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Diagnosing and Treating Vulvar Conditions: Tricks of the Trade Michael S. Policar, MD, MPH UCSF School of Medicine www.PolicarLectures.com.

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Presentation on theme: "Diagnosing and Treating Vulvar Conditions: Tricks of the Trade Michael S. Policar, MD, MPH UCSF School of Medicine www.PolicarLectures.com."— Presentation transcript:

1 Diagnosing and Treating Vulvar Conditions: Tricks of the Trade Michael S. Policar, MD, MPH UCSF School of Medicine www.PolicarLectures.com

2 ObjectivesObjectives Explain 3 differences between lichen sclerosus and lichen simplex chronicus. Explain 3 differences between lichen sclerosus and lichen simplex chronicus. List the 3 major presentations of Bartholin duct conditions and the preferred treatment for each. List the 3 major presentations of Bartholin duct conditions and the preferred treatment for each. List the 3 main causes of vulvar pain and 2 treatment options for each. List the 3 main causes of vulvar pain and 2 treatment options for each. List the 3 possible conditions in the differential diagnosis of a tender cystic mass of the vulva. List the 3 possible conditions in the differential diagnosis of a tender cystic mass of the vulva.

3 Presentations of Vulvar Conditions Vulvar itching – Dermatoses – Vulvovaginitis Vulvar papules and nodules – Genital warts – VIN, SC cancer – Pigmented lesions Chronic vulvar pain – Vestibulodynia – Vulvodynia Acute vulvar pain – Abcess, cellulitis – Vulvar ulcers – Trauma

4 The Itchy Vulva The Lichens: LS, LSC, LS+LSC The Lichens: LS, LSC, LS+LSC Systemic: psoriasis, lichen planus Systemic: psoriasis, lichen planus Eczemas: atopic dermatitis, contact dermatitis (irritant, allergic) Eczemas: atopic dermatitis, contact dermatitis (irritant, allergic) Fungal vulvitis: candidal, tinea Fungal vulvitis: candidal, tinea Recurrent genital herpes Recurrent genital herpes VIN (Vulvar Intraepithelial Neoplasia) VIN (Vulvar Intraepithelial Neoplasia)

5 Vulvar Skin Complaints: History Nature and duration of symptoms Nature and duration of symptoms Previous treatment and response Previous treatment and response Personal, family history: eczema, psoriasis Personal, family history: eczema, psoriasis Other sites involved: mouth, eyes, elbows, scalp Other sites involved: mouth, eyes, elbows, scalp All medications applied to vulva All medications applied to vulva –Antibiotics, hormones, steroids, etc Skin care: soaps, baby wipes, menstrual pads, new clothing, scrubbing, etc Skin care: soaps, baby wipes, menstrual pads, new clothing, scrubbing, etc New sexual partner(s); barrier contraceptives New sexual partner(s); barrier contraceptives

6 Vulvar Dermatoses New Terminology Old Terminology Lichen sclerosus - Lichen sclerosus et atrophicus Lichen sclerosus - Lichen sclerosus et atrophicus - Kraurosis vulvae - Kraurosis vulvae Squamous cell - Hyperplastic dystrophy hyperplasia - Neurodermatitis - Lichen simplex chronicus Squamous cell - Hyperplastic dystrophy hyperplasia - Neurodermatitis - Lichen simplex chronicus Other dermatoses - Lichen planus, psoriasis Other dermatoses - Lichen planus, psoriasis VIN - Hyperplasic dystrophy/atypia VIN - Hyperplasic dystrophy/atypia - Bowenoid papulosis - Bowenoid papulosis - Vulvar CIS - Vulvar CIS

7 Lichen Sclerosus: Natural History Most common vulvar dystrophy Most common vulvar dystrophy Bimodal ages: children, older women Bimodal ages: children, older women Cause: unknown; probably autoimmune Cause: unknown; probably autoimmune Chronic, progressive, lifelong condition Chronic, progressive, lifelong condition Most common in Caucasian women Most common in Caucasian women Can affect non-vulvar areas Can affect non-vulvar areas Squamous cell carcinoma Squamous cell carcinoma –3-5% lifetime risk –30-40% SCCA develops with LS

8 Lichen Sclerosus: Findings Symptoms Symptoms –Itching, burning, dyspareunia, dysuria Signs Signs –Thin white parchment paper epithelium –Fissures, ulcers, bruises, or hemorrhage –Submucosal hemorrhage –Depigmentation (white) or hyperpigmentation in keyhole distribution: vulva and anus –Introital stenosis and loss of vulvar architecture –Reduced skin elasticity

9 Lichen Sclerosus: Treatment Preferred treatment Preferred treatment –Clobetasol (Temovate) 0.05% BID x 2-3 wk, to QD –Taper to med potency steroid 2-4x/month for life Testosterone ointment is time honored, but little evidence to support Testosterone ointment is time honored, but little evidence to support Adjunctive therapy: anti-pruritic therapy Adjunctive therapy: anti-pruritic therapy –Atarax or Benedryl PO, especially at night –Doxypin, QHS or topically –If not effective: amitriptyline PO Perineoplasty may help dyspareunia, fissuring Perineoplasty may help dyspareunia, fissuring

10 Lichen Simplex Chronicus = Squamous Cell Hyperplasia Irritant initiates scratch-itch cycle Irritant initiates scratch-itch cycle –Candida –Chemical irritant, allergen –Lichen sclerosus Presentation: always itching; burning, pain, and tenderness Presentation: always itching; burning, pain, and tenderness Thickened leathery red (white if moisture) raised lesion Thickened leathery red (white if moisture) raised lesion In absence of atypia, no malignant potential In absence of atypia, no malignant potential –If atypia present, classified as VIN

11 L. Simplex Chronicus: Treatment Removal of irritants or allergens Removal of irritants or allergens Treatment Treatment –Triamcinolone acetonide (TAC) 0.1% ointment BID x4-6 weeks, then QD –Other moderate strength steroid ointments –Intralesional TAC once every 3-6 months Anti-pruritics Anti-pruritics –Hydroxyzine (Atarax) 25-75 mg QHS –Doxepin 25-75 mg PO QHS –Doxepin (Zonalon) 5% cream; start QD, work up

12 Lichen Sclerosus + LSC Mixed dystrophy deleted in 1987 ISSVD System Mixed dystrophy deleted in 1987 ISSVD System 15% all vulvar dystrophies 15% all vulvar dystrophies LS is irritant; scratching causes LSC LS is irritant; scratching causes LSC DDX: LS with plaque, candida, VIN DDX: LS with plaque, candida, VIN Treatment Treatment –Clobetasol x12 weeks, then steroid maintenance –Stop the itch!!

