Download Pruritus vulvae

BENIGN AND MALIGNANT
CONDITIONS OF VULVA
AND VAGINA
DR. AHMED JASIM
ASS.PROF.
MBCHB-DOG-FICMS
COSULTANT OF GYN. & OBST.
Conditions
affecting the vulva
and vagina:
THE VULVA
Pruritus vulvae:
Is a common symptom which is an irritation of vulva
sufficient to lead to scratching
PRURITUS VULVAE:
CAUSES:
• 1. Infections.
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trichomonas vaginalis or candidasis
Parasites such as scabies and lice.
Threadworms
2.Skin conditions may affect vulval skin.
eczema, psoriasis, lichen simplex, lichen planus,
and lichen sclerosus.
3.Sensitization of the vulval skin to drugs or
chemicals as soap and disinfectant
, chemical spermicide, ointments.
4. Medical disorders:
Diabetes, chronic renal failure, polycythemia, liver
cirrhosis, Hodgkin's disease.
Urinary incontinence.
PRURITUS VULVAE:
• 5. Non neoplastic epithelial disorder as lichen
sclrosus, squamous hyperplasia
• 6. Neoplasia:
• VIN, carcinoma, lymphoma, Paget's disease
• 7. Excess or inappropriate hygiene.
• 8.Psychogenic causes.
DIAGNOSIS:
• History:
• Carfull history ,including the use of any substance
which might lead to allergy.
EXAMINATION
• general examination of the patient including
inspection for dermatological lesion of face,
mucous membrane, hands, wrist, elbows,
trunk,and knees
• Any evidence of systemic disease
• Gynaecological examination including
inspection of cervix and vagina and vulva
urethral meatus and anal area
• Colposcopic examination of cervix and
vagina and vulva
• Palpation of inguinal lymph nodes.
INVESTIGATIONS
• Bacteriological examination of vaginal secretions
and scraping from the skin.
• Full blood count.
• Blood sugar
• Biopsy of the skin of vulva.
• successful treatment depends on two
cardinal principles:
• 1. to remove any underlying cause.
• 2. to stop further damage to the skin by
scratching.
• The help of dermatologist may be sought in
difficult cases.
• Great care should be taken in prescribing
any of anti-pruritics
• Corticosteroid applications sometimes used.
VULVAL ULCER
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Aphthous ulcer
Herpes gentalis.
Primary syphilis.
Crohn's disease.
Behcet's disease.
Lymphgranuloma venereum.
Chancroid.
Tuberculosis.
Malignant ulcer.
VULVAL LUMPS
• Most vulval lumps are benign and
can be treated conservatively.
• Excisional biopsy is indicated in
solid lesions or when the diagnosis
is uncertain.
BARTHOLIN'S CYST AND ABSCESS
• Bartholin's glands lies on each
side of the vagina and it's duct
opens into the posterior part of the
vestibule..
BARTHOLIN'S CYST
• Is the most common vagial vulvar tumour. Cyst
may arise from the duct of the Bartholin's gland
that lies in subcutaneous tissue below the lower
third of labium majorum. Cysts can develop if
the opening of bartholin duct becomes blocked
and distended with mucoid secretion.
• It present as painless swellings or some time
present with discomfort posterolaterally in the
introitus and usually unilaterally. It may become
infected, to form an bartholin's abscess.
• treatment:
• . marsupilizeation the cyst (permit
adequate drainage and mostly
the function of the gland is
retained).
• or
• cyst excision.
BARTHOLIN'S ABSCESS
• Bartholin's abscess involves an
accumulation of pus that forms a
lump(swelling (in Bartholin's glands
• the gland may be infected by
gonococci, staphylococci,
streptococci or a mixture of organisms.
• it causes severe discomfort when
walking or sitting.
BARTHOLIN'S ABSCESS
• Diagnosis:
• Symptom: it causes severe discomfort when
walking or sitting.
• Physical examination:
• Diagnosis of a Bartholin abscess is made primarily
upon the following physical examination findings:
• the position of the labial swelling at the junction of
anterior two third (2/3)and posterior one third(1/3)
of the labium majorum is diagnostic
• painful red swelling with reddens of the surrounding
tissue and odematous.
