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 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. 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. 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) 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.