13 PsoriasisPsoriasis 30% have family history 30% have family history Triggered by stress, drugs, infections, alcohol, cold Triggered by stress, drugs, infections, alcohol, cold Usually involves extensor skin beyond the vulva elbows, knees, scalp, nails Usually involves extensor skin beyond the vulva elbows, knees, scalp, nails –Genital involvement: mons, vulva, crural folds –Pruritis, soreness Red epithelial patches with elevated silver scales Red epithelial patches with elevated silver scales Rx: Dovonex, topical steroids Rx: Dovonex, topical steroids

14 Lichen Planus Probable autoimmune disease Probable autoimmune disease May present as purple, well-demarcated, flat topped papules on oral, genital tissues May present as purple, well-demarcated, flat topped papules on oral, genital tissues Erythematous erosive lesions on vestibule or in vagina Erythematous erosive lesions on vestibule or in vagina Vulvar burning or pruritus Vulvar burning or pruritus 50% of women with classic LP will have genitalia involved 50% of women with classic LP will have genitalia involved DDX: LS, syphilis, herpes, chancroid, Behcets DDX: LS, syphilis, herpes, chancroid, Behcets DX: biopsy essential DX: biopsy essential

15 Lichen Planus: Treatment No one satisfactory treatment exists No one satisfactory treatment exists Emollients, vulvar care; treat superinfection Emollients, vulvar care; treat superinfection Vulva: clobetasol ointment with taper Vulva: clobetasol ointment with taper Vagina: Anusol HC 25 mg supp; ½-1 supp PV BID x4 weeks, then taper Vagina: Anusol HC 25 mg supp; ½-1 supp PV BID x4 weeks, then taper Short course of oral steroids if necessary Short course of oral steroids if necessary Vaginal dilators to prevent scarring Vaginal dilators to prevent scarring Other Rx: Tacrolimus 0.1% (Protopic) BID, Acitretin, methotrexate, Dapsone Other Rx: Tacrolimus 0.1% (Protopic) BID, Acitretin, methotrexate, Dapsone

16 Vulvar Eczema Atopic dermatitis Atopic dermatitis –Endogenous eczema Contact dermatitis: Exogenous eczema Contact dermatitis: Exogenous eczema –Irritant contact dermatitis (ICD) –Allergic contact dermatitis ACD) Lichen Simplex Chronicus Lichen Simplex Chronicus –End stage eczema

17 Atopic Dermatitis Prevalence: 10-15% of population Prevalence: 10-15% of population If 2 parents with eczema, 80% risk to children If 2 parents with eczema, 80% risk to children Criteria for diagnosis Criteria for diagnosis –Itching/ scratch cycle –Exacerbations and remissions –Eczematoid lesions on vulva and elsewhere (crural folds, scalp, umbilicus, extremities) –Personal or family of hay fever, asthma, rhinitis, or other allergies –Clinical course longer than 6 weeks

18 Atopic Dermatitis: Treatments Avoid scratching; stress management Avoid scratching; stress management Emollients (bland, petrolatum based) Emollients (bland, petrolatum based) Topical steroids (moderate potency) Topical steroids (moderate potency) Intralesional triamcinolone Intralesional triamcinolone Tacrolimus (Protopic) 0.03% to 0.1% BID Tacrolimus (Protopic) 0.03% to 0.1% BID Oral antihistamines or doxypin 5% cream Oral antihistamines or doxypin 5% cream –Intended mainly to relieve itching –Sedation in 20% –May cause contact dermatitis

19 Contact Dermatitis Irritant contact dermatitis (ICD) Irritant contact dermatitis (ICD) –Elicited in most people with a high enough dose »Potent irritant: chemical burn »Weaker irritant: applied repeatedly before sxs –Rapid onset vulvar itching (hours-days) Allergic contact dermatitis (ACD) Allergic contact dermatitis (ACD) –Delayed hypersensitivity –10-14d after first exposure; 1-7d after repeat exposure Atopy, ICD, ACD can all present with Atopy, ICD, ACD can all present with –Itching, burning, swelling, redness –Small vesicles or bullae more likely with ACD

20 Contact Dermatitis Common contact irritants Common contact irritants –Urine, feces, excessive sweating –Saliva (receptive oral sex) –Repetitive scratching, overwashing –Detergents, fabric softeners –Topical corticosteroids –Toilet paper dyes and perfumes –Hygiene pads (and liners), sprays, douches –Lubricants, including condoms

21 Contact Dermatitis Common contact allergens Common contact allergens –Poison oak, poison ivy –Topical antibiotics, esp neomycin, bacitracin –Spermicides –Latex (condoms, diaphragms) –Vehicles of topical meds: propylene glycol –Lidocaine, benzocaine –Fragrances

22 Contact Dermatitis: Treatment Exclude contact with possible irritants Exclude contact with possible irritants Restore skin barrier with sitz baths, compresses Restore skin barrier with sitz baths, compresses After hydration, apply a bland emollient After hydration, apply a bland emollient –White petrolatum, mineral oil, olive oil Short term mild-moderate potency steroids Short term mild-moderate potency steroids –TAC 0.1% BID x10-14 days (or clobetasol 0.05%) –Fluconazole 150 mg PO weekly Cold packs: gel packs, peas in a zip-lock bag Cold packs: gel packs, peas in a zip-lock bag Doxypin or hydroxyzine (10-75 mg PO) at 6 pm Doxypin or hydroxyzine (10-75 mg PO) at 6 pm Replace local estrogen, if necessary Replace local estrogen, if necessary If recurrent, refer for patch testing If recurrent, refer for patch testing

23 General Vulvar Care Measures Wear loose fitting clothing Wear loose fitting clothing 100% cotton underwear 100% cotton underwear –Rinse underwear twice –Low irritant soap; no use of fabric softeners 100% cotton menstrual pads 100% cotton menstrual pads –www.gladrags.com Mild bathing soaps: Cetaphil, Kiss-My-Face, Basis Mild bathing soaps: Cetaphil, Kiss-My-Face, Basis Vulvar water rinse (or very soft toilet paper) Vulvar water rinse (or very soft toilet paper) Use vaginal lubricants: Replens, KY, Olive Oil Use vaginal lubricants: Replens, KY, Olive Oil

24 Measures for Vulvar Itching Aveeno Oatmeal compresses or tub soaks Aveeno Oatmeal compresses or tub soaks Tea bags (compress, sitz, or tub) Tea bags (compress, sitz, or tub) Cold pack, especially before bed Cold pack, especially before bed Sedating antihistamines at bedtime Sedating antihistamines at bedtime Emollient during activities Emollient during activities –Aquaphor, SBR Lipocream, A&D ointment, petrolatum Doxypin 5% cream (20% will become drowsy) Doxypin 5% cream (20% will become drowsy)

