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Vulval and vaginal benignand malignant conditions    Dr. Muhabat Salih Saeid- MRCOG- London, UK.
Vulval anatomyThe vulva (external genitalia ) includes:   Mons pubis   clitoris   labia majora and minora   Perineum: ...
Non-neoplastic epithelial disordersClassification:2.  Lichen sclerosis.3.  Squamous cell hyperplasia (formerly:    hyperpl...
Lichen sclerosus  Comprises 70% of benign epithelial disorders   → epithelial thinning, inflammation &   histological cha...
Lichen Planus   General Appearance    ◦ Erosive lesions at vestibule w/without      adhesions resulting in stenosis    ◦ ...
Treatment Intravaginal hydrocortisone  suppositories BID x 2m Steroid creams (medium-high potency) Vaginal estrogen cre...
Vulvar Psoriasis   Physical Appearance    ◦ Red moist lesions w/without scales      Treatment: Topical corticosteroids
Squamous Cell Hyperplasia     (Atopic Eczema/Neurodermatitis)   Physical Appearance   Benign epithelial thickening and h...
Lichen Simplex Chronicus   Physical Appearance    ◦ Thickened white epithelium on      vulva    ◦ Generally unilateral an...
Benign Vulval lumps   Bartholin’s cyst.   Epidermal inclusion cyst.   Skene’s duct cyst.   Congenital mucous cysts: ar...
Bartholin glands  Two in number.  Lie posteriolaterally to the  vaginal orifice, one on  either side  Normally not seen no...
Bartholin Duct CystMost common Vulval cyst. usually unilateral, on the   posterio-lateral side of the   introitus. usua...
Bartholins Abscess      Rx: drainage &      Marsupialization
Skenes Gland • are found on each side of urethra • Normally neither seen nor felt
Skenitis May become swollen and tender, particularly with GC or chlamydia Rx: drainage. Culture for GC, Chlamydia
Inclusion Cysts of the Vulva  Contain creamy, yellow  debris & lined with  stratified epithelium.  Found in the perineum, ...
(vulval intraepithelial neoplasia) VINClassification   VIN I - mild dysplasia with    hyperplastic vulvar    dystrophy wi...
VIN Dx & Rx Dx: colposce + biopsies Rx: - low grade VIN: observation. - VIN3: local excision or laser vaporization - Top...
Vulval carcinoma
•  Introduction• Vulval cancer is uncommon and accounts   for approximately 1-4% of all gynecological   cancer y incidence...
AETHIOLOGY:Little is known A viral factor has been suggested by the detection of antigens induced by Herpes simplex virus ...
PATHOLOGYPrimary Tumor 90% of lesions are of squamous in origin. 3-5 of lesions are melanoma. 2% of lesions is basal cell ...
Vulval CarcinomaClinical Staging (F.I.G.O.):   Stage I :   1a: confined to vulva with <1mm invasion.   1b: confined to vu...
A new FIGO staging based on surgicalfindings in 1988, it is more accurate as the involvement of groin nodes ismissed on cl...
NEW FIGO STAGING OFVULVA CARCINOMAStage 1   cm lesion 2    Confined to the vulva or perineum nodes          size Or less  ...
SQUAMOUS CELL CARCINOMA    Are usually seen in the anterior part of the vulva.    2/3 of cases in the labia majora.    1/3...
Clinical Features & DiagnosisMost patients with invasive diseasecomplain of: Irritation or purities in 70% of cases Vulvar...
The major problem in invasive vulvar canceris delay between the first appearance of thesymptoms and referral to the gyneco...
On Examination2. Lesion can take any form from flat white lesion   to large ulcer.the size of the tumor ,involvement   of ...
Treatment of Vulval Carcinoma Stage I & II :  Radical local excision with 1cm disease–free margin. Stage III & IV :  - A...
Benign Vaginal lesions
Symptoms of Vaginitis   Abnormal vaginal discharge   Pruritus   Irritation   Burning   Soreness   Odor   Dyspareuni...
