Vulval & Vaginal lesionsVulval & Vaginal lesions

Dr. Abdallah H. AlsadigDr. Abdallah H. Alsadig

MDMD

Vulval anatomyVulval anatomy

The vulva (external genitalia ) includes:The vulva (external genitalia ) includes:

Mons pubisMons pubis

clitorisclitoris

labia majora and minoralabia majora and minora

Perineum: a less hairy skin & subcutaneous tissue Perineum: a less hairy skin & subcutaneous tissue area lying between the vaginal orifice & the anus & area lying between the vaginal orifice & the anus & covering the perineal body. Its length is 2-5 cm or covering the perineal body. Its length is 2-5 cm or more. The urethra opens on to it. more. The urethra opens on to it.

Vestibule: a forecourt or a hall next to the entrance. It Vestibule: a forecourt or a hall next to the entrance. It is the area of smooth skin lying within the L. minora & is the area of smooth skin lying within the L. minora & in front of the vaginal orifice. in front of the vaginal orifice.

Hymen.Hymen.

Non-neoplastic epithelial disordersNon-neoplastic epithelial disorders

Classification:Classification:

1.1. Lichen sclerosis.Lichen sclerosis.

2.2. Squamous cell hyperplasia (formerly: hyperplastic Squamous cell hyperplasia (formerly: hyperplastic dystrophy).dystrophy).

3.3. Other dermatoses.Other dermatoses.

- lichen planus.- lichen planus.

- psoriasis.- psoriasis.

- seborrhoeic dermatitis- seborrhoeic dermatitis

- inflammatory dermatoses.- inflammatory dermatoses.

- ulcerative dermatoses.- ulcerative dermatoses.

Lichen sclerosusLichen sclerosus

Comprises Comprises 70% of benign epithelial disorders 70% of benign epithelial disorders →→ epithelial thinning, inflammation & epithelial thinning, inflammation & histological changes in the dermis.histological changes in the dermis.

AetiologyAetiology:: unknown unknownSx:Sx: Itching (commonest), vaginal soreness + Itching (commonest), vaginal soreness + Dyspareunia. Burning and pain are uncommon.Dyspareunia. Burning and pain are uncommon.SignsSigns:: crinkled skin, L. minora atrophy, crinkled skin, L. minora atrophy, constriction of V. orifice, adhesions, constriction of V. orifice, adhesions, ecchymoses & fissures. ecchymoses & fissures.

Dx:Dx: Biopsy is mandatory Biopsy is mandatory

Rx:Rx: - emollients, topical steroids. - emollients, topical steroids.

- Testosterone: not effective than petroleum jelly - Testosterone: not effective than petroleum jelly & & →→ pruritus, pain & virilization. pruritus, pain & virilization.

- Surgery: avoided unless malignant changes- Surgery: avoided unless malignant changes

Squamous cell hyperplasiaSquamous cell hyperplasia

Df:Df: thickened skin with white hyperkeratotic patches, thickened skin with white hyperkeratotic patches, excoriation & fissures.excoriation & fissures.

HistoHisto: hyperkeratosis, cellular epithelial: hyperkeratosis, cellular epithelial proliferation proliferation with with normal maturationnormal maturation & & inflammatory responseinflammatory response in in the dermis (lymphatic & plasma cell infiltration).the dermis (lymphatic & plasma cell infiltration).

AetiologyAetiology: repetitive surface irritation & trauma from : repetitive surface irritation & trauma from irritants that causing scratching & rubbing.irritants that causing scratching & rubbing.

RX:RX: is the same as Lichen sclerosis is the same as Lichen sclerosis

Benign Vulval lumpsBenign Vulval lumps

Bartholin’s cyst.Bartholin’s cyst.Epidermal inclusion cyst.Epidermal inclusion cyst.Skene’s duct cyst.Skene’s duct cyst.Congenital mucous cysts: Congenital mucous cysts: arise from mesonephric ducts remnants.arise from mesonephric ducts remnants.

Cyst of the canal of Nuck: Cyst of the canal of Nuck: can give rise to hydrocele in labia maqjoracan give rise to hydrocele in labia maqjora..Sebaceous cyst.Sebaceous cyst.Papillomatosis (solid).Papillomatosis (solid).Fibroma (solid).Fibroma (solid).Lipoma (solid).Lipoma (solid).Condylomata (solid).Condylomata (solid).

Cysts are either congenital or arise from obstructed glands.Cysts are either congenital or arise from obstructed glands. Manifestations arise from the cysts (cosmotic) or from Manifestations arise from the cysts (cosmotic) or from

infection.infection.

Bartholin glandsBartholin glands

Two in number.Two in number.

Lie posteriolaterally to the Lie posteriolaterally to the vaginal orifice, one on vaginal orifice, one on either sideeither side

Normally not seen nor felt.Normally not seen nor felt.

If enlarged, can be a If enlarged, can be a painless cyst or painful painless cyst or painful abscessabscess

Bartholin Duct CystBartholin Duct Cyst

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 MarsupializationMarsupialization..

