TEALE FENNING

Nick Raine-Fenning

Gynaecology 3: March 2008

A 62 year old woman presents with vulval atrophy, superficial ulceration and leucoplakia;

What would you want to know from her history (9 marks)

What investigations are important (4 marks)

You rule out neoplasia what would you do short term (3 marks) and long term (4 marks)

Nick Raine-Fenning · Posted: Wed Apr 02, 2008 8:38 pm Post subject:

There has been some discussion about this question / subject already - click here to read more.

Xerxes I · Posted: Fri Apr 04, 2008 8:02 am Post subject:

A 62 year old woman presents with vulval atrophy, superficial ulceration and leucoplakia;

What would you want to know from her history (9 marks)

Vulval cancer is a very rare gynaecological cancer but it should be ruled out in all cases presenting with suspicious vulvar lesion.

This lesion is more likely to be benign (most likely lichen sclerosus or candidiasis) but as there is a 3% risk of malignant changes in the background of lichen sclerosus, questions should be asked about the character of the lesion.

The time of onset and speed of growth of the lesion should be sought. a chronic lesion with little change over time is less likely to be of sinister nature. Vulvar lesios, howevere are missed sometimes by the patient and are not noticed for a long time, especially is they are not sexually active. Sexual history should be taken with special consideration to concurrent pain, dryness and postcoital bleeding. This is important when planning the management and in case surgery becomes necessary and also can provide more information about the likely underlying pathology.
It is important to note whether the lesionis or has recently become painful or itchy. details of its change in colour contour nd consitency should be asked if known. Has there been such a lesion in that area whn she was younger? does she know any other family member with similar problem.

History of concurrent diseasse is both important to reach the diagnosis and also to establish fitness for any surgery if needd. Polyuria and polydypsia are suggestive of diabetes mellitus wich makes the person susceptible to candidiasis. History of recurrnt inections can be suggestive of immunodeficiencies which points towards candidiasis.

History of recurrent oral mucosa ulcers may be suggestive of Behjet's disease. Presence or history of other autoimmune diseases point towards Lichen sclerosus. History of any significant illness including cardiovascular , renal or respiratory disease is important when considering surgery.

Significant weight loss raises the alarms for malignant condition. Vulvar cancer is linked to cervical cancer and HPV infection in some cases, therefore a history of cervical smears and any cervical pathology should be sought. genital atrophy can also cause frequence and dysuria.

Any lumps in the groins? history of smoking?

What investigations are important (4 marks)

Biopsy and histology is the gold standard investigation as it can diagnose or rule out malignncy. this should ideally be done under general anesthesia so that examination under anaesthesia could be possible and sufficient samples obtaines.
A cervical smear should be taken if not up to date and presence or absence of lymphadenopathy especially in inguinal region should be ascertained.

High vaginal swabs and swabs from the ulcer should be sent for culture and sensitivity to diagnse any infectious cause, especially candidiasis.

You rule out neoplasia what would you do short term (3 marks) and long term (4 marks)
if candida infection, treat with oral or topical fluconazole. If undrlying cause, sort out. If lichen, steroid different potencies. If sex a problem, graduated dilators. local oestrogen no role in lichen but will help with atrophy and sexual function and dryness etc.

3% risk of malignant chnges. regular visits, patient information, let them know what the wrrying signs are. leaflets, support groups, lubricants, etc

Abik · Posted: Thu Aug 14, 2008 6:00 pm Post subject:

can't believe they wrote leukoplakia - I thought this word was obsolete.

History-

itching? soreness? dyspareunia? discharge? bleeding?
how long has she had it?
what has she tried and did anything help?
has anyone given her a previous diagnosis - LS, LP, cancer?
impact on QOL
scratching at night?

other skin diseases? psoriasis, eczema, LS elsewhere
sore mouth?
nail problems

washing habits - bath/shower
soaps/shampoos
baby wipes/ dettol in the bath!

drug history, allergies
PMH
cervical smear history (DD includes VIN)

investigations?

actually probably none at first - this is likely to be a clinical diagnosis and the use of empirical treatment if diagnosis confident on examination is well accepted.
many people will do a biopsy to confirm diagnosis and exclude SCC
also need ferritin (assoc with LS), glucose,

treatment

I still think this question is rubbish.
I assume they are tryin to lead you towards lichen sclerosis as the most probable diagnosis.
short term she need to aviod irritants - soaps, panty liners, wet wipes and use an emoillient to wash with and to soothe eg aqueous, cetamacrogol. A potent topical steriod should be used if LS, LP, eczema, lichen simplex or chronic inflammation - dermovate daily for a month then alt days then prn
she shuld be reviewed in 3 months to confrim response

long term she should be told to coninue with emoillient and steriod prn if working. if symptoms not controlled will ned to be seen back in clinic or by vulval specialist
if controled warned to see GP if lump, non-healing ulcer, bleeding, uncontroled sx and warned of small risk of cancer. no evidence of need for long term f/u