Tutorial lecture slides for medical students

1. Vaginal lesions
By
Geoffrey Mutale

2. INTRODUCTION
• Benign or malignant neoplasms of the vagina
are uncommon.
• The frequency of benign lesions ranges from
rare to very rare.
• Neoplasms that may develop in other
locations within the genital tract may also be
found in the vagina.
• Most vaginal tumors produce no symptoms
until significant size is reached.
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3. Cont’
• Symptoms and signs may include a sensation of
pressure, dyspareunia, obstruction of the vagina
or urethra, or vaginal bleeding.
• However, most lesions will be detected during a
routine exam in the asymptomatic patient.
• Vaginal neoplasms may be divided into cystic or
solid lesions and a third category best described
as related conditions.
• As is true for any neoplasm, biopsy provides a
definitive diagnosis.
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4. CYSTIC TUMORS
Gartner's Duct Cyst
• Gartner's duct cysts develop as a result of
incomplete regression of the mesonephric or
wolffian duct during fetal development.
• In the male, these ducts form the epididymis.
• When present, these cysts may be multiple, and
are located submucosally along the lateral
aspects of the upper vagina.
• If these cysts are small, asymptomatic, and
located in the lateral aspects of the upper vagina,
no treatment is indicated.
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5. Cont’
• If the diagnosis is in question, or there is a history
of antenatal exposure to synthetic hormones,
adenosis of the vagina must be considered.
• Histologic evaluation reveals nonsecretory,
columnar epithelium.
• The presence of mucosa, which stains normally
with Lugol's solution, helps to exclude the
diagnosis of adenosis. Regardless of size, biopsies
should be performed on symptomatic cysts or
they should be excised.
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6. Cont’
• Larger cysts in the vaginal fornix may extend
to the lateral aspects of the cervix and require
excision in the operating room.
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7. Bartholin's cyst
• A Bartholin's cyst occurs when a Bartholin's
gland within the labia becomes blocked.
• Small cysts may result in minimal or no symptoms.
• Larger cysts may result in swelling on one side of the
vagina, as well as pain during sex or walking.
• If the cyst becomes infected, an abscess can occur,
which is typically red and very painful.
• If there are no symptoms, no treatment is needed.
• Bartholin's cysts affect about 2% of women at some
point in their life.
• They most commonly occur during childbearing years
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8. Paramesonephric Duct Cyst
• In contrast to Gartner's duct cysts,
paramesonephric duct cysts are lined with
secretory epithelium resembling endocervix or
fallopian tube, suggesting müllerian origin.
• These cysts may be found anywhere in the vagina
and frequently contain mucus.
• Vaginal adenosis is excluded by staining with
Lugol's solution.
• The diagnosis is established with an excisional
biopsy if the cyst is large, symptomatic, or only
recently identified.
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9. Inclusion Cyst
• Inclusion cysts of the vagina result from mucosa
trapped in the submucosal area by surgical
procedures such as episiotomy, colporrhaphy, or
trauma including childbirth.
• As the cysts enlarge, symptoms may develop.
• These cysts are lined with squamous epithelium
and contain keratin and squamous debris.
• Foreign-body reaction and inflammation
surround the cyst.
• Treatment involves excision of the intact cyst and
approximation of normal epithelium.
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10. Sebaceous cysts
• These are cysts that develop when oil-
producing sebaceous glands of the vulva
(external genitalia) become blocked.
• This will form a lump filled with a yellow-
white, greasy material.
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11. Cont’
Endometriosis
• Endometriosis in the vagina may develop at the
site of a previous operation or as primary
implants.
• Nodularity of the posterior vaginal fornix may
represent endometriotic implants of the
posterior cul-de-sac and may eventually erode or
grow into the vaginal mucosa.
• When visualized colposcopically, these implants
may appear dark blue or brown.
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12. Cont’
• If associated with fibrosis, the submucosal implants
may appear white.
• Biopsy may yield chocolate-colored material
representing old hemorrhage and dense fibrosis.
• Endometrial glands and stroma are usually identified
histologically although the presence of both are not
required to make the diagnosis.
• The diagnosis is made by biopsy unless endometriosis
is identified in other parts of the pelvis.
• Small, symptomatic lesions are treated by excision or
laser vaporization.
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13. Cont’
• Large lesions arising in the posterior cul-de-sac
and extending into the posterior vaginal fornix
may require laparotomy to accomplish excision.
• Preoperative therapy with gonadotropin
releasing hormone analogs may greatly reduce
the size of the implants, therefore, reducing the
extent of excision or vaporization.
• We recommend outpatient mechanical bowel
preparation prior to surgery.
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14. Cont’
• For the symptomatic patient who does not
wish surgical excision of the lesion,
gonadotropin releasing hormone analog
therapy followed by suppression with oral
contraceptives may be beneficial.
