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Evaluation and Management of Vulvar Disease, An Issue of Obstetrics and Gynecology Clinics, E-Book

Evaluation and Management of Vulvar Disease, An Issue of Obstetrics and Gynecology Clinics, E-Book

Aruna Venkatesan

(2017)

Additional Information

Book Details

Abstract

Vulvar disorders are prevalent but often overlooked conditions in the curricula of obstetrics and gynecology, dermatology, and primary care residency training programs. This has led many outpatient clinicians to feel unprepared to evaluate the patient with a vulvar complaint. Often patients with complex, chronic vulvar disorders have seen multiple providers in consultation before they are appropriately diagnosed and treated, leading to frustration amongst patients and providers alike as well as excessive health care costs. The goal of this issue is to present a practical review on vulvar disease for outpatient clinicians to improve patient care. The topics highlighted in this issue represent gaps in knowledge among residents, fellows, providers, and course and conference attendees. The issue begins with a general approach to the evaluation and management of vulvar disorders and  then moves on to an article on vulvar pathology that will help clinicians obtain the most useful pathology reads from their biopsies. Also addressed are specific vulvar disorders or presenting findings that are common or challenging. A pelvic floor physical therapy colleague provides information on how this modality can help manage vulvar pain. The issue concludes with an article on hot topics in vulvar disease. In the last several years there has been a growing number of newly trained physicians committed to advancing patient care in the area of vulvar disease, and many of this issue’s authors are part of this group. This issue should serve as a useful resource in the office of any provider who evaluates patients with vulvar complaints.

