Vulval disorders

Vulval disorders

1. Diseases Of Vagina & Vulva Mrs. U SREEVIDYA, Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2. Mu co sa Lined by stratified squamous epithelium without secreting glands. Loose connective tissue. Submucosa Musc u l a r layer Consists of indistinct inner circular and outer longitudinal. Fibrous coat derived from vascular endopelvic fascia.

3. 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 O e strog e n gycogen from vaginal epithelial cells doderlein’s bacilli lactic acid

4. During menst r uat i on After abortion and labour, alkaline lochia An excessive cervical discharge, such as endo c e rv ici t is Doderlein’s bacilli maintain normal ecosystem of vagina.

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

6. 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

7. DISEASES OF THE VULVA

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

9. VAGINAL INFECTIONS & INFLAMMATIONS

10. 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. S ymptoms 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

11. 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.

12. Second most common cause of vaginal inflammation after bacterial vaginosis. Most commonly caused by a type of fungus known as Candida albicans nucleus E p it he li al cell hy pha blastospores

13. 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.

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

15. 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.

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

17. No rmal Bacterial Vaginosis Candidiasis Trichomoniasis Symptom p rese n tat io n 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

18. 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.

19. 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.

20. CYSTS AND NEOPLASMS OF VAGINA & VULVA

21. 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.

22. 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.

23. Benign Conditions (Neoplasms) of the Vulva

24. 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

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

26. 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.

27. lichen simplex

28. 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.

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

30. * 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 .

31. lichen sclerosis advanced

32. 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 .

33. erosive lichen planus lichen planus of vulva & vagina

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

35. 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.

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

37. 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.

38. Vulval Fibroma

39. 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 .

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

41. 1) Psoriasis appears velvety but lack the characteristics. scaly patches found on the knees & elbows, vulva. T r e a tme n t: T opi c al corticosteroids

42. 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.

43. oral ulcer vulvar ulcer Behcet′ s disease

44. 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.

45. 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.

46. 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 2 nd most common – but still <5% Associated with HPV

47. 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 .

48. 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 .

49. 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.

50. 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.

51. squamous cell carcinoma of vulva

52. * 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.

53. * 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.

54. 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.

55. * 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.

56. Paget′ s disease

57. 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

58. 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

59. 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

60. 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

61. 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.

62. 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.

63. Malignant Melanoma * the 2 nd 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.

64. malignant melanoma of the vulva

65. * 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 .