Diseases of vulva

Educational Materials

1. Diseases of vulva
Associate Clinical. Prof. Dr Aisha M EL- Bareg, MD, PhD
Senior Consultant Obs & Gyn / Reproductive. Med
Faculty of Medicine, Misurata University, Libya

2. External genitalia

3. Anatomical consideration
•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

4. 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 majora.
•Sebaceous cyst.
•Papillomatosis (solid).
•Fibroma (solid).

5. •Lipoma (solid).
•Condylomata (solid).

Cysts are either congenital or arise from
obstructed glands.
Manifestations arise from the cysts (cosmetic)
or from infection.

Benign Vulval lumps

6. Bartholin’s Cyst
•Bartholin’s glands situated in posterior part of the
labia. Normally not seen nor felt
•If enlarged, can be a painless cyst or painful
abscess
•Lymphatics drain to inguinal nodes
•Secrete mucus, particularly
during intercourse

7. •Can block causing retention cyst and if
superimposed with infection-an abscess.
•Treated surgically by marsupialization

Bartholin’s Cyst

8. Don’t Confuse it with:
Inclusion Cyst of the Vulva
Right Vaginal Wall Cyst

9. Skene's Gland
•Each side of urethra
•Normally neither seen
nor felt
•May become swollen
and tender, particularly
with GC or chlamydia
•Culture, I&D if pointing

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

11. Lichen sclerosus
•Etiology: unknown
•Can affect both sexes and at any
age
•Typically found in anogenital
region in postmenopausal women
•It can be a symptomatic

Comprises 70% of benign epithelial disorders →
epithelial thinning, inflammation & distinctive
histological changes in the dermis.

12. •Sx: intractable itching (commonest), vaginal soreness +
Dyspareunia.
•Signs: crinkled skin, L. minora atrophy, constriction of
V. orifice, adhesions, ecchymosis & fissures.
•Dx: Biopsy is mandatory
•Rx: emollients, topical steroids.
- Testosterone: not effective than petroleum jelly & →
pruritus, pain & virilization.
- Surgery: avoided unless malignant changes

Lichen sclerosus

13. Lichen Planus
•General Appearance
–Erosive lesions at vestibule w/without adhesions
resulting in stenosis
–May have associated oral mucotaneous lesions
and desquamated vaginitis
–Patient c/o irritating vaginal , vulvar soreness,
intense burning, pruritus, and dyspareunia
w/post-coital bleeding
–Types: Papulosquamous LP/ Hypertrophic LP and
Erosive LP

14. Lichen Planus
•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, Vaginal estrogen cream if atrophic
epithelium, Vaginal dilators for stenosis
–Surgery for severe vaginal synechiae
–Vulvar hygiene
–Emotional support

16. Vulval Psoriasis
•Physical Appearance
–Red moist lesions
w/without scales

•Treatment: Topical
corticosteroids

17. 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
Squamous Cell Hyperplasia
(Atopic Eczema/ Neurodermatitis)

18. 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: vulvar candidiasis

19. Inflammatory dermatomes
•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

20. 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 color and can
be secondarily infected
•It is uncommon vulvar problem
•Treatment: Antifungal as miconazole or
ketoconazole cream

21. 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 ulcer
•Syphilis are papule and then ulcerate
•Cancroids, granuloma inguinale, and
lymphgranulma venerum
•Diagnosis: Serology, Culture
•Treatment
•According to the cause

22. 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

23. •Diagnosis confirmed histopathologically
•Treatment
–25% trichloroacetic acid (TCA), Podophyllin
–Podophyllin should not be used during pregnancy
–If resistant to podophyllin
•liquid nitrogen application, cryosurgery,
electro diathermy, Carbon dioxide laser
•Interferon
Genital warts
Condylomata accuminata

24. (Vulvar Intra-epithelial Neoplasia (VIN)

Neoplastic cells are confined to the surface
epithelium of the vulva
It is a premalignant condition < CIN
The major factor is HPV (type 16, and 33)
Incidence of invasive carcinoma 4%.
VIN affects mainly labia minora and perineum
but may extend to peri anal area
May persist for longer periods of LP > 10 years

25. •May be asymptomatic but can cause:
•Pruritus-soreness, burning (white lesions}

Vulvar Intra-epithelial Neoplasia (VIN)

26. Histological Classification of VIN
1.Squamous Intra-epithelial Neoplasia (SIN)
•VIN 1 (lower 1/3 of vulvar epithelium)
•VIN 2 (lower 2/3 of vulvar epithelium)
•VIN 3 (full thickness of the vulvar epithelium)
2.Non-squamous Intra-epithelial Neoplasia
•Paget’s disease
•Tumors of the melanocyte

27. •Diagnosis: Colposcopy and biopsy
•Treatment: depends on age and extent
wide local excision
skinning vulvectomy
simple vulvectomy
Carbon dioxide laser Rx
5% 5-fluoro-uracil ointment

28. Carcinoma of the Vulva
•Uncommon, accounts for app. 1-4% all female
genital malignancy.
•Seen in elderly women, Average age of 60 years
•Etiology: UNKNOWN
–Herpes simplex virus type 2
–HPV types 16, 18, 31
–Genetic factors
–Coal tar containing chemicals
–Impairment of the immune system

29. •Primary tumor
–90% squamous cell carcinoma
–Melanoma
–Sarcoma
–Basal cell carcinoma
–Bartholin’s gland carcinoma
–Verrucous carcinoma

Secondary tumor
•It is occasionally found in vulva
•The primary is commonly from the Cx and
endometrium.

Carcinoma of the Vulva- types

30. •Free of symptoms
•Pruritus vulvae or irritation of the vulva
•Hyperpigmented, a white or red lesion
•Ulcerative or tumor as late lesions
•Spread is mainly lymphatic and also direct
Carcinoma of the Vulva- clinical pictures

31. •The labia majora is the most common site of
involvement and accounts for about 50% of cases.
•The labia minora accounts for 15% to 20% of cases.
•The clitoris and Bartholin’s glands are less
frequently involved.
Carcinoma of the Vulva- Site

36. •Stage 0 VIN or CIS of the vulva
•Stage I Tumor confined to the vulva and/or perineum < 2 cm
in greatest dimension, No lymphnode
•Stage II Tumor confined to the vulva and/or perineum > 2 cm
in greatest dimension, No lymphnode
•Stage III Tumor of any size with:
i.Spread to the lower urethra and/or the vagina, anus and/or
ii.Unilateral regional lymphnode metastasis
•Stage IV A Tumor invasion: upper urethra, bladder mucosa, rectal
mucosa, pelvic bones and/or regional lymphnode
•Stage IVB Any distant metastasis and /or the pelvic nodes
Carcinoma of the Vulva- FIGO staging

37. Risk factors for node metastasis
•clinical node status,
•age,
•degree of differentiation,
•tumor stage,
•tumor thickness,
•depth of stromal invasion, and
•presence of capillary-lymphatic space invasion

38. 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
•IVP, MRI, CTS

39. 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 tumor
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. Complications of Radical Vulvectomy
•Femoro-inguinal lymphocysts
•Leg oedema
•Wound breakdown
•Thromboembolism
•Wound infection
•Secondary hemorrhage