1. Vulvar Lesions
CAPT Mike Hughey, MC, USNR

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

3. Bartholin Duct Cyst
Video

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

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

6. 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

7. Skenitis
Will need I&D
Culture for GC, Chlamydia

8. 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%

9. 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

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

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

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

13. 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

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

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

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

17. 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

18. 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

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

20. 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

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

22. Condyloma Lata Treatment
Same as Primary Syphilis

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

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

25. 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.

26. 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

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

28. 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)

29. 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)

30. 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