Diseases of the Vagina Azza AlYamani Prof. Obstet. & Gynecol.

1. Diseases of the Vagina Azza AlYamaniProf.Obstet. & Gynecol.

2. Anatomy of the vagina * it is a flattened muscular tube extending from the hymenal ring at the introitus up to the fornices . It is about 8 cm in length. * the posterior fornix (Douglus pouch) allows easy access to the peritoneal cavity from the the vagina by culdocentesis or colpotomy. * its epithelium is non-keratinized squamousin type normally devoid of mucous glands and hair follicles.

3. Benign Conditions

4. Structural and Benign Neoplastic Conditions : (1)Urethral diverticula * small sac-like projections in the anterior vaginal wall along the posterior urethra, it may or may not communicate with the urethra. it can cause : = recurrent urinary tract infections. =dyspareunia. *treatment : *urethral dilatation or *surgical excision of the diverticulum.

6. (2) Bartholin’s cyst * it is the most common vulvo vaginal mass. It presents as swelling postrolateral in the introitus usually unilateral , 3cm in diameter. It is not infected but can be symptomatic. * after 40 y. it is necessary to palpate the base of the cyst to rule out carcinoma. *teatment : by marsupialization.

7. Bartholin′ s cyst

9. *Bartholin abscess * infection of the gland may result from blockage and accumulation of purulent material and a large painful inflammatory mass can develop. * The treatment by incision of the abscess and left drain in place for 2-4 weeks.

11. (3) Inclusion cysts * result from infolding of the vaginal epithelium, located in the posterior or lateral wall of the lower 1/3 of the vagina. * They are most frequently associated with lacerations from delivery or surgery. They are treated by surgical excision. (4) Endometriotic cysts * are endometriotic implants located in the upper 1/3 of the vagina. * presents as black cysts which may bleeds at the time of menstruation. * they are most common in an episiotomy wound.

12. (5) vaginal adenosis * multiple mucus – containing vaginal cysts rarely give symptoms. * common in daughters of women who took di ethyl stilboesterol ( DES) during pregnancy. (6) Prolapse as ; cystocele , rectocele and enterocele.

13. cystocele

14. (7) Fistula as ; vesico vaginal , recto vaginal and uretero vaginal fistulas. They may result from obstetric or surgical trauma , invasive cancer and radiation therapy. (8) Erosive lichen planus erythematous papules involve vagina as well as vulval vestibule . Condylomaacuminata ,flat warts ( HPV) and herpes simplex infections can be found in the vaginal vault.

16. Erosive lichen planus

17. (9) Gartner’s duct cyst * aregenerally thick-walled , soft cystsresulting from embryonic remnants. Gartner′s cyst arise from the remnant of the Wolffian duct . * they vary in size from 1 – 5cm , found on the antero lateral walls in the upper ½ of the vagina and more laterally in the lower vagina. * most of them are asymptomatic. * require no intervention. if ttt is required , marsupialization is effective and safer than excision.

18. Gartener’s cyst

19. In summary Benign Conditions: 1. urethral diverticula. 2. Bartholin’s cysts & abscess. 3. inclusion cysts. 4. endomeriotic cysts. 5. vaginal adenosis. 6. prolapse. 7. fistula. 8. erosive lichen planus. 9. Gartner’s duct cyst.

20. Vaginal intraepithelial neoplasia(VAIN)

21. Vaginal Intraepithelial Neoplasia (VAIN) VAIN or carcinoma in situ : * much less common than CIN and VIN. * occurs in the upper 1/3 of the vagina. * caused by HPV infection or after irradiation for cervical cancer . * women with past history of in situ or invasive ca.cx or ca. vulva are at increased risk.

22. *Diagnosis by: =Pap smear is abnormal. =colposcopy. findings are similar to cervical lesions. abnormal epithelial proliferation and maturation above the basement membrane. VAIN I : inner 1/3 . VAIN II: inner 2/3 . VAIN III: full thickness involvement. =vaginal biopsy directed by colposcopy & Lugol′s iodine.

23. * management =vaginal vault lesion surgical excision to exclude invasive cancer. =multifocal lesions laser therapy or topical 5 fluorouracil. =extensive disease total vaginectomy and neovagina using a split thickness skin graft.

24. In summary VAIN diagnosis: 1. Pap smear. 2. colposcopy. 3. vaginal biopsy. management : 1.vaginal vault lesion. 2. multifocal lesions. 3. extensive disease.

25. Vaginal Cancer Squamous Cell Carcinoma Clear Cell Adenocarcinoma rare cancer

26. Squameous Cell Carcinoma of the Vagina * uncommon tumor. * mean age 60 – 70 years. *30% have a history of insitu or invasive cervical cancer that was treated at least 5ys earlier. *50% of lesions are in the upper1/3 of vagina on the posterior wall.

27. *Symptoms: = vaginal bleeding. = vaginal discharge. = urinary symptoms. *examination: ulcerative , exophytic and infiltrative growth patterns.

28. Squamous cell carcinoma of vagina

29. *pattern of spread: =direct invasion to bladder ,urethra or rectum or progressive lateral extension to the pelvic side wall. =lymphatic to the obturator ,internal iliac and external iliac nodes. lesions in the lower vagina drains to the inguino femoral nodes. =hematogenous is uncommon until the disease is advanced.

30. Staging is made clinically by: * chest X-ray. * pelvic & abdominal CT. * MRI for metastatic spread & bulky pelvic and para aortic lymph nodes. * PET (position emission tomography) to look for metastatic disease.

31. FIGO staging of Vaginal Cancer

32. Management 1. Radiotherapyor chemo radiotherapy are the main methods of treatment for 1ry vaginal cancer. 2. Radical surgery has a limited role : *Radical hysterectomy + radical vaginectomy+ pelvic lymphadenectomy, for stage 1 in the posterior fornix. *Pelvic exenteration with creation of a neovagina ,if LN. are free.

33. Clear Cell Adenocarcinoma *An association between in utero exposure to di ethyl stilbesterol (DES) and the latter development of clear cell carcinoma in the vagina was reported in 1971. *Vaginal adenosis (columnar epithelium) is the most common anomaly ,present in 30% of exposed females.

34. * this tissue behaves similarly to the columnar epithelium of the cervix & is replaced initially by immature metaplasticsquamous epithelium. * the risk for developing a clear cell adenocarcinoma following DES exposure in utero is only 1/1000 . * the mean age is 19years, rare before 14y. few cases reported in women in their 40s & 50s.

35. *Treatment : for early tumor , radical hysterectomy and vaginectomy ( cereation of neovagina) or radiation therapy is effective. *The 5-year survival rate is 80%, which is better than that for squameous cell carcinoma of the vagina.

36. Thank you