Gynecologic Assessment of the Elderly Patient

Frequently Encountered Findings and Conditions

Vulvar Inflammations and Infections

Specific changes in vulvovaginal anatomy are associated with the combined effects of aging and estrogen deficiency, with estrogen deficiency being most associated with vulvar inflammation and vaginal or vulvar infections. Skin changes found elsewhere on the body -- such as seborrheic keratoses or skin tags (achrochordon) -- can also be seen on the vulva and are generally treated as they would be in other locations. Fissures, ulcerations, or hypertrophic or verrucous lesions on the vulva or perineum should be considered potentially malignant, and biopsy is usually recommended.

Pruritus

Pruritus is a very common vulvar symptom and is most often related to either estrogen deficit or a yeast infection. Observational clues of estrogen deficiency include atrophic, sagging structures, mucosal thinning, and small, petechial hemorrhages. Patients with diabetes mellitus or those taking antibiotics or corticosteroids are particularly prone to infection with yeast of the Candida species. Findings include a thin, white exudate on the vulvar structures: a sampling of the material may show hyphae on microscopic examination. Candida may also cause a bright red, well demarcated rash, or with a thick cottage cheese-like exudate. Systemic disease associated with immunosuppression, such as diabetes mellitus, pernicious anemia, liver disease, lymphoma, or leukemia, should be ruled out if a confirmed yeast infection does not respond to treatment or recurs frequently.

Another cause of vulvar pruritus is Lichen sclerosis. The white lesion of Lichen sclerosis resembles skin change associated with severe estrogen deficiency; appearance is often depicted as "cigarette paper" or "papyrus" skin. Atrophy may progress to vaginal stenosis and loss of the labia minora. In addition to vulvar tissue, the perianal area may also be involved.

Diagnosis of Lichen sclerosis is confirmed by biopsy, most often performed after topical estrogen therapy (for presumed estrogen deficiency) fails to resolve the condition. Low-potency topical corticosteroids may increase symptoms, especially pruritus. Topical testosterone (2% testosterone propionate in sesame oil), white petrolatum, or high-potency topical corticosteroids are the current treatments of choice.

Burning and Irritation

Estrogen deficiency can produce atrophic tissue that subsequently tingles or burns when it comes in contact with urine. Urinalysis to check for urinary tract infection is indicated.

Burning in the presence of beefy red vaginal mucosa suggests Candida infection or Paget disease of the vulva, also called adenocarcinoma in situ. Typically, Paget disease causes the vulva to have a velvety red or eczematous appearance. When a "yeast infection" does not clear after aggressive treatment, reddened areas of the vulva should be biopsied to rule out Paget disease. If this is found, there is a 30% incidence of coexistent cancer of the breast, cervix, bladder, gallbladder, or colon. Additional evaluation of these sites to search for occult malignancy is indicated.^[1]

Vulvar and Vaginal Discharge

Vaginal discharge generally results from local vaginal conditions, but fistulas should also be considered, especially in patients with a history of pelvic radiation, malignancy, or inflammatory bowel disease. Atrophic vaginitis is believed to be the most common cause of vaginal discharge in an elderly woman not being treated with corticosteroids or antibiotics. As previously mentioned, discharge associated with atrophic vaginitis may be initially misdiagnosed as a yeast infection. However, this discharge does not have a foul odor, as does discharge associated with some bacterial infections; the microscopic examination would also be negative for findings indicative of yeast or common bacterial infections.

Microscopic evaluation of discharge associated with atrophic vaginitis will reveal minimal bacteria and a significant number of basal cells (small round cells with large nuclei, somewhat resembling plasma cells). Basal or immature epithelial cells are a hallmark of estrogen deficiency when seen in the absence of bacterial or fungal infection.

However, bacterial vaginosis is more common in elderly women than in those who are younger. The thinning of the vaginal mucosa makes it easier for bacteria to enter the subepithelial tissues. Organisms such as Gardnerella vaginalis may be detected in association with malodorous vaginal discharge. Vulvar itching and a malodorous yellow-green vaginal discharge are hallmarks of trichomoniasis.

Vulvar Swelling

Vulvar swelling or areas of thickening raise the possibility of malignancy. Swelling on either side of the posterior vulva located at approximately 4 and 8 o'clock usually reflects inflammation of the Bartholin's glands. Any enlargement of these glands should be carefully evaluated because adenocarcinoma of Bartholin's glands is very aggressive. Basal cell carcinoma is an indolent lesion sometimes found on the vulva. It is characterized by a pearly appearance with telangiectasias.

Swelling around the urethra can be caused by circumferential prolapse of the meatus. In this condition, the entire meatus appears bright red in color, and the friable, prolapsed tissue can be a source of bleeding. Treatment with topical estrogen is sometimes helpful, but there is not much information to support this approach.

A urethral caruncle appears as a localized area of swelling and prolapse (resembling a polyp) around the urethra. This single lesion may reflect estrogen deficiency and respond to replacement therapy. If the lesions do not respond in approximately 6 weeks, biopsy is indicated to rule out malignancy.

