vulva

Benign and malignant conditions of vulva and vagina

Dr. Ahmed jasim
Ass.Prof.
MBChB-DOG-FICMS
COSULTANT OF GYN. & OBST.

Conditions affecting the vulva and vagina:

The vulva
Pruritus vulvae:
Is a common symptom which is an irritation of vulva sufficient to lead to scratching

Pruritus vulvae: Causes:

1. Infections.
trichomonas vaginalis or candidasis
Parasites such as scabies and lice.
Threadworms
2.Skin conditions may affect vulval skin.
eczema, psoriasis, lichen simplex, lichen planus, and lichen sclerosus.
3.Sensitization of the vulval skin to drugs or chemicals as soap and disinfectant , chemical spermicide, ointments.
4. Medical disorders:
Diabetes, chronic renal failure, polycythemia, liver cirrhosis, Hodgkin's disease.
Urinary incontinence.


Pruritus vulvae:

5. Non neoplastic epithelial disorder as lichen sclrosus, squamous hyperplasia

6. Neoplasia:
VIN, carcinoma, lymphoma, Paget's disease
7. Excess or inappropriate hygiene.
8.Psychogenic causes.

Diagnosis:

History:
Carfull history ,including the use of any substance which might lead to allergy.

Examination

general examination of the patient including inspection for dermatological lesion of face, mucous membrane, hands, wrist, elbows, trunk,and knees
Any evidence of systemic disease
Gynaecological examination including inspection of cervix and vagina and vulva urethral meatus and anal area
Colposcopic examination of cervix and vagina and vulva
Palpation of inguinal lymph nodes.

investigations

Bacteriological examination of vaginal secretions and scraping from the skin.
Full blood count.
Blood sugar
Biopsy of the skin of vulva.


successful treatment depends on two cardinal principles:
1. to remove any underlying cause.
2. to stop further damage to the skin by scratching.
The help of dermatologist may be sought in difficult cases.
Great care should be taken in prescribing any of anti-pruritics
Corticosteroid applications sometimes used.

Vulval ulcer

Aphthous ulcer
Herpes gentalis.
Primary syphilis.
Crohn's disease.
Behcet's disease.
Lymphgranuloma venereum.
Chancroid.
Tuberculosis.
Malignant ulcer.

Vulval lumps

Most vulval lumps are benign and can be treated conservatively.
Excisional biopsy is indicated in solid lesions or when the diagnosis is uncertain.


Bartholin's cyst and abscess
Bartholin's glands lies on each side of the vagina and it's duct opens into the posterior part of the vestibule..

Bartholin's cyst

Is the most common vagial vulvar tumour. Cyst may arise from the duct of the Bartholin's gland that lies in subcutaneous tissue below the lower third of labium majorum. Cysts can develop if the opening of bartholin duct becomes blocked and distended with mucoid secretion.
It present as painless swellings or some time present with discomfort posterolaterally in the introitus and usually unilaterally. It may become infected, to form an bartholin's abscess.

treatment:

. marsupilizeation the cyst (permit adequate drainage and mostly the function of the gland is retained).
or
cyst excision.

Bartholin's abscess

Bartholin's abscess involves an accumulation of pus that forms a lump(swelling (in Bartholin's glands
the gland may be infected by gonococci, staphylococci, streptococci or a mixture of organisms.
it causes severe discomfort when walking or sitting.

Bartholin's abscess

Diagnosis:
Symptom: it causes severe discomfort when walking or sitting.
Physical examination:
Diagnosis of a Bartholin abscess is made primarily upon the following physical examination findings:
the position of the labial swelling at the junction of anterior two third (2/3)and posterior one third(1/3) of the labium majorum is diagnostic
painful red swelling with reddens of the surrounding tissue and odematous.
the swelling is hot, tender and fluctuant


Bartholin's abscess
treatment:
drain the abscess by marsupilzation (pouch making).
Antibiotic therapy.
the drained pus should be sent for culture.
biopsy may be recommended in older women to rule out an underlying Bartholin's gland tumor.

Vulvae intraepithelial neoplasia(VIN):

It may present at any age
It dose not have the same malignant potential of that of CIN.
It usually asymptomatic but it may present as Pruritus vulvae.
colposcopic examination and biopsy are important.
observation with regular follow up is required.

Vulval Intraepithelial neoplasia:

there are three grades from mild to sever dysplasia as for CIN but doesn’t have the same malignant potential

Clinical features in VIN III

Itching is the most common symptom.
Half of patients are asymptomatic.
Most have visible or palpable abnormalities of the vulva (20% are warty, and multicentric in about two third of cases).
Most lesions are elevated ,of different color : may be white , red ,pink , or brown.
Diagnosis:
-inspection for abnormal areas.
-colposcopic examination of the entire vulva after 5 %
acetic acid will highlight additional acetowhite areas.
-biopsy will confirm the diagnosis.