• the swelling is hot, tender and fluctuant
BARTHOLIN'S ABSCESS
treatment:
• drain the abscess by marsupilzation (pouch
making).
• Antibiotic therapy.
• the drained pus should be sent for culture.
• biopsy may be recommended in older
women to rule out an underlying Bartholin's
gland tumor.
VULVAE INTRAEPITHELIAL
NEOPLASIA(VIN):
• It may present at any age
• It dose not have the same malignant
potential of that of CIN.
• It usually asymptomatic but it may present
as Pruritus vulvae.
• colposcopic examination and biopsy are
important.
• observation with regular follow up is
required.
Vulval Intraepithelial neoplasia: •
there are three grades from mild
to sever dysplasia as for CIN but
doesn’t have the same malignant
potential
CLINICAL FEATURES IN VIN III
Itching is the most common symptom. •
Half of patients are asymptomatic. •
Most have visible or palpable abnormalities of the •
vulva (20% are warty, and multicentric in about two
third of cases).
Most lesions are elevated ,of different color : may be •
white , red ,pink , or brown.
Diagnosis: •
-inspection for abnormal areas.
-colposcopic examination of the entire vulva after
5%
acetic acid will highlight additional acetowhite
areas.
-biopsy will confirm the diagnosis.
Management : •
-regular follow up with multiple biopsy
-local superficial surgical excision with safe margin
with primary closure.
-for extensive lesions skinning vulvectomy with
replacement by split –thickness skin graft with the
subcutaneous tissues are preserved.
-Laser ablation is used for multiple small lesions
involving the clitoris, labia minora and perineum.
CARCINOMA OF VULVA
• It is uncommon (accounts 5% of
genital cancer). It is a disease
primarily of the older age group with
the majority of cases presenting
between the ages of 60 and 75 .
CARCINOMA OF VULVA
• Presentation:
• ulcer or swelling on the vulva with soreness or
irritation.
• slight bleeding may occur.
• offensive purulent discharge .
• enlarged inguinal glands.
• Examination:
• Ulcer or hypertrophic growths in vulva .
• Lymph node examination
• Investigation:
• The diagnosis is made by biopsy.
• As well as investigate patient as in
other carcinoma
staging •
FIGO staging system is a surgical staging system revised in 1994:
Stage 0 carcinoma in situ ,intraepithelial carcinoma.
Stage I tumors confined to vulva or perineum ,lesion =or
<2 cm; no nodal metastasis.
Ia stromal invasion <or = 1 mm
Ib stromal invasion > 1 mm.
Stage II tumors confined to vulva or perineum ,
lesion >2 cm, no nodal metastasis.
Stage III any size tumors with adjacent spread and or unilateral
l.N.
metastasis.
Stage IV
IVa invades any or combinations of the following :upper
urethra
,bladder mucosa ,rectal mucosa ,pelvic bones or
bilateral
regional L.N.
IVb any distant metastasis including pelvic L.N.
TREATMENT
• radical excision of the vulva and inguinal lymph
nodes on both sides.
• radiotherapy in special situation.
Survival rate:
Overall 5 years survival is about 70%. •
Survival correlates significantly with the lymph node •
status regardless the stage,
one L.N. involvement
50% 5 years survival
no L.N. involvement
90% 5 years survival
VAGINA
FOREIGN BODIES IN THE
GENITAL TRACT:
• The foreign bodies could be:
• A. Therapeutic agents:
• 1. Packs and dressing of various kinds may be left
in vagina after operation.
• 2. Supporting pessaries.
• 3. Contraceptive device: (Sponges, occlusive
caps, condoms which have slipped out).
• B. Articles inserted by the patient
or entering accidentally.Mostly in
mentally retarded patient and
children.
• C. instruments for inducing
abortion and labour as: laminaria
tents, chatheter.
• D. menstrual tampone.
EFFECTS
• it is varies from irritation to local vaginitis result in
ulceration of the vaginal walls and perforation and
pressure necrosis and this can involve neighboring
structure to cause urinary and faecal fistulae.
