Which of the following would be part of the best approach to treatment of a clinical yeast infection diagnosed by wet mount and not initially responsive to fluconazole?

• a)
  

  Collection of yeast culture with species identification if positive.

  
  
• b)
  

  Repeat the wet mount to rule out another infectious cause of the patient’s symptoms.

  
  
• c)
  

  Consider treatment with a non-azole such as boric acid as the patient may have a non-albicans Candida species.

  
  
• d)
  

  Tell the patient to pick up an over-the-counter antifungal.

  
  
• e)
  

  Treat the patient with a repeat course of fluconazole then consider starting maintenance therapy if symptoms do not improve and microscopy or culture data suggest persistent infection.

Which of the following mechanisms is true regarding recurrent bacterial vaginosis (RBV) infections?

• a)
  

  It is due to lack of partner treatment.

  
  
• b)
  

  It is due to formation of a biofilm by Gardnerella vaginalis that is difficult to penetrate with antibiotics

  
  
• c)
  

  It may be due to the presence of metronidazole resistant organisms in vaginal secretions

  
  
• d)
  

  It may be due to insufficient duration of treatment or lack of maintenance regimen for symptomatic relief

  
  
• e)
  

  It may require treatment with a maintenance regimen such as twice weekly vaginal metronidazole gel application for 4-6 months.

Partner testing and treatment is recommended in which of the following scenarios?

• a)
  

  Sexual partner of 32 year old female with 3 documented episodes of bacterial vaginosis per year.

  
  
• b)
  

  Sexual partner of a 40 year old female with HIV and persistent trichomoniasis despite multiple courses of metronidazole.

  
  
• c)
  

  Sexual partner of a 26 year old gravida 2 para 2 currently undergoing treatment for C. glabrata yeast infection.

  
  
• d)
  

  Sexual partner of a 19 year old gravida 0

  
  
• e)
  

  Sexual partner of a postmenopausal woman with atrophic vaginitis.

The following statement(s) is/are true about vulvar lichen sclerosus

• a)
  

  Vulvar scarring is pathognomonic of lichen sclerosus.

  
  
• b)
  

  A patient who has symptoms while on ultrapotent corticosteroids (UPCS) should be treated by calcineurin inhibitors.

  
  
• c)
  

  In the absence of an appropriate treatment, VLS will turn into squamous cell carcinoma.

  
  
• d)
  

  Differentiated VIN is more likely to evolve to vulvar squamous cell carcinoma (VSCC) than usual VIN.

  
  
• e)
  

  Vulvar lichen sclerosus is a cause of multifocal pigmentation.

Which of the following statement(s) about vulval contact dermatitis is/are true?

• a)
  

  It is the most frequent reason for consultation in a vulval clinic

  
  
• b)
  

  There are two types of vulval contact dermatitis

  
  
• c)
  

  Patch tests are very useful in identifying the antigen involved in contact dermatitis

  
  
• d)
  

  Diagnosis relies on biopsy

  
  
• e)
  

  Topical corticosteroids are helpful in the treatment of contact dermatitis

An 84 year old woman with dementia but otherwise good health presents with a two year history of vulvar pruritus and perineal bleeding. Physical exam reveals scratch marks and a 3 cm white irregular area on the right labium majus. She is uncomfortable with the exam in the office, allowing only a quick view of the perineum. The next step in management would be?

• a)
  

  Administration of topical antifungal cream for 6 weeks.

  
  
• b)
  

  Topical lidocaine as needed for discomfort.

  
  
• c)
  

  Pelvic examination and wide local excision of the mass under anesthesia.

  
  
• d)
  

  Pelvic examination and biopsy of the mass under anesthesia.

  
  
• e)
  

  Magnetic Resonance Imaging (MRI) of the pelvic and femoral node chains.

