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Physician Assistant Exam: The Vulva and Vagina

For the Physician Assistant Exam, it is important that you know about tissues that enter the vaginal canal when they shouldn’t, infections and cancer that affects the vulva. These conditions affect many women and therefore will be covered on the PANCE.

How to treat vaginal infections

Bacterial vaginosis (BV) is caused by bacterial overgrowth, most commonly Gardnerella vaginalis. The main tipoff for bacterial vaginosis is the presence of a thin, grayish white discharge that smells “fishy” with the addition of KOH (potassium hydroxide). Other high-yield test-taking tips include a vaginal pH that’s greater than 4.5. “Clue cells” are present on the wet mount as well. The treatment is with metronidazole (Flagyl).

Candidal vulvovaginitis is a common form of vaginitis in women. Risk factors include diabetes and multiple rounds of antibiotics. On pelvic examination, you can see what looks like a “cottage-cheese” or “yogurt-like” discharge. The woman usually complains of severe itching. The treatment is one dose of fluconazole (Diflucan) 150 mg or topical antifungals like Monistat.

Recognize protrusions: Things that end in -cele

Besides uterine prolapse, two medical conditions that can affect the vagina are the rectocele and the cystocele. The rectocele is rectal tissue that protrudes into the vaginal wall. A cystocele is a weakness in the pelvic structures that causes the bladder to protrude into the vaginal wall.

Risk factors for these conditions include multiple pregnancies as well as prior pelvic surgeries. Each of these, over time, can cause a weakening of the pelvic floor musculature. Treatment includes the use of a pessary and Kegel exercises. Surgery is indicated in severe cases.

Cancer of the vulva

The most common presenting symptom of cancer of the vulva is a lump or sore on the vulva that causes pruritus or is painful. Another presenting symptom can be acyclic vaginal bleeding. Risk factors include age as well as having a history of multiple sex partners or prior HPV infection. Tobacco use is a risk factor, as it is for nearly every type of cancer.

The workup includes a pelvic examination. If you suspect a lesion of being cancerous, you further examine the lesion with a colposcopy. The treatment is mainly surgical, although chemotherapy and radiation may be done as well.

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