25 Rules for Topical Steroid Use Topical steroids are not a cure Topical steroids are not a cure –Use potency that will control condition quickly, then stop, use PRN, or maintain with low potency Limit the amount prescribed to 15 grams Limit the amount prescribed to 15 grams Ointments are stronger, last longer, less irritating Ointments are stronger, last longer, less irritating Show the patient exactly how to use it: thin film Show the patient exactly how to use it: thin film L. minora are steroid resistant L. minora are steroid resistant L. majora, crural fold, thighs thin easily; get striae L. majora, crural fold, thighs thin easily; get striae At any suggestion of 2 o candidal infection, use steroid along with topical antifungal drug At any suggestion of 2 o candidal infection, use steroid along with topical antifungal drug

26 Evaluation: Recurrent VV Itching Symptom diary Symptom diary Detailed search for anatomic causes (e.g., fistula) Detailed search for anatomic causes (e.g., fistula) Saline, KOH slides during symptomatic period Saline, KOH slides during symptomatic period Vaginal pH, amine test Vaginal pH, amine test Candidal culture and speciation, or PCR Candidal culture and speciation, or PCR If at risk for glucose intolerance, check FBS If at risk for glucose intolerance, check FBS If vaginitis is chronic, severe, recalcitrant, or if oral thrush or lymphadenopathy, consider HIV If vaginitis is chronic, severe, recalcitrant, or if oral thrush or lymphadenopathy, consider HIV

27 CDC Classification of VVC Uncomplicated VVC (80-90%) Uncomplicated VVC (80-90%) –Sporadic or infrequent VVC, or AND –Mild-to-moderate VVC, or AND –Likely to be Candida albicans, or AND –Non-immunecompromised women Complicated VVC (10-20%) Complicated VVC (10-20%) –Recurrent VVC, or –Severe VVC, or –Non-albicans candidiasis, or –Uncontrolled DM, immunosuppression, pregnancy

28 VC: SEVEN DAY Therapy Miconazole Monistat-72% cream, 100 mg sup 100 mg sup TerconazoleTerazol-70.4% cream ClotrimazoleGynelotrimin 71% cream, Mycelex100 mg tab Mycelex100 mg tab –Rx: 1 application at bedtime for 7 days OTC drugs in italics

29 VC: THREE DAY Therapy Butoconazole Femstat 32% cream Butoconazole Femstat 32% cream Miconazole Monistat-3200 mg supp Miconazole Monistat-3200 mg supp TerconazoleTerazol-380 mg supp, TerconazoleTerazol-380 mg supp, 0.8% cream Rx: 1 application at bedtime for 3 days Rx: 1 application at bedtime for 3 days Alternative: Alternative: –Miconazole 2% creamBID x 3 days –Clotrimazole 1% cream –Clotrimazole 100 mg tab2 QHS x 3 days OTC drugs in italics

30 VC: ONE DAY Therapy ClotrimazoleMycelex G-500 ClotrimazoleMycelex G-500 500 mg suppository 500 mg suppository TioconazoleVagistat-1 6.5% ointment TioconazoleVagistat-1 6.5% ointment MiconazoleMonistat 1 1.2 gm suppository MiconazoleMonistat 1 1.2 gm suppository Butoconazole Gynazole-1 2% bioadh cream* Butoconazole Gynazole-1 2% bioadh cream* Rx: 1 app at bedtime (*anytime) FluconazoleDiflucan 150 mg FluconazoleDiflucan 150 mg Rx:1 tablet PO OTC drugs in italics

31 Uncomplicated VVC: Treatments Non-pregnant Non-pregnant – 3, 7 day topicals equal efficacy and price –Recommend: 3 day topical or fluconazole PO Mild or early case: any 1 or 3 day regimen Mild or early case: any 1 or 3 day regimen If first course fails If first course fails –Reconfirm microscopic diagnosis –Treat with alternate antifungal Rx –Candidal culture to speciate No role for nystatin, candicidin No role for nystatin, candicidin

32 CDC 2002: Complicated VVC Severe VVC Advanced findings: erythema, excoriation, fissures Advanced findings: erythema, excoriation, fissures Treat for 7-14 days of topical therapy or fluconazole 150 mg PO repeat in 3 days Treat for 7-14 days of topical therapy or fluconazole 150 mg PO repeat in 3 days Compromised host Conventional antimycotic tx for 7-14 days Conventional antimycotic tx for 7-14 daysPregnancy Topical azoles for 7 days Topical azoles for 7 days

33 Candidia glabrata Vaginitis Main symptom is intense vulvo-vaginal burning, rather than itching Main symptom is intense vulvo-vaginal burning, rather than itching KOH : yeast spores and buds, not hyphae KOH : yeast spores and buds, not hyphae Treatments Treatments –Best coverage (lowest MIC) with butoconazole –Imidazoles for 7-14 days –Boric acid 600 mg QD x 14 days –Topical gentian violet –Fluconazole not recommended (by CDC)

34 CDC 2002: Complicated VVC Recurrent VVC (RVVC) > 4 episodes of symptomatic VVC per year > 4 episodes of symptomatic VVC per year Most women have no predisposing condition Most women have no predisposing condition –Partners are rarely source of infection Confirm with candidal culture, since often due to non-albicans species Confirm with candidal culture, since often due to non-albicans species Early treatment regimen: self-medication 3 days with onset of symptoms Early treatment regimen: self-medication 3 days with onset of symptoms

35 RVVC: Treatment RVVC: Treatment –Treat for 7-14 days of topical therapy or fluconazole 150 mg PO q 72 o x3 doses, then –Maintenance therapy x 6 months »Fluconazole 100-200 mg PO 1-2 per week »Itraconazole 100 mg/wk or 400 mg/month »Clotrimazole 500 mg suppos 1 per week »Boric acid 600 mg suppos QD x14, then BIW »Gentian violet: Q week x2, Q month X 3-6 mo CDC 2002: Complicated VVC

36 Vaginal Candidiasis Tips 2/3 of women who believe that the have chronic or recurrent Candida dont 2/3 of women who believe that the have chronic or recurrent Candida dont –Verify diagnosis with PCR, fungal culture Consider Candida glabrata Consider Candida glabrata –Different presentation, different treatments Oral or vaginal yoghurt doesnt work because Oral or vaginal yoghurt doesnt work because – Lactobacillus strains dont adhere to vaginal cells –Predominant normal flora is L. crispatus, not L. acidophilus or L. bulgaricus

37 HPV Infection: Overview Pendulum has swung widely over four decades Pendulum has swung widely over four decades –Controversies persist regarding HPV transmission, treatment, and prevention PH model: STD protection cancer prevention PH model: STD protection cancer prevention –Primary prevention with HPV vaccine Once infected with HPV Once infected with HPV –Most HPV infections are transient »Women < 30 yo; LR types; immunocompetent –Persistent HPV infection causes HG lesions »Women > 30 yo; HR types; immunosuppressed