Risk factors for vulvar cancer include:

• a)
  

  HPV infection

  
  
• b)
  

  Cigarette smoking

  
  
• c)
  

  Lichen sclerosis

  
  
• d)
  

  Immunosuppression

  
  
• e)
  

  Chronic inflammatory conditions

What is/are recognised reasons for women continuing to engage in sex when vulvo-vaginal pain is present?

• a)
  

  Guilt

  
  
• b)
  

  Sacrifice

  
  
• c)
  

  Fear

  
  
• d)
  

  Resignation

  
  
• e)
  

  Shame

In terms of help-seeking behaviours, what percentage of women who report chronic vulvo-vaginal pain receive a formal diagnosis?

• a)
  

  85%

  
  
• b)
  

  60%

  
  
• c)
  

  36%

  
  
• d)
  

  40%

  
  
• e)
  

  10%

Concerning differences between women with vulvo-vaginal pain and non-afflicted women relative to their physiological level of sexual arousal when exposed to an erotic stimulus, which of the following is/are true?

• a)
  

  Women with pain are less aroused.

  
  
• b)
  

  Women with pain report more negative feelings toward the erotic stimulus.

  
  
• c)
  

  Women with pain do not report more negative feelings toward the erotic stimulus.

  
  
• d)
  

  Women with pain are equally aroused.

  
  
• e)
  

  Women with pain report more positive feelings toward the erotic stimulus.

The following therapies for vulvodynia have been evaluated with a randomized placebo controlled trial:

• a)
  

  Topical lidocaine

  
  
• b)
  

  Submucosal botulinum toxin A

  
  
• c)
  

  Oral desipramine

  
  
• d)
  

  Oral gabapentin

  
  
• e)
  

  Vestibulectomy

The proposed etiology for vulvodynia has included:

• a)
  

  Hyperkalemia

  
  
• b)
  

  Hyperoxaluria

  
  
• c)
  

  Neuropathic pain pathway

  
  
• d)
  

  Genetic predisposition for inability to regulate inflammatory activity

  
  
• e)
  

  Inflammation

The following statement(s) is/are true regarding the epidemiology of vulvodynia

• a)
  

  It is considered to be rare

  
  
• b)
  

  Patients with vulvodynia are generally forthcoming with their complaints

  
  
• c)
  

  A large population based study has suggested that Hispanic women are significantly more likely to develop vulvodynia than Caucasian or African American women

  
  
• d)
  

  Patients are generally thought to have improvement of symptoms regardless of treatment modality over a two year time span

  
  
• e)
  

  Symptoms have been associated with older age

The following is/are recommendations for vulvar skin care

• a)
  

  Douching is acceptable

  
  
• b)
  

  White cotton underwear is preferred

  
  
• c)
  

  A daily emollient skin protectant can provide a barrier and is recommended

  
  
• d)
  

  Dryer sheets should be avoided

  
  
• e)
  

  Waxing of the vulva is an acceptable method of hair removal

Hidradenitis suppurativa (HS) is a common painful disabling skin condition. Which of the following statements is/are true?

• a)
  

  HS is an acute deep cutaneous folliculitic infection due to synergistic bacterial pathogens.

  
  
• b)
  

  HS is a disorder of apocrine glands that are repeatedly inflamed and ruptured resulting in deep painful boils associated with sweating and obesity.

  
  
• c)
  

  HS is a chronic folliculo-occlusive disease due to follicular rupture and associated immune response.

  
  
• d)
  

  HS is primarily a dysregulation of the innate and adaptive immune systems causing destruction of follicular units in intertriginous areas.

  
  
• e)
  

  HS is a rare condition that affects women 40–50 years of age.

Obesity, birth control methods, smoking, androgens and bacteria are factors associated with HS. Which of the following statements is/are true?

• a)
  

  There is a direct correlation between obesity and severity of disease.

  
  
• b)
  

  Hormones are an important factor so medroxyprogesterone acetate is an effective contraceptive.

  
  
• c)
  

  Smoking is not a factor in hidradenitis suppurativa. It has no effect on follicular occlusion, neutrophil chemotaxis or TNF production by keratinocytes.

