Anatomy of the vagina
* it is a flattened muscular tube extending from the hymenal ring at the introitus up to the fornices . It is about 8 cm in length.
* the posterior fornix ( Douglus pouch ) allows easy access to the peritoneal cavity from the the vagina by culdocentesis or colpotomy.
* its epithelium is non-keratinized squamous in type normally devoid of mucous glands and hair follicles.

Structural and Benign Neoplastic
Conditions :
(1)Urethral diverticula
* small sac-like projections in the anterior vaginal wall along the posterior urethra, it may or may not communicate with the urethra.
it can cause :
= recurrent urinary tract infections.
=dyspareunia.
* treatment :
*urethral dilatation or
*surgical excision of the diverticulum.

(2) Bartholin’s cyst
* it is the most common vulvo vaginal mass. It presents as swelling postrolateral in the introitus usually unilateral , 3cm in diameter. It is not infected but can be symptomatic.
* after 40 y. it is necessary to palpate the base of the cyst to rule out carcinoma.
* teatment : by marsupialization.

Bartholin′ s cyst

* Bartholin abscess
* infection of the gland may result from blockage and accumulation of purulent material and a large painful inflammatory mass can develop.
* The treatment by incision of the abscess and left drain in place for 2-4 weeks.

(3) Inclusion cysts
* result from infolding of the vaginal epithelium, located in the posterior or lateral wall of the lower 1/3 of the vagina.
* They are most frequently associated with lacerations from delivery or surgery. They are treated by surgical excision.
(4) Endometriotic cysts
* are endometriotic implants located in the upper
1/3 of the vagina.
* presents as black cysts which may bleeds at the time of menstruation.
* they are most common in an episiotomy wound.

(5) vaginal adenosis
* multiple mucus – containing vaginal cysts rarely give symptoms.
* common in daughters of women who took di ethyl stilboesterol ( DES) during pregnancy.
(6) Prolapse as ; cystocele , rectocele and enterocele.

cystocele

(7) Fistula as ; vesico vaginal , recto vaginal and uretero vaginal fistulas. They may result from obstetric or surgical trauma , invasive cancer and radiation therapy.
(8) Erosive lichen planus erythematous papules involve vagina as well as vulval vestibule . Condyloma acuminata ,flat warts ( HPV) and herpes simplex infections can be found in the vaginal vault.

Erosive lichen planus

(9) Gartner’s duct cyst
* are generally thick-walled , soft cysts resulting from embryonic remnants. Gartner′s cyst arise from the remnant of the Wolffian duct .
* they vary in size from 1 – 5cm , found on the antero lateral walls in the upper ½ of the vagina and more laterally in the lower vagina.
* most of them are asymptomatic.
* require no intervention. if ttt is required , marsupialization is effective and safer than excision.

Gartener’s cyst

In summary
Benign Conditions:
1. urethral diverticula.
2. Bartholin’s cysts & abscess.
3. inclusion cysts.
4. endomeriotic cysts.
5. vaginal adenosis.
6. prolapse.
7. fistula.
8. erosive lichen planus.
9. Gartner’s duct cyst.

VAIN or carcinoma in situ :
* much less common than CIN and VIN.
* occurs in the upper 1/3 of the vagina.
* caused by HPV infection or after irradiation for cervical cancer .
* women with past history of in situ or invasive ca.cx or ca. vulva are at increased risk.

* Diagnosis by:
= Pap smear is abnormal.
= colposcopy .
findings are similar to cervical lesions.
abnormal epithelial proliferation and maturation above the basement membrane.
VAIN I : inner 1/3 .
VAIN II: inner 2/3 .
VAIN III: full thickness involvement.
= vaginal biopsy directed by colposcopy & Lugol′s iodine.

* management
= vaginal vault lesion surgical excision to exclude invasive cancer.
= multifocal lesions laser therapy or topical 5 fluorouracil.
= extensive disease total vaginectomy and neovagina using a split thickness skin graft.

In summary
VAIN diagnosis:
1. Pap smear.
2. colposcopy.
3. vaginal biopsy.
management :
1.vaginal vault lesion.
2. multifocal lesions.
3. extensive disease.

* uncommon tumor.
* mean age 60 – 70 years.
* 30% have a history of in situ or invasive cervical cancer that was treated at least 5ys earlier.
* 50% of lesions are in the upper 1/3 of vagina on the posterior wall.

* Symptoms:
= vaginal bleeding.
= vaginal discharge.
= urinary symptoms.
* examination: ulcerative , exophytic and infiltrative growth patterns.

* pattern of spread:
= direct invasion to bladder , urethra or rectum or progressive lateral extension to the pelvic side wall .
= lymphatic to the obturator ,internal iliac and external iliac nodes.
lesions in the lower vagina drains to the inguino femoral nodes.
= hematogenous is uncommon until the disease is advanced.

is made clinically by:
* chest X-ray.
* pelvic & abdominal CT.
* MRI for metastatic spread & bulky pelvic and para aortic lymph nodes.
* PET (position emission tomography) to look for metastatic disease.

Stage I Carcinoma limited to the vaginal wall.
Stage II Carcinoma has involved the subvaginal tissue but not extended into the pelvic side wall .
Stage III Carcinoma has extended to the pelvic side wall .
Stage IV
IV
IV a b
Carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum.
Spread to bladder or rectum .
Spread to distant organs .

1. Radiotherapy or chemo radiotherapy are the main methods of treatment for 1ry vaginal cancer.
2. Radical surgery has a limited role :
* Radical hysterectomy + radical vaginectomy + pelvic lymphadenectomy , for stage 1 in the posterior fornix.
* Pelvic exenteration with creation of a neovagina ,if LN. are free.

* An association between in utero exposure to di ethyl stilbesterol (DES) and the latter development of clear cell carcinoma in the vagina was reported in 1971.
* Vaginal adenosis ( columnar epithelium ) is the most common anomaly ,present in 30% of exposed females.

* this tissue behaves similarly to the columnar epithelium of the cervix & is replaced initially by immature metaplastic squamous epithelium.
* the risk for developing a clear cell adenocarcinoma following DES exposure in utero is only 1/1000 .
* the mean age is 19 years , rare before 14y.
few cases reported in women in their 40s & 50s.

* Treatment : for early tumor , radical hysterectomy and vaginectomy ( cereation of neovagina) or radiation therapy is effective.
* The 5-year survival rate is 80% , which is better than that for squameous cell carcinoma of the vagina.