Vulval and vaginal benign and malignant conditions

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Dr. Muhabat Salih Saeid
MRCOG-London, UK.
The vulva (external genitalia ) includes:
 Mons pubis
 clitoris
 labia majora and minora
 Perineum: a less hairy skin & subcutaneous
tissue area lying between the vaginal orifice &
the anus & covering the perineal body. Its length
is 2-5 cm or more. The urethra opens on to it.
 Vestibule: a forecourt or a hall next to the
entrance. It is the area of smooth skin lying
within the L. minora & in front of the vaginal
orifice.
 Hymen.
Classification:
1.
Lichen sclerosis.
2.
Squamous cell hyperplasia (formerly: hyperplastic
dystrophy).
3.
Other dermatoses.
- lichen planus.
- psoriasis.
- seborrhoeic dermatitis
- inflammatory dermatoses.
- ulcerative dermatoses.
Comprises 70% of benign epithelial disorders
→ epithelial thinning, inflammation &
histological changes in the dermis.
 Etiology: unknown
 Symptoms Itching (commonest), vaginal
soreness + Dyspareunia. Burning and pain are
uncommon.
 Signs: crinkled skin, L. minora atrophy,
constriction of V. orifice, adhesions,
ecchymoses & fissures.
 Diagnosis: Biopsy is mandatory
 Treatment: - emollients, topical steroids.
- Testosterone: not effective than petroleum jelly
& → pruritus, pain & virilization.
- Surgery: avoided unless malignant changes


General Appearance
◦ Erosive lesions at vestibule with/without
adhesions resulting in stenosis
◦ May have associated oral mucotaneous lesions
and desquamative vaginitis
◦ Patient complainingof irritating vaginal
discharge, vulvar soreness, intense burning,
pruritus, and dyspareunia with post-coital
bleeding
◦ Types: PapulosquamousLP/Hypertrophophic LP
/Errosive LP
 Intravaginal hydrocortisone
suppositories BID x 2m
 Steroid creams (medium-high potency)
 Vaginal estrogen cream if atrophic
epithelium present
 Vaginal dilators for stenosis
 Surgery for severe vaginal synechiae
 Vulvar hygiene
 Emotional support

Physical Appearance
◦ Red moist lesions with or without scales
 Treatment: Topical corticosteroids


Physical Appearance
Benign epithelial thickening and hyperkeratosis
◦ Acute phase with red/moist lesions
◦ Causing pruritus leading to rubbing &
scratching Circumscribed, single or unifocal
◦ Raised white lesions on vulva or labia majora
and clitoris.
 Treatment: Sitz baths, lubricants, oral
antihistamines, Medium potency topical
steroid twice daily

Physical Appearance
◦ Thickened white epithelium on vulva
◦ Generally unilateral and localized
 Treatment: Medium potency
steroid twice daily prn
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
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Bartholin’s cyst.
Epidermal inclusion cyst.
Skene’s duct cyst.
Congenital mucous cysts: arise from mesonephric ducts
remnants.
Cyst of the canal of Nuck: can give rise to hydrocele in labia
maqjora.
Sebaceous cyst.
Papillomatosis (solid).
Fibroma (solid).
Lipoma (solid).
Condylomata (solid).
Cysts are either congenital or arise from obstructed glands.
Manifestations arise from the cysts (cosmotic) or from infection.
Two in number.
Lie posteriolaterally to the
vaginal orifice, one on
either side
Normally not seen nor felt.
If enlarged, can be a
painless cyst or painful
abscess
Most common Vulval cyst.
 usually unilateral, on the
posterio-lateral side of the
introitus.
 usually about 2 cm &
contains sterile mucus.
 Usually asymptomatic.
 secondary infections →
Bartholin's abscess.

