Benign Vulval Diseases pdf - D. Huda

Benign Vulval Diseases

Vulvitis :

Definition :

Inflammatory reaction affecting vulval structures .

Classification :

I- Primary ( inflammation is specific for the vulva ) :

1. STDs :

a. Syphilis ( 1

, 3

& 3

) . b. Soft sore .

    c. Gonococcal bartholinitis .                 d. LGV (lymphgranuloma venereum).
    e.HPV infection .
    f. HSV infection .           g. Molluscum contagiosa infection .

2. Skin diseases :

a. Frunculosis . b. Moniliasis .
c. Intertrigo ( Non specific inflammation in skin folds in obese cases due to

moisture ) .

    d. Tinea cruris .                       e. Psoriasis .
     f.  pediculosis
   g  scabies .

3- Chronic specific infections :

a. Tuberculosis . b. Bilharziasis . c. Filariasis .

II- Secondary :

1. Urinary conditions
2. Vaginal conditions
3. Rectal conditions :

4. iatrogenic : Due to drug allergy to many applications .

Clinical picture of acute vulvitis :

I- Symptoms :

    1. Local pain and pruritus .
    2. Swelling and redness of the vulval skin .
    3. Frequency of micturition and dysuria may occur .
    4. Inguinal pain due to inguinal adenitis may also occur .

II- Signs :

1. Edema and congestion of the vulval area with evidence of itching marks .
2. The vulva is warm and tender .

3. Local inflammatory swelling may be seen in cases with Bartholin abscess

formation .

4. Firm tender inguinal masses due to inguinal adenitis which become fluctuant if

suppuration occurs .

5. Rarely , constitutional manifestations may be evident in cases with severe

spreading infections and if abscess develops .

III- Special investigations :

1. Swab for microbiological examination , culture and sensitivity for determination of

the infecting organism .

2. Serological tests for STDs .
3. Investigations for UTI .
4. Investigations for DM.
5. Investigations for associated vaginitis .

Treatment :

I- General measures

1. Local cleanliness by shaving of hair and frequent warm baths .
2.  Local  dryness  by  wearing  cotton  panties  and  careful  dryness  after  micturition  ,
defecation , douching or bathing .
3.  Use  of  local  antiseptics  as  povidone  iodine  (  betadine  )  or  chlorhexidine  +

Cetrimide ( savlon ) .

4. Sexual abstinence . Physical rest may be rarely needed .
5. Antihistaminics , sedatives or hypnotics may be used for pruritus .
6.  Estrogen  therapy  to  increase  vulval  epithelial  resistance  in  children  and

postmenopausal women ( either local or systemic ) .

II- Suitable antibiotices for treatment of the causative organism .
III- Treatment of the predisposing factors: Specially DM and malnutrition .
IV- Treatment of complications such as draining a Bartholin abscess .

Diabetic vulvuitis :

It is the product of recurrent vulval candidiasis + 2

bacterial infection which may be

chronic  +  Epithelial  changes  due  to  chronic  irritation  and  pruritus  .  Symptoms  of
diabetic vulvitis may last for a long time after diabetic control and after treatment of
all microbial infection .
* Diabetic vulvitis is characterized by :
    1. Extensive spreading infection .
    2. Reddish gray area .
    3. Severe itching due to :

a. Glycosuria . b. diabetic neuritis .
c. The inflammatory process . d. Associated monilia infection .

* Treatment :

    1. Control of DM .
    2. Treatment of vulvitis .
    3. Treatment of associated monilia or other genital infections .

Bartholinitis :

* Definition : Inflammatory process of the Bartholin gland .
* Usually caused by gonococcal infection , occasionally by pyogenic organisms or

Chlamydia due to obstruction of bartholin glands.

* Routes of infection :
    a. Sexual contact .
    b. Exogenous ( postoperatively or postnatal ) .
    c. Spreading from the vagina .

* Clinical picture :

1. Picture of vulvitis .

2. Tender firm mass in the posterior 1/3 of labia majora which becomes fluctuant

when suppuration occurs .

3. The overlying skin is red , edematous , and indurated .
4. Inguinal adentitis may be seen .

* Special investigations : As vulvitis .
* Treatment :
    1. Treatment of vulvitis .
    2. Drainage of the abscess through a mucocutaneous junction incision .
    3. Excision of the Bartholin gland in cases of chronic abscess .

Pruritus vulvae ( Vulval itching ) :

Causes :

I- Pruitus associated with vaginal discharge

Resulting from irritant vaginal discharge .