Bartholin's AbscessBartholin's Abscess

Rx: drainage & Rx: drainage & MarsupializationMarsupialization

Skene's GlandSkene's Gland

• are found on each side of urethra• Normally neither seen nor felt

SkenitisSkenitis

May become swollen and tender, particularly with

GC or chlamydia Rx: drainage.Rx: drainage.

Culture for GC, ChlamydiaCulture for GC, Chlamydia

Inclusion Cysts of the Vulva

Contain creamy, yellow Contain creamy, yellow debris & lined with stratified debris & lined with stratified epithelium.epithelium.

Found in the perineum, Found in the perineum, posterior V. wall & other posterior V. wall & other parts of the vulva.parts of the vulva.

Arise from perineal skin Arise from perineal skin buried at obstetrical injuries.buried at obstetrical injuries.

Usually symptomless.Usually symptomless.

Rx: excision. Rx: excision.

Vulval CarcinomaVulval Carcinoma

Vulval & vaginal cancers Vulval & vaginal cancers are rare (1000 new are rare (1000 new cases/year in UK).cases/year in UK).

Majority are of epidermal Majority are of epidermal originorigin

Age: 60-75 years.Age: 60-75 years.

90-95% of Vulval cancer 90-95% of Vulval cancer are of Squamous origin.are of Squamous origin.

Melanoma of the vulva is Melanoma of the vulva is second most common type second most common type (4-9%).(4-9%).

AetiologyAetiology

Vulval dermatomes (lichen sclerosis): a common Vulval Vulval dermatomes (lichen sclerosis): a common Vulval inflammatory dermatosis (HPV 16 & 33) affecting older inflammatory dermatosis (HPV 16 & 33) affecting older women with ↑chance of malignant progression. women with ↑chance of malignant progression.

Vulval Intraepithelial Neoplasia (VIN) : 80% will lead to Vulval Intraepithelial Neoplasia (VIN) : 80% will lead to invasive cancer at 10 years if not treated & 7-8% if invasive cancer at 10 years if not treated & 7-8% if treated. VIN3 is a pre-invasive condition.treated. VIN3 is a pre-invasive condition.

Human papilloma virus (HPV): associated with 30% of Human papilloma virus (HPV): associated with 30% of Vulval cancer & with 80-90% of Vulval cancer in women Vulval cancer & with 80-90% of Vulval cancer in women less than 50 years of age.less than 50 years of age.

Smoking: co-factor of HPV & VIN development.Smoking: co-factor of HPV & VIN development. VIN affects mainly L.minora & perineum.VIN affects mainly L.minora & perineum.

Classification of VINClassification of VIN

VIN I - mild dysplasia with VIN I - mild dysplasia with hyperplastic vulvar dystrophy hyperplastic vulvar dystrophy with mild atypiawith mild atypia

VIN II - Moderate dysplasia, VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy hyperplastic vulvar dystrophy with moderate atypiawith moderate atypia

VIN III - Severe dysplasia; VIN III - Severe dysplasia; hyperplastic vulvar dystrophy hyperplastic vulvar dystrophy with severe atypia (it replaces the with severe atypia (it replaces the term carcinoma in situ, Bowen’s term carcinoma in situ, Bowen’s diseasedisease).).

Carcinoma in situ

VIN Dx & RxVIN Dx & Rx

Dx: colposce + biopsiesDx: colposce + biopsies

Rx: Rx:

- low grade VIN: observation.- low grade VIN: observation.

- VIN3: local excision or laser vaporization- VIN3: local excision or laser vaporization

- Topical immunomodulator: imiquimod- Topical immunomodulator: imiquimod

Vulval CarcinomaVulval Carcinoma

Clinical Staging (F.I.G.O.):Clinical Staging (F.I.G.O.):Stage I :Stage I :

1a: confined to vulva with <1mm invasion. 1a: confined to vulva with <1mm invasion. 1b: confined to vulva with a diameter < 2 cm & no inguinal 1b: confined to vulva with a diameter < 2 cm & no inguinal

lymph nodes affection.lymph nodes affection.Stage II :Stage II : limited to vulva with diameter > 2 cm) & no limited to vulva with diameter > 2 cm) & no inguinal lymph nodes affection.inguinal lymph nodes affection.Stage III :Stage III : adjacent spread to the lower urethra and/or vagina adjacent spread to the lower urethra and/or vagina and/or anus and/or unilateral lymph nodes affection.and/or anus and/or unilateral lymph nodes affection.Stage IV :Stage IV :

A.A. Bilateral inguinal nodes metastases, involvement of mucosa Bilateral inguinal nodes metastases, involvement of mucosa of rectum, urinary bladder, upper urethra or pelvic bones. of rectum, urinary bladder, upper urethra or pelvic bones.

B.B. Distant metastasis. Distant metastasis.