38 HPV Infection: Overview Therapeutic eradication of HPV is not possible Therapeutic eradication of HPV is not possible –Goal is the control of existing and new lesions Treatment should be limited to Treatment should be limited to –High grade pre-invasive disease »CIN (cervix), VaIN (vagina), VIN (vulva) »Anal IN, Penile IN –Genital warts that cause »Irritative symptoms of vulva, anus, or penis »Cosmetically objectionable lesions Treatment must not be worse than disease Treatment must not be worse than disease

39 EGW Treatment: General Principles Advise patient to stop cigarette smoking Advise patient to stop cigarette smoking Evaluate for trichomoniasis; treat if present Evaluate for trichomoniasis; treat if present No one treatment is ideal for all patients or all warts No one treatment is ideal for all patients or all warts More than one modality may be necessary More than one modality may be necessary –Should be used sequentially; not simultaneously Treatment must be individualized Treatment must be individualized –Size of the warts; extent, location of the outbreak –Personal preferences, medical status of patient –Experience of clinician –Available treatment resources –Cost considerations

40 Vulvar Papules: Differential Diagnosis VIN or vulvar carcinoma VIN or vulvar carcinoma –Usually multifocal in premenopausal women –Raised with irregular edges but not exuberant –Red, white, or hyperpigmented –Opaque white with vinegar application Condyloma latum Condyloma latum –Diagnostic of secondary syphilis –Not as exuberant as condyloma accuminata –Circular flat papules, usually in clusters –If suspected, order syphilis serology (RPR or VDRL) Other lesions: molluscum contagiosum, skin tags, nevi, scars Other lesions: molluscum contagiosum, skin tags, nevi, scars

41 Vulvar Papules: Evaluation Exam of vulva, perineum, and anus Exam of vulva, perineum, and anus –If questionable, use vinegar for acetowhitening Biopsy Biopsy –Typical condys do not require biopsy –Biopsy atypical condys, VIN, or vulvar carcinoma Cervical Pap smear for multicentric disease Cervical Pap smear for multicentric disease If perianal warts, evaluate anus by Pap + anoscopy If perianal warts, evaluate anus by Pap + anoscopy Test for other infectious conditions Test for other infectious conditions –GC, chlamydia, syphilis, HIV –NaCl suspension for vaginal trichomoniasis

42 EGW: No Treatment Small asymptomatic vulvar and vaginal genital warts Small asymptomatic vulvar and vaginal genital warts Non-specific acetowhitening of laba majora, labia minora, or introitus (non-HPV) Non-specific acetowhitening of laba majora, labia minora, or introitus (non-HPV) Vestibilar papillomatosis (non-HPV) Vestibilar papillomatosis (non-HPV) In placebo-control groups of women with genital warts, 10-30% of cases resolve spontaneously within 3 months In placebo-control groups of women with genital warts, 10-30% of cases resolve spontaneously within 3 months

43 EGW: Clinician Applied Treatments TCA or BCA 85-90% TCA or BCA 85-90% –Moderate vulvar, vaginal GW; not cervical GW Podophyllin 10-25% Podophyllin 10-25% –Resin is less effective, more irritating than TCA Cryotherapy (liquid N 2, cryoprobe) Cryotherapy (liquid N 2, cryoprobe) –Used for isolated vulvar, vaginal, cervical lesions Office excision Office excision –Simple surgical excision: scissors or scalpel –Electrocautery (coagulation), electrodessication

44 Self-Applied: Condylox 0.5%Gel Purified podophylotoxin; derived from podophyllin Purified podophylotoxin; derived from podophyllin –Mechanism: mitotic spindle poison; blocks cell division Use: Apply BID for 3 days, then four days off Use: Apply BID for 3 days, then four days off Expect response by 4 wks; if so, use up to 8 wks Expect response by 4 wks; if so, use up to 8 wks Response rate (8 weeks): 80% of women Response rate (8 weeks): 80% of women Pregnancy category C Pregnancy category C Cost (AWP) is $57 per 4 week cycle Cost (AWP) is $57 per 4 week cycle

45 Condylox R 0.5% Gel Advantages Advantages –Good short term wart resolution rates –Fewer adverse effects than podophyllin resin –Shorter course, less expensive than Aldara Disadvantages Disadvantages –Must apply correctly, consistently for optimal effect –Mild-moderate pain, local irritation may occur –Safety in pregnancy has not been established

46 Self-Applied: Aldara 5% Cream Immune response modifier Immune response modifier –Stimulates natural killer cell, T-cell activity –Induces a-interferon production from local tissues –No antiviral effect or direct tissue destruction Apply to EGW every other day x3, then 2 days off Apply to EGW every other day x3, then 2 days off –Use Mon, Wed, Fri, then Sat, Sun off –Wash off in morning using mild soap and water –Expect response by 4 wks; if so, use up to 12 wks Pregnancy category B Pregnancy category B PHS price is $60 per 4 week cycle PHS price is $60 per 4 week cycle

47 Aldara 5% Cream Advantages Advantages –Good short term wart resolution rates –Little toxicity; mainly erythema and irritation –Pain or irritiation; discontination in < 2% –Drug of choice in large vulvar EGW blooms in women and for immunosuppressed patients Disadvantages Disadvantages –Must apply correctly and consistently –May take longer for response than podofilox

48 Anal and Perianal Warts 25% women with vulvar warts have perianal warts 25% women with vulvar warts have perianal warts Vaginal-to-anal self-inoculation + microtrauma Vaginal-to-anal self-inoculation + microtrauma Intra-anal warts often 2 o to anoreceptive sex Intra-anal warts often 2 o to anoreceptive sex If perianal warts, examine for intra-anal warts If perianal warts, examine for intra-anal warts –Anal Pap; anoscopy if lesion extends upward Treatment Treatment –Imiquimod (Aldara) cream –Cryotherapy –TCA/BCA

49 Genital Warts: Complex Treatments CO 2 Laser CO 2 Laser –Extensive or refractory vulvar warts or VIN Topical 5-FU (Efudex): Topical 5-FU (Efudex): –Extensive intravaginal condylomata accuminata –Primary or recurrent VAIN Extensive surgical excision or electrocautery Extensive surgical excision or electrocautery –Extensive refractory lower genital tract lesions Interferon injections: Interferon injections: –Refractory vulvar lesions

50 VISITSCOSTS Visit Number NumberPts.Pct.Distrib.CumulativeDistrib.Pct.Distrib.CumulativeDistrib. 111523.0%23.0%11.2%11.2% 217034.0%57.0%24.7%35.8% 38717.4%74.4%17.8%53.7% 45210.4%84.8%13.6%67.2% 5285.6%90.4%9.2%76.4% >5489.6%100.0%23.6%100.0% PPFA Visit and Cost Distribution 46.4% 25.6%