• infection may spread to produce salpingitis and
peritonitis.
• carcinoma of vagina is a late squeal.
• The condition present as offensive vaginal discharge with
blood stained as the main symptoms.
• treatment:
• the foreign body must be removed.
VAGINAL DISCHARGE:
• A vaginal secretion is normal in women in the
reproductive age group.
• It consists of transudate containing desquamated
vaginal epithelium, mucous secreated by cervical
glands and endometrial glands.
• The amount of discharge varies from woman to
woman and varies throughout the menstrual
cycle(There is a cyclical variation of the amount of
secretion).
• Normal discharge is usually clear
or white. Infections may cause
discharge of varying color,
consistency, amount and odor. A
sudden change in discharge may
signify pathological condition.
PHYSIOLOGICAL DISCHARGE
CAN BE INCREASED IN:
• pregnancy.(due to increased estrogen
production and greater blood flow to the
area around the vagina).
• in oral contraception users.
• At mid menstrual cycle
• During sexual intercourse.
• Exccesive vaginal discharge is a common
gynaecological complaint and can cause
vulval symptoms. Comprehensive clinical
assessment is essential.
EXCESSIVE VAGINAL DISCHARGE
COULD BE DUE TO:
• . Physiological.
• 2. Infection.(bacterial vaginosis, candidases,
trichomonal vaginosis)
• 3. Foreign bodies as tampon, vaginal ring.
• 4. malignant (endometrial ,cervical, vaginal
cancer).
• 5. Fistula.
• 6. Atrophic vaginitis.
• 7. large cervical ectropion
VAGINAL ATROPHY
• It typically occurs in women of any age who
experience a fall in estrogenic stimulation to
the urogenital tissues as in
• Menopausal women.
• Premenopausal women.
• Postpartum period.
• Lactation.
• During administration of antiestrogenic drugs
(breast cancer hormonal treatment).
• Prior to puberty.
VAGINAL ATROPHY
Symptoms:
• The patient may Present with vaginal bleeding,
vaginal discharge, or vaginal
• dryness and dyspareunia (pain during sexual
intercourse).
• Superficial infection, with Gram-positive cocci or
Gram-negative bacilli, may be
• associated.
VAGINAL ATROPHY
• Examination:
• Shows pale, thin vaginal epithelium with loss of
rugal folds and prominent subepithelial vessels,
sometimes with adjacent petechial haemorrhage or
ecchymoses.
TREATMENT:
• Requires oestrogen to restore the vaginal
epithelium and pH.
• This is usually by topical oestrogen cream, but
care must be taken to avoid excessive
absorption through the thinned mucosa.Vaginal
cream inserted nightly for a week and repeated
monthly to prevent atrophy.
• Alternatively in postmenopausal women,
hormone replacement therapy(HRT)can be
used.
FISTULA
A fistula may be due to:
Trauma.
Carcinoma.
Crohn’s disease.
Childbirth :(Fistula of the anterior wall is now
uncommon in association with childbirth, but
rectovaginal fistula may follow an obstetric tear or
extension of an episiotomy, and an incomplete or
inadequate repair).
• Gynaecological surgery Fistulae involving ureter,
bladder or rectum may follow gynaecological
surgery.
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VAGINAL INTRAEPITHELIAL
NEOPLASIA(VAIN):
• It is seldom seen alone and is usually a vaginal
extension of CIN (Cervical Intra epithelial
Neoplasia).
• Classification of intraepithelial neoplasias of the
vagina parallels that of the cervix VaIN 1, VaIN2,
and VaIN 3.
• VaIN is usually asymptomatic and is diagnosed by
abnormal cytologic testing. Infrequently women
complain of postcoital staining or unusual vaginal
discharge
VAGINAL INTRAEPITHELIAL
NEOPLASIA(VAIN):
• VaIN usually occurs in the upper
third of the vagina on the posterior
wall
• VaIN lesions may be either single
discrete or multifocal.
• Diagnosis is made by colposcopy.
• The usual treatment involves laser
vaporization.