Atrophic Vaginitis   Pre-pubertal – lactating – postmenopausal   Reduced endogenous estrogen   Causing thinning of the ...
Patient Complaints   Genital     Dryness/Itching/Burning     Dyspareunia     Vulvar pruritus     Feeling of pressure     ...
Treatment for Atrophic Vaginitis   Treated with estrogen replacement (vaginal/oral)   Oral BCP (ethinyl estradiol up to ...
Vaginal Carcinoma Incidence: 1-2% of all gyn. Cancer. Classification: 1. primary: squamous (common, 85%), adenocarcinoma...
Vaginal CarcinomaClinical Staging (F.I.G.O.): Stage I: tumour confined to vagina. Stage II : tumour invades paravaginal ...
TREATMENT Stage 1:1. Tumour < 0.5 cm deep: a. surgery: local excision or total vaginectomy with reconstruction. b. radiot...
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)
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gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)

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gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)

  1. 1. Vulval and vaginal benignand malignant conditions Dr. Muhabat Salih Saeid- MRCOG- London, UK.
  2. 2. Vulval anatomyThe vulva (external genitalia ) includes: Mons pubis clitoris labia majora and minora Perineum: a less hairy skin & subcutaneous tissue area lying between the vaginal orifice & the anus & covering the perineal body. Its length is 2-5 cm or more. The urethra opens on to it. Vestibule: a forecourt or a hall next to the entrance. It is the area of smooth skin lying within the L. minora & in front of the vaginal orifice. Hymen.
  3. 3. Non-neoplastic epithelial disordersClassification:2. Lichen sclerosis.3. Squamous cell hyperplasia (formerly: hyperplastic dystrophy).4. Other dermatoses. - lichen planus. - psoriasis. - seborrhoeic dermatitis - inflammatory dermatoses. - ulcerative dermatoses.
  4. 4. Lichen sclerosus Comprises 70% of benign epithelial disorders → epithelial thinning, inflammation & histological changes in the dermis. Aetiology: unknown Sx: Itching (commonest), vaginal soreness + Dyspareunia. Burning and pain are uncommon. Signs: crinkled skin, L. minora atrophy, constriction of V. orifice, adhesions, ecchymoses & fissures. Dx: Biopsy is mandatory Rx: - emollients, topical steroids. - Testosterone: not effective than petroleum jelly & → pruritus, pain & virilization. - Surgery: avoided unless malignant changes
  5. 5. Lichen Planus General Appearance ◦ Erosive lesions at vestibule w/without adhesions resulting in stenosis ◦ May have associated oral mucotaneous lesions and desquamative vaginitis ◦ Patient c/o irritating vaginal , vulvar soreness, intense burning, pruritus, and dyspareunia w/post-coital bleeding ◦ Types: Papulosquamous LP/Hypertrophophic LP /Errosive LP
  6. 6. Treatment Intravaginal hydrocortisone suppositories BID x 2m Steroid creams (medium-high potency) Vaginal estrogen cream if atrophic epithelium present Vaginal dilators for stenosis Surgery for severe vaginal synechiae Vulvar hygiene Emotional support
  7. 7. Vulvar Psoriasis Physical Appearance ◦ Red moist lesions w/without scales  Treatment: Topical corticosteroids
  8. 8. Squamous Cell Hyperplasia (Atopic Eczema/Neurodermatitis) Physical Appearance 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
  9. 9. Lichen Simplex Chronicus Physical Appearance ◦ Thickened white epithelium on vulva ◦ Generally unilateral and localized  Treatment: Medium potency steroid twice daily prn
  10. 10. 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 maqjora. Sebaceous cyst. Papillomatosis (solid). Fibroma (solid). Lipoma (solid). Condylomata (solid). Cysts are either congenital or arise from obstructed glands. Manifestations arise from the cysts (cosmotic) or from infection.
