The Vulva

Terminology

Normal Anatomy

Normal Anatomy

Symptoms your patients will tell you about
• Pruritus (itch). General or just one spot
• Soreness: stinging / burning / pain
• Difficulty with sex
• Lumps

Causes of pruritus vulvae and/or pain
• Candida albicans infection
• Irritant contact dermatitis
• Seborrhoeic dermatitis
• Psoriasis
• The three lichens:
-Lichen simplex
-Lichen sclerosus
-Lichen planus

Candida albicans – vulvovaginal

Candida albicans – vaginal

Irritant contact dermatitis
• Erythema
• Oedema
• Fissuring
Soap, water, rubbing

Irritant contact dermatitis
• Burn-like
• Glazed erythema
• Superficial erosions
• Oedema
Faecal and urinary incontinence

Seborrhoeic dermatitis
• Usually patient has it at other sites also
• Mons pubis and flexures
• May or may not be scaly
• Mild or absent symptoms

Seborrhoeic dermatitis

Causes of pruritus vulvae
• Candida albicans infection
• Irritant contact dermatitis
• Seborrhoeic dermatitis
• The three lichens:

Vulval psoriasis

Vulval psoriasis

Causes of pruritus vulvae and /or pain
• Candida albicans infection
• Irritant contact dermatitis
• Seborrhoeic dermatitis
• Psoriasis
:
• Lichen simplex
• Lichen sclerosus
• Lichen planus

Lichens
• All three cause similar skin change
• The skin becomes thickened, pale, with increased skin markings [grooves]and fissures

Lichen Simplex
• Chronic irritation causes the skin change
• Remove the irritant and the skin recovers

Lichen simplex
• Perineum - ?Candida
• Skin thickening
• Fissuring
• Skin coloured
• Dyspigmentation common

Lichen simplex
• Unilateral, labium major
• Due to rubbing because of intense itch
• Well-demarcated
• Skin thickening
• Increased skin markings
• Skin coloured
• Dyspigmentation common

Lichen sclerosus
• Probably an immune system disease
• Itch: nil to very severe
• Soreness: nil to very severe
• Altered anatomy from tissue destruction
• Dyspareunia / apareunia because of symptoms or changed anatomy

The Itch of lichen sclerosus
• Mainly the labia minora, clitoral hood and/or perineum
• Perianal in 50%
• Extragenital in 15%

Who gets Lichen Sclerosus
• Most are 50 years or older but children and teenagers may be affected
• May have other associated autoimmune conditions
– 25% thyroid antibodies;
– 10% psoriasis

LS and VIN
• Lichen Sclerosus is associated with pre malignant change
• VIN, Vulval Intraepithelial neoplasia
• VIN untreated may become SCC

Lichen sclerosus
• Distribution: figure of 8 with wings
– Usually bilateral
• Colour – white,crinkly
(‘cigarette-paper’)
• Sclerosis – firm

Lichen sclerosus
• White, like vitiligo
• Anatomic change
– Loss of labia minora

Lichen sclerosus
• Distorted clitoral hood and labia minora
• Postinflammatory white areas
• Postinflammatory brown pigmentation

Lichen sclerosus
• Resorption of labia minora
• Fissures in the labial sulcus and onthe perineum

Lichen sclerosus
• Flattening of clitoral hood
• Resorption of labia minora
• Haemorrhages

Lichen sclerosus
• Flattening of clitoral hood
• Resorption of labia minora

Lichen sclerosus
• Severe introital narrowing
• Splitting of posterior forchette

Lichen sclerosus
• Bridging / fusion / agglutination of left and right labia
• Ulceration

Lichen sclerosus
• Distortion of labia minora
• Ulceration
• Haemorrhage

Lichen sclerosus
• Ulcer right labium minor

Lichen sclerosus
• Hyperkeratosis
– Consider biopsy

LS in a teenager

Psoriasis + lichen sclerosus
• Psoriasis less symptomatic but more impressive
• Psoriasis ‘outside’
• Lichen sclerosus ‘inside’
• Psoriasis does not alter anatomic features

