
52Lichen sclerosus
- Prevalence 1300 11000
- Very often associated with urinary incontinence
- Any age but particularly peri or post menopause
and prepuberty - Unknown aetiology
- ? Circulating autoantibodies to BMZ proteins
e.g. ECM1 - Clin exp derm 200429(5)499-504
53Lichen sclerosus
- Symptoms
- Intense itching
- Pain
- Dyspareunia
54Lichen sclerosus
- Signs
- Pallor
- Atrophy
- Excoriations
- Erosions and purpura
- Hyperkeratosis
- Loss of vulval architecture/scarring
55- 4 slides of LS including perianal, and
extragenital disease
56Lichen sclerosus treatment
- Explain diagnosis (not infectious, not cancerous)
- Control rather than cure
- Information leaflet, patient support group
- Emollients
- Dermovate
57Lichen sclerosus treatment
- Super-potent topical steroid e.g. Dermovate
- Once daily for 1 month
- Alternate days for 1 month
- Twice weekly for 1 month
- then as required, if relapse occurs return to
frequency that controlled symptoms - BJD 2010163(4)672-682
58Lichen sclerosus treatment
- Reassure re steroid side effects
- 30g over 3 months to control disease
- 30g over 6 months safe as maintenance treatment
- Teach self examination and advise to seek help if
any non-healing erosions/lumps
59- 4 slides of LS, some with advanced disease
-
60LS treatment failure
- Treatment non-compliance
- Fear of steroids
- Poor understanding of anatomy
- Incorrect diagnosis
- Biopsy
- Incontinence
- Complicated LS
- Lichen planus overlap
- Additional diagnosis
- Vulvodynia
- squamous cell carcinoma
61Treatment applied to wrong site
62 63Vulval lichen planus
- Symptoms
- Pain
- Itching
- Discharge
- Bleeding
- Dyspareunia
64Images of oral and vulval lichen planus
65Vulval lichen planus
- Signs
- Erythematous flat-topped papules on keratinised
skin - Fine reticulate white pattern on mucosal surfaces
- Erosions in more severe disease
- Scarring
- Discharge
- Vaginal stenosis
66- 4 slides of lichen planus
67Vulval lichen planus - treatment
- Explain diagnosis (not infectious, not cancerous)
- Control rather than cure
- Information leaflet, patient support group
- Emollients
- Topical steroids
68Vulval lichen planus - treatment
- Patients should be referred to dermatology
- Erosive disease very resistant to treatment
- Superpotent topical steroids
- Prednisolone pessaries
- Oral steroids
- Hydroxychloroquine, Methotrexate, Mycophenolate
mofetil. - Surgery last resort, in conjunction with
steroids and dilators to prevent restenosis
69Summary
- Assessment of vulval patient
- History, examination, investigations
- Treatment principles
- Emollients and topical steroids
- Overview of most common vulval dermatoses
- Eczema, psoriasis, candidiasis, lichen sclerosus,
lichen planus
70Lecture two - Objectives
- Assessment and treatment of women with vulvodynia
- Assessment and treatment of women with
premalignant disease (VIN) - Knowledge of the team approach to women with
vulval disease and role of the general
gynaecologist
71Assessment and treatment of women with vulvodynia
72VULVODYNIA
- Vulval discomfort, most often described as a
burning pain, occurring in the absence of visible
findings or a specific, clinically identifiable,
neurological disorder - A chronic pain syndrome
- Unprovoked or provoked pain
- Localised or generalised
- Hemivulvodynia
- Clitorodynia
- Vestibulodynia (aka vestibulitis)
73Assessment of women with vulval pain
- Pain
- Site
- Radiation
- Relieving/aggravating factors
- Severity of pain-subjective/objective
- Impact on function? (Work, play)
- Other pain issues sexual pain?
- Back problems? Coccyx injuries?
74Clinical examination
- Often normal appearances
- Allodynia (touch sensitivity) may be seen (Q tip
swab test) - Important not to overlook subtle skin disease eg
small fissures, vulval eczema
75Vulvodynia additional points
- Patient experience is often poor
- Delay in the diagnosis/focus on medical
treatments - Often misdiagnosis or inappropriate diagnosis
- Stress, anxiety and sexual issues are often
overlooked in gynaecology clinics
76Management of women with vulvodynia4 Ps
- Patient education and reassurance
- Pain modifying drugs
- Physical treatments
- Psychological and psychosexual therapy support
77Patient education and reassurance
- Give a diagnosis and written information
- Explain chronic pain pathway mechanisms
- Explain what it is not! Eg cancer , STDs, impact
on fertility - Refer to patient support organisations eg Vulval
Pain Society
78Pain modifying drugs
- Tricyclic antidepressants
- Ami or nortryptyline
- Escalate dose/warn of often shortlived side
effects - Gabapentin/pregabalin
- 70 response rate
- Important to judge benefit/SE of treatment
79Physical treatments
- Pelvic floor hypertonicity is common in pain
- Desensitisation make less sensitive!
