35.     Vulval ulceration commonly occurs in:  

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MCQ Paper 1

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a. squamous cell cancer True
b. diabetes False
c. herpes True
d. Crohn’s disease False
e. lichen sclerosis False
f. lichen planus False
g. secondary syphilis False
h. scabies False
i. herpes gestationalis False
j. lympho-granuloma venereum False
k. primary syphilis True
l. papillomatous warts False
m. Behçet's disease True

A question along these lines comes up with monotonous regularity, so stuff it in the old memory bank.

The key thing to remember is that vulval ulceration is typical of herpes in young women and malignancy in the elderly.

Diabetes may produce vulvitis.

Lichen sclerosis is the old term for the thinning of the vulval skin, which is common in older women.

Of unknown aetiology, it is associated with maddening itching, particularly at night.

Chronic scratching can lead to ulceration, but it is usually superficial and not “common”.

Crohn’s disease can cause fistula formation in the genital region, but, again, it is not “common”.

Lichen planus is associated with a white “lacy” appearance of the skin and is not pre-malignant or associated with ulceration.

As mothers have taught for generations and everyone knows, syphilis is mostly caught from toilet seats.

As a result, superior “keep-fit” classes for women concentrate on exercises to allow them to hover over the toilet without ever alighting.

These are euphemistically categorised as “self defence” activities.

The poshest public toilets now have disposable seat covers to help with this potential threat.

They have to be applied and removed using protective bacteriological clothing or a “no-touch” technique, so are a bit esoteric.

The lesion of primary syphilis is the “chancre” - an ulcer at the site of infection.

Your predilections are thus revealed and lesions of the ear, umbilicus, pet hamster etc. will generate much fascinated speculation.

The “chancre”, develops after about 1 – 5 weeks and then tends to heal.

Secondary disease comes with widespread dissemination of the spirochete.

It causes generalised signs and symptoms: fever, skin rashes, arthritis, oral ulcers, lymphadenopathy.

This, too, settles and the untreated move on to tertiary syphilis.

The classical feature is the “gumma”.

John Selwyn Gummer was in Mrs. Thatcher’s cabinet.

His masterstroke was to feed his exquisite tiny daughter beef burgers for the benefit of television.

And so to prove irrefutably that British Beef was safe and could not transmit BSE.

I had hoped that he would attract condite punishment and be know ever after as “Gumma”.

I was even tempted to suggest it to journalists, but desisted.

Why the digression?

I am sitting in the bar of the MireMare hotel outside Rhodes.

The beer costs £2.40 for a volume so diminutive that you are advised to down it in a flash for fear of evaporation.

I am consuming it at an appropriately cautious Scottish rate to defer the purchase of another.

This leaves plenty of time for digression, so bear with me.

The gumma is an ulcer of skin or mucous membrane, thus tertiary syphilis would have got a “true” in the above question.

Remember that a significant proportion of these patients go on to neuro-syphilis with severe consequences.

These are reflected in the old diagnostic label “General Paralysis of the Insane”.

It is rare now, though something similar may be seen as a temporary phenomenon among our more libidinous medical students.

I remember seeing a case as a student, but haven’t since.

You get scabies from close personal contact, classically sharing a bed. It is not sexually transmitted – it is a matter of proximity.

The female of the mite, Sarcoptes scabei, burrows under the skin, leaving a trail of debris and faeces.

This causes horrible irritation and papular rashes, particularly of the finger webs, hands and breasts.

Not surprisingly the irritation continues for some time after eliminating the little beggar. It is not particularly a problem of the vulva.

Behçet's disease is rare, but there must be ulceration to make the diagnosis.

It can be oral or genital, but is often both.

See MCQ4, question 40 for fuller details. 

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