Vulval and vaginal benign and malignant conditions

1. Vulval and vaginal benign and malignant conditions Dr. MuhabatSalihSaeid MRCOG-London, UK.

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.

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

5. Lichen sclerosus • 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

6. Lichen Planus • General Appearance • Erosive lesions at vestibule with/without adhesions resulting in stenosis • May have associated oral mucotaneous lesions and desquamativevaginitis • Patient complainingof irritating vaginal discharge, vulvar soreness, intense burning, pruritus, and dyspareunia with post-coital bleeding • Types: PapulosquamousLP/Hypertrophophic LP /Errosive LP

7. Treatment • 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

11. Vulvar Psoriasis • Physical Appearance • Red moist lesions with or without scales • Treatment: Topical corticosteroids

13. Squamous Cell Hyperplasia(Atopic Eczema/Neurodermatitis) • 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

15. Lichen Simplex Chronicus • Physical Appearance • Thickened white epithelium on vulva • Generally unilateral and localized • Treatment: Medium potency steroid twice daily prn

17. 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.

18. 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

19. 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.

20. Bartholin's Abscess Rx: drainage & Marsupialization

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

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

24. 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.

25. (vulval intraepithelial neoplasia) VIN Classification • VIN I - mild dysplasia with hyperplasticvulvar dystrophy with mild atypia • VIN II - Moderate dysplasia, hyperplasticvulvar dystrophy with moderate atypia • VIN III - Severe dysplasia; hyperplasticvulvar dystrophy with severe atypia (it replaces the term carcinoma in situ, Bowen’s disease). Carcinoma in situ

26. VIN Diagnosis and Treatment • Dx: colposcopy + biopsies • Rx: - low grade VIN: observation. - VIN3: local excision or laser vaporization - Topical immunomodulator: imiquimod

27. Vulval carcinoma

28. 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.

29. AETIOLOGY: 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.

30. PATHOLOGY 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.

31. 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.

32. 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%.

33. NEW FIGO STAGING OF VULVA CARCINOMA

34. SQUAMOUS CELL CARCINOMA • 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:- • 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

35. Clinical Features & Diagnosis 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

36. The major problem in invasive vulvar cancer is delay between the first appearance of the symptoms and referral to the gynecological opinion due to : • The doctor fails to recognize the gravity of the lesion and prescribes topical therapy. • Older women are often embarrassed and shy.

37. On Examination • Lesion can take any form from flat white lesion to large ulcer. • The size of the tumor ,involvement of the urethra and anus should be noted. • Inspection of the cervix and cervical cytology. • Needle aspiration of any suspicious groin node. Diagnosis is made on histology from full thickness generous biopsy.

38. 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.

40. Benign Vaginal lesions

41. BENIGN LESIONS OF THE Vagina • CYSTIC SWELLINGS • SOLID TUMORS • ATROPHIC VAGINITIS • VAGINAL ADENOSIS

42. Cystic swellings • Gartner’s Cyst • Dilatation of the Gartner’s (Wollfian) duct • Anterior and lateral vaginal walls • Epithelial inclusion cysts • Endometrioma • Uretheral diverticulum

43. Solid Tumors • Fibromyoma • Condylomaaccuminata • Bilharzial polyps

44. Condyloma acuminata, vulva

45. Condyloma acuminata, vaginal wall

46. Vaginal Fibromyoma • 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

47.  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

49. Management of vaginal leiomyoma • Removal of tumor by vaginal route, wherever possible, with subsequent histopathological examination appears to be the optimum management plan

50. Atrophic vaginitis • 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)