A 64-year-old woman comes to the office for evaluation of dysuria and difficulty voiding. The patient began having difficulty voiding a year ago, but it has progressively worsened and now causes a sensation of incomplete emptying. She awakens several times at night to void but has no uncontrolled leakage of urine. The patient also has increasing vulvar pruritus, which she attributes to irritation from wiping with toilet paper so frequently. She has no chronic medical conditions and has had no surgeries. The patient has not been sexually active for the last 5 years; her husband has multiple medical conditions that preclude intercourse. Her last Pap test was 3 years ago and she has no history of abnormal testing. She has no known medication allergies. The patient has a 20-pack-year smoking history but quit a few years ago; she does not use alcohol or illicit drugs. Vitals signs are normal. BMI is 23 kg/m². The abdomen is soft; there is no suprapubic or costovertebral angle tenderness. Pelvic examination reveals thin, hypopigmented lesions that extend from the clitoris to the labia majora and perineum. The labia minora appear fused over the urethra. Diffuse erosions and excoriations are present on the vulva. Speculum examination reveals an atrophic vagina with no lesions. Urinalysis is within normal limits. Which of the following is the most appropriate treatment for this patient?

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Explanation: 11ec2b69_bf19_27b1_8f63_79e15b36b12c_MD0005_00 This patient has lichen sclerosus, a chronic, benign inflammatory vulvar disease common in postmenopausal women. In early stages of the disease, the vulva thins, causing hypopigmented areas and increasing skin sensitivity that results in intense pruritus (and associated erosions and excoriations). Chronic irritation and scratching transforms the thinned skin to thickened skin (ie, lichenification) with eventual formation of vulvar plaques, often with perianal skin thickening in a classic "figure-of-eight" pattern. In severe cases, normal anatomic structures may be obliterated or atrophied, such as loss of the labia minora (blue arrow) and clitoral hood (red arrow), which can irritate and obstruct the urethra resulting in dysuria, incomplete voiding, and nocturia. perianal skin thickening labia minora Although lichen sclerosus is clinically diagnosed, a vulvar punch biopsy is recommended due to the association of lichen sclerosus with vulvar cancer. Standard treatment is with high-potency topical corticosteroids that decrease inflammation, thereby resolving symptoms and reducing the risk of malignancy. When the clinical picture is strongly suggestive of lichen sclerosus, biopsy can be deferred for cases that are refractory to treatment. (Choice A) Vulvar candidiasis (treated with antifungal agents) can present with vulvar pruritus; however, there is typically associated vulvar erythema and edema and a thick, white discharge (not seen in this patient). (Choice B) Topical antibiotics can be used if there is a superimposed infection (eg, Staphylococcus aureus) from excoriations and chronic irritation. Superimposed infection is suspected in patients with continued symptoms (eg, pain, irritation) after treatment is initiated. (Choice D) Trichloroacetic acid is commonly used for the treatment of condyloma acuminata (ie, genital warts) which are typically raised, soft, and have a cauliflower-like appearance. (Choice E) Surgery is not indicated as first-line therapy for uncomplicated lichen sclerosus, and is used only for severe adhesions that cause disfigurement. Surgery is not recommended until after initial treatment with corticosteroids, as it improves tissue quality and prevents postoperative complications (eg, wound breakdown, infection). Educational objective: Lichen sclerosus typically presents as vulvar pruritus and thinned skin. Severe disease can cause thickened vulvar plaques that result in loss of normal vulvar architecture and urethral obstruction. Treatment is with high-potency topical corticosteroids. References: Lichen sclerosus in women: a review. (http://www.ncbi.nlm.nih.gov/pubmed/28661705)

A 64-Year-Old Woman Comes to the Office for Evaluation of Dysuria