Vulval disorders

DISEASES OF VAGINA & VULVA
Mrs. U SREEVIDYA,
Msc. NURSING,
Associate Professor,
Apollo college of nursing,
CHITTOOR

Mucosa
• Lined by stratified squamous epithelium without secreting
glands.
• Loose connective tissue.
Submucosa
Muscular
layer
• Consists of indistinct inner circular and outer longitudinal.
• Fibrous coat derived from vascular endopelvic fascia.

Age pH
Birth-2weeks Acidic 4-5
2 weeks till puberty Alkaline 6-8
Reproductive period Acidic 4-5 (4.5 is normal)
Post menopausal Neutral or alkaline 6-7
•Varies during menstrual cycle and different phases of life.
•Acidity is due to lactic acid
•Oestrogen gycogen from vaginal epithelial cells
doderlein’s bacilli
lactic acid

During
menstruation
After abortion
and labour,
alkaline lochia
An excessive
cervical
discharge,
such as
endocervicitis
Doderlein’s
bacilli maintain
normal
ecosystem of
vagina.

CONTENTS OF NORMAL VAGINAL DISCHARGE:
Squamous cells debris
Doderlein’s bacilli
Lactic acid
Tissue fluid

Anatomical consideration of vulva
• Vulvar 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 glands, contain few sweat
glands but no hair follicles.
• The epithelium of the vestibule is neither pigmented nor
keratinized, but contain eccrine glands. These glands and epithelial
appendages are source of lumps

DISEASES OF THE VULVA
TYPES OF VULVAL & VAGINAL
DISORDERS
oCongenital
 Hypoplasia
 Imperforate hymen
oInflammatory conditions (vulvitis)
 Dermatological and nonspecific
vulvitis
 Pelvic inflammatory disease (PID)
 Bartholin gland cysts
 Miscellaneous infections of the vulva
oVulvar dystrophies
(leukoplakias)
 Atrophic dystrophy (lichen
sclerosis)
 Hyperplastic dystrophy
(squamous hyperplasia)
 Mixed dystrophies
oTumors
 Condyloma acuminatum
 Papillary hidradenoma
 Vulvar carcinoma

VAGINAL
INFECTIONS &
INFLAMMATIONS

Vaginitis is an inflammation of the vagina. It can result in
discharge, itching and pain, and is often associated with an irritation or
infection of the vulva. It is usually due to infection.
Symptoms
• Irritation and/or itching of the genital area
• Inflammation (irritation, redness, and swelling caused by the presence of
extra immune cells) of the labia majora, labia minora, or perineal area
• Vaginal discharge
• Foul vaginal odor
• Pain/irritation with
sexual intercourse

Types and Causes of Vaginitis
Various conditions can cause an infection or inflammation of
the vagina as "vaginitis." The most common kinds are:
•Bacterial vaginosis, inflammation of the vagina due to an overgrowth
of bacteria. It typically causes a strong fishy odor.
•Candida or "yeast" infection, an overgrowth of the fungus candida,
which is normally found in small amounts in the vagina.
•Chlamydia is the most common sexually transmitted infection (STI)
in women, usually in those ages 18 to 35 who have
multiple sex partners.

Second most common cause
of vaginal inflammation
after bacterial vaginosis.
Most commonly caused by a
type of fungus known
as Candida albicans
nucleus
Epithelial
cell
hypha
blastospores

•Gonorrhea is another common infection spread through sex. It
often comes along with chlamydia.
•Trichomoniasis is an infection spread by sex that’s caused by
a parasite. It raises the risk for other STIs.
•Viral vaginitis is inflammation caused by a virus, like
the herpes simplex virus (HSV) or human papillomavirus
(HPV), which spread through sex. Sores or warts on the
genitals can be painful.

Common cause
of vaginitis.
Caused by the single-
celled protozoan parasite
Trichomonas vaginalis
n

•Vaginal atrophy: This condition commonly occurs
after menopause. It can also develop during other times in the
life when estrogen levels decline, such as while breastfeeding.
Reduced hormone levels can cause vaginal thinning
and dryness. These can lead to vaginal inflammation.
•Irritants: Soaps, body washes, perfumes, and vaginal
contraceptives can all irritate vagina. This can cause
inflammation. Tight-fitting clothes may also cause heat
rashes that irritate vagina.