 Rx: excision or
Marsupialization.
Rx: drainage &
Marsupialization
•They are found on each
side of urethra
Normally neither seen nor
felt
May become swollen
and tender,
particularly with
GC or chlamydia
Rx: drainage.
Culture for GC,
Chlamydia
Contain creamy, yellow
debris & lined with
stratified epithelium.
Found in the perineum,
posterior V. wall & other
parts of the vulva.
Arise from perineal skin
buried at obstetrical
injuries.
Usually symptomless.
Rx: excision.
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
VIN I - mild dysplasia with
hyperplastic vulvar dystrophy
with mild atypia
VIN II - Moderate dysplasia,
hyperplastic vulvar dystrophy
with moderate atypia
VIN III - Severe dysplasia;
hyperplastic vulvar dystrophy
with severe atypia (it replaces
the term carcinoma in situ,
Bowen’s disease).
Carcinoma in situ
Dx: colposcopy + biopsies
 Rx:
- low grade VIN: observation.
- VIN3: local excision or laser vaporization
- Topical immunomodulator: imiquimod

Introduction
Vulval cancer is uncommon and accounts
for approximately 1-4% of all gynecological
cancer
incidence : 1.8 /100.000, It is predominantly
seen in postmenopausal and old women
(mean age 65 years ) ,and only 2% were less
than 30 years.
In countries such as south Africa where
sexually transmitted diseases are common,
the mean age of presentation is 59 years.
Little is known
A viral factor has been suggested by the
detection of antigens induced by
Herpes simplex virus type (HSV2)
Type 16/18 human papilloma virus
(HPV),in vulval intraepithelial neoplasia.
Primary Tumor
90% of lesions are of squamous in origin.
3-5 of lesions are melanoma.
2% of lesions is basal cell carcinoma.
Less than 1% is sarcoma.
Secondary Tumors
It is occasionly found in vulva
Most commonly the primary lesion is from the
cervix or the endometrium .
Clinical Staging (F.I.G.O.):




A.
B.
Stage I :
1a: confined to vulva with <1mm invasion.
1b: confined to vulva with a diameter < 2 cm & no inguinal
lymph nodes affection.
Stage II : limited to vulva with diameter > 2 cm) & no
inguinal lymph nodes affection.
Stage III : adjacent spread to the lower urethra and/or vagina
and/or anus and/or unilateral lymph nodes affection.
Stage IV :
Bilateral inguinal nodes metastases, involvement of mucosa
of rectum, urinary bladder, upper urethra or pelvic bones.
Distant metastasis.
A new FIGO staging based on
surgical findings in 1988, it is more
accurate as the involvement of
groin nodes is missed on clinical
examination in up to 30% of cases
and over diagnosis in 5%.
2 cm lesion size Or
less
Confined to the vulva or perineum nodes
histo-Logically negative.
> 2cm lesion size
Confined to the vulva or perineum nodes
histo-Logically negative.
Tumor of any size spread to lower urethra
vagina anus +/- Unilateral metastasis
A
Involvement of :
Upper urethra
Bladder mucosa
Rectal mucosa
Pelvic bone
Bilateral L.N.metastasis
B
Distant metastases and / or pelvic nodes
Are usually seen in the anterior part of the vulva.
2/3 of cases in the labia majora.
1/3 of cases in the clitoris ,labia minora,fourchitte,
and perineum.
Spread:1.
2.
3.
LYMPHATIC > 50%
Direct spread occurs in 25% to the urethra, vagina and
rectum
Hematogenous spread to bone or lung is rare
The lymph nodes are arranged in 5 groups in each
groin
Most patients with invasive disease
complain of:
Irritation or purities in 70% of cases
Vulvar mass or ulcer in 55% of cases
Bleeding in 28% of cases
Discharge in 2-3% of cases
1.
The doctor fails to recognize the
gravity of the lesion and prescribes
topical therapy.
2.
Older women are often embarrassed
and shy.
On Examination
1. Lesion can take any form from flat white lesion
to large ulcer.
2. The size of the tumor ,involvement of the
urethra and anus should be noted.
3. Inspection of the cervix and cervical cytology.
4. Needle aspiration of any suspicious groin node.
Diagnosis is made on histology from full
thickness generous biopsy.
Stage I & II :
Radical local excision with 1cm disease–free margin.
 Stage III & IV :
- According to the general health.
- Chemotherapy & Radiotherapy to shrink the tumour to
permit surgery which may preserve the urethral & anal
sphincter function.
- Radical vulvectomy + inguinal L. nodes dissection.
- Reconstructive surgery with skin grafts or
myocutaneous flaps for healing.
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
CYSTIC SWELLINGS