Lichen sclerosus: treatment
• Ultrapotent topical steroid, usually clobetasol ointment
• Once daily until clear (one to three months)
• Then alternate days for the same duration
• Then once or twice per week long-term or
PRN
• Explain to patient precisely where to apply the ointment

Lichen planus
• Less common
• More painful
• Just as destructive
• More likely to be seen on other parts of the patient
• Two types: cutaneous and mucosal

Lichen planus: cutaneous type
• Violaceous plaques
• Wickham’s striae
• Labia majora
• Irregular distribution

Lichen planus: mucosal type
• May be very itchy
• More often very painful
• Very tender to touch
• Destructive – loss of clitoral hood, labia minora
• May cause introital narrowing
• More likely to involve vagina (unlike lichen sclerosus)
• May also affect oral mucosa
– Buccal mucosa, inner lips, tongue
– Desquamative gingivitis

Erosive lichen planus
• Red glistening painful mucosal patch
• Loss of labia minora

Erosive Lichen Planus

Erosive lichen planus

Erosive lichen planus
• Mucosal disease may result in postinflammatory pigmentation

Erosive lichen planus
• Destruction of tissue
• Introital narrowing
• Eaten-away appearance

Erosive lichen planus: treatment
• Topical clobetasol daily
– May be required daily long-term
• Topical calcineurin inhibitors, e.g., pimecrolimus cream
• Oral prednisone
• Methotrexate
• Often symptoms respond better than signs

Plasma cell Vulvitis
• Much less common
• Much less destructive
• Often asymptomatic

Plasma cell vulvitis
• Deeper red than LP
– Haemorrhagic
• More internal
• More patchy

Plasma cell vulvitis
• May extend periurethrally
• Contact bleeding

Plasma cell vulvitis: treatment
• Topical antibiotic
– Clindamycin cream
– Metronidazole cream
• Hydrocortisone cream

Symptoms your patients will tell you about
• Pruritus (itch). General or just one spot
• Soreness : stinging / burning / pain
• Difficulty with sex

Lumps that might not cause symptoms
• Frightening things
• Not so frightening things

Pre malignant and Malignant lesions
• Vulval intraepithelial neoplasia, VIN
• Invasive squamous cell carcinoma
• Melanoma

Vulval intraepithelial neoplasia
• This is a pre malignant lesion
• Mild or no symptoms but does have signs
• Two types: Usual and Differentiated
• Usual VIN = HPV related
Differentiated VIN = Lichen sclerosus or lichen planus related
– more likely to become an aggressive SCC

HPV
• Human Papilloma Virus
• Low risk and High risk, but HrHPV types are associated with cancers in many parts of the body: cervix, vagina, vulva, anal canal, mouth.
• Sexually transmitted
• Vaccine
• ENT surgeons now very interested

VIN

VIN

VIN

+ Lichen sclerosus
VIN

Invasive squamous cell carcinoma
• Arises within VIN [HPV or lichen sclerosus]
• Irregular, hard nodule, often ulcerated
• May be multifocal
• Often aggressive

Invasive squamous cell carcinoma

Invasive squamous cell carcinoma

Melanoma
• Rare
• Not related to fair skin or sun exposure
• Mild or no symptoms

Vulval melanoma

Melanoma

Less frightening things
• You will often notice lumps or bumps
• Ask about them
• The patient may be waiting to see if you think its abnormal.

Sebaceous Cyst

Vaginal Wall prolapse

Prolapse

Varicosities

Genital Warts

Others
• Urethral caruncle
• Bartholin’s cyst
• Asymmetrical labia

Bartholins cyst

Urethral caruncle

It’s a very private area
• Our perception of our vulva is effected by:
• Culture
• Religion
• Age
• Education
• Marital status
• Sexual experiences
• Facebook

Vulval Disease
• Most women present late, and very distressed
• They often feel guilt or ashamed
• They always feel embarrassed
• They worry it’s an STI
• If there is a lump they think it’s a wart
• Results of surveys of the impact of vulva disease are alarming

Vulval disease
• Any one of the conditions I have discussed today, even the most innocuous will disrupt their sex lives no matter their age.
• Patients can become very socially isolated and their relationships severely altered.
• There is usually something we can do to help

Vulva Sign