Treatment of Vulval CarcinomaTreatment of Vulval Carcinoma

Stage I & II :Stage I & II :

Radical local excision with 1cm disease–free margin.Radical local excision with 1cm disease–free margin.

Stage III & IV :Stage III & IV :

- According to the general health. - According to the general health.

- Chemotherapy & radiotherapy to shrink the tumour to permit - Chemotherapy & radiotherapy to shrink the tumour to permit surgery which may preserve the urethral & anal sphincter surgery which may preserve the urethral & anal sphincter function.function.

- radical vulvectomy + inguinal L. nodes dissection.- radical vulvectomy + inguinal L. nodes dissection.

- reconstructive surgery with skin grafts or myocutaneous - reconstructive surgery with skin grafts or myocutaneous flaps for healing.flaps for healing.

Vaginal Intraepithelial Neoplasia (VaIN)Vaginal Intraepithelial Neoplasia (VaIN)

Extremely uncommon (150 times < CIN).Extremely uncommon (150 times < CIN).

70% associated with CIN (extension of the transformation 70% associated with CIN (extension of the transformation zone into the vaginal fornices).zone into the vaginal fornices).

Predisposing factorsPredisposing factors: similar to those of CIN (HPV), but the : similar to those of CIN (HPV), but the age of VaIN is higher than CIN, diethylstilboesterol in utero age of VaIN is higher than CIN, diethylstilboesterol in utero (metaplastic transformation into the vagina), previous history (metaplastic transformation into the vagina), previous history of CIN), radiotherapy of CA cervix.of CIN), radiotherapy of CA cervix.

VaIN is gradedVaIN is graded 1-3 but is less invasive than CIN: 1-3 but is less invasive than CIN:

- - VaIN1: mild dysplasia.VaIN1: mild dysplasia.

- VaIN2: moderate dysplasia.- VaIN2: moderate dysplasia.

- VaIN3: severe dysplasia.- VaIN3: severe dysplasia.

Dx:Dx: V. smear, colposcopy, biopsy (even after hysterectomy). V. smear, colposcopy, biopsy (even after hysterectomy).

Rx:Rx: low gradelow grade: observation. : observation. high gradehigh grade: excision, 5-: excision, 5-fluoroyracil, diathermy. Alternatively, Radiotherapy. fluoroyracil, diathermy. Alternatively, Radiotherapy.

Vaginal CarcinomaVaginal Carcinoma

IncidenceIncidence: 1-2% of all gyn. Cancer.: 1-2% of all gyn. Cancer.

ClassificationClassification::

1. 1. primaryprimary: : squamous squamous (common, 85%), (common, 85%), adenocarcinomaadenocarcinoma (17-21 (17-21 years of age, metastasis to L.Ns), years of age, metastasis to L.Ns), clear cell adenocarcinomaclear cell adenocarcinoma (DES).(DES).

2. 2. secondarysecondary: metastasis from the cervix, endometrium,…..others.: metastasis from the cervix, endometrium,…..others.

50% in the upper 350% in the upper 3rdrd, 30% in lower 3, 30% in lower 3rdrd & 19% in middle 3 & 19% in middle 3rdrd..

Posterior V. lesions more common than anterior & the anterior Posterior V. lesions more common than anterior & the anterior are more common than lateral lesions.are more common than lateral lesions.

SpreadSpread: direct & lymphatic.: direct & lymphatic.

Vaginal CarcinomaVaginal Carcinoma

Clinical Staging (F.I.G.O.):Clinical Staging (F.I.G.O.): Stage IStage I: tumour confined to vagina.: tumour confined to vagina.

Stage II :Stage II : tumour invades paravaginal tissue but not tumour invades paravaginal tissue but not to pelvic sidewall.to pelvic sidewall.

Stage III :Stage III : tumour extends to pelvic sidewall. tumour extends to pelvic sidewall.

Stage IV :Stage IV :

a) tumour invades mucosa of bladder or rectum a) tumour invades mucosa of bladder or rectum and/or beyond the true pelvis.and/or beyond the true pelvis.

b) Distant metastasis.b) Distant metastasis.

TREATMENT TREATMENT

Stage 1:Stage 1:

1. Tumour < 0.5 cm deep: 1. Tumour < 0.5 cm deep:

a. surgery: local excision or total vaginectomy with reconstruction.a. surgery: local excision or total vaginectomy with reconstruction.

b. radiotherapy.b. radiotherapy.

2. Tumour > 0.5 cm deep: (a) wide vaginectomy, pelvic 2. Tumour > 0.5 cm deep: (a) wide vaginectomy, pelvic lymphadenectomy + reconstruction of vagina. (b) radiotherapylymphadenectomy + reconstruction of vagina. (b) radiotherapy

stage 2: (a) radical vaginectomy, lymphadenectomy (b) stage 2: (a) radical vaginectomy, lymphadenectomy (b) radiotherapy radiotherapy

Stage 3: radiotherapy.Stage 3: radiotherapy.