51 PPFA First Line Treatment Analysis MAXIMUM First Line Therapy No. Patients Avg. Visits Avg. Cost VisitsCosts TCA3303.1$262.9317 $ 1,074.95 Cryotherapy913.0$440.7917 $ 2,443.30 Aldara422.4$234.789$705.35 TCA + Aldara 271.5$241.124$408.40 Cryo + Aldara 71.4$270.032$409.80 TCA + Condylox 23.5$305.166$457.86 Condylox16.0$457.866$457.86

52 First-time EGW Patient Recurrent Single location of lesions ? Yes Treat with TCA/Cryo TreatmentCompleted Aldara,withEducationMaterials Patient Presents with EGW Multiplelocations No EGW Treatment Algorithm No Yes Patient cleared in < 3 visits in < 3 visits

53 Vulvar Intraepithelial Neoplasia (VIN) Due to infection with HPV 18 or LSC (no HPV) Due to infection with HPV 18 or LSC (no HPV) Graded I-III, based upon severity of atypia Graded I-III, based upon severity of atypia Sxs: itching, burning, ulceration Sxs: itching, burning, ulceration 4 Ps 4 Ps –Papule formation: raised lesion –Pruritic: itching is prominent –Patriotic: red, white, or blue (hyperpigmented) –Parakeratosis on microscopy

54 Vulvar Intraepithelial Neoplasia Location Location –Multifocal: premenopause, imcompromised –Unifocal in postmenopause –May be multicentric Precursor to vulvar cancer; low hit rate Precursor to vulvar cancer; low hit rate Smoking cessation may improve outcome Smoking cessation may improve outcome Tx: Wide local excision, laser ablation Tx: Wide local excision, laser ablation Recurrence is common (48% at 15 years) Recurrence is common (48% at 15 years)

55 Differential Diagnosis: Dark Lesions Hyperpigmentation due to scarring Hyperpigmentation due to scarring Lentigo, benign genital melanosis Lentigo, benign genital melanosis Benign nevi Benign nevi VIN VIN Invasive squamous cell carcinoma Invasive squamous cell carcinoma Malignant melanoma Malignant melanoma

56 Vulvar Melanoma: ABCD Rule A: Asymmetry A: Asymmetry B: Border Irrigularities B: Border Irrigularities C: Color black or multicolored C: Color black or multicolored D: Diameter larger than 6 mm D: Diameter larger than 6 mm Any change in mole should arouse suspicion Any change in mole should arouse suspicion Biopsy mandatory when melanoma is a possibility Biopsy mandatory when melanoma is a possibility

57 Fox-Fordyce Disease Disorder of apocrine glands Disorder of apocrine glands Found on mons, labia majora, axilla Found on mons, labia majora, axilla Cyclic pruritis; improves with menopause Cyclic pruritis; improves with menopause Treatments: Treatments: –OCs –Retinoic acid

58 HidradenomaHidradenoma Milk line location (interlabial sulcus) Milk line location (interlabial sulcus) Benign tumor Benign tumor 0.5-2 cm diameter 0.5-2 cm diameter Solid consistency Solid consistency Often umbilicated center Often umbilicated center Non tender Non tender Treatment: shells out easily with excision Treatment: shells out easily with excision Path mimics adenocarcinoma Path mimics adenocarcinoma

59 Pagets Disease Occurs in milk line Occurs in milk line Extramammary disease may invovle genital, perianal and axillary areas Extramammary disease may invovle genital, perianal and axillary areas Lesions are brick red, scaly, velvety eczematoid plaque with sharp border Lesions are brick red, scaly, velvety eczematoid plaque with sharp border S/S: itching, burning, bleeding S/S: itching, burning, bleeding Cellular origin unclear Cellular origin unclear Treatment: excision with > 3 mm border from visible margin Treatment: excision with > 3 mm border from visible margin Local recurrence rate is 31-43% Local recurrence rate is 31-43%

60 Tips for Vulvar Biopsies Where to biopsy Where to biopsy –Homogeneous : one biopsy in center of lesion –Heterogeneous: biopsy each different lesions ELA-Max (10% lidocaine cream) applied 20-30 minutes pre-op may be sufficient for anesthesia ELA-Max (10% lidocaine cream) applied 20-30 minutes pre-op may be sufficient for anesthesia Skin local anesthesia Skin local anesthesia –Use smallest, sharpest needle: insulin syringe –Inject s-l-o-w-l-y –Most lesions will require ½ cc. lidocaine or less Stretch skin; rotate 3 or 4 mm Keyes punch Stretch skin; rotate 3 or 4 mm Keyes punch

61 Tips for Vulvar Biopsies Lift circle with forceps or needle; snip base Lift circle with forceps or needle; snip base Hemostasis with AgNO3 stick, Monsels, Gelfoam, hemostatic mesh Hemostasis with AgNO3 stick, Monsels, Gelfoam, hemostatic mesh Separate pathology container for each area biopsied Separate pathology container for each area biopsied

62 Chronic Vulvar Pain Syndromes Vestibulodynia (VBD): painful vestibule Vestibulodynia (VBD): painful vestibule –Vulvar vestibulitis syndrome Vulvodynia (VVD): painful vulva Vulvodynia (VVD): painful vulva –Dysesthetic (Essential) vulvodynia –Pudendal neuralgia Vulvar pain of known cause Vulvar pain of known cause –Lichen sclerosis, L planus, Behcet dz, Crohn dz –Dermatitis: allergic/ irritant/ eczema/ LSC –Infections: Candida, Herpes, Bartholinitis –Trauma, scarring

63 Vulvodynia: More Questions Than Answers Little agreement regarding definition, epidemiology, diagnosis, management, etiology, and Little agreement regarding definition, epidemiology, diagnosis, management, etiology, and Pressing need for large-scale, controlled studies to explore these issues in greater detail Pressing need for large-scale, controlled studies to explore these issues in greater detail Defined as chronic vulvar pain in which other pathologic etiologies have been ruled out, but duration of pain is not agreed upon Defined as chronic vulvar pain in which other pathologic etiologies have been ruled out, but duration of pain is not agreed upon –Pain lasting from 3 to 6 months is typically considered to be chronic

64 Percent of Women <25 25-3435-44 45-54 55-64 Age at First Onset (y) Vulvodynia: Age-Specific Incidence Harlow BL, Stewart EG. J Am Med Womens Assoc. 2003;58:82-88.

65 Vulvodynia: Ethnicity Percent of Women Hispanic African American White Asian Other Nonwhite Harlow BL, Stewart EG. J Am Med Womens Assoc. 2003;58:82-88.