  11. 11. Bartholin glands Two in number. Lie posteriolaterally to the vaginal orifice, one on either side Normally not seen nor felt. If enlarged, can be a painless cyst or painful abscess
  12. 12. Bartholin Duct CystMost common Vulval cyst. usually unilateral, on the posterio-lateral side of the introitus. usually about 2 cm & contains sterile mucus. Usually asymptomatic. secondary infections → Bartholins abscess. Rx: excision orMarsupialization.
  13. 13. Bartholins Abscess Rx: drainage & Marsupialization
  14. 14. Skenes Gland • are found on each side of urethra • Normally neither seen nor felt
  15. 15. Skenitis May become swollen and tender, particularly with GC or chlamydia Rx: drainage. Culture for GC, Chlamydia
  16. 16. Inclusion Cysts of the Vulva Contain creamy, yellow debris & lined with stratified epithelium. Found in the perineum, posterior V. wall & other parts of the vulva. Arise from perineal skin buried at obstetrical injuries. Usually symptomless. Rx: excision.
  17. 17. (vulval intraepithelial neoplasia) VINClassification VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia VIN III - Severe dysplasia; hyperplastic vulvar dystrophy with severe atypia (it replaces the term Carcinoma in situ carcinoma in situ, Bowen’s disease).
  18. 18. VIN Dx & Rx Dx: colposce + biopsies Rx: - low grade VIN: observation. - VIN3: local excision or laser vaporization - Topical immunomodulator: imiquimod
  19. 19. Vulval carcinoma
  20. 20. • Introduction• Vulval cancer is uncommon and accounts for approximately 1-4% of all gynecological cancer y incidence : 1.8 /100.000, It is predominantly seen in postmenopausal and old women (mean age 65 years ) ,and only 2% were less than 30 years. r In countries such as south Africa where sexually transmitted diseases are common, the mean age of presentation is 59 years.
  21. 21. AETHIOLOGY:Little is known A viral factor has been suggested by the detection of antigens induced by Herpes simplex virus type (HSV2) Type 16/18 human papilloma virus (HPV) , in vulval intraepithelial neoplasia.
  22. 22. PATHOLOGYPrimary Tumor 90% of lesions are of squamous in origin. 3-5 of lesions are melanoma. 2% of lesions is basal cell carcinoma. Less than 1% is sarcoma.Secondary Tumors It is occasionly found in vulva Most commonly the primary lesion is from the cervix or the endometrium .
  23. 23. Vulval CarcinomaClinical Staging (F.I.G.O.): Stage I : 1a: confined to vulva with <1mm invasion. 1b: confined to vulva with a diameter < 2 cm & no inguinal lymph nodes affection. Stage II : limited to vulva with diameter > 2 cm) & no inguinal lymph nodes affection. Stage III : adjacent spread to the lower urethra and/or vagina and/or anus and/or unilateral lymph nodes affection. Stage IV :H. Bilateral inguinal nodes metastases, involvement of mucosa of rectum, urinary bladder, upper urethra or pelvic bones.I. Distant metastasis.
  24. 24. A new FIGO staging based on surgicalfindings in 1988, it is more accurate as the involvement of groin nodes ismissed on clinical examination in up to30% of cases and over diagnosis in 5%.