II- Pruritus without vaginal discharge ( about 20% of the cases ) :

    1. General causes :
        a. Systemic diseases as diabetes , jaundice , uremia and leukemia .
        b. Allergy .
        c. Achlorhydria and vitamin A deficiency .
        d. Psychological ( neurdermatitis ) .
    2. Local causes :
        a. Non neoplastic epithelial disorders ( previously known as dystrophies ) .

b. Cases of acute vulvitis due to skin diseases whether , fungal , parasitic or

allergic .

c. 2

to anal pruritus e.g. due to oxyuris infestation .

vulval candidiasis

caused by candida albicans ,diagnosis confirmed by biopsy, treatment by 7-10 days
of topical azol therapy,in resistant cases fluconazole orally 150 mg weekly for 6
months.

Investigations :

    1. Urine analysis for sugar , and GTT .
    2. Examination of scrapings from the vulval skin for fungus infection .
    3. Fractional test meal .
    4. Full blood examination , and serum bilirubin .
    5. Stool analysis .
    6. Biopsy may be taken from any suspicious lesion of the vulva e.g. leukoplakia .

Treatment :

I- Treatment of the cause .
II- General treatment

Sedatives , anthistaminics , estrogen in menopausal patients and bland diet .

III- Local treatment :

1. Local cleanliness .
2. Antipruritic local applications as calamine lotion , hydrocortisone ointment and

estrogen in menopausal patients .

Ulcers of the vulva (important)

I. Sexually transmitted diseases :

1. Syphilis

a. 1

Chancre painless solitary ulcer , firm enlarged non tender lymph

nodes .
investigation
*positive vinereal laboratory researches (VDRL and RPR), dx confirmed by biopsy.
b. 2

Mucous patches or ulcerated condylomata lata .

c. 3

Gumma or diffuse systemic inflammation .

treatment by benzathin pencillin, doxycyclin in case of pencillin allergy.

2. Soft sore ( chancroid )

Tender red papules filled with pus, no induration, tender inguinal lymph nodes
caused by heamohpolus ducreyi ,dx confirmed by biopsy ,treatment by azithromycin
1 g po.

3. Lymphogranuloma venereum

Ulceration of vulva , rectum and groin, hard tender masses (bubos) arise in the
inguinal areas caused by chlamydia tracomatis, dx confirmed by biopsy , treatement
by doxycyclin or erythromycin
.

4. Granuloma inguinale

Presented    with  clean  granulomatous  sharply  defined  multiple  confluent  ulcers  ,
diagnosis  confirmed  by  biopsy(Donovan  bodies)  treatement  by  3  weeks  of  doxy
cyclin or ciprofluxacin.

5. Herpes genitalis

Produce itching and tingling , multiple small painful blisters progress to shallow
ulcer may associated with urinary retention , crust over 7-10 days .
Recurrence rate is 50%
Treatment
*spontaneous resolution
*acyclovir 200mg every 6 hours for 5 days
*may need folys catheter.

6.HPV (Condyloma accuminata)

presented with flat warts not associated with

pain, its self limited over about 9 months, podophylin or cauterization can be used in
extensive conditions.

II- Traumatic ulcer .
III- Tuberculous ulcer .
IV- Bilharzial ulcer .
V- Malignant ulcer .

1. Squamous cell carcinoma .
2. Basal cell carcinoma ( Rodent ulcer ) .

VII- Behcet ulcers .

Swellings of the Vulva :

I- Congenital :
II- Traumatic ( hematoma ) :

May occur after labor or after excision of Bartholin cyst as a diffuse cystic tender
swelling dark in color . Treatment : Incision and ligation of the bleeding vessels if the
hematoma is large or increasing in size .

III- Inflammatory :

Vulvitis , Bartholin's abscess , hypertrophic tuberculosis , bilharzial polypi ,
condylomata lata ,
condylomata acuminata

caused by human papilloma virus  presented with flat warts not associated with pain,
its  self  limited  over  about  9  months,  podophylin  or  cauterization  can  be  used  in
extensive conditions.
.

IV- Benign neoplasms :

1. Fibroma .
2. Lipoma .
3.  Papilloma  (  benign  tumor  formed  of  connective  tissue  core  covered  by

epithelium ) .

4. Adenoma of the Bartholin gland .
5. Hidradenoma : A rare benign tumor of sweat glands that may ulcerate and

bleed and so it may be mistaken for carcinoma .

6. Other tumors include leiomyoma ( from the tissues of the round ligament )

neurofibroma , hemangioma , Cerry angioma , angiokeratoma and granular
cell myeloblastoma .

7. Urethral caruncle .

* Is a small red pedunculated swelling at the posterior lip of the urethral

orifice .

* Clinically it presents with dysuria , dyspareunia and irregular bleeding .
* Treatment : Cautery or excision including the base and dealing with any

cause as chronic urethritis .

V- Malignant neoplasms :

    1. Primary carcinomas or sarcomas .
    2. Secondary :
      a. Direct extension of carcinoma of the vagina or urethra .
      b. Retrograde lymphatic or vascular spread . The commonest are secondaries of

choriocarcinoma reaching the vulva by retrograde vascular spread .