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Vaginal lesions
Prof Greta Dreyer
University of Pretoria
Outline
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Infections
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Vaginal Intra-epithelial Lesions
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Vaginal cancer
Primary
 Secondary
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Infections
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Viral
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Bacterial
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Vaginosis
Vaginitis / cervicitis
Fungal
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HPV
HSV 2
Candida albicans, glabrata, etc
Immunocompromise
Viral infections
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HPV
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Condyllomata accuminata = warts
• Benign neoplasm
• Associated with ”LOW RISK” HPV types 6 and 11
• Preventable with vaccination that targets these viral
types
• Treated with:
• Chemicals = podophyllin NOT in vagina, absorbed =
toxin
• Local destruction = cauterisation, laser
• Cytotoxins = chemoRx, 5FU = BURNS the vagina due
to cytotoxic effect, EFFECTIVE
• Immunostimulants = ALDARA,= imiquimod =
EFFECTIVE vulva, vagina
Viral infections
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HSV TYPE 2
Cold sore, fever ulcer
 Typically vulvar lesion, cervical lesion
 Nerve distribution, Zoster type, can be
chronic, severe
 Treat systemically NOT locally
(placebo)
 AB, urination, keep clean (NaCl H2O)
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Bacterial infections
 Vaginosis
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CHANGE in vaginal flora for the worse!
Often associated with sexual intercourse
pH alkaline (>4,5), watery discharge, fishy
Gardnerella vaginalis and friends colonise
Not major inflammatory reaction
Treatment
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Kill offensives – metronidazole, clindamycin
Change environment – lower the pH
Enhance “good” bacteria = Lactobacillus
Bacterial infections
 Vaginitis
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Also change in vaginal flora
watery discharge, itch, burning
Often Streptococcus culture
Can have inflammatory reaction
Pre- and post-menopausal condition
Treatment:
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Kill offensives – Penicillin
Change environment – increase the estrogen,
enhance “good” bacteria = Lactobacillus
Bacterial infections
 Vaginitis
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STI’s – NOT a problem if vagina only
Chlamydia and Gonococcus = friends
Identical clinical picture
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/ Cervicitis
PAIN, RED, discharge
Upper abdomen, peri-hepatitis, peritonitis
Difficult to confirm, culture, identify
Treated empirically
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Ciprofloxacin stat
Doxycyclin for 21 days
Fungal infections
 Vaginitis / Vulvitis
 NOT an STI
 Can be transmitted, aggrevated
 Opportunistic infection
 Commensal in GIT
 After AB, hospitalisation, ICU, UTI
Fungal infections
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Also associations with:
Low estrogenic states
 OC use
 Eczema, dermatitis
 High glucose states
 Chronic trauma
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Fungal infections
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Treatment:
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Local antifungals
• Creams, vaginal tablets, suppositories, SR
tabs
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Systemic antifungals
• Stat, repeat (1x pw, 1x pm), courses
• Equally effective, preference dictates
• Better choice for recurrent, hypersensitivity
states
• NOT for pregnant, LIPID soluble
Immuno-compromise
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HIV, transplant, severe malnourishment
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MIXED infections
Severe Candida, also C. glabrata
SEVERE HPV related disease
KS, other HSV, Zoster
Lymphoma, carcinoma
(Spontaneous) non-malignant fistulation
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Immuno-compromise
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Improve immunity if possible
Improve nutrition
Improve hygiene
Saltwater sit and douche
Chronic AB (TMP-SMZ), AF (Flu-conazole)
Repeated AV (Acyclovir)
Diagnosis including serology, cytology,
histology
VA ginal I ntra-epithelial
N eoplasia – VAIN now SIL
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With or without current cervical lesions
Prior cervical lesions
HPV “HIGH RISK” viral types
16, 18, 31, 33, 35, 45
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Diagnosis:
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Cytology
HPV typing
Colposcopy = vagina-scope
Iodine = Schiller’s TEST (not LIST) = Iodine NEG
Acetic acid = AWE
VAIN or Vaginal SIL:
Treatment
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Exclude invasion = histology = biopsy
Increase immunity, smoking cessation
Imiquimod
5FU local application
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Excision
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Vault excision
In theatre, mark area carefully
MONOCLONAL disease, usually confluent
Can be multi-focal
Destruction
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Laser
Caterisation
With or without current cervical lesions
PRIMARY Vaginal cancer
Squamous OR
 Adenocarcinoma
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Staging = FIGO cervical cancer
 Treatment usually (chemo) radiation
 HPV related
 SCARCE!!
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PRIMARY Vaginal cancer
Sarcoma OR
 Melanoma
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Treatment usually surgery
 Systemic recurrence
 NOT HPV related
 VERY SCARCE!!
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SECONDARY Vaginal cancer
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Direct spread
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CERVIX
VULVA
ENDOMETRIUM
OVARIAN
RECTUM
BLADDER / URETHRA
Metastatic disease
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COLON
OVARY
STOMACH
BREAST
THYROID
LYMPHOMA
SECONDARY Vaginal cancer
BIOPSY
 FIND SOURCE
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STAGE and TREAT appropriately
Summary
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Infections
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Vaginal Intra-epithelial Lesions
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Vaginal cancer
Primary
 Secondary
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Thank You