Table of Contents

Section Title Page Action Price
Front Cover Cover
Evaluation and\rManagement of Vulvar\rDisease\r i
Contributors iii
CONSULTING EDITOR iii
EDITOR iii
AUTHORS iii
Contents v
Foreword: Differentiating Between Normal, Benign, and Potentially Serious Vulvar Conditions v
Preface: Evaluation and Management of Vulvar Disease v
A General Approach to the Evaluation and the Management of Vulvar Disorders v
High-Yield Vulvar Histopathology for the Clinician v
Vulvar Neoplasms, Benign and Malignant v
Red Rashes of the Vulva vi
Atopic and Contact Dermatitis of the Vulva vi
Vulvar Pruritus and Lichen Simplex Chronicus vi
Genital Lichen Sclerosus and its Mimics vi
Erosive Lichen Planus vii
Fissures, Herpes Simplex Virus, and Drug Reactions: Important Erosive Vulvar Disorders vii
A Clinical Approach to Vulvar Ulcers vii
Challenging Ulcerative Vulvar Conditions: Hidradenitis Suppurativa, Crohn Disease, and Aphthous Ulcers vii
Vulvovaginal Graft-Versus-Host Disease viii
Vulvodynia: Diagnosis and Management viii
Pelvic Floor Physical Therapy for Vulvodynia: A Clinician’s Guide viii
OBSTETRICS AND GYNECOLOGY CLINICS\r ix
FORTHCOMING ISSUES ix
December 2017 ix
March 2018 ix
June 2018 ix
RECENT ISSUES ix
June 2017 ix
March 2017 ix
December 2016 ix
Foreword:\rifferentiating Between Normal, Benign, and Potentially Serious Vulvar Conditions xi
Preface:\rEvaluation and Management of Vulvar Disease xiii
A General Approach to the Evaluation and the Management of Vulvar Disorders 321
Key points 321
CLINICAL HISTORY 321
ANATOMY 322
EXAMINATION 323
ANCILLARY TESTS 324
DIAGNOSTIC PROCEDURES 325
REFERENCES 326
High-Yield Vulvar Histopathology for the Clinician 329
Key points 329
INTRODUCTION 329
PERFORMING BIOPSIES 330
Punch Biopsy 330
Curved Iris Scissors 330
Shave Biopsy 330
Kevorkian Biopsy 331
Specific Considerations Based on Type of Lesion 331
Ulcers 331
Lichen planus 331
Immunobullous disorders 331
Avoiding Artifacts from Tissue Manipulation 332
Fixation 332
FILLING OUT THE REQUISITION FORM 333
READING THE PATHOLOGY REPORT 335
Recognizing Potential Poor Clinical and Histopathologic Correlation 335
Considering Effect of Previous Treatment 336
Use Current Terminology 336
SUMMARY 336
REFERENCES 336
Vulvar Neoplasms, Benign and Malignant 339
Key points 339
VULVAR PIGMENTED LESIONS 339
BENIGN PIGMENTED VULVAR LESIONS 339
MELANOTIC MACULES 340
VULVAR MELANOSIS 341
DYSPLASTIC NEVI AND ATYPICAL NEVI OF THE GENITAL TYPE 341
RECURRENT NEVI 341
MALIGNANT LIGMENTED VULVAR LESIONS 342
Melanoma 342
DIAGNOSIS 342
TREATMENT 342
NON MELANOMA SKIN MANCERS 343
Basal cell carcinoma 343
PAGET DISEASE 343
Background 343
Diagnosis 344
Treatment 344
Prognosis 346
Premalignant Vulvar Disease, High-Grade Intraepithelial Lesion, and Differential Vulvar Intraepithelial Neoplasia 346
HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESIONS 347
HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION TREATMENT 347
DIFFERENTIATED VULVAR INTRAEPITHELIAL NEOPLASIA 348
Diagnosis 348
SQUAMOUS CELL CARCINOMA 349
Treatment 349
REFERENCES 350
Red Rashes of the Vulva 353
Key points 353
NEOPLASMS 353
Squamous Intraepithelial Lesions of the Vulva: High and Low-grade Squamous Intraepithelial Lesions of the Vulva and Differe ... 353
Treatment of low-grade squamous intraepithelial lesion/condyloma 355
Treatment of high-grade squamous intraepithelial lesion/differentiated vulvar intraepithelial neoplasia 356
Paget Disease of the Vulva 358
INFLAMMATORY 361
Psoriasis 361
Seborrheic Dermatitis 362
Eczema 363
Contact Dermatitis 363
INFECTIOUS 365
Candidiasis 365
Tinea 367
Perianal Streptococcal Disease 368
Erythrasma 369
REFERENCES 369
Atopic and Contact Dermatitis of the Vulva 371
Key points 371
ATOPIC DERMATITIS 371
Diagnostic Evaluation 372
Management 372
Eliminating irritant and allergen exposure 373
Controlling pruritus 373
Repairing barrier function 373
Applying topical antiinflammatories 374
IRRITANT AND ALLERGIC CONTACT DERMATITIS 374
Definitions 374
The Vulva as a High-Risk Site 374
Diagnostic Evaluation 375
Management 377
SUMMARY 377
REFERENCES 377
Vulvar Pruritus and Lichen Simplex Chronicus 379
Key points 379
INTRODUCTION: NATURE OF THE PROBLEM 379
HISTORY 380
PHYSICAL EXAMINATION 381
DIAGNOSIS 383
Skin Scraping 383
Wet Mount 383
Skin Biopsy 384
TREATMENT 384
Nonpharmacologic Treatment Options 385
Combination Therapies 386
Treatment Resistance or Complications 386
EVALUATION OF OUTCOME AND LONG-TERM RECOMMENDATIONS 387
SUMMARY 387
REFERENCES 387
Genital Lichen Sclerosus and its Mimics 389
Key points 389
INTRODUCTION 389
CLINICAL MANIFESTATIONS 389
DIAGNOSIS 390
MANAGEMENT 393