  
  
• d)
  

  Androgens promote the development of hidradenitis suppurativa. This is supported by the infrequency of HS before puberty, flares before periods, the worsening with use of androgenic birth control pills and improvement with use of anti-androgens.

  
  
• e)
  

  Bacteria such as coagulase-negative Staphylococci, Gram negative rods and anaerobic bacteria frequently cause secondary infection.

Clinically, hidradenitis suppurativa has a wide spectrum of presentations with various patterns. Which of the following statements is/are correct?

• a)
  

  The primary lesion is a deep-seated inflammatory nodule in the groin, axillae or chest that may last days to months, rupture, recur or resolve.

  
  
• b)
  

  Like acne, hidradenitis suppurativa presents with early formation of scattered comedones in axillae and groin.

  
  
• c)
  

  The most severe stage, Hurley stage III, is commonly seen in the majority of hidradenitis suppurativa patients.

  
  
• d)
  

  Sinus tracts are easily identified and seldom persist or recur.

  
  
• e)
  

  All HS lesions heal with unsightly scars.

When making the diagnosis and managing atopic vulvitis in a pre-pubertal female:

• a)
  

  Eczema is usually evident on clinical examination of the skin elsewhere

  
  
• b)
  

  A personal or family history of atopy are not relevant

  
  
• c)
  

  Ecchymoses (bruising) are a common clinical signs of untreated atopic vulvitis

  
  
• d)
  

  Management should begin with soap substitution and the regular use of an emollient

  
  
• e)
  

  Topical corticosteroids are harmful and should not be used due to the risk of skin thinning

Lichen sclerosus:

• a)
  

  Is a rare condition in pre-pubertal girls

  
  
• b)
  

  The main trigger for the condition is sexual abuse

  
  
• c)
  

  Clinical signs consist of well-demarcated white plaques, wrinkled skin, telangiectasia and ecchymoses

  
  
• d)
  

  Does not affect non-genital skin

  
  
• e)
  

  Should be treated with a vulvar care regimen and the use of a superpotent topical steroid

Vulvar capillary hemangiomata:

• a)
  

  Are usually present at birth and do not change in size

  
  
• b)
  

  Are more common in premature children or those with low birth weight

  
  
• c)
  

  Do not require treatment

  
  
• d)
  

  Ulcerate more frequently than haemangiomata in non-flexural sites

  
  
• e)
  

  Can be treated with oral beta-blockers

Desquamative inflammatory vaginitis (DIV) is a syndrome of purulent vaginitis. Diagnosis is based on which of the following?

• a)
  

  A positive culture of Group B Streptococcus

  
  
• b)
  

  It is a diagnosis of exclusion; other causes of purulent vaginitis need to be excluded before making the diagnosis of DIV

  
  
• c)
  

  A wet mount (office based microscopy of vaginal discharge) is essential to confirm diagnosis

  
  
• d)
  

  It is unlikely that DIV will affect women in reproductive age because of its association with estrogen deficiency

  
  
• e)
  

  A biopsy of the vaginal wall is necessary to confirm diagnosis in cases of DIV.

Which of the following are considered true regarding the treatment for Desquamative Inflammatory Vaginitis?

• a)
  

  Topical vaginal estrogen

  
  
• b)
  

  Topical corticosteroid agents

  
  
• c)
  

  Always clindamycin since it is superior to topical corticosteroids

  
  
• d)
  

  Initially with a one week vaginal clindamycin course without the need for maintenance treatment

  
  
• e)
  

  It can be complicated since one in four patients (25%) receiving vaginal anti-inflammatory regimens develop secondary vaginal yeast infections

The following statement(s) is/are true about clinical and pathological aspects of VIN:

• a)
  

  The 2004 International Society for the Study of Vulvar Disease (ISSVD) classification for squamous VIN uses the grading system (VIN 1, 2 and 3) like Cervical Intraepithelial Neoplasia.

