What is vestibulitis? How is it managed?

Vestibulitis is defined as a constellation of symptoms and signs, including entry dyspareunia, vestibular erythema, and vestibular tenderness in the absence of an active dermatosis or disorder that would otherwise explain the findings. Management includes symptomatic relief with 5% lidocaine ointment; tricyclic antidepressants may be helpful. Surgical treatment should only be considered in severe cases that are refractory to medical management.

Benign Lessions of the vulva and vagina

Reff: GENERAL GYNECOLOGY AND INFERTILITY > 1 BENIGN LESIONS OF THE VULVA AND VAGINA

What is the vulva composed of?
The vulva is composed of the labia majora, labia minora, mons pubis, clitoris, vestibule, urinary meatus, vaginal orifice, hymen, Bartholin's glands, Skene's ducts, and vestibulovaginal bulbs.

Name the five disorders in which infectious agents cause lesions of the vulva.

• Chancroid (Haemophilus ducreyi)
• Syphilis (Treponema pallidum)
• Lymphogranuloma venereum (Chlamydia trachomatis serovar)
• Human papillomavirus
• Genital herpes 

 Describe the clinical features and treatment of each disorder listed in question 2.

Chancroid: Sexually transmitted with an incubation period of 3-10 days. Presents as small, tender papules that soon break down to form ragged, tender, nonindurated ulcers usually located on the labia, fourchette, perineum, and perianal areas. May be single, but are more often multiple.▪ Treatment-current drug of choice is erythromycin.

Syphilis: Sexually transmitted with an incubation period of about 2 weeks. The first lesion is a macule, which soon becomes papular, then ulcerates to form a primary chancre. Classic description of the primary chancre is an indurated, painless ulcer with a dull red base. If untreated, primary stage typically lasts 3-8 weeks and then the ulcer spontaneously heals. In secondary syphilis, skin rashes may be macular, papular, papulosquamous, or pustular, and any of these may occur on the vulva. Condyloma lata are seen in secondary syphilis and are characterized by confluent, spongy, gray masses with flat tops and broad bases located at the periphery of the vulva. In late syphilis, vulvar lesions termed gummas appear as squamous lesions or subcutaneous nodules that sometimes ulcerate.▪ Treatment-remains penicillin for all stages.

Lymphogranuloma venereum (LGV): Rare in temperate climates. Incubation period is between 3 days and 3 weeks. The primary lesion is a small, painless papule, vesicle, or ulcer, typically located on the fourchette but may also occur on the labia or cervix. The secondary stage is characterized by enlargement of the inguinal glands to form a painful mass, which tends to suppurate and form sinuses.▪ Treatment-early LGV responds to tetracycline. Prolonged treatment may be necessary.

Human papillomavirus: Sexually transmitted with incubation periods ranging from 3 weeks to 8 months. Manifest on the vulva as genital warts. Commonly are papular, appearing as small, raised, rounded lesions, usually multiple. However, may present as condylomata acuminata, which are irregular, fleshy, vascular tumors affecting any part of the vulva.▪ Treatment-repeat application of trichloroacetic acid, podophyllin, topical imiquimod (Aldara), cryotherapy, or laser surgery.

Genital herpes virus: Sexually transmitted with incubation period of first attack usually 2-10 days. Lesions are initially vesicular, but rupture to form single, multiple, or grouped shallow, tender, ulcers, 1-2 mm in diameter. Lesions are most common on the labia majora and minora, clitoris, perineum, and perianal areas.

Treatment-acyclovir is the drug of choice for the treatment of outbreaks. However, it does not influence the rate of recurrence. List the common cystic lesions of the vulva and vagina Cysts of epidermal origin: sebaceous cysts, epidermal inclusion cysts, hidradenoma Cysts of embryonic origin: Gartner's duct cysts (arise from vestigial remnants of the vaginal portion of the Wolffian ducts) Duct cysts: Bartholin's gland Cysts of urethral and paraurethral origin: Skene's duct cysts, urethral or suburethral diverticulum

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FERTILIZATION AND EARLY CLEAVAGE

Reff :  Katz: Comprehensive Gynecology, 5th ed.

         In most mammals, including humans, the egg is released from the ovary in the metaphase II stage. When the egg enters the fallopian tube, it is surrounded by a cumulus of granulosa cells (cumulus oophorus) and intimately surrounded by a clear zona pellucida. Within the zona pellucida are both the egg and the first polar body. Meanwhile, spermatozoa are transported through the cervical mucus and the uterus and into the fallopian tubes. During this transport period the sperm undergo two changes: capacitation and acrosome reaction. These changes activate enzyme systems within the sperm head and make it possible for the sperm to transgress the cumulus oophorus and the zona pellucida.

       The sperm are attracted to an egg through the process known as chemotaxis, which is related to capacitation of the sperm. The process is aided by the binding of progesterone to a surface receptor on the sperm. This allows an increase in intracellular calcium ion concentration, which increases sperm motility (chemokinesis). Once the sperm has passed the barrier of the zona pellucida, it attaches to the cell membrane of the egg and enters the cytoplasm. When the sperm enters the cytoplasm, intracytoplasmic structures, the coronal granules, arrange themselves in an orderly fashion around the outermost portion of the cytoplasm just beneath the cytoplasmic membrane, and the sperm head swells and gives rise to the male pronucleus. The egg completes its second meiotic division, casting off the second polar body to a position also beneath the zona pellucida. The female pronucleus swells as well. In most mammals the male pronucleus can be recognized as the larger of the two. The pronuclei, which contain the haploid sets of chromosomes of maternal and paternal origin, do not fuse in mammals. How-ever, the nuclear membranes surrounding them disappear, and the chromosomes contained within each membrane arrange themselves on the developing spindle of the first mitotic division. In this way the diploid complement of chromosomes is reestablished, completing the process of fertilization.

         Cell division (cleavage) then occurs, giving rise to the two-cell embryo. The first division takes about 20 hours to complete, and the actual phase of fertilization generally occurs in the ampulla of the fallopian tube. A significant number of fertilized ova do not complete cleavage for a number of reasons, including failure of appropriate chromosome arrangement on the spindle, specific gene defects that prevent the formation of the spindle, and environmental factors. Importantly, teratogens acting at this point are usually either completely destructive or cause little or no effect. Twinning may occur by the separation of the two cells produced by cleavage, each of which has the potential to develop into a separate embryo. Twinning may occur at any stage until the formation of the blastula, since each cell is totipotential. Both genetic and environmental factors are probably involved in the causation of twinning.