66 Vulvodynia: Symptoms Pain – Knifelike; with genital area contact Pain – Knifelike; with genital area contact Itching – With or without pain Itching – With or without pain Burning – Persistent Burning – Persistent Dyspareunia – Pain and discomfort on penetration Dyspareunia – Pain and discomfort on penetration Sexual response – Hypervigilance for coital pain Sexual response – Hypervigilance for coital pain Skin changes – Erythema, scaling, fissures Skin changes – Erythema, scaling, fissures Sadownik LA. J Reprod Med. 2000;45:679-684; Hansen A, et al. J Reprod Med. 2002;47:854-860; Welsh BM, et al. Med J Aust. 2003;178:391-395; Payne KA, et al. Eur J Pain. 2005;9:427-436.

67 Vulvodynia: Psychosocial Assessment Women reporting vulvar and nonvulvar pain are twice as likely as asymptomatic women to report: Women reporting vulvar and nonvulvar pain are twice as likely as asymptomatic women to report: –History of depression (P<0.001) –Chronic vaginal infections (P<0.001) –Poorer quality of life (P<0.001) –Greater stress Strongest correlates of chronic vulvar pain are self- report of vaginal infections and stress Strongest correlates of chronic vulvar pain are self- report of vaginal infections and stress Bachmann GA, et al. J Reprod Med. 2006;51:3-9.

68 Work-up of Patient Presenting with Pain Only Vulvar vestibular syndrome likely (typically younger age)* Pain Alone Normal on examination Abnormalities on examination Pain localized and provoked by pressure Diagnosis depends on examination Pain poorly localized and spontaneous Dysesthetic vulvodynia likely (typically older age) Welsh BM et al. Management of common vulval conditions. MJA 2003; 178: 391-395. ©Copyright 2003. The Medical Journal of Australia - reproduced with permission.

69 VVS: Epidemiology 15% RA women: introitus painful to touch 15% RA women: introitus painful to touch –½ mild; doesnt affect activities –½ sig. dyspareunia; ½ asked for help VVS has two common times of onset VVS has two common times of onset –1 o VVS: onset as teen; present in mother –2 o VVS: onset post-partum; no family hx Many causes investigated, none proven Many causes investigated, none proven –Chronic candida, HPV not causes –Connection with interstitial cystitis

70 VVS: Presentation Symptoms Symptoms –Pain symptoms on touch or vaginal entry –Absence of symptoms during daily activities –Avoidance of pants with tight inseam –Avoidance of tampons due to insertional pain Signs Signs –Inflamed patches of skin or regions of vestibule –Positive swab test: »Intense pain during rolling of moistened cotton swab over red areas on vestibule »Skin beyond ½ cm of inflamed area non-tender

71 VVS: Diagnosis Definitive test for VVS (Goetsch ) Definitive test for VVS (Goetsch ) –Perform swab test –4% lidocaine with cotton app, wait a few minutes –Repeat test; if pain is sig. diminished, dx is VVS ISSVD diagnostic criteria ISSVD diagnostic criteria –Severe pain on touch or attempted entry –Tenderness to pressure localized within vestibule –Only finding is vestibular erythema –Symptoms must have been present for > 6 months –No evidence of vaginitis or vulvar dermatoses

72 Vulvar Pain, Burning: Diagnosis Pain mapping Pain mapping KOH suspension for candida KOH suspension for candida –If negative, culture and speciate Thats it!!!... Thats it!!!... In the absence of lesions, no role for In the absence of lesions, no role for –Vestibular or vulvar biopsy –HPV screening (Hybrid Capture) –HSV culture or antibody testing

73 VVS: Management Ineffective Therapies Antifungals Antifungals Topical or systemic antibiotics Topical or systemic antibiotics Antivirals (acyclovir) Antivirals (acyclovir) Dietary restriction of oxalates Dietary restriction of oxalates Interferon injections Interferon injections Laser therapy Laser therapy

74 VVS: Stepwise Approach to Treatment Vulvar skin care measures Vulvar skin care measures Topical steroids: estrogen, cortisone Topical steroids: estrogen, cortisone Local anesthetics Local anesthetics Neuropathic pain medications Neuropathic pain medications –Tricyclic antidepressants –Anti-seizure drugs Physical therapy and biofeedback Physical therapy and biofeedback Surgery Surgery –Vestibulectomy

75 Vulvar Pain Measures Acute pain: ice pack applied to vulva Acute pain: ice pack applied to vulva Episodic relief (30 minutes before intercourse) Episodic relief (30 minutes before intercourse) –Lidocaine »Xylocaine jelly 2%, Xylocaine ointment 5% –EMLA cream (lidocaine 2.5% + prilocaine 2.5%) –L-M-X 4 Cream (4% lidocaine) –L-M-X 5 Anorectal Cream (5% lidocaine) –Dispense 30 gm tube; limit to 2.5 gm/application –Avoid oral contact of partner Avoid benzocaine, diphenhydramine additives Avoid benzocaine, diphenhydramine additives

76 Vulvar Pain Measures Overnight topical anesthetics Overnight topical anesthetics –Apply ointment to introitus + vaginal cotton ball Topical sedatives for relief if itching Topical sedatives for relief if itching –Doxepin (Zonalon) 5% cream –Start once a day, then work up Systemic Systemic –Tricyclics: amitriptyline (10-25 mg) QHS »Nortriptyline, desipramine fewer side effects –Anticonvulsants »Gabapentin (Neurontin), carbamazepine (Tegretol)

77 Tricyclics for Vulvar Pain Must take daily, not as needed Must take daily, not as needed May take weeks to kick-in May take weeks to kick-in May have good days and bad days, even with tx May have good days and bad days, even with tx Start at low dose, then work up every week Start at low dose, then work up every week –Start with 10 mg…progress to 100-150 mg. Because of sedation, dry mouth, take at bedtime Because of sedation, dry mouth, take at bedtime –If excessively tired in am, take after dinner Once pain is controlled, slowly taper Once pain is controlled, slowly taper –If too fast, get bounce-back pain, nausea, fatigue

78 VVS: Surgical Therapy Woodruffs vestibulectomy (perineoplasty) Woodruffs vestibulectomy (perineoplasty) –Surgical excision of vestibule, with undermining of vagina and pull through to cover defect –60-89% cure rate Adverse effects Adverse effects –Removal of glands necessary for sexual lubrication –1 month recovery –Scar tissue; May mildly disfigure vulva –Potential recurrence of symptoms after 6 months

79 Vulvar Vestibulitis: Surgery Masheb RM, Nash JM, Brondolo E, Kerns RD. Pain. 2000;86:3-10. Glazer HI, et al. J Reprod Med. 1995;40:283-290. At 6-month follow-up, 60% to 89% of patients show improvement and approximately 10% have deteriorated At 6-month follow-up, 60% to 89% of patients show improvement and approximately 10% have deteriorated Higher SES, older age, and participation in psychological evaluation/postoperative sex therapy predict better outcomes Higher SES, older age, and participation in psychological evaluation/postoperative sex therapy predict better outcomes Childlessness, deep dyspareunia, and diffuse genital pain predict poor outcomes Childlessness, deep dyspareunia, and diffuse genital pain predict poor outcomes