DIFFERENTIAL DIAGNOSES 394
Lichen Planus 395
Lichen Simplex Chronicus 395
Endogenous and Exogenous Dermatitis 397
Estrogen Deficiency 397
Vitiligo 398
Candidiasis 399
Psoriasis 399
Paget Disease 400
Mucous Membrane Pemphigoid 404
SUMMARY 404
REFERENCES 404
Erosive Lichen Planus 407
Key points 407
INTRODUCTION 407
PATIENT HISTORY 407
Vulvar Disease 407
Oral Disease 408
Other Mucosal Sites 408
Psychosocial History 408
PHYSICAL EXAMINATION 408
Vulvovaginal Examination 408
Oral Examination 410
Other Common Locations 411
Additional Testing: Biopsy 411
Histopathology 412
Diagnostic Criteria 412
PHARMACOLOGIC TREATMENT OPTIONS 413
Local Treatment 413
Topical corticosteroids 413
Topical calcineurin inhibitors 413
Systemic treatments 414
Corticosteroids 414
Methotrexate 414
Mycophenolate mofetil 414
Hydroxychloroquine 414
Naturopathic therapies 416
Oral curcuminoids 416
Zinc 416
NONPHARMACOLOGIC TREATMENT OPTIONS 416
Photodynamic Therapy 416
LASER THERAPY 416
COMBINATION THERAPIES 417
TREATMENT RESISTANCE AND COMPLICATIONS 417
SURGICAL TREATMENT OPTIONS 417
EVALUATION OF OUTCOME AND LONG-TERM RECOMMENDATIONS 417
DEVELOPMENT OF SQUAMOUS CELL CARCINOMA 418
Monitoring Guidelines 418
Impact on Quality of Life 418
Vulvodynia 418
SUMMARY 418
REFERENCES 419
Fissures, Herpes Simplex Virus, and Drug Reactions 421
Key points 421
GENERAL CONSIDERATIONS 421
FISSURES 426
Splitting at the Posterior Fourchette 426
Fissures Within Interlabial Sulci and Other Folds 427
DRUG REACTIONS AFFECTING THE VULVA 428
FIXED DRUG ERUPTION 428
Histopathological Findings 429
Investigations 429
Management 429
STEVENS-JOHNSON SYNDROME/TOXIC EPIDERMAL NECROSIS AND ERYTHEMA MULTIFORME MAJUS 430
Pathogenesis 430
Histopathology 430
Assessment and Management 430
Treatment 433
Genitourinary care 433
HERPES SIMPLEX INFECTION: HERPES VIRUS 1 AND 2, VARICELLA ZOSTER VIRUS 434
Epidemiology 435
Primary Herpes Simplex Genitalis 436
Recurrent Herpes Simplex Genitalis 437
Herpes Simplex Genitalis in Immunocompromised Women 437
Herpes Simplex Genitalis Investigations and Therapy 439
Complications of Herpes Simplex Genitalis More Common in Immunocompromised Individuals 439
Varicella Zoster Virus Infection 439
SUMMARY 440
REFERENCES 440
A Clinical Approach to Vulvar Ulcers 445
Key points 445
VULVAR ULCERS 445
Background 445
Patient History 446
Physical Examination 446
Approach to the Patient, Evaluation, and Work-Up 449
ACKNOWLEDGMENTS 450
REFERENCES 450
Challenging Ulcerative Vulvar Conditions 453
Key points 453
HIDRADENITIS SUPPURATIVA 453
History and Physical Examination 455
Approach to the Patient: Evaluation and Workup 455
Management 456
METASTATIC CROHN DISEASE OF THE VULVA 462
History and Physical Examination 463
Approach to the Patient: Evaluation and Workup 463
Management 465
VULVAR APHTHOUS ULCERS 465
History and Physical Examination 467
Approach to the Patient: Evaluation and Workup 467
Management 468
ACKNOWLEDGMENTS 469
REFERENCES 469
Vulvovaginal Graft-Versus-Host Disease 475
Key points 475
INTRODUCTION 475
PATHOPHYSIOLOGY 475
EPIDEMIOLOGY 476
CLINICAL FEATURES 477
DIAGNOSTIC CRITERIA 479
Biopsy and Histology 481
DIFFERENTIAL DIAGNOSES 482
MANAGEMENT OF CHRONIC GRAFT-VERSUS-HOST DISEASE 483
IATROGENIC EFFECTS AND POTENTIAL COMPLICATIONS 486
SUPPORTIVE CARE 486
PREVENTION AND SURVEILLANCE 487
SUMMARY 488
REFERENCES 488
Vulvodynia 493
Key points 493
INTRODUCTION 494
CAUSE OF VULVODYNIA 495
DIAGNOSIS 495
History 495
Pain History 496
Sexual History 496
Medical History 496
Physical Examination 497
Vulvar Inspection 497
Sensory Examination: Cotton Swab Test 497
Speculum Examination 499
Manual Examination 499
Laboratory and Point-of-Care Testing 499
Management 500
Promotion of Vulvar Health 500
Psychological Interventions 501
Alternative Therapy 502
Physical Therapy 502
MEDICAL MANAGEMENT OF VULVODYNIA 502
Local Therapy 502
Oral Medication 503
Surgical Management of Provoked Vestibulodynia 504
Summary of Treatment Options 506
SUMMARY 506
REFERENCES 506
Pelvic Floor Physical Therapy for Vulvodynia 509
Key points 509
INTRODUCTION OF NEW NOMENCLATURE 509
PREVALENCE OF MUSCULOSKELETAL IMPAIRMENTS IN WOMEN WITH VULVODYNIA 510
PELVIC FLOOR ANATOMY AND PHYSIOLOGY 511
PATIENT HISTORY 513
PHYSICAL THERAPY EXAMINATION 513
SKIN INSPECTION AND INTERNAL EXAMINATION 515
Skin Inspection 515
Internal Pelvic Floor Muscle Examination 515
General considerations for the pelvic floor examination 516
PHYSICAL THERAPY ASSESSMENT AND TREATMENT PLAN 517
CASE EXAMPLES 518
ASSESSMENT AND TREATMENT 519
EVIDENCE FOR PHYSICAL THERAPY TREATMENT 519
SUMMARY 521
HOW TO FIND A PELVIC FLOOR PHYSICAL THERAPIST 521
REFERENCES 522