Vulval & Vaginal lesions

1. Vulval & Vaginal lesions Dr. Abdallah H. Alsadig MD

2. Vulval anatomy 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.

3. Non-neoplastic epithelial disorders Classification: • Lichen sclerosis. • Squamous cell hyperplasia (formerly: hyperplastic dystrophy). • Other dermatoses. - lichen planus. - psoriasis. - seborrhoeic dermatitis - inflammatory dermatoses. - ulcerative dermatoses.

4. Lichen sclerosus • Comprises 70% of benign epithelial disorders → epithelial thinning, inflammation & histological changes in the dermis. • Aetiology: unknown • Sx: Itching (commonest), vaginal soreness + Dyspareunia. Burning and pain are uncommon. • Signs: crinkled skin, L. minora atrophy, constriction of V. orifice, adhesions, ecchymoses & fissures. • Dx: Biopsy is mandatory • Rx: - emollients, topical steroids. - Testosterone: not effective than petroleum jelly & → pruritus, pain & virilization. - Surgery: avoided unless malignant changes

5. Squamous cell hyperplasia • Df: thickened skin with white hyperkeratotic patches, excoriation & fissures. • Histo: hyperkeratosis, cellular epithelial proliferation with normal maturation & inflammatory response in the dermis (lymphatic & plasma cell infiltration). • Aetiology: repetitive surface irritation & trauma from irritants that causing scratching & rubbing. • RX: is the same as Lichen sclerosis

6. Benign Vulval lumps • 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.

7. Bartholin glands • 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

8. Bartholin 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 Marsupialization.

9. Bartholin's Abscess • Rx: drainage & Marsupialization

10. Skene's Gland • are found on each side of • urethra • Normally neither seen nor • felt

11. Skenitis • May become swollen and tender, particularly with GC or chlamydia • Rx: drainage. • Culture for GC, Chlamydia

12. Inclusion Cysts of the Vulva • 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.

13. Vulval Carcinoma • Vulval & vaginal cancers are rare (1000 new cases/year in UK). • Majority are of epidermal origin • Age: 60-75 years. • 90-95% of Vulval cancer are of Squamous origin. • Melanoma of the vulva is second most common type (4-9%).

14. Aetiology • Vulval dermatomes (lichen sclerosis): a common Vulval inflammatory dermatosis (HPV 16 & 33) affecting older women with ↑chance of malignant progression. • Vulval Intraepithelial Neoplasia (VIN) : 80% will lead to invasive cancer at 10 years if not treated & 7-8% if treated. VIN3 is a pre-invasive condition. • Human papilloma virus (HPV): associated with 30% of Vulval cancer & with 80-90% of Vulval cancer in women less than 50 years of age. • Smoking: co-factor of HPV & VIN development. • VIN affects mainly L.minora & perineum.

15. Classification of VIN • 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

16. VIN Dx & Rx • Dx: colposce + biopsies • Rx: - low grade VIN: observation. - VIN3: local excision or laser vaporization - Topical immunomodulator: imiquimod

17. Vulval Carcinoma Clinical Staging (F.I.G.O.): • 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.

18. Treatment of Vulval Carcinoma • 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.

19. Vaginal Intraepithelial Neoplasia (VaIN) • Extremely uncommon (150 times < CIN). • 70% associated with CIN (extension of the transformation zone into the vaginal fornices). • Predisposing factors: similar to those of CIN (HPV), but the age of VaIN is higher than CIN, diethylstilboesterol in utero (metaplastic transformation into the vagina), previous history of CIN), radiotherapy of CA cervix. • VaIN is graded 1-3 but is less invasive than CIN: - VaIN1: mild dysplasia. - VaIN2: moderate dysplasia. - VaIN3: severe dysplasia. • Dx: V. smear, colposcopy, biopsy (even after hysterectomy). • Rx:low grade: observation. high grade: excision, 5-fluoroyracil, diathermy. Alternatively, Radiotherapy.

20. Vaginal Carcinoma • Incidence: 1-2% of all gyn. 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 V. lesions more common than anterior & the anterior are more common than lateral lesions. • Spread: direct & lymphatic.

21. Vaginal Carcinoma 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.

22. TREATMENT • 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.

23. thanks