•History collection
•Pelvic examination
•Laboratory tests – Blood
- vaginal smear
Diagnosis

Normal Bacterial Vaginosis Candidiasis Trichomoniasis
Symptom
presentation
Odor, discharge, itch
Itch, discomfort,
dysuria, thick
discharge
Itch, discharge,50%
asymptomatic
Vaginal discharge
Clear to
white
Homogenous,
adherent, thin, milky
white; malodorous
“foul fishy”
Thick, clumpy, white
“cottage cheese”
Frothy, gray or yellow-
green; malodorous
Clinical findings
erythema “strawberry cervix”
Vaginal pH 3.8 - 4.2 > 4.5 Usually < 4.5 > 4.5
KOH “whiff” test Negative Positive Negative Often positive
Inflammation and Cervical petechiae
NaCl wet mount Lacto-bacilli
Clue cells (> 20%),
no/few WBCs
Few WBCs
Motile flagellated
protozoa, many
WBCs

TREATMENT:
Treatment for vaginal infections will depend on cause of the
infection. Like:
•Metronidazole tablets, cream, or gel, or clindamycin cream or gel
may be prescribed for a bacterial infection.
•Antifungal creams or suppositories may be prescribed for a yeast
infection.
•Metronidazole or tinidazole tablets may be prescribed for
trichomoniasis.
•Estrogen creams or tablets may be prescribed for vaginal atrophy.
If infection is caused by an irritant, such as soap, doctor
will recommend a different product to reduce irritation.

Vaginitis Prevention
• Proper hygiene can help to prevent some vaginal infections.
• Avoid clothes that hold in heat and moisture and should
wear cotton underwear.
• Eating yogurt can reduce the chance of fewer infections.
• Condoms are the best way to prevent passing infections between
sexual partners.
• Get a complete gynecologic exam every year, including a Pap
smear if doctor recommends it.

CYSTS AND
NEOPLASMS OF
VAGINA & VULVA

Vaginal Cysts
Gartner’s cyst
Lies on anterolateral vaginal wall
Arise from remnants of mesonephric duct.
Treatment: simple excision.
Inclusion cyst
Posterior surface of lower end of vagina
Develops in episiotomy or surgical wounds.
Treatment: simple excision.

Bartholin’s cyst
Infection of Bartholin’s Gland
Protrudes into lower part of vagina.
Treatment:Treated surgically by marsupialization
Endometriotic cyst
Posterior vaginal wall behind cervix.
Bluish bulge or subepithelial irregular nodular
mass.
Treatment: surgical excision or danazole.

Benign Conditions (Neoplasms)
of the Vulva

Vulvo-vaginal problems are among 10 leading
disorders encountered by primary care clinicians.
* Benign lesions of the vulva are mentioned in three
categories :
1. Epithelial conditions.
2. Benign neoplastic disorders.
3. Dermatologic disorders.
* VIN (Vulval intra epithelial neoplasia)
* Cancer vulva

(1) Epithelial Conditions
1) Lichen simplex .
2) Lichen sclerosis.
3) Lichen planus, erosive lichen planus.

1) Lichen Simplex
“ squamous cell hyperplasia “
* it is a local thickening of the epithelium resulting
from a prolonged itching .
* symptoms :
pruritus and pain.
* signs :
white or reddish thickened ,leathery ,raised surface.
usually discrete lesion but may be multiple.
* treatment :
• moderate-strength steroid ointment.
• antipruritic agent.

2) Lichen Sclerosis
* it is a chronic progressive disease which constrict
and destroy the normal genital anatomy . In the
long term ,labia minora are lost ,labia majora
flatten ,clitoris becomes inverted .
* frequently found on the vulva of postmenopausal
women & can involve all the genital area from
mons to the anal area.

* symptoms:
intense pruritus , dyspareunia and burning pain.
* signs:
thin inelastic atrophic skin ,white with a crinkled ,
tissue paper appearance.

