Differentials
Gonorrhea
SIGNS / SYMPTOMS
Pelvic or lower abdominal pain and fever may be present if ascending infection.
INVESTIGATIONS
Neisseria gonorrhoeae grown on chocolate agar culture.
Chlamydia
SIGNS / SYMPTOMS
Many are asymptomatic; intermenstrual bleeding, cervicitis, and abdominal pain may be differentiating.
INVESTIGATIONS
Chlamydia trachomatis on nucleic acid amplification technique.
Cervicitis
SIGNS / SYMPTOMS
Intermenstrual bleeding; friable cervix on physical examination; genital warts may be present if caused by human papillomavirus (HPV).
INVESTIGATIONS
Cervical discharge collected for Gram stain may indicate Neisseria gonorrhoeae or Chlamydia trachomatis. Cervical cytological testing may be positive for HPV.
Lichen planus
SIGNS / SYMPTOMS
Pruritus, intense vulvodynia, and dyspareunia are common symptoms.
Differentiating signs may include presence of violaceous, flat-topped papules or plaques. These lesions may be present elsewhere on the body (e.g., flexor wrists and ankles).
INVESTIGATIONS
Diagnosis is typically clinical.
Histopathology may demonstrate a band-like lymphocytic infiltrate, necrotic keratinocytes, and hyperkeratosis.
Desquamative inflammatory vaginitis
SIGNS / SYMPTOMS
Noninfectious cause of chronic inflammatory vaginitis.
Causes purulent and copious discharge, dyspareunia, vaginal rash, vestibulo-vaginal irritation, and vaginal inflammation or erythema.
Most common during perimenopause.
INVESTIGATIONS
Elevated pH (>4.5).
Inflammation of the vaginal walls with increased erythema and petechiae on examination.
Microscopy of vaginal secretions shows increased inflammatory and parabasal epithelial cell counts and abnormal vaginal flora.
Vaginal wall biopsy shows features of acute and chronic desquamative inflammation.
Pelvic irradiation
SIGNS / SYMPTOMS
Results from ionizing radiation-induced damage to noncancerous tissues during radiation therapy. Risks are higher in women who have been treated for cervical or ovarian cancer.
Acute: inflammatory reaction during, immediately after, or within 3 months of radiation therapy. Causes gastrointestinal symptoms (e.g., nausea, diarrhea, abdominal cramps, urgency, bleeding).
Chronic: develops between 6 months and 3 years, but can occur up to 30 years after treatment. Causes bowel dysmotility (e.g., urgency, malabsorption and altered feces transit). Increases risk of bowel wall stricture and perforation, adhesions, fissures, and severe bleeding.
Latent: symptoms due to secondary malignancies (often endometrial cancer, secondary rectal or bladder tumors) years or decades after radiation therapy.
INVESTIGATIONS
Diagnosis is based on a history of cervical cancer or ovarian cancer and symptoms.
Blood tests: CBC, urea and electrolytes, LFT, glucose and calcium.
Vaginal cancer
SIGNS / SYMPTOMS
Abnormal vaginal bleeding, odorous or blood-stained discharge, dyspareunia, persistent pelvic/vaginal pain, a lump/growth. Risk is increased in those with a history of human papillomavirus, cervical intraepithelial neoplasia, or vaginal intraepithelial neoplasia.
More common in women over 60 years and rare in women under 40.
INVESTIGATIONS
Lymphadenopathy or tumor infiltration on pelvic examination.
Vaginal wall biopsy: positive for vaginal cancer.
Fallopian tube cancer
SIGNS / SYMPTOMS
Rare. Palpable pelvic mass and abnormal vaginal bleeding, especially after menopause; white, clear, or pinkish discharge; abdominal pain or pressure.
INVESTIGATIONS
Pelvic examination: abnormality in the shape or size of the uterus, vagina, ovaries, or fallopian tubes.
CA125 assay: positive.
Abdominal or transvaginal ultrasound: positive for a tumor.
Rarely detected by pelvic examination or ultrasound unless very advanced stage.
Cervical cancer
SIGNS / SYMPTOMS
Abnormal vaginal bleeding, dyspareunia, pain in the lower back or pelvis. Late-stage disease may present with watery or foul-smelling vaginal discharge, most likely from a necrotic mass, severe vaginal bleeding, and gastrointestinal effects.
INVESTIGATIONS
Cytology: abnormal cells present.
Colposcopy with biopsy: cervical cancer cells present in the cervical tissue.
Vaginal fistula
SIGNS / SYMPTOMS
Can result from injury during childbirth, pelvic surgery, Crohn disease or another inflammatory bowel disease, infection, or radiation treatment. Symptoms include foul-smelling vaginal discharge, passage of gas, stool, or pus from the vagina, dyspareunia, irritation or pain in the vulva, vagina, and perineum, and recurrent urinary tract infections.
INVESTIGATIONS
Pelvic examination: positive for fistula.
Dye test: leakage from the vagina on coughing or bearing down.
Cystoscopy: fistula identified in bladder or urethra.
Retrograde pyelogram/CT urogram: injected dye identifies fistula.
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