SOLID TUMORS

ATROPHIC VAGINITIS

VAGINAL ADENOSIS

Gartner’s Cyst
◦ Dilatation of the Gartner’s (Wollfian) duct
◦ Anterior and lateral vaginal walls

Epithelial inclusion cysts

Endometrioma

Uretheral diverticulum

Fibromyoma

Condyloma accuminata

Bilharzial polyps

A vaginal leiomyoma is normally a
benign smooth muscle tumour in the vagina.
These tumours are extremely rare and the
aetiology is unknown. The imaging findings
are those of a nonspecific well-defined
enhancing soft tissue mass centred on the
vagina
The lesion may be very large, but is
usually under 6 cm in size. Patients
are asymptomatic in the early stages.
Symptoms arise with the growth of
tumour mainly due to compression.
Most leiomyomas are not diagnosed
clinically but only on histological
examination

Removal of tumor by vaginal route,
wherever possible, with subsequent
histopathological examination appears
to be the optimum management plan

Thinning and atrophy of vaginal
epithelium

Most common in Pre-pubertal –
lactating and postmenopausal
women with low estrogen levels

Dyspareunia and vaginal spotting
(differential includes uterine
cancer)
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Abnormal vaginal discharge
Pruritus
Irritation
Burning
Soreness
Odor
Dyspareunia
Bleeding
Dysuria

Genital
Dryness/Itching/Burning
Dyspareunia
Vulvar pruritus
Feeling of pressure
Yellow malodorous discharge /leukorrhea
Spotting
Irritation/tear

Urinary
Dysuria/ Frequency/Hematuria
Urinary tract infection
Stress incontinence

Treated with estrogen replacement (vaginal/oral)

Oral BCP (ethinyl estradiol up to 50ug)



Conjugated estrogen up to 1.25mg in combination
with medroxyprogesterone acetate to prevent
endometrial hyperplasia
Vaginal cream 1g daily for one month then ½ dose
2X/week (1g vaginal cream=0.625mg conjugated
estrogen)
◦ should give with 2.5mg medrxyprogesterone x14d
Estrogen vaginal ring delivers 6-9ug estrodiol daily
Incidence: 1-2% of all gynaecological cancer.
 Classification:
1. primary:
squamous (common, 85%),

Adenocarcinoma (17-21 years of age, metastasis to L.Ns),
Clear cell adenocarcinoma (DES).
2. secondary: metastasis from the cervix, endometrium, others.
 50% in the upper 3rd, 30% in lower 3rd & 19% in middle 3rd.
 Posterior Vaginal lesions more common than anterior & the anterior
are more common than lateral lesions.
 Spread: direct & lymphatic.
Clinical Staging (F.I.G.O.):
 Stage I: tumour confined to vagina.
 Stage II : tumour invades paravaginal tissue but not
to pelvic sidewall.
 Stage III : tumour extends to pelvic sidewall.
 Stage IV :
a) tumour invades mucosa of bladder or rectum
and/or beyond the true pelvis.
b) Distant metastasis.
Stage 1:
1. Tumour < 0.5 cm deep:
a. surgery: local excision or total vaginectomy with
reconstruction.
b. radiotherapy.
2. Tumour > 0.5 cm deep: (a) wide vaginectomy, pelvic
lymphadenectomy + reconstruction of vagina. (b)
radiotherapy
 stage 2: (a) radical vaginectomy, lymphadenectomy
(b) radiotherapy
 Stage 3: radiotherapy.

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