Transcript Benign diseases of vulva and vagina

Benign diseases of vulva
Dr. R. Elgantri
Associated prof.
Department of Obs. & Gyn.
Alfath University
Benign disease of vulva
Anatomical consideration
Vulval skin comprises stratified squamous epithelium as in other parts of body
The mons pubis and labia majora contain fat, sebaceous, apocrine and eccrine sweat
glands and blood vessels , which can develop varicosities
Labia minora are rich in sebaceous gland, contain few sweat gland but no hair follicles
The epithelium of the vestibule is neither pigmented nor keratinized, but contain
eccrine glands. These glands and epithelial appendages are a source of lumps
Deep to the posterior parts of labia majora are the Bartholin’s gland or greater
vestibular glands, whose ducts open into the posterior part of the vagina,
just behind the midpoint and superficial to hymenal ring.
The glands and ducts can be the site of infection or cyst formation
Presenting features
The usual presenting features are:
vulval pruritus
vulval pain, burning
lump
superficial dyspareunia
white discoloration of vulva
Examination should include examination external genitalia and the whole
genital tract
Vulval biopsy
Is necessary to confirm the diagnosis if not clear and to see whether is preinvasive or invasive
Colposcopy of the vulva is helpful to determine area from which biopsy should
be taken
Non-neoplastic epithelial disease
Lichen sclerosus
squamous cell hyperplasia
other dermatomes
contact and allergic dermatitis
seborrhoeic dermatitis
psoriasis
lichen planus
Hid adenitis supperutiva
Behest's disease
Lichen sclerosis
Is characterized by epithelial thinning, inflammation and distinctive
histological changes in the dermis
The incidence is unknown
It can affect both sexes and can occur at any age
Typically found in anogenital region in postmenopausal women
It can be asymptomatic but the most common presentations are:
intractable itching (pruritus vulvae)
vaginal soreness
dyspareunia
Etiology
unknown
Signs:
- crinkled or parchment-like appearance that usually extends
around the anal area in a figure of eight configuration
- atrophy of labia minora
- constriction the vaginal orifice
- adhesion and telangiectasia
Prognosis
Can occur in children and in2/3rd of cases the lesions will clear at puberty
In adults, it is a chronic condition that can be considered as pre-malignant (the
rate progression varies from0 to 9%)
Management
The aims of management are to control the symptoms and to detect changes
suggestive of malignant change
General measures
Reassurance; that it is well recognized condition and can be
satisfactorily controlled with simple measures
Bland emollient should be used liberally and can provide significant relief
Topical steroids
Clobetasol propionate provide significant relief than local testosterone and
petroleum jelly
Surgery
In general surgery should be avoided unless there is malignant change
Lichen planus
It can be acute or chronic condition affecting the skin or mucous membranes or
both
On keratinized skin, lichen planus is characterized by flat-topped , shiny
papules
On the vulva, the appearance ranges from delicate, white reticulated papules to
an erosive, desquamated process
Incidence
It is uncommon
Etiology
unknown
Prognosis
The lesions tend to disappear after weeks or months
Erosive lesions heal poorly and may be pre-malignant
Diagnosis: is confirmed by biopsy
Treatment
Topical steroid
Short courses of systemic corticosteroids
Inflammatory dermatomes
Can be classified as either:
contact dermatitis
primary irritant dermatitis
It is difficult to differentiate between the two
Typical findings are:
diffuse reddening of the involved skin with excoriation and
ulceration. Secondary infection may occur.
D.D:
vulval candidiasis
Etiology
Local irritants as perfumed soap, deodorant, bubble baths,
tight clothing, and urine
The incidence is unknown
Treatment
avoid local cause
oral antihistamine
topical corticosteroid
Seborrhoeic dermatitis
Occurs in areas of the skin where sebaceous glands are active, such as face,
body folds, and less common genitalia
The common sites of the vulva are labia majora and mons pubis
The lesions are scaly, orange pink in colour and can be secondarily infected
Seborrhoeic dermatitis is un common vulval problem
Caused by Malassezia infection which is a yeast
Treatment: Antifungal as miconazole or ketoconazole cream
Ulcerative dermatomes
The ulcerating lesions may be solitary or multiple, painful or non-tender
The lesions are uncommon
Etiology
Herpes simplex virus which are vesicle then ulcerating
Syphilis are papule and then ulcerate
Chancroid, granuloma inguinale, and lymphgranulma venerum
Diagnosis
Serology
Culture
Treatment
According to the cause
Genital warts
Condylomata accuminata
Are caused by HPV. May involve not only the vulval skin but also the vagina
and cervix
There are more than 50 types of HPV, most important type 6,11,18
Typically lesions are elevated, discrete but sometimes confluent and covering
large area
Tends to increase in size in patients using COP and during pregnancy
The disease transmitted sexually
Diagnosis confirmed his pathologically
Treatment
Application of 25% tricholacetic acid followed by 25% podophyllin at weekly
intervals to lesions and patient asked to bath 6-8h later to remove any
excess
Podophyllin should not be used during pregnancy
If resistant to podophyllin
Should be treated by
liquid nitrogen application
cryosurgery
electro diathermy
Carbon dioxide laser
interferon
Squamous cell hyperplasia
This is a diagnosis of exclusion
Histologically there is hyperkeratosis, lengthening and distortion of the rete
pegs
An inflammatory response in the dermis usually occurs, consisting of
lymphocytic and plasma cell infiltration
The skin is thickened with white hyperkeratosis patches, excoriation and
fissures
The incidence is unknown but less common than lichen sclerosis
Etiology/risk factors
May be the result of repetitive surface irritation and trauma from irritants that
cause scratching and rubbing
Prognosis
The risk of vulval carcinoma has been estimated to be 1-5%
Treatment
As the lichen scleroses
Benign neoplastic lesions
The majority of benign and malignant vulval tumors are of
epithelial origin
Less commonly they will arise from:
epidermal appendages (hid adenoma, sebaceous adenoma)
mesoderm (fibroma, lipoma, neurofibroma,leiomyoma, and
hemangioma)
vestibular glands
Vulval intraepithelial neoplasia
Pre-malignant disease of the vulva is much less common than CIN
The major factor in the etiology is HPV (type 16, and 33)
The incidence varies from 4% if treated to 80% for untreated cases
VIN affects mainly labia minora and perineum but may extend to per anal area
Presentation
pruritus, soreness, and burning in 60% of cases
but
may be asymptomatic