  
  
• b)
  

  Higher incidence of VIN is reported among black women.

  
  
• c)
  

  The p53− p16+ phenotype supports VIN usual type and p53+ p16− supports VIN differentiated type.

  
  
• d)
  

  VIN differentiated type lesions are usually multifocal.

  
  
• e)
  

  HPV-DNA can be identified in most VIN usual type

The following statement(s) is/are true about VIN therapy:

• a)
  

  There are wide differences between cold knife, LEEP or laser techniques of VIN removal.

  
  
• b)
  

  Wide local excision with a 5-mm peripheral margin and resection depth is recommended up to 4 mm in the pilous areas.

  
  
• c)
  

  In VIN, usual type CO2 laser vaporization represents the standard approach.

  
  
• d)
  

  In VIN, usual type the duration of Imiquimod therapy is 2 years.

  
  
• e)
  

  The antigenic targets for therapeutic vaccines against HPV viruses in VIN are L1 and L2 proteins.

In the presence of ano-genital warts (AGW), patients should be offered which of the following?

• a)
  

  Partner notification

  
  
• b)
  

  Quadrivalent HPV prophylactic vaccine

  
  
• c)
  

  Bivalent HPV prophylactic vaccine

  
  
• d)
  

  Patient applied therapy

  
  
• e)
  

  Office administered therapy

Vulval surgery depends on the correct lymphatic drainage knowledge and pathology of the lesion. Which of the following sentences is/are true?

• a)
  

  The vulval lymphatics cross the genito-crural folds.

  
  
• b)
  

  The deep femoral lymph nodes are located beneath the femoral fascia outside the opening of the fossa ovalis.

  
  
• c)
  

  Only very lateral vulval lesions drain into the ipsilateral groin.

  
  
• d)
  

  The clinical vulval free margin must be more than 3 cm to reduce the local recurrence risk.

  
  
• e)
  

  Vulval lesions with stromal invasion less than 2-3 mm are not associated with groin metastases.

Superficial inguinal lymphadenectomy is indicated in which of the following?

• a)
  

  For cancer with stromal invasion ≤1 mm.

  
  
• b)
  

  Only in a vulval lesion with diameter ≤2 cm, independently of the stromal depth invasion.

  
  
• c)
  

  When sentinel lymph node dissection is positive for metastasis.

  
  
• d)
  

  In invasive vulval cancer with clinically negative groin nodes.

  
  
• e)
  

  It is no longer employed for the surgical treatment of invasive vulval cancer.

Which of the following is/are true regarding the surgical technique of groin lymphadenectomy?

• a)
  

  It requires mandatory removal of the femoral fascia along with the sartorius and adductor longus muscles fascia.

  
  
• b)
  

  It can be done by preserving the femoral fascia.

  
  
• c)
  

  It must be carried out through an en-bloc incision including the vulva.

  
  
• d)
  

  It can be done with a separate incision.

  
  
• e)
  

  It must be total or radical when indicated.

Regarding when a primary initial HSV infection occurs, patients should be:

• a)
  

  Reported to the public health system as a notifiable disease

  
  
• b)
  

  Tested with type- specific serology

  
  
• c)
  

  Tested with a viral identification assay if a lesion is present, with either a viral culture, DFT or PCR

  
  
• d)
  

  Treated with topical antiviral treatment

  
  
• e)
  

  Offered psychosexual counseling since rapid adaptation to a diagnosis of genital herpes can help recovery

A young female with a first episode of ulcers in the genital area seeks your advice. Regarding making a definitive diagnosis which of the following is/are true?

• a)
  

  Pap cytology smear will be sufficient.

  
  
• b)
  

  Clinical diagnosis is sufficient.

  
  
• c)
  

  A culture is necessary to confirm a diagnosis of HSV.

  
  
• d)
  

  Rapid herpes assay is the best test to use.

  
  
• e)
  

  PCR is the least sensitive.