Management :
-regular follow up with multiple biopsy
-local superficial surgical excision with safe margin with primary closure.
-for extensive lesions skinning vulvectomy with replacement by split –thickness skin graft with the subcutaneous tissues are preserved.
-Laser ablation is used for multiple small lesions involving the clitoris, labia minora and perineum.

Carcinoma of vulva

It is uncommon (accounts 5% of genital cancer). It is a disease primarily of the older age group with the majority of cases presenting between the ages of 60 and 75 .

Carcinoma of vulva

Presentation:
ulcer or swelling on the vulva with soreness or irritation.
slight bleeding may occur.
offensive purulent discharge .
enlarged inguinal glands.

Examination:

Ulcer or hypertrophic growths in vulva .
Lymph node examination

Investigation:

The diagnosis is made by biopsy.
As well as investigate patient as in other carcinoma


staging
FIGO staging system is a surgical staging system revised in 1994:
Stage 0 carcinoma in situ ,intraepithelial carcinoma.
Stage I tumors confined to vulva or perineum ,lesion =or
<2 cm; no nodal metastasis.
Ia stromal invasion <or = 1 mm
Ib stromal invasion > 1 mm.
Stage II tumors confined to vulva or perineum ,
lesion >2 cm, no nodal metastasis.
Stage III any size tumors with adjacent spread and or unilateral l.N.
metastasis.
Stage IV
IVa invades any or combinations of the following :upper urethra
,bladder mucosa ,rectal mucosa ,pelvic bones or bilateral
regional L.N.
IVb any distant metastasis including pelvic L.N.

Treatment

radical excision of the vulva and inguinal lymph nodes on both sides.
radiotherapy in special situation.


Survival rate:

Overall 5 years survival is about 70%.

Survival correlates significantly with the lymph node status regardless the stage,
one L.N. involvement 50% 5 years survival
no L.N. involvement 90% 5 years survival

Vagina

foreign bodies in the genital tract:
The foreign bodies could be:
A. Therapeutic agents:
1. Packs and dressing of various kinds may be left in vagina after operation.
2. Supporting pessaries.
3. Contraceptive device: (Sponges, occlusive caps, condoms which have slipped out).

B. Articles inserted by the patient or entering accidentally.Mostly in mentally retarded patient and children.
C. instruments for inducing abortion and labour as: laminaria tents, chatheter.
D. menstrual tampone.


Effects
it is varies from irritation to local vaginitis result in ulceration of the vaginal walls and perforation and pressure necrosis and this can involve neighboring structure to cause urinary and faecal fistulae.
infection may spread to produce salpingitis and peritonitis.
carcinoma of vagina is a late squeal.
The condition present as offensive vaginal discharge with blood stained as the main symptoms.

treatment:

the foreign body must be removed.

VAGINAL DISCHARGE:

A vaginal secretion is normal in women in the reproductive age group.
It consists of transudate containing desquamated vaginal epithelium, mucous secreated by cervical glands and endometrial glands.
The amount of discharge varies from woman to woman and varies throughout the menstrual cycle(There is a cyclical variation of the amount of secretion).

Normal discharge is usually clear or white. Infections may cause discharge of varying color, consistency, amount and odor. A sudden change in discharge may signify pathological condition.

Physiological discharge can be increased in:

pregnancy.(due to increased estrogen production and greater blood flow to the area around the vagina).
in oral contraception users.
At mid menstrual cycle
During sexual intercourse.
Exccesive vaginal discharge is a common gynaecological complaint and can cause vulval symptoms. Comprehensive clinical assessment is essential.


Excessive Vaginal discharge could be due to:
. Physiological.
2. Infection.(bacterial vaginosis, candidases, trichomonal vaginosis)
3. Foreign bodies as tampon, vaginal ring.
4. malignant (endometrial ,cervical, vaginal cancer).
5. Fistula.
6. Atrophic vaginitis.
7. large cervical ectropion

Vaginal atrophy

It typically occurs in women of any age who experience a fall in estrogenic stimulation to the urogenital tissues as in
Menopausal women.
Premenopausal women.
Postpartum period.
Lactation.
During administration of antiestrogenic drugs (breast cancer hormonal treatment).
Prior to puberty.

Vaginal atrophy

Symptoms:
The patient may Present with vaginal bleeding, vaginal discharge, or vaginal
dryness and dyspareunia (pain during sexual intercourse).
Superficial infection, with Gram-positive cocci or Gram-negative bacilli, may be
associated.


Vaginal atrophy
Examination:
Shows pale, thin vaginal epithelium with loss of rugal folds and prominent subepithelial vessels, sometimes with adjacent petechial haemorrhage or ecchymoses.

Treatment:

Requires oestrogen to restore the vaginal epithelium and pH.
This is usually by topical oestrogen cream, but care must be taken to avoid excessive absorption through the thinned mucosa.Vaginal cream inserted nightly for a week and repeated monthly to prevent atrophy.
Alternatively in postmenopausal women, hormone replacement therapy(HRT)can be used.

