Benign diseases of the
vulva, vagina and cervix
The vulva
• Is the part of the female genital tract located between the
genitocrural folds laterally, the mons pubis anteriorly, and the anus
posteriorly.
• Embryologically, it is the result of the junction of the cloacal
endoderm, urogenital ectoderm, and paramesonephric mesodermal
layers.
• This hollow structure contains
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LABIA MAJORA
LABIA MINORA
CLITORIS
VESTIBULE
URINARY MEATUS
VAGINAL ORIFICE
HYMEN
BARTHOLIN GLANDS
SKENE DUCTS.
The vulva
• Different epithelia, from keratinized squamous epithelium
to squamous mucosa, cover the vulva.
• The labia minora are rich with sebaceous glands but
have few sweat glands and no hair follicles.
• The epithelium of the vestibule is neither pigmented nor
keratinized and contains eccrine glands.
BENIGN LESIONS OF THE VULVA
• According to the International Society for the Study of
Vulvar Disease (ISSVD) in 1989:
– Inflammatory diseases.
– Blistering diseases.
– Pigmentary changes.
– Benign tumors, hamartomas and cysts
– Congenital malformations.
Inflammatory diseases
1. Lichen sclerosus
2. Squamous cell hyperplasia (+/- atypia)
3. Lichen simplex chronicus (localized
neurodermatitis)
4. Primary irritant dermatitis
5. Intertrigo
6. Allergic contact dermatitis
7. Fixed drug eruption
8. Erythema multiforme
9. Toxic epidermal necrolysis
10.Atopic dermatitis
11.Seborrheic dermatitis
12.Psoriasis
13.Reiter disease
14.Lichen planus
15.Lupus erythematosus
16.Darier disease
17.Aphthosis and Behçet disease
18.Pyoderma gangrenosum
19.Crohn disease
20.Hidradenitis suppurativa
21.Fox-Fordyce disease
22.Plasma cell vulvitis
23.Vulvar vestibulitis syndrome
Blistering diseases
1. Familial benign chronic
pemphigus (Hailey-Hailey
disease)
2. Bullous pemphigoid
3. Cicatricial pemphigoid
4. Pemphigus vulgaris
5. Erythema multiforme
6. Epidermolysis bullosa
Pigmentary changes
1. Acanthosis nigricans
2. Lentigo
3. Melanocytic nevus
4. Postinflammatory hyperpigmentation
5. Postinflammatory hypopigmentation
6. Vitiligo
Benign tumors, hamartomas, and
cysts
1. Bartholin cysts
8. Hidradenoma
2. Epidermal inclusion cyst (Dermoid cyst)
9. Lipoma
3. Endometriosis
10. Chronic Inflammatory swellings
4. Hydrocele of the canal of Nuck
11. Hemangioma
5. Skene duct cyst
12. Lymphangioma
6. Seborrheic keratosis
13. Angiokeratoma
7. Acrochordon (fibroepithelial polyp)
14. Pyogenic granuloma
8. Fibroma, fibromyoma, and dermatofibroma 15. Sebaceous gland hyperplasia
16. Papillomatosis
BENIGN LESIONS OF THE VULVA
•
BARTHOLIN’s CYST
•
ATROPHIC LICHEN (LICHEN SCLEROSUS ET ATROPHICUS)
•
SQUAMOUS HYPERPLASIA
•
LICHEN SIMPLEX CHRONICUS
•
HIDRADENOMA PAPILLIFERUM
Bartholin’s Cyst/Abscess
• Medial to labia minor
• Blockage of duct following infection
– N. gonorrhea
– Staphylococci
– Anaerobes
• Thomas Bartholin
• Danish professor
• In 1652 he gave the first full
description of the human
lymphatic system.
Marsupalization
lichen
What is lichen?
A fungus, usually of the class Ascomycetes,
that grows symbiotically with algae, resulting
in a composite organism that
characteristically forms a crustlike or
branching growth on rocks or tree trunks.
In pathology….
Any of various skin diseases characterized by
patchy eruptions of small, firm papules.
