Dr Ayman Ewies - Vulvar Colposcopy 2009

Colposcopy Course

1. Vulvar Disease
Ayman Ewies
Consultant Gynaecologist
The Ipswich Hospital
24
th
April 2009

2. 2
Role of Colposcopy
Assessment of:
1.VIN.
2.Carcinoma.

3. Classification of the International Society for
Study of Vulvar Diseases (ISSVD)
Non Neoplastic Epithelial
Disorders
VIN Carcinoma
Lichen Scelerosis Squamous Intra-epithelial
Neoplasia: VIN I-III
Squamous Cell Hyperplasia Non squamous Intra-epithelial
Neoplasia:
-Paget’s disease
-Melanoma in situ

Other Dermatoses

4. Vulvar Intra-epithelial Neoplasia
VIN

5. 5
Incidence & Risk Factors
Incidence:
–VIN I & II is unknown
–VIN III: 2.1/10 000

Risk factors:
1.Multiple sexual partners.
2.Recurrent genital infections.
3.Immuno-suppression.
4.Smoking.
5.HPV.

Most cases of VIN III are associated with HPV (mainly
16).

Vulvar condylomas are associated with 20-30% of VIN
lesions.

6. 6
Malignancy Potential

The malignancy risk: 5-10% in treated individuals (may be much
higher in untreated women).

Spontaneous regression is well documented, especially for VIN I and
II.

Regression is most likely in women under age of 30 with multi-focal
disease.

Progression risk is higher in postmenopausal women with uni-focal
lesions.


VIN (HPV-related) was found adjacent to vulvar cancer in 30% of
cases.

7. 7
Symptoms

VIN is usually symptomatic (unlike CIN).

Common symptoms:
1.Pruritus.
2.Pain.
3.Burning sensation.
4.Dyspareunia.
5.Lump/lesion (less common).

Common sites:
1.Posterior fourchette.
2.Perineum.
3.Around the clitoris.
4.Lower part of labia majora and labia minora.
5.Older women often have a single lesion, while younger women
(under the age of 50) tend to have multi-focal disease.

8. 8
Signs

The clinical appearance is variable.

Typically lesions are:
–Papular with sharp borders.
–Keratotic rough surfaces.

Sometimes, they resemble condyloma accuminata.

The colour may be white, red or brown.

Cervical cytology, colposcopy and vaginoscopy are
indicated in all cases

9. 9
Treatment

Aim:
1.To eradicate symptoms.
2.To prevent malignant transformation.

Choice depends on:
1.Site.
2.Size.
3.Focality.
4.Grade.
5.Age and General condition.

(preservation of appearance and function of the vulva as
well as the psychological issues should be
considered)

10. 10
Treatment VIN I & II

Surveillance with vulvoscopy & biopsies

11. 11
Treatment VIN III

 Medical:
1.5-FU.
2.Imiquimod
3.α-interferon.

 Laser ablation (CO
2):
•High recurrence rate especially in hair-bearing skin.
•It may be better in young women, particularly, for small areas of peri-
urethral and peri-clitoral disease.

 Surgical:
1.Laser excision.
2.Wide local excision with knife (appropriate in the majority of cases).
3.Simple vulvectomy (in a minority of selected cases).
4.Skinning vulvectomy and skin grafting.

An excision margin of 5 mm of healthy tissue is recommended to reduce risk of
recurrence

12. Lichen Sclerosus (LS)

13. 13
Lichen Sclerosus

It is an inflammatory skin disorder whose underlying cause
is not known.
–It probably has an auto-immune origin with seemingly genetic
predisposition.

It is usually seen in the elderly but can occur at young ages.

The associated atrophic changes are reversible.

The life time risk of developing vulvar carcinoma is 3-5%.

It is found adjacent to 60% of vulvar cancer cases.

14. 14
Symptoms
The commonest symptoms:
1.Pruritus (commonest).
2.Vulvodynia.
3.Dyspareunia.
4.Dysuria.

The common sites:
1.Labia minora.
2.Inner surfaces of labia majora.
3.Clitoris.
4.Perineum.
5.Perianal area.

15. 15
Signs
The classical clinical appearance:
1.Ivory pallor of the vulva with epidermal atrophy
giving a parchment-like wrinkled surface.
2.Loss of elasticity.
3.Fissuring.

As the disease progresses:
1.The architecture of the vulva is distorted.
2.Resorption and fusion of labia minora.
3.Loss of clitoral hood.
4.The epithelial surface becomes waxy, shiny and
speckled.

16. 16
Diagnosis
Although the clinical features are often straight forward,
biopsy is mandatory:

1.To confirm the diagnosis.

2.To rule out underlying VIN or micro-invasive
disease.

17. 17
Treatment
Aims:
1.Relief of symptoms.
2.Prevention of progression.

Potent topical corticosteroids with maintenance therapy at the lowest
possible dose.

The patient should be advised to use treatment only on the affected
areas and could use a mirror if necessary.

Treatment is recommended if there are clinical signs even in absence of
symptoms.

Long-term follow-up is required in view of possible malignant
potential.

18. Vulvoscopy

19. 19
Indications for referral

1.Colour changes e.g. whitening, pigmentation, redness, etc.

2.Ulceration.

3.Swelling.

4.Fungating mass.

5.Wart non-responsive to standard treatment.

6.Enlarged inguinal lymph nodes.

20. 20
Vulvoscopic Examination

This should include:
1.Mons pubis.
2.Labia majora.
3.Labia minora.
4.Clitoris.
5.Urethral openings.
6.Vestibule.
7.Introitus.
8.Perineum.
9.Perianal area.

21. 21
Vulvoscopic Examination

Vulvar lesions are difficult to assess because:
1.They do not have a typical appearance.
•Histologically identical lesions can have varied
appearances.

2.The vulva is less likely to stain with acetic acid and
toluidine blue.

22. 22
Vulvoscopic Examination

Clean the vulva with normal saline.

Apply 3-5% acetic acid (for 2-5 minutes since the lesion
appears late):

1.The thick hair-bearing epithelium, e.g. external surface of the labia
majora, does not exhibit features of vascular aberration (mosaicism
and punctation).

2.In the non-hair bearing parts, e.g. labia minora and the vestibule,
the skin is thinner  aceto-whitness, punctation and mosaicism can
be identified.

23. 23
Vulvoscopic Examination
Collin’s Test

Toluidine blue, a nuclear stain, can be used to mark vulvar
lesions.

While the test lacks specificity it can be helpful in
identifying areas for appropriate biopsy.

1.Clean the vulva with normal saline.
2.Apply aqueous toluidine solution (1%) for 2 minutes.
3.Rinse the area with acetic acid 1%.
4.Abnormal cells with high nuclear content retain the blue
stain.

24. 24
Vulvar Biopsies
All lesions should be biopsied.

The biopsy should include the area of transition from
normal to abnormal tissue.

Keyes punch forceps is a suitable method for office
biopsy:

25. 25
Vulvar Biopsies
Keyes punch forceps:
Removes 3-6 mm of skin.

The depth depends on the pressure
applied.

The biopsy site can be left to heal
spontaneously (2 weeks|).

Haemostasis can be achieved by:
1.Monsel’s solution.
2.Silver nitrate.
3.Diathermy.
4.Sutures.