Fistula

A fistula may be due to:
Trauma.
Carcinoma.
Crohn’s disease.
Childbirth :(Fistula of the anterior wall is now uncommon in association with childbirth, but rectovaginal fistula may follow an obstetric tear or extension of an episiotomy, and an incomplete or inadequate repair).
Gynaecological surgery Fistulae involving ureter, bladder or rectum may follow gynaecological surgery.

Vaginal intraepithelial neoplasia(VAIN):

It is seldom seen alone and is usually a vaginal extension of CIN (Cervical Intra epithelial Neoplasia).
Classification of intraepithelial neoplasias of the vagina parallels that of the cervix VaIN 1, VaIN2, and VaIN 3.
VaIN is usually asymptomatic and is diagnosed by abnormal cytologic testing. Infrequently women complain of postcoital staining or unusual vaginal discharge


Vaginal intraepithelial neoplasia(VAIN):
VaIN usually occurs in the upper third of the vagina on the posterior wall
VaIN lesions may be either single discrete or multifocal.
Diagnosis is made by colposcopy.
The usual treatment involves laser vaporization.

Carcinoma of the vagina:

It is rare gynaecological tumours accounting for 1-2% of all gynaecological cancers.
The peak incidence is between age 60 & 70 years.
Vaginal carcinoma may be primary or secondary.

PATHOLOGY

Only 10-20% of vaginal carcinomas are primary.
Squamous cell carcinoma is the most common malignant tumor of the vagina
Clear cell adenocarcinoma is found in women who had exposure to diethylstilbesterol in utero (DES) and to a lesser degree in post menopausal individuals.
Metastatic tumors are the most common cancer found in the vagina.

Secondary carcinoma can arise by:

direct extension from the cervical carcinoma.
Endometrial cancer.
Choriocarcinoma.
From vulva.
From rectum or anus.
Distant metastasis may occur from primary carcinoma in the breast or gastrointestinal tract.


Clinical features:

Usually occurs after the menopause and most commonly affects the upper posterior wall.

Vaginal bleeding mainly post coital.
Offensive watery discharge.
Fistula (rectum, bladder).

staging

FIGO staging used of vaginal carcinoma staging.

Staging:

Stage I invasive cancer confined to the
vaginal mucosa.
Stage II subvaginal extension not involving
the pelvic side wall.

Stage III extends to pelvic side walls.

Stage IVa extends to mucosa of bladder &rectum
Stage IVb spread beyond the pelvis.


treatment:
Surgery:
removal of whole vagina ,uterus,and pelvic lymph nodes
Radiotherapy in some cases.

Lesion of urethra:

Urethral Caruncle:
Small, fleshy bright red out-growths of the distal edge of the urethra.
It is always single lesion arises from the posterior wall of urethrra
Usually seen in post-menopausal women. there is high rate of recurrence after treatment.

Urethral Caruncle:

It cause:
1.No symptoms
2.Symptomatic:
A. Very tender causing dysparunia or pain on micturition.
B. Slight bleeding may occur.

Urethral Caruncle:

Treatment by:
Topical estrogen therapy.
If no response biobsy should be done to exclude serious morphology. Once malignancy ruled out, it can be treated by surgery either by:
Excision or destruction by diathermy.


Urethral diverticulae
It usually found in the distal third of posterior urethral wall bulging towards the vagina. It's incidence is 3%.

Urethral diverticulae

Clinical presentation:
It is vary but usually include frequency , dysuria, dysparunia, voiding difficulties and recurrent urinary tract infection. Post micturition dribble is classical symptom.
Vaginal examination can show:
No physical sign.
Or
suburethral mass.
Tenderness can be palpated.

Urethral diverticulae

Investigation:
Voiding cystourethrogram.
Treatment:
Surgical repair if patient affected by symptoms. Treatment by marsupilization and vaginal diverticulectomy.

Diethylstibestrol (DES) - Related Lesions

DES is a drug that was administered frequently to pregnant women who were at high risk for early pregnancy loss during the 1940’s through the 1960’s.
it can be the cause of :
1. Vaginal Adenosis
Vaginal adenosis refers to the replacement of the normal squamous epithelium of the vagina by columnar epithelium. It is asymptomatic and presents as red, granular patches on the vaginal mucosa.
Benign but rarely, may give rise to clear cell adenocarcinoma.


2. Structural changes of the cervix and vagina and uterus.
These are in the form of:
Transverse vaginal septum.
Cervical hypoplasia.
T-shaped uterus.
others

3. Exposed individual have an increased risk of abortion, preterm labour, ectopic pregnancy.
4. Clear cell adenocarcinoma
It affects young women, average 17 years old. Two thirds of patients have history of in utero DES exposure. The risk in exposed population is 1 in 1000.

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