• Causes vulvovaginitis; most frequent mycoses of women; 10% of women are carriers
• Risk factors: diabetes, oral contraceptives, pregnancy
• Transmission: male genitalia are not a relevant reservoir for recurrent vulvovaginal candidosis, thus decreasing the possibility of sexual heterosexual transmission (J Eur Acad Dermatol Venereol 2011;25:145)
• Recurrent vulvovaginal candidosis: mostly caused by identical Candida strains suggesting C. albicans persistence in female anogenital area, particularly in external vulva (Mycoses 2011;54:e807)

• Acute vulvovaginitis: most commonly C. albicans followed by C. glabrata
• Chronic recurrent vulvovaginitis: C. albicans and C. glabrata are often equally distributed (Med Monatsschr Pharm 2010;33:324)

• Small white surface patches with leukorrhea and itching

• Fungal hyphae on wet mount

• Local and systemic antimycotic agents based on the severity of disease and etiological agent

• Small gram negative rods, implicated in vaginitis when other causes can't be found
• Presence of 3 of 4 criteria indicate BV (bacterial vaginosis, Medscape Womens Health 1997;2:2):
  • Homogenous noninflammatory discharge (not many WBCs)
  • pH >4.5
  • Clue cells (bacteria attached to border of epithelial cells, >20% of epithelial cells)
  • Positive "whiff" test

• Caused by Calymmatobacterium granulomatis, an encapsulated, non-motile, gram negative rod
• Soft granulomatous area enlarges by peripheral extension and ulcerates

• Genital ulceration, genital tract bleeding

• Donovan bodies (small round encapsulated bodies within histiocytes), seen best with silver or Giemsa stains
• Also pseudoepitheliomatous hyperplasia, plasma cells, histiocytes, small abscesses

• Soft tissue neoplasm if it spreads to retroperitoneum
• Squamous cell carcinoma

• Sexually transmitted disease characterized by labial ulcers with punched out centers
• Usually HSV2 in young women
• 1/3 are symptomatic (lesions 3-7 days after sex); lesions heal in 1-3 weeks, but virus is latent in regional nerve ganglia
• 2/3 suffer recurrences (less painful)
• High risk of transmission to neonate during vaginal birth, especially if active primary infection

• Extremely painful ("heartbreak of herpes"), papules in vulva, progress to vesicles, later coalescent ulcers
• Also affects vagina and cervix

• 23 year old woman with associated necrotizing lymphadenitis (Arch Pathol Lab Med 1985;109:1043)
• 38 year old HIV+ woman with chronic herpes infection (Case Rep Dermatol 2012;4:192)
• 44 year old HIV+ woman with hypertrophic herpes simplex genitalis with concomitant early invasive squamous cell carcinoma (Int J Gynecol Pathol 2012;31:286)

Ulcerative form

• Multinucleated giant cells with molding, ground glass nuclei

Edge of ulceration

Immunohistochemistry

• HPV subtypes 6, 8,11,13 associated with papillary lesions
• HPV subtypes 16, 18, 31, 33 associated with flat lesions
• HPV 16 produces E6 protein that binds to p53, and E7 protein that binds to Rb protein
• Koilocytotic atypia is a viral cytopathic effect, often NOT present in vulvar condylomas
• Verrucopapillary lesions, even in children/young adults, are likely to be HPV associated (Am J Surg Pathol 1994;18:728)
  
  
• HPV and vulvar neoplasia:
  • HPV leads to pathogenetic pathways for vulvar squamous cell carcinoma and vulvar intraepithelial neoplasia (VSCC and VIN)
• HPV associated vulvar squamous cell carcinoma: basaloid or warty type; arise from VIN of usual type
• HPV independent vulvar squamous cell carcinoma: keratinizing, associated with differentiated VIN and lichen sclerosus; frequently have p53 mutation
• Most studies show no survival differences between HPV-associated and HPV-independent tumors (Histopathology 2013;62:161)

HPV+ squamous cell carcinoma

HPV-

• Sexually transmitted disease caused by Chlamydia trachomatis, L1-L3 serotypes, treated with tetracycline
• Initially small ulcer at contact site, then inguinal adenopathy with stellate abscesses surrounded by epithelioid histiocytes, then scarring, fistulas and strictures of urethra, vagina, rectum (Prim Care 1990;17:153)
• Squamous cell carcinoma or adenocarcinoma may be engrafted on lymphogranulomatous structures

• Frei test (intradermal skin test), complement fixation, immunofluorescence

• 22 year old woman (Br J Vener Dis 1984;60:390)

Vulvoperineal lesions

Immunoperoxidase staining

Immunoperoxidase and May-Grunwald-Giensa staining

Direct immunofluorescence

• Sexually transmitted disease that affects vulva only

• Molluscum bodies

• Causes spontaneous abortions and chorioamnionitis

• Affects entire gynecologic tract in adults except vagina; only children get vaginitis
• Causes infertility
• Begins in Bartholin's glands or other vestibular or periurethral glands, then spreads to cervix, tubes, ovaries

• Acute suppurative reaction, inflammation within mucosa and submucosa only

• Clinical syndrome due to various bacteria
• Compared to N. gonorrhea, exudates are less with Staphylococcal or Streptococcal infections or coliforms, but infection extends throughout wall to serosa and may cause bacteremia
• Complications: bacteremia, infertility, intestinal obstruction due to adhesions, peritonitis

• Emerg Med Clin North Am 2003;21:631

• First symptom is small, round, firm ulcer known as chancre, which is infectious
  • Occurs where bacteria first enters body - usually vulva in women ~3 weeks after infection
  • Usually disappears in 3-6 weeks even without treatment
• Composed of plasma cells, lymphocytes, histiocytes, covered by zone of ulceration with neutrophils and necrosis; also endarteritis
• Adjacent lymph nodes may be enlarged with plasma cells, endarteritis within or outside capsule, fibrosis (capsular, pericapsular), follicular hyperplasia

• Usually rash on palms and soles that doesn't itch, which appears 2-10 weeks after chancre
• Other symptoms include headache, sore throat, swollen lymph glands, tiredness
• Lesions contain bacteria and are infectious
• This stage may disappear without treatment but will recur and progress if not treated appropriately

• Begins when symptoms of secondary syphilis are over
• Early latent syphilis is infectious
• Late latent syphilis has low to no risk of infecting the partner
• If not treated appropriately, latent syphilis may progress to tertiary syphilis

• Affects very small number of syphilis patients even if never treated
• Can affect heart, eyes, brain, joints, nervous system, bones

• Semin Dermatol 1994;13:262, National Institutes of Health

• Large, flagellated, ovoid protozoan, causes up to 25% of vaginitis cases
• Diagnose with wet mount
• 15% of women in sexually transmitted disease clinic are infected
• Purulent discharge, local discomfort, "strawberry" cervix (fiery red with thin epidermis)
• Infection limited to epithelium and lamina propria

• Foul frothy discharge, pH >4.5 (in 70% of cases), punctuate cervical microhemorrhages (25% of cases) and motile trichomonads on wet mount (25-75% of cases, Medscape Womens Health 1997;2:2)

• Oral metronidazole; treatment failure is usually due to nontreatment of male partner

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