condition affecting
TRANSCRIPT
Vulval skin is an extension of general skin surfaces
and it is important in the history to ask about
general skin problems as this might point towards
the diagnosis, for example psoriasis or eczema can
synchronously affect the vulva and the limbs. The
history should focus on the presenting complaint. It
is important to discuss current methods of skin care
(e.g. use of scented products which can
aggravate symptoms), which topical treatments
are being used (e.g. some creams such as
antifungal can aggravate the problem) and the
impact of the symptoms on sexual functioning.
Treatment should be given based on a
correct diagnosis and empirical
treatment should be discouraged
because of the potential side effects of
treatment. Good skin care of the vulva
is essential, with an avoidance of
scented and over-the-counter
products as these can produce
unnecessary irritation on the skin.
Vulval pruritus Vulval pain Superficial dyspareunia
Infections, e.g. candidiasis,
Trichomonas vaginalis
Infections, e.g. candidiasis Skin conditions, e.g. lichen
sclerosus
(causes vulval splitting)
Skin conditions, e.g. lichen
sclerosis, eczema, VIN
Skin conditions, e.g. lichen
sclerosis, eczema, VIN
Vulvodynia
Contact dermatitis Vulvodynia Vulval fissures
Skin bridges of the vulva
Vulvar lichen sclerosis (VLS) is a
chronic, inflammatory skin
condition of the vulva that
most commonly affects
postmenopausal women. It
can affect men, women, and
children on any area
Symptoms are insidious or
aggressive onset
Treatment: Topical Ultra potent
Corticosteroids.
Topical Calcineurin Inhibitors
Vulvodynia is a chronic type of pain that
affects the vulvar area and occurs without
an identifiable cause or visible pathology.
There are two subtypes of vulvodynia:
provoked vestibulodynia (also referred to
as vulvar vestibulitis syndrome) and
generalized vulvodynia. Vulvodynia is
classified according to the site of the pain
as generalized or localized.
Symptoms of herpes simplex virus infection include watery blisters in the skin or mucous membranes of the mouth, lips or genitals. Lesions heal with a scab characteristic of herpetic disease. Sometimes, the viruses cause very mild or atypical symptoms during outbreaks.
HSV replication
types of cysts:
1-Inclusion cysts : They are usually very small and located in the lower back of the vaginal wall.
2-Bartholin's gland cysts: are fluid-filled cysts that form on the Bartholin's glands. These glands sit on either side of the opening to the vagina and produce the fluid that lubricates the vaginal lips (labia).
3-Gartner's duct cysts: occur when ducts in a developing embryo don't disappear. These remaining ducts can form vaginal cysts later in life.
4-Müllerian cysts
Diagnosis is limited to visual assessment.
Treatment is
recommended for all
women with VIN. Wide
local excision is
recommended when
cancer is suspected. When
occult invasion is not a
concern, VIN can be treated with surgical
therapy, laser ablation, or
medical therap. (topical
imiquimod 5%).
Types
Squamous cell
carcinoma
Melanoma
Basal cell carcinoma
Vulvar cancer can
be caused by other
lesions such
as adenocarcinoma
or sarcoma
FIGO’s staging of carcinoma of the vulva
IA Tumor confined to the vulva or perineum, ≤ 2cm in size with stromal invasion ≤ 1mm, negative nodesIB Tumor confined to the vulva or perineum, > 2cm in size or with stromal invasion > 1mm, negative nodesII Tumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodesIIIA Tumor of any size with positive inguino-femoral lymph nodes
(i) 1 lymph node metastasis greater than or equal to 5 mm(ii) 1-2 lymph node metastasis (is) of less than 5 mm
IIIB (i) 2 or more lymph nodes metastases greater than or equal to 5 mm(ii) 3 or more lymph nodes metastases less than 5 mm
IIIC Positive node(s) with extracapsular spreadIVA (i) Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone
(ii) Fixed or ulcerated inguino-femoral lymph nodesIVB Any distant metastasis including pelvic lymph nodes
TreatmentThe extent of the surgery is dictated
by the anatomical staging. Surgery is
a mainstay of therapy and usually
accomplished by use of a radical
vulvectomy, removal of vulvar tissue
as well as the removal of as inguinal
and femoral lymph nodes as
possible (known as
complete inguinofemoral
lymphadenectomy
Vaginal disease
The main vaginal problem is infection which is covered
previously, Genital infections in gynecology. Bacterial
(bacterial vaginosis), fungal (Candida albicans) and
protozoal (Trichomonas vaginalis) infections can produce
vaginal inflammation and discharge. Microbiological swabs
will confirm the diagnosis and the symptoms should soon
resolve. Few skin conditions affect the vagina. Worthy of
mention is erosive lichen planus of the vagina which is an
autoimmune inflammatory skin condition that causes
vaginal pain, inflammation and if untreated vaginal
stenosis.
Treatment is usually with vaginal trainers (to stretch
the narrowing) and intravaginal steroids.
Conditions affecting the vulva, such as lichen
sclerosis and eczema, do not affect the vagina.
Intraepithelial neoplasia can affect the genital
tract (CIN and VIN) as discussed above
Treatment can involve cauterization, surgical
excision, radiotherapy and observational follow
up depending on the patient, grade of disease
and size of the lesion. VAIN assessment and
treatment can be complicated and is best
managed by specialist teams. There is a risk of
vaginal cancer in untreated patients, but this risk
remains unclear.
This is a rare cancer that accounts for around 250 new cases a year. The cause remains unknown, although the risk factors are likely to be similar to cervical cancer. The disease frequently presents at an advanced stage in the absence of symptoms with early disease.
FIGO Nomenclature
FIGO Nomenclature
Stage IThe carcinoma is limited to the vaginal wall.
Stage II
The carcinoma has involved the subvaginal tissue but
has not extended to the pelvic wall.Stage III
The carcinoma has extended to the pelvic wall.Stage IV
The carcinoma has extended beyond the true pelvis or
has involved the mucosa of the bladder or rectum;
bullous edema as such does not permit a case to be
allotted to stage IV.
IVa - Tumor invades bladder and/or rectal mucosa
and/or direct extension beyond the true pelvis.
IVb - Spread to distant organs.
FIGO staging and prognosis of vaginal cancer