80 Essential Vulvodynia Pudendal neuralgia is likely cause Pudendal neuralgia is likely cause Seen mainly in older women Seen mainly in older women Presentation Presentation –Poorly localized pain; diffuse and variable hypersensitivity –May cause constant, unremitting burning –Altered perception to light touch –Vulva and introitus appear normal –No effect of topical lidocaine Treatment Treatment –Low dose TCAD:desipramine, imipramine, amitriptylene –Gabapentin, carbamazepine, venlafaxine

81 Posterior Fourchette Fissure Tender shallow ulcer or fissure at 6 oclock of introitus Tender shallow ulcer or fissure at 6 oclock of introitus Causes severe dyspareunia (or apareunia) Causes severe dyspareunia (or apareunia) –Paper cut acute pain Possible causes Possible causes –LS, apthosis, chronic candida, OB laceration, ? atrophy Diagnosis: biopsy usually not helpful Diagnosis: biopsy usually not helpful

82 Posterior Fourchette Fissure Management Management –Emollients and moisturizers –Elamax cream 30 min before intercourse –Water or oil-based lubricant with intercourse –High potency topical steroids; steroid injection » Cox: add topical estrogen (Estrace) cream to corticosteroid –Local destruction (AgNO 3 or electrocautery) –Surgery: perineoplasty, Y-V flap

83 - National Vulvodynia Associationn www.nva.org - www.thevbook.com Resources V Book chapters: V Book chapters: It Hurts It Hurts Sexual Healing Sexual Healing V Book chapters: V Book chapters: It Hurts It Hurts Sexual Healing Sexual Healing

84 The Vulvodynia Guideline Haefner, HK, et al. Journal of Lower Genital Tract Disease 2005; 9:40-51 Haefner, HK, et al. Journal of Lower Genital Tract Disease 2005; 9:40-51 www.jlgtd.com www.jlgtd.com www.jlgtd.com –Links and Resources »ASCCP guidelines »The Vulvodynia Guideline PolicarLectures.com PolicarLectures.com –Reproductive HC links –Vulvar Skin Conditions and Colposcopy

85 Patient Resources International Society for the Study of Vulvovaginal Disease: www.issvd.org International Society for the Study of Vulvovaginal Disease: www.issvd.org National Vulvodynia Association: www.nva.org National Vulvodynia Association: www.nva.org Vulvar Pain Foundation: www.vulvarpainfoundation.org Vulvar Pain Foundation: www.vulvarpainfoundation.org Interstitial Cystitis Association: www.ichelp.org Interstitial Cystitis Association: www.ichelp.org

86 Bartholin Duct Conditions Bartholin duct and gland at 5, 7 oclock cephalad (deep) to hymeneal ring Bartholin duct and gland at 5, 7 oclock cephalad (deep) to hymeneal ring Makes serous secretion to lubricate introitus Makes serous secretion to lubricate introitus If BG duct is transected or blocked, fluid accumulates If BG duct is transected or blocked, fluid accumulates –Non-infected: BD cyst –Infected: BD abcess or cellulitis All treatments are designed to drain and create a new duct All treatments are designed to drain and create a new duct

87 Bartholin Duct: Infectious Conditions Bartholin duct cellulitis Bartholin duct cellulitis –Red induration of latl perinuem, no abcess –Most commonly due to skin streptococcus –Tx: PO cephalosporin, moist heat –Will either resolve or point as abcess –Treat immunecompromised women aggressively Bartholin duct abcess Bartholin duct abcess –Fluctulent abcess; pus with needle aspiration –Tx: I&D, insert Word catheter x 6 weeks –Culture pus for gonorrhea –Cephalosporin if cellulitis; metronidazole if anaerobic

88 Bartholin Duct: Non Infectious Bartholin duct cyst Bartholin duct cyst –Nontender cystic mass –Treat only if symptomatic or recurrent –Tx: marsupialize or insert Word catheter x 6 weeks Bartholin duct carcinoma Bartholin duct carcinoma –Most common in women over 40 –Can be adenoca, transitional cell, or squamous cell –Firm non-tender mass in region of Bartholin gland –Suspect if recurrent BD cyst or abcess with firm base after drainage

89 Vulvar Ulcer: Differential Diagnosis Genital Herpes Genital Herpes Syphilis Syphilis Chancroid Chancroid Tropical STD: granuloma inguinale, LGV Tropical STD: granuloma inguinale, LGV Behcets Disease: mouth, eye, genital ulcers Behcets Disease: mouth, eye, genital ulcers Crohns Disease: Crohns Disease: – Knife-cut ulcers, GI-cutaneous fistulae Lichen planus, lichen sclerosus Lichen planus, lichen sclerosus

90 Genital Ulcers: Management Syphilis Syphilis –VDRL or RPR Chancroid Chancroid –Test for H ducreyi (culture, PCR, DNA) Herpes simplex Herpes simplex –Early lesion: HSV culture, PCR, or DFA –Late lesion: DFA or cytology –Type-specific HSV serology Biopsy if Bechets or Crohns suspected Biopsy if Bechets or Crohns suspected Presumptively treat for best guess or syphilis + chancroid Presumptively treat for best guess or syphilis + chancroid

91 ChancroidChancroid Due to Hemophilis ducreyi Due to Hemophilis ducreyi 10% also have syphilis or herpes 10% also have syphilis or herpes –Co-factor for HIV infection Symptoms/ signs Symptoms/ signs –One or more painful genital ulcers –Regional adenopathy; may suppurate (buboe) Lab: culture <80% sensitive; contact lab before sampling Lab: culture <80% sensitive; contact lab before sampling Treatment Treatment –Azithromycin 1 gram PO –Ceftriaxone 250 mg IM F/U in 7 days; treat partners within 10 days F/U in 7 days; treat partners within 10 days

92 Herpes Simplex Virus: Organism Tests Sensit Specif Cost Comment PCR +4+4 $$$$ Not in most labs HSV culture ELVIS rapid +3+4$$$ No typing ELVIS rapid +3+4$$$ No typing ELVIS std +3+4 $$$ Reflex typing ELVIS std +3+4 $$$ Reflex typing Cytopathic +3+3 $$ Phasing out Cytopathic +3+3 $$ Phasing out Herpes DFA +2+3$$ Scrape; plate Cytology +1+3$$ Scrape; plate