- Digital massage
- Vaginal trainers/dilators
- Pelvic floor exercises
- Use of a simple vibrator
- Biofeedback
80Psychological and psychosexual therapy support
- Behaviours
- Avoid intimacy
- Becomes withdrawn emotionally
- Push self to make up for it
-
- Thoughts Physical sensations
- Im less of a woman Muscle tension
Further pain - I better not lead my partner on
Headaches - He might find someone else Irritable
bowel symptoms - Ill try make up for it in other
ways Sinking feeling in stomach - Emotions
81Psychological and psychosexual therapy support
- Sexual dysfunction (esp vaginismus) is near
universal with provoked pain - Patients will benefit from psychosexual therapy
if there is sexual dysfunction (eg vaginismus,
low libido, poor arousal) - Stress/anxiety will fuel pain
- Discuss strategies to reduce this eg lifestyle,
counselling, CBT.
82Vulvodynia - Role of the gynaecologist
- Assessment and make a diagnosis
- Education and reassurance
- Discussion of chronic pain pathways
- Start basic treatment
- Encourage self management
- Triage to vulval team depending on patients needs
- Think 3Ps
83Assessment and treatment of women with VIN
84VIN ISSVD 2005 Classification
- Usual type warty, undifferentiated
- Combines VIN2/3. No VIN1.
- Associated with high risk HPV.
- Differentiated type
- Associated with vulval cancer, lichen sclerosus,
squamous hyperplasia -
84
85VIN Clinical Features
- Itch, sore or a lump
- Gross appearance white/warty, red, pigmented,
ulcer - Unifocal or multifocal
- Can affect any vulval structure and perineum. 80
of lesions are on the labia - 10-15 asymptomatic
85
86VIN made easy!
- Unifocal disease
- Less than 1cm in diameter
- Site amenable to primary closure if surgery
considered - GENERAL GYNAECOLOGY MANAGEMENT IF CONFIDENT
- Multifocal disease
- Large areas greater than 1cm
- Difficult site eg clitorus or perineum (surgery
might compromise function) - Immunosuppressed patients
- Difficult lesions to assess eg indurated lesions
- VIN associated with LS
- REFER TO VULVAL SERVICE
87 88- Picture of multifocal VIN
89Making a diagnosis
- Full history smoking? immunosuppression?
- Examination of genital tract with good light
(include perianal area) - Punch biopsy(ies)
- Check cervix / last smear
90Risk of invasive disease
- Exact risk unknown
- 15 of cases of VIN associated with invasive
disease - 3 in treated patients
- 30-50 in untreated patients
- 1 rate of invasive disease in surgical specimens
91Management objectives
- Exclude invasive disease
- Symptoms relief
- Preservation of function
- Sustained remission
- Reduce the risk of malignant progression
92Treatment options
- Surgery
- Aim for complete excision of lesion with a clear
margin with primary closure - Advantages
- High cure rates
- Good symptom relief
- Disadvantages
- Close/incomplete margins have a higher recurrence
rate - Not recommended for multifocal disease
- Can produce disfigurement if difficult site (eg
perineum or clitoral hood) or large areas (gt2cm)
93Other treatment options
- Topical agents imiquimoid (70 response rate,
but needs vulval service supervision) - Conservative management - eg in pregnancy, young
women
94VIN- Role of the gynaecologist
- Assessment and make a diagnosis
- Education and reassurance
- Uncomplicated VIN surgical management
- Complicated VIN refer to vulval team
95A team approach for managing vulval disease
- A vulval service is defined as an
multidisciplinary team of health professionals
interested in vulval disorders - Vulval team in vulval clinic
- Dermatology and gynaecology
- Psychosexual counselling
- Physiotherapy
- Pain management
- Clinical psychology
- Plastic surgery
- Self management important
- Management is provided at all levels of care (eg
GP and hospital) - Referral to a vulval clinic depending on the
needs of the patients