* diagnosis:
• multiple biopsies are necessary.
• it reveals a thin atrophic epithelium with inflammatory cells
lining the basement membrane.
* treatment:
● potent topical steroids.
• 80% of lesions respond- long term therapy with low potent
steroids.
● other local treatments are: esrtogen cream and
anaesthetics.

3) Lichen planus
* it is a purplish ,polygonal papules that may
appear in their erosive form.
* it involve the vulva ,the vagina and the mouth
( vulval – vaginal –gingival syndrome ).
* symptoms:
vulval burning , severe dyspareunia when
vaginal stenosis develop in advanced stages.
* treatment:
topical and systemic steroids .

erosive lichen planus lichen planus
of vulva & vagina

(2) Benign Neoplastic condions
1) epidermal inclusion and sebaceous cysts.
2) vulvar varicosities.
3) fibromas and lipomas.
4) clitoromegaly.

1) epidermal inclusion & sebaceous cysts
* they are nontender , mobile , spherical ,slow
growing cysts located below the epidermis.
* sebaceous cysts are firmer because they are
filled with dry caseous material.
* treatment :
most of inclusion cysts require no treatment. If
they are symptomatic - surgical excision.

2) Vulval Varicosities
Can enlarge especially during pregnancy
to cause discomfort and carry a possible
risks for rupture or thrombosis.

3) Fibromas and Lipomas
Fibromas:
* are the most common benign solid tumors
that arise in the deeper connective tissue
of the vulva.
* they are slow growing 1–10 cm in diameter,
but may become huge .
Lipomas:
* slow growing tumors composed of adipose
cells.

4) Clitoromegaly
* may develop after birth in response to
excessive androgen exposure . It is a sign
of virilization.
* diagnosed when the clitoral length exceeds
30 mm or the width at the base exceeds
10 mm.

( 3) Dermatologic Disorders
1) Psoriasis.
2) Behcet ′s syndrome.
3) Crohn ΄s disease .
4) Acanthosis nigricans .

1) Psoriasis
• appears velvety but lack the characteristics.
• scaly patches found on the knees & elbows,
vulva.
• Treatment: Topical corticosteroids

2) Behcet ′s syndrome
* ulcers in the vulval , oral and ocular areas.
* genital lesions can result over time in a scarred
vulva.
* etiology : is unknown.
* diagnosis : based on the concurrence ulcers in
vulva ,mouth & ocular involvement ,
• the recurrent nature of the disease and exclusion of
syphilis and Crohn’s disease.
* treatment : no effective treatment.

oral ulcer vulvar ulcer
Behcet′ s disease

3) Crohn’s disease
* vulval ulcers can precede the
development of GIT ulcerations .
* vulval ulcers are slit-like or knife – cut ulcers
with prominent edema.
• Draining sinuses and fistulas to the rectum may
occur.

4) Acanthosis nigricans
* most commonly found in the axilla or the
nape of the neck and then vulva.
* characterized by its darky pigmented
velvety or warty surface .
* etiology : related to insulin resistance.

Vulval Neoplasms
Introduction
• 5% of female genital malignancies
• Usually occurs in the 70-80 year old population
• Histology is necessary for diagnosis
• Occurs anywhere on vulva
• Most common type is squamous cell carcinoma
• Melanoma is 2nd most common – but still <5%
• Associated with HPV

Epidemiology
Two different etiologic types of vulval cancers :
1. A less common type:
* in younger women .
* related to HPV infection and smoking.
* commonly associated with VIN .

2. The more common type:
* in old women .
* unrelated to HPV infection or smoking.
* concurrent VIN is uncommon.
* long standing lichen sclerosis is common.
• 5% of patients have +ve serologic tests for
syphilis , lymphogranuloma venereum
and granuloma inguinale.

Vulval Intraepithelial Neoplasia (VIN)
2 types of VIN :
1. squamous cell carcinoma in situ
VIN III or Bowen’s disease.
2. Adenocarcinoma in situ
VIN III or Paget’s disease.