Lichen Sclerosus et Atrophicus
• Most patients are post-menopausal women
• Stenosis of the introitus develops
Lichen Sclerosus et Atrophicus
Note the white, parchment-like or plaque-like lesion
Lichen Sclerosus et Atrophicus
• During early stages the patient may not have symptoms.
• Some patients develop intractable pruritus
• Burning and pain are less likely manifestations.
• Figure-of-8 or keyhole configuration.
• In late stages normal architecture may be lost
– atrophy of the labia minora, constriction of the vaginal orifice
(kraurosis), synechiae, ecchymoses, fissures.
• Squamous cell carcinoma develops in 3-6% cases
Lichen Sclerosus et Atrophicus
• Thinning of the surface epithelium with some
hyperkeratosis.
Lichen Sclerosus et Atrophicus
• Etiology
– Unknown. A higher prevalence of the disease in
postmenopausal women suggests hormonal factors,
but this has not been confirmed.
– Studies identifying an infection are inconclusive
– Weakly linked to autoimmune diseases and genetic
factors
– Local factors (eg, trauma, friction, chronic infection
and irritation)
– Recurrence near vulvectomy scars has been
observed.
Lichen Sclerosus et Atrophicus
• Treatment
– Potent topical corticosteroids
– Testosterone propionate is ineffective and has
many adverse effects
– Close follow-up -----epithelial cancer.
Squamous Hyperplasia
Associated with a response to hormonal
influences or exposure to exogenous irritants
Precursor of squamous cell CA if cells are
atypical
Squamous Hyperplasia
• This lesion produces hyperplastic thickening of the
superficial squamous epithelium.
• This lesion is a precursor of squamous cell carcinoma
of the vulva
Squamous Hyperplasia
• Note the keratin horn cysts and the infiltrate of
inflammatory cells at the base of the lesion.
Squamous Hyperplasia
• ITCHING is a common symptom.
• If hyperkeratosis is not prominent, lesions may appear
as reddish plaques.
• The clitoris, labia minora, and inner aspects of the labia
majora are more commonly affected.
• Extensive lesions may result in stenosis of the vaginal
introitus.
Squamous Hyperplasia
• Etiology
– Repetitive scratching or rubbing from irritants
– Treatment is aimed at halting the
itch-scratch-itch cycle.
Squamous Hyperplasia
• Treatment
– The same as lichen sclerosus
– General attention to proper hygiene.
– If the skin is moist or macerated, aluminum acetate
5% solution applied 3-4 times daily for 30-60 minutes
is beneficial.
– Systemic antihistamines or tricyclic antidepressants
– Refractory lesions, intralesional injections of
triamcinolone acetonide may be an alternative.
lichen simplex chronicus
• Hyperkeratotic, usually ill-defined,
grayish, thickened, and sometimes
excoriated lesion.
• Usually located over the labia
majora.
• Hyperpigmentation.
• Itching is always present and may
be intense.
lichen simplex chronicus
• Lichen simplex chronicus of the vulva is the end stage of
the itch-scratch-itch cycle.
• The initial stimulus to itch may be:
– Underlying seborrheic dermatitis.
– Intertrigo
– Tinea.
– Psoriasis.
– In most cases, the underlying cause is not evident and may have
been transient vulvitis or vaginal discharge.
• Any itching disease of the vulva may become secondarily
lichenified.
lichen simplex chronicus
• Epidermal and epithelial hyperplasia,
• Hyperkeratosis.
• Fibrotic vertical streaks of collagen between the
hyperplastic rete are present.
lichen simplex chronicus
• Treatment
– Includes removal of irritants and/or allergens
– Topical application of mild-to-high–potency corticosteroids.
– Avoid soaps and cleansing agents other than aqueous cream.
– Discourage excessive cleaning of the genital area; use of hot
water; overheating; and wearing of synthetic, rough, and/or
tight clothing.
• Lichen simplex chronicus may be associated with
underlying diseases (eg, Paget disease, Bowen disease)
Lichen planus
• Three types:
– Papulosquamous
– Erosive
– Hypertrophic
• Malignancy is possible in long-standing and ulcerative
lichen planus.
