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