Vulvar Assessment

Which of the following diagnosis does NOT typically present as a hyperpigmented vulvar lesion?

The differential diagnosis of hyperpigmented lesions on the vulva depends on the clinical morphology.
Choose the best answer:

Vulvar melanosis: Choose the best answer.

Dysplastic nevi: Choose the best answer.

Hyperpigmented vulvar patches and plaques can include the following differential diagnoses:

Vulvodynia is defined is vulvar pain without clear identifiable cause with a duration of at least: Choose the best answer.

Vulvodynia is best characterized by all the following descriptors, except: Choose the best answer.

32yo G2P2 presents reporting 6-month history of clitoral pain. She reports severe discomfort as soon as the clitoris is touched with slow spontaneous resolution of pain over approximatel ly one hour. She had a vaginal delivery of a 4500-gram infant 9 months ago. Prior to the delivery, she denies having vulvar pain or dyspareunia. Which vulvodynia descriptors would characterize this patient’s presentation?

Physical examination of patients with vulvodynia should include the following, except: Choose the best answer.

A 40-year-old patient presents with multiple mildly pruritic lesions on the vulva for 6 months. She reports a slight increase in size. The patient’s history is significant for smoking and asthma . She has a history of previously undergoing a cone biopsy of the cervix. On exam, there are multiple irregular pigmented papules on a large portion of her vulva. Which of the following is the most appropriate next step in establishing the diagnosis? Choose the best answer.

A biopsy of one of the pigmented mamillated papules shows full thickness epithelial dysmaturation with block positive p16 staining. Which is the most likely diagnosis? Choose the best answer.

In the future, even after successful vulvar treatment, this patient is at risk for which of the following?
Choose the best answer.

A 70-year-old woman with a 10-year history of lichen sclerosus has used topical steroids intermittently.

She discontinues topical steroids when she is asymptomatic despite medical advice. She presents 2 years after her last follow up for medication refill and exam. On exam, there are atrophic white plaques with partial resorption of the labia minora and burying of the clitoris. A 7mm scaling white plaque is present left of the clitoris. Biopsy of the white plaque shows inter-anastomosing elongated rete ridges with premature squamatization, including keratin pearl formation in rete ridges, basal layer mitotic figures and prominent intercellular spaces between epithelial cells. Which is the most likely diagnosis?

Choose the best answer.

Which of the following are risk factors for developing HPV independent squamous cell carcinoma?

A 55-year-old woman presents with 6 months of vulvar burning, severe dyspareunia and increased vaginal discharge. She had undergone a hysterectomy 10 years ago. She has not had a previous abnormal pap test; otherwise, her medical history is unremarkable. On exam there is a 2 cm erythematous, glazed, well-demarcated patch with white reticulated thin papules and plaques on her left labium minus. Her labia minora have resorbed bilaterally and her introitus is narrowed and foreshortened to a depth of 3 centimeters. The vaginal pH (obtained from the lateral sidewall of the vagina) is 6. On speculum exam, the patient has significant pain which limits the exam, but friable vaginal epithelium and copious discharge are noted. The wet mount has parabasal cells along with numerous WBCs are seen. The most likely diagnosis is:

A biopsy and immunofluorescent testing are performed. On biopsy, findings of lichenoid interface dermatitis, along with the visual appearance of her vulva and vaginal agglutination, she is given a diagnosis of lichen planus.

A 65-year-old woman presents with a one-year history of progressively worsening vulvar pruritus and burning. She has a history of type II diabetes and hypertension. She has been using over the counter anti-itch cream daily with some relief. On exam, there are white plaques on the labia minora bilaterally and on the perineum extending toward the anus. There is resorption of the labia minora bilaterally. A biopsy shows thinning epidermis with loss of a normal rete ridge pattern. Choose the best diagnosis.

The most appropriate initial treatment of lichen sclerosus is: Choose the best answer.

A 35-year-old woman presents with 9 months of progressively worsening vulvar burning and pruritus primarily at night. She has been treated empirically with a topical antifungal by three providers in the last few months for a presumed yeast infection. Her symptoms never resolved. She has irritable bowel syndrome. Her review of systems and medical history are otherwise unremarkable. She uses a hypoallergenic soap and flushable toilet wipes. On exam, there is diffuse erythema bilaterally on the labia majora and edema of her labia minora with linear erosions consistent with scratching. Architecture is intact. A small amount of white vaginal discharge is present. Wet prep shows a pH of 4.5, mature squamous cells, no clue cells and no hyphae. Fungal culture is negative. Biopsy shows spongiosis and a dermal infiltrate of lymphocytes with occasional eosinophils. The best diagnosis is:

A 30-year-old woman has been complaining of vulvovaginal itching for one month. The patient has completed a 7 day course of over the counter topical antifungal, with partial relief but her symptoms recurred. On exam, she has erythematous labia bilaterally with edema and excoriation. You suspect a refractory yeast infection.

The best first step is:

Vaginal culture grew candida glabrata. Recommended treatment is:

The diagnostic test for trichomonas with the greatest sensitivity and specificity is: Choose the best answer.

Tinidazole is an alternative to metronidazole in the treatment of trichomonas. In women who are breastfeeding, the Centers for Disease Control and Prevention (CDC) recommends: Choose the best answer.

Often misdiagnosed as condyloma, _______________________ is characterized by fine projections of the vestibular epithelium or labia minora.

The nerve that supplies the somatic motor and sensory nerves to the majority of the vulva, distal vagina and anal canal:

The area inside the dotted line is referred to as_______________.

In the assessment of pelvic floor hypertonicity, the examiner typically will palpate the levator ani. All of the following muscles are part of the levator ani except:

Currently, labial hypertrophy is being marketed as a labia minora length greater than:

The following statements are true of labiaplasty:

A 21-year-old woman presents with a history of grouped painful vesicles and erosions on the mons. A biopsy had been performed previously. You are able to view the histology image. The pathology is most consistent with:

A 66-year-old woman presents with years of vulvar burning and itching previously treated as candidiasis.

The pathology combined with history is most consistent with:

A 66-year-old woman presents with years of vulvar burning and itching previously treated as candidiasis. A biopsy had been performed prior to her visit with you. The pathology combined with history is most consistent with:

A 22-year-old woman presents with firm flesh colored umbilicated papules on the labia. See biopsy below

A 40-year-old woman presents with a bump present for 3 years on the labia majora.

A 60-year-old woman presents with an itchy brown papule on the inner thigh. See biopsy below.

A 25 yr. old woman presents with multiple small flesh colored to red papules on bilateral labia minora. See biopsy below.

A 60-year-old woman presents with brown papule on labia majora for three months. See biopsy below.