Lichen planus
• The papulosquamous form:
– Occurring as part of a generalized
disease
– Is the most common and is
characterized by:
• Flat-topped
• Polyhedral,
• Violaceous, shiny, and itchy papules
located on keratinized skin of the
labia and mons pubis. Delicate and
whitish reticulated papules may be
present on the mucosa, but no
atrophy or scarring is observed.
Lichen planus
• The erosive form:
– Involves the mucous membranes of the mouth and vulvovaginal
area and may be locally destructive, leading to atrophy and
scarring.
– Synonyms include erosive vaginal lichen planus, desquamative
inflammatory vaginitis, vulvovaginal-gingival syndrome, and
ulcerative lichen planus.
–Itching is rare, but pain, burning,
and irritation occur and may be
responsible for dyspareunia and
dysuria.
Lichen planus
• The rare hypertrophic form:
– Resembling lichen sclerosus, manifests
with extensive white scarring of the
periclitoral area with variable degrees of
hyperkeratosis.
– It may be very itchy.
– Extensive vaginal involvement may result
in a malodorous discharge.
– Large denuded areas may become
adherent, causing stenosis of the vaginal
introitus and dyspareunia.
– Marked atrophy may develop with time.
ID/CC A 75 year old woman visits her gynecologist
for a routine checkup and is found to have
white spots on her genitalia
HPI
She complains of slight outer
vaginal itching but denies any
postmenopausal bleeding, vaginal
discharge, or drug intake
PE
Hypochromic macules on labia
majora extending to perineum and
inner thighs in patchy distribution
with scale formation; skin is
thickened
Pruritus vulva
• Causes:
– General
– Local
– Psychosomatic
– Idiopathic
• General Examination
• Local examination:
– Smears
– Culture and sensitivity
– BIOPSY: KEYE’s Dermatological knife
BENIGN LESIONS OF THE Vagina
• CYSTIC SWELLINGS
• SOLID TUMORS
• ATROPHIC VAGINITIS
• VAGINAL ADENOSIS
Cystic swellings
• Gartner’s Cyst
– Dilatation of the Gartner’s (Wollfian) duct
– Anterior and lateral vaginal walls
• Epithelial inclusion cysts
• Endometrioma
• Uretheral diverticulum
Solid Tumors
• Fibromyoma
• Condyloma accuminata
• Bilharzial polyps
Atrophic vaginitis
• Thinning and atrophy of vaginal
epithelium
• Most common in postmenopausal
women with low estrogen levels
• Dyspareunia and vaginal spotting
(differential includes uterine cancer)
Vaginal Adenosis
• Persistent Mullerian columnar
epithelium in the anterior wall
and upper 1/3 of vagina
• Manifestation of maternal DES
exposure
• Red, granular patches
• Precursor of clear cell
adenocarcinoma
Vaginal Adenosis
• Note the red granular patches on the vaginal mucosa on
the left. The slide on the right shows glandular
development.
• Most patients are 7-35 years of age
BENIGN LESIONS OF THE cervix
• CERVICITIS
• EROSION
• POLYPS
Inflammatory Lesions of the Cervix
• Cervicitis (acute)
• Symptoms: backache, bearing-down feeling in the
pelvis, dull pain in the lower part of the
abdomen, urinary tract symptoms
Erosion of the Cervix
• Characterized by columnar epithelium replacing squamous
epithelium, grossly resulting in an erythematous area
• Causes:
– Physiological:
– Cervicitis: Acute or Chronic
– Hormonal therapy
Erosion of the Cervix
• Erosion of the cervix following delivery. A normal cervix
is on the left
Erosion of the Cervix
• SMEAR
– If infection---- Treat cause
– IF CIN ------ Manage according to stage
Chronic Cervicitis
• Chronic inflammation, sometimes ulceration with repair,
atypia or dysplasia, nabothian cysts from endocervical
glands
• Backache is a common symptom
Chronic Cervicitis
Nabothian Cysts
• Endocervical glands blocked by inflammation or
scarring.
Chronic Cervicitis
• Chronic inflammation underlies an area of cervical
dysplasia
Endocervical Polyps
Postcoital bleeding and
irregular vaginal spotting
• Inflammatory
proliferations of cervical
mucosa; not true
neoplasms
• Soft; may protrude
through the cervical os