When any vulvar lesion is detected, biopsy is usually indicated. This is especially important if the lesion is white, brown, red, raised, or ulcerated. Invasive carcinoma of the vulva is primarily a disease that occurs in older women; peak incidence is 85 years. Screening by simple inspection as part of an annual examination is helpful because patients will often fail to report an area of irritation.

The anterior vulva is the most common site of involvement with invasive carcinoma: around the clitoris, the vestibule, or along the labia. The malignancy most often resembles either a flat infiltrative or ulcerative lesion. Associated symptoms include pruritus, mass, irritation, and bloody vaginal discharge. The prognosis depends on the extent of the tumor and involvement of regional lymph nodes. Radiation therapy is usually not as effective as surgical therapies.

Pelvic Prolapse

The precise cause of pelvic prolapse is not known but may be the result of a number of insults. Likely contributors include damage during birthing, striated muscle weakness or neuromuscular disease produced by disease, trauma, aging, and loss of tissue elasticity and turgor produced by estrogen deficiency. Additionally, women with Marfan's syndrome and Ehlers-Danlos syndrome have an increased incidence of pelvic prolapse, thus implying a role for collagen synthesis and possibly genetic predisposition.

Symptoms of pelvic prolapse include increased pelvic pressure exacerbated by activities increasing abdominal pressure (eg, sitting, straining, or bending over) and relieved by being supine; backache; urinary incontinence; and patient report of seeing a mass protruding from the vagina. Prolapse is graded by the extent of descent: Grade 1 (or first degree) prolapse is some movement of the organ from its usual position; grade 2 prolapse implies the organ is near the vaginal introitus; grade 3 prolapse is when the organ is at or bulging from the introitus.

Prolapse is usually easy to appreciate on examination, but determining the precise organ or the structure prolapsing can be more difficult. It is sometimes necessary to use a small speculum and separate the blades to identify the source. Bulging of the anterior vaginal wall suggests bladder prolapse (cystocele); bulging of the posterior vaginal wall from the rectum is a rectocele; internal herniation of the small intestine into the recto-vaginal septum is an enterocele. The uterus can also prolapse, as can the vaginal apex in women who had hysterectomies. More than one structure can prolapse concomitantly: uterine prolapse is often seen with a coexistent enterocele (because the rectovaginal septum is enlarged as the uterus drops), or with a cystocele or rectocele. Management of prolapse involves enhancing pelvic support with a pessary or other vaginal appliance, or through surgical repair.

Uterine Prolapse. Uterine prolapse, sometimes called descensus, is most often related to damage of genital structures during childbirth. Total eversion of the vagina is called procidentia. In addition to the presence of a protruding mass and feeling a sense of pressure, the prolapse can affect the bladder and rectum, leading to incomplete emptying. Cervical protrusion can also predispose to mucosal dryness and infection.

Cystocele. This defect in the pubovesical and pubocervical fascia produces an anterior wall bulge. Urethrocele is also usually present. Cystocele may compromise bladder emptying, leading to increased postvoid residual urine volume and recurrent urinary tract infections. A large cystocele may reduce urinary leakage by putting a kink in the urethra, effectively increasing the resistance to urine flow. Urinary incontinence can also result if the prolapse affects the posterior urethra-vesical angle, which is normally 90 degrees. An increase in this angle due to prolapse can compromise the transmission of intra-abdominal pressure that normally pinches the bladder neck shut when abdominal pressure acutely increases. Loss of this mechanism can allow the bladder pressure to exceed the urethral resistance, causing leakage when increased abdominal pressure (secondary to laughing, jogging, sneezing, squatting, or bending over) occurs.

Rectocele. A rectocele is caused by a defect in the rectovaginal fascia with separation of the levator ani musculature. Symptoms include difficulty defecating and feeling pressure in the perineum with defecation. Some patients may use a finger to push on the posterior vaginal wall to help empty the rectum.

Enterocele. An enterocele is a true herniation through the pelvic outlet and may cause lower abdominal pain and pelvic pressure that is relieved by lying down. The discomfort may be minimal on arising in the morning and steadily worsen until bedtime. The condition may not be evident on supine pelvic examination, even with the patient bearing down. If suspicion for an enterocele is high, the patient should be examined while standing with one leg placed on a 10- to 12-inch step. When the patient bears down, the bowel can be felt as it slides into the rectovaginal septum.

Postmenopausal Bleeding

Any vaginal bleeding in a postmenopausal woman is abnormal and requires that the source of bleeding be identified. Approximately one third of cases are caused by a premalignant or malignant cervical or endometrial lesion. The most common malignancies causing vaginal bleeding are vulvar, cervical, endometrial carcinomas and hormone-secreting ovarian malignancies. Endometrial hyperplasia is not rare and, when detected via biopsy, raises the possibility of an ovarian estrogen-secreting (thecal cell or granulosa cell) tumor.

Benign causes of bleeding include friable mucosa associated with atrophic vaginitis, urethral caruncle, trauma caused by sexual activity, cervical erosions, endometrial polyps, and endometrial hyperplasia. Estrogen replacement therapy can also produce vaginal bleeding, but any bleeding in older women needs to be fully investigated to rule out other causes. Evaluation includes careful pelvic examination, with biopsy of suspicious lesions. Referral for further evaluation is usually indicated.