  25. 25. NEW FIGO STAGING OFVULVA CARCINOMAStage 1 cm lesion 2 Confined to the vulva or perineum nodes size Or less .histo-Logically negativeStage 2 2cm lesion < Confined to the vulva or perineum nodes size .histo-Logically negativeStage 3   Tumor of any size spread to lower urethra vagina anus +/- Unilateral metastasisStage 4 A : Involvement of Upper urethra Bladder mucosa Rectal mucosa Pelvic bone Bilateral L.N.metastasis  B Distant metastases and / or pelvic nodes
  26. 26. SQUAMOUS CELL CARCINOMA Are usually seen in the anterior part of the vulva. 2/3 of cases in the labia majora. 1/3 of cases in the clitoris ,labia minora,fourchitte, and perineum.Spread:-5. LYMPHATIC > 50%6. Direct spread occurs in 25% to the urethra, vagina and rectum7. Hematogenous spread to bone or lung is rare The lymph nodes are arranged in 5 groups in each groin:
  27. 27. Clinical Features & DiagnosisMost patients with invasive diseasecomplain of: Irritation or purities in 70% of cases Vulvar mass or ulcer in 55% of cases Bleeding in 28% of cases Discharge in 2-3% of cases
  28. 28. The major problem in invasive vulvar canceris delay between the first appearance of thesymptoms and referral to the gynecologicalopinion due to :1. The doctor fails to recognize the gravity of the lesion and prescribes topical therapy.2. Older women are often embarrassed and shy.
  29. 29. On Examination2. Lesion can take any form from flat white lesion to large ulcer.the size of the tumor ,involvement of the urethra and anus should be noted3. Inspection of the cervix and cervical cytology.4. Needle aspiration of any suspicious groin node.diagnosis is made on histology from full thickness generous biopsy.
  30. 30. 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 tumour 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.
  31. 31. Benign Vaginal lesions
  32. 32. Symptoms of Vaginitis Abnormal vaginal discharge Pruritus Irritation Burning Soreness Odor Dyspareunia Bleeding Dysuria
  33. 33. Atrophic Vaginitis Pre-pubertal – lactating – postmenopausal Reduced endogenous estrogen Causing thinning of the vaginal epithelium Vaginal epithelium susceptible to trauma and infection pH high
  34. 34. Patient Complaints Genital Dryness/Itching/Burning Dyspareunia Vulvar pruritus Feeling of pressure Yellow malodorous discharge /leukorrhea Spotting Irritation/tear Urinary Dysuria/ Frequency/Hematuria Urinary tract infection Stress incontinence
  35. 35. Treatment for Atrophic Vaginitis Treated with estrogen replacement (vaginal/oral) Oral BCP (ethinyl estradiol up to 50ug) Conjugated estrogen up to 1.25mg in combo w/medroxyprogesterone acetate to prevent endometrial hyperplasia Vaginal cream 1g daily qhs x1m then ½ dose 2X/ week (1g vaginal cream=.625mg conjugated estrogen) ◦ should give w/ 2.5mg medrxyprogesterone x14d Estrogen vaginal ring (change q3m) (Estring) delivers 6-9ug estrodiol daily Vagifem 1tab intravaginally x2w then 3x/w for 3-6m
  36. 36. Vaginal Carcinoma Incidence: 1-2% of all gyn. Cancer. Classification: 1. primary: squamous (common, 85%), adenocarcinoma (17-21 years of age, metastasis to L.Ns), clear cell adenocarcinoma (DES). 2. secondary: metastasis from the cervix, endometrium, …..others. 50% in the upper 3rd, 30% in lower 3rd & 19% in middle 3rd. Posterior V. lesions more common than anterior & the anterior are more common than lateral lesions. Spread: direct & lymphatic.
  37. 37. Vaginal CarcinomaClinical Staging (F.I.G.O.): Stage I: tumour confined to vagina. Stage II : tumour invades paravaginal tissue but not to pelvic sidewall. Stage III : tumour extends to pelvic sidewall. Stage IV : a) tumour invades mucosa of bladder or rectum and/or beyond the true pelvis. b) Distant metastasis.
  38. 38. TREATMENT Stage 1:1. Tumour < 0.5 cm deep: a. surgery: local excision or total vaginectomy with reconstruction. b. radiotherapy.2. Tumour > 0.5 cm deep: (a) wide vaginectomy, pelvic lymphadenectomy + reconstruction of vagina. (b) radiotherapy stage 2: (a) radical vaginectomy, lymphadenectomy (b) radiotherapy Stage 3: radiotherapy.

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