Squamous cell carcinoma in situ:
VIN III ( Bowen′s disease )
* mean age 45 years.
* symptoms:
50% asymptomatic.
itching is the most common symptom.
* signs:
most lesions are elevated ,white ,red ,pink ,
brown or grey in color.
20% of lesions are warty in appearance.

squamous cell carcinoma of vulva

* diagnosis:
1.careful inspection of the vulva in bright
light and with the aid of a magnifying glass.
2. 5% acetic acid aceto white areas.

* treatment :
1. local superficial excision.
with margins of 5 mm are adequate.
2. skinning vulvectomy in extensive lesions.
3. laser therapy
if lesions involves the clitoris , labia minora
or perineal area.

Adenocarcinoma in situ
VIN III ( Paget′ s disease )
* occurs in white postmenopausal elderly women.
also occurs in the nipple area of the breast.
* 20% is associated with adenocarcinoma.
symptoms:
itching and tenderness are common.
signs:
* well demarcated and eczematus with white
plaque like lesions.
* growth may progresses beyond the vulva to the
mons pubis ,buttocks & thighs.

* diagnosis
histologically:
adenocarcinoma in situ characterized by
large ,pale , pathognomonic Paget’ s cells,
typically located both in the epidermic and
in the adnexal structures.
* treatment:
1. local superficial excision.
with margins 5-10 mm.
2. laser therapy
in recurrences which are common.

FIGO Staging of Cancer Vulva
Tumor limited to the vulva or perineum or both ,and
2 cm or < in diameter ,and no nodal metastases.
as above + stromal invasion < 1mm.
as above + stromal invasion > 1 mm.
Tumor limited to the vulva or perineum or both ,and
> 2 cm in diameter ,and no nodal metastases.
Tumor of any size with :
• adjacent spread to the urethra &/or vagina &/or
anus with localized lymphnode involvement
Stage I
Ia
Ib
Stage II
Stage III

Tumor invades any of the following pelvic :
upper urethra ,bladder mucosa ,rectal
mucosa ,pelvic bone or bilateral regional
node metastasis ,or a combination.
Any distant metastasis including pelvic
lymph nodes.
Stage IV
IVa
IVb

Special Investigations
• A biopsy with histological confirmation
• A full blood count, Urea and electrolytes, Liver
function tests
• Colposcopy in early lesions, Chest X-ray
• FNA of the lymph nodes
• Urethrocystoscopy, Proctoscopy
• MRI, CTS

Management
A) Early vulval cancer
* Stage I a
( penetration depth < 1mm below the basement
membrane & no nodal metastases )
radical local excision é surgical margins
1cm, patient do not need groin dissection.
* Stage I b & Stage II
( penetration > 1mm )
radical local excision + ipsilateral inguinal
femoral lymphadenectomy

B) Advanced vulval cancer
* Stage III
( involves the proximal urethra ,anus or rectovaginal
septum )
radical vulvectomy which includes a bowel,
urinary stroma or rectovaginal septum.
+ bilateral groin dissection.
Preoperative radiation or chemo-radiation should
be used to shrink the tumor ,followed by more
conservative surgical excision.

C) Stage-IV- with Positive lymph nodes
Radiation is,
used with > one nodal metastasis (<5mm),
or evidence of extra nodal spread .
postoperative radiation to both groins
and to the pelvis.
Prognosis:
= it correlate significantly with LN status.
with –ve nodes have a 5-yrs survival rate is 90%.
with +ve nodes have a 5-yrs survival rate is 50%.
= patient with no involved node have a good
prognosis regardless of stage.

Malignant Melanoma
* the 2nd most common vulvar cancer.
* may arise from a preexisting uveal - commonly
involve labia minora or clitoris.
* occurs in postmenopausal white women.
* diagnosis :
*any pigmented lesion of the vulva - requires
excisional biopsy for histopathology.
* usually smaller lesions and tend to
metastasized early.

malignant melanoma of the vulva

* prognosis and treatment:
correlates to the depth of penetration into
the dermis. The 5-yrs survival rate is seen in 30%.
* superficial lesion radical local excision alone
with margins of 1 cm, is adequate.
* deeper lesions 1 mm or > radical local
excision + ipsilateral inguinal femoral
lymphadenectomy.

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