CARCINOMA OF THE VAGINA:
• It is rare gynaecological
tumours accounting for 1-2% of
all gynaecological cancers.
• The peak incidence is
between age 60 & 70 years.
• Vaginal carcinoma may be
primary or secondary.
PATHOLOGY
• Only 10-20% of vaginal carcinomas are primary.
• Squamous cell carcinoma is the most common
malignant tumor of the vagina
• Clear cell adenocarcinoma is found in women who
had exposure to diethylstilbesterol in utero (DES)
and to a lesser degree in post menopausal
individuals.
• Metastatic tumors are the most common cancer
found in the vagina.
SECONDARY CARCINOMA CAN
ARISE BY:
• direct extension from the cervical
carcinoma.
• Endometrial cancer.
• Choriocarcinoma.
• From vulva.
• From rectum or anus.
• Distant metastasis may occur from primary
carcinoma in the breast or gastrointestinal
tract.
CLINICAL FEATURES:
• Usually occurs after the menopause and
most commonly affects the upper posterior
wall.
• Vaginal bleeding mainly post coital.
• Offensive watery discharge.
• Fistula (rectum, bladder).
• staging
• FIGO staging used of vaginal
carcinoma staging.
STAGING:
Stage I
invasive cancer confined to the •
vaginal mucosa.
Stage II subvaginal extension not involving •
the pelvic side wall.
Stage III extends to pelvic side walls. •
Stage IVa extends to mucosa of bladder &rectum •
Stage IVb spread beyond the pelvis. •
• treatment:
• Surgery:
• removal of whole vagina ,uterus,and pelvic lymph
nodes
• Radiotherapy in some cases.
LESION OF URETHRA:
URETHRAL CARUNCLE:
• Small, fleshy bright red out-growths of the distal
edge of the urethra.
• It is always single lesion arises from the posterior
wall of urethrra
• Usually seen in post-menopausal women. there is
high rate of recurrence after treatment.
URETHRAL CARUNCLE:
It cause:
1.No symptoms
2.Symptomatic:
A. Very tender causing dysparunia or pain on
micturition.
• B. Slight bleeding may occur.
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URETHRAL CARUNCLE:
Treatment by:
• Topical estrogen therapy.
• If no response biobsy should be done to exclude
serious morphology. Once malignancy ruled out, it
can be treated by surgery either by:
• Excision or destruction by diathermy.
URETHRAL DIVERTICULAE
• It usually found in the distal third of posterior urethral
wall bulging towards the vagina. It's incidence is
3%.
URETHRAL DIVERTICULAE
• Clinical presentation:
• It is vary but usually include frequency ,
dysuria, dysparunia, voiding difficulties and
recurrent urinary tract infection. Post
micturition dribble is classical symptom.
• Vaginal examination can show:
• No physical sign.
• Or
• suburethral mass.
• Tenderness can be palpated.
URETHRAL DIVERTICULAE
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Investigation:
Voiding cystourethrogram.
Treatment:
Surgical repair if patient affected by symptoms.
Treatment by marsupilization and vaginal
diverticulectomy.
DIETHYLSTIBESTROL (DES) RELATED LESIONS
• DES is a drug that was administered
frequently to pregnant women who were at
high risk for early pregnancy loss during the
1940’s through the 1960’s.
• it can be the cause of :
• 1. Vaginal Adenosis
• Vaginal adenosis refers to the replacement
of the normal squamous epithelium of the
vagina by columnar epithelium. It is
asymptomatic and presents as red, granular
patches on the vaginal mucosa.
• Benign but rarely, may give rise to clear cell
adenocarcinoma.
• 2. Structural changes of the cervix and vagina and
uterus.
• These are in the form of:
• Transverse vaginal septum.
• Cervical hypoplasia.
• T-shaped uterus.
• others
• 3. Exposed individual have an increased risk of
abortion, preterm labour, ectopic pregnancy.
• 4. Clear cell adenocarcinoma
• It affects young women, average 17 years old. Two
thirds of patients have history of in utero DES
exposure. The risk in exposed population is 1 in
1000.