93 Herpes Simplex Virus Serologic Tests Use only type-specific tests for HSV-2 antibody Use only type-specific tests for HSV-2 antibody –Almost all HSV-2 is sexually acquired –HSV-1 antibody orolabial or genitally acquired Envelope glycoprotein G (gG) HSV-type specific assays Envelope glycoprotein G (gG) HSV-type specific assays – HerpeSelect-1 ELISA or HerpeSelect-2 ELISA – HerpeSelect-1 and 2 Immunoblot G – POCkit HSV-2, biokitHSV-2 (point of care) Sensitivity: 80-98%; specificity > 96% Sensitivity: 80-98%; specificity > 96%

94 HSV-2 Serologic Diagnostic Testing History suggestive of HSV but no lesions to test History suggestive of HSV but no lesions to test –If seronegative, not due to genital herpes –If seropositive, HSV lesion or prior infection Culture negative recurrent lesion Culture negative recurrent lesion –If seronegative, not due to genital herpes –If seropositive, HSV lesion or prior infection Suspected 1 o herpes, if initial testing negative and more than 6 weeks prior Suspected 1 o herpes, if initial testing negative and more than 6 weeks prior –If seronegative, not due to genital herpes –If seropositive, HSV infection confirmed

95 HSV-2 Serologic Screening Screen general population Should not be offered Universal screening in pregnancy Should not be offered Screening in HIV-positive patients Should generally be offered Screening in patients in partnerships with HSV-2 infected people Should generally be offered Screening in patients at risk for STD/HIV Should be offered to select patients Guidelines for the Use of HSV-2 Type-Specific Serologies, CA DHS 2003

96 HSV-2 Serologic Screening At risk for STD/HIV (current STD or HR behavior), offer to select patients [C] if: At risk for STD/HIV (current STD or HR behavior), offer to select patients [C] if: –Patient is motivated to reduce risky behavior –Patient is willing to use condoms or Rx consistently –Risk reduction counseling will be provided Arguments against screening Arguments against screening –Limited evidence that counseling or Rx works –Limited evidence that condoms will be used –Little value if risk reduction counseling not given

97 Transmission of HSV-2 to Susceptible Partners with Suppressive Therapy Corey et al, NEJM 2004; 350:11-20 Control Group (N=741) Valacyclovir Group (N=743) RCT of 1,484 hetero couples Valacyclovir 500 mg QD or placebo QD for 8 monthsValacyclovir 500 mg QD or placebo QD for 8 months Monthly HSV serology for susceptible partnersMonthly HSV serology for susceptible partners The valacyclovir group showed 47% less HSV-2 transmission47% less HSV-2 transmission Lower frequency of sheddingLower frequency of shedding Fewer copies of HSV-2 DNA when shedding occurredFewer copies of HSV-2 DNA when shedding occurred

98 Prevention of Genital Herpes Incident HSV infection reduced by 1.7% over 1 year Incident HSV infection reduced by 1.7% over 1 year –96.4% dont seroconvert in absence of treatment – 1.9% seroconvert with treatment – Must treat 59 people to prevent one case/ year Indications may include Indications may include –Discordant couples (reassess annually) –Infected persons with multiple partners –MSM –HIV-positive Counsel regarding condoms, disclosure, abstinence Counsel regarding condoms, disclosure, abstinence * Discussed at the 2006 Guidelines Meeting

99 Genital Herpes and Antiviral Drugs Primary Herpes Primary Herpes –Shortens median duration of lesions by 3-5 days »Therefore, initiate within 6 days of onset –May decrease systemic symptoms –No effect on subsequent risk, frequency, or severity of recurrences Recurrent Herpes Recurrent Herpes –Shortens the mean duration by 1 day –Initiate meds within 2 days of onset »Best to start with onset of prodromal symptoms »Patient should have supply of meds available

100 HSV: Adjunctive Therapy Frequent dosing of NSAID (ibuprofen) or aspirin Frequent dosing of NSAID (ibuprofen) or aspirin Sitz baths (TID) in cool or warm water or use milk compresses Sitz baths (TID) in cool or warm water or use milk compresses Burrows solution sitz baths (Domeboro) or Burrows compresses Burrows solution sitz baths (Domeboro) or Burrows compresses To avoid towel drying, use the cool setting of a hand dryer To avoid towel drying, use the cool setting of a hand dryer If urinary tract symptoms prominent, urinate in warm sitz bath If urinary tract symptoms prominent, urinate in warm sitz bath Topical local anesthetics may provide limited relief Topical local anesthetics may provide limited relief

101 HSV: Suppression Therapy Acyclovir given continuously to decrease frequency, severity of outbreaks Acyclovir given continuously to decrease frequency, severity of outbreaks –Studies have shown befeficial effect for up to five years –Will not affect natural history of HSV infection –Prior pattern of recurrences after discontinuation Used for those with >6 recurrences per year Used for those with >6 recurrences per year After 1 year, discontinue to allow assessment of recurrent episodes After 1 year, discontinue to allow assessment of recurrent episodes Most widely used regimen is acyclovir 400 mg PO BID; may be increased to 3-5 times per day Most widely used regimen is acyclovir 400 mg PO BID; may be increased to 3-5 times per day

102 Management of Vulvar Hematoma Almost all are due to straddle injuries Almost all are due to straddle injuries Initial management Initial management –Pressure –Ice packs –Watchful waiting Complex management Complex management –Use if extreme pain or failure of conservative mgt –Incise inside hymeneal ring, evacuate clots –Pack with strip gauze, sitzbaths

103 Additional References Marzano DA, The bartholin gland cyst: past, present, and future. J Low Genit Tract Dis 2004 Jul;8(3):195-204 Marzano DA, The bartholin gland cyst: past, present, and future. J Low Genit Tract Dis 2004 Jul;8(3):195-204 Bauer A, Vulvar dermatoses--irritant and allergic contact dermatitis of the vulva. Dermatology 2005;210(2):143-9. Bauer A, Vulvar dermatoses--irritant and allergic contact dermatitis of the vulva. Dermatology 2005;210(2):143-9. Smith YR, Vulvar lichen sclerosus : pathophysiology and treatment. Am J Clin Dermatol. 2004;5(2):105-25. Smith YR, Vulvar lichen sclerosus : pathophysiology and treatment. Am J Clin Dermatol. 2004;5(2):105-25. Fischer G, Management of vulvar pain. Dermatol Ther 2004;17(1):134-49. Fischer G, Management of vulvar pain. Dermatol Ther 2004;17(1):134-49. Edwards L, Vulvar fissures: causes and therapy. Dermatol Ther 2004;17(1):111-6 Edwards L, Vulvar fissures: causes and therapy. Dermatol Ther 2004;17(1):111-6 Foster DC, Vulvar disease. Obstet Gynecol 2002; 100(1): 145-63. Foster DC, Vulvar disease. Obstet Gynecol 2002; 100(1): 145-63.


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