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15. SOLID TUMORS
Leiomyoma
• Vaginal leiomyomas or fibromyomas are rare lesions
usually located in the anterior vaginal wall.
• Between 250 and 300 cases have been reported in the
world literature.
• These lesions are benign smooth muscle neoplasms,
usually solitary and in many cases asymptomatic.
• Histologically, they resemble leiomyoma of other
origins.
• Proposed sites of origin include vaginal smooth muscle,
local arterial musculature, or smooth muscle of the
bladder or urethra.
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16. Cont’
• As is true of uterine leiomyomata, the vaginal lesions
are estrogen dependent.
• Malignant conversion is extremely rare.
• When large, symptoms can include vaginal discharge or
bleeding, dyspareunia, or urinary retention.
• The differential diagnosis of a midline anterior vaginal
mass includes urethral diverticulum, fibroepithelial
polyp, cystocele, Skene duct abscess, or vaginal
malignancy.
• Therapy involves excision in the symptomatic patient.
Recurrence is uncommon but reported
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18. Cont’
• Fibroepithelial Polyp
• Fibroepithelial polyps of the vagina are
uncommon and usually asymptomatic.
• In infants and young girls, sarcoma botryoides
must be ruled out.
• Fibroepithelial polyps of the vagina are usually
small and may be multiple.
• During pregnancy, these lesions may become
enlarged, very edematous, and bizarre in
appearance.
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19. Cont’
• Histologically, the polyps are composed of a
squamous epithelial surface with a
fibrovascular stalk and edematous stroma.
• Proposed etiologies include stromal
proliferation or granulation tissue reaction as
a result of local injury.
• Therapy involves excision of the polyp and
stalk in the symptomatic patient or the patient
with a large polyp
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20. Cont’
Condyloma Acuminatum
• Condyloma acuminatum represents the clinical
manifestation of human papillomavirus infection.
• There are currently more than 120 human
papillomavirus types identified.
• These lesions may be associated with
condylomata of the cervix and vulva or appear
only as vaginal lesions.
• Histologic evaluation confirms the diagnosis and
rules out a dysplastic lesion.
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21. Cont’
• The microscopic description is similar to that for
condyloma in other locations.
• Clinical management includes topical therapy
with carefully applied bichloroacetic or
trichloroacetic acid.
• For large or multiple lesions, excision,
cauterization, laser vaporization, or loop
electrical excision may be required.
• Cryotherapy may be helpful for small lesions;
however, depth of thermal injury may be difficult
to control.
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22. Cont’
• The entire genital tract should be evaluated
and any obvious lesions treated
simultaneously.
• Overly aggressive treatment, especially with
laser or cautery may result in significant
distortion and scarring of the vagina and
should be avoided.
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23. Rare Lesions
• Prolapse of the fallopian tube into the vagina
following hysterectomy is uncommon; however, it
may be alarming as the edematous fimbria may
appear very much like a well-differentiated
adenocarcinoma to the unsuspecting.
• Hemangiopericytoma, neurofibromas, mixed cell
tumors, granular cell myoblastoma, myxoma,
rhabdomyoma, and benign cystic teratoma are
rare neoplasms found in the vagina.
• Excisional biopsy is required to make the
diagnosis.
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24. RELATED CONDITIONS
Urethral Caruncle
• Urethral caruncles present as localized, red, friable
lesions at the urethral meatus.
• They are generally seen in the postmenopausal woman
and are thought to result from a localized area of
prolapse of the urethral mucosa with secondary
inflammatory changes.
• They can be confused with acute circumferential
prolapse of the urethral mucosa, a condition usually
seen in young girls.
• Urethral carcinoma must be excluded in patients with
larger urethral caruncles.
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25. Cont’
• There may be pain, dysuria, and bleeding.
• Small asymptomatic urethral caruncles may not
require any treatment.
• Larger or symptomatic lesions can be treated by
topical application of estrogen.
• To establish the diagnosis, small biopsies may be
performed under local anesthesia.
• Large or persistent lesions may require excision
and reapproximation with fine absorbable suture.
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26. Diethylstilbestrol (DES) Associated Changes of
the Vagina
• DES is a synthetic substitute for the hormone
estrogen that was sometimes prescribed to
pregnant women in the 1940s, 50s, 60s, and early
70s.
• However, doctors stopped prescribing it when it
was found to be linked to cervical and vaginal
cancer.
• An estimated 1 out of 1000 women treated with
DES will develop adenocarcinoma of the cervix or
vagina.
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27. Suburethral Diverticulum
• A urethral or suburethral diverticulum is a small
protruding pouch of urethral tissue into the
vaginal space.
• Patients with this condition often complain of
recurrent urinary tract infections, urinary
frequency, burning with urination, and painful
intercourse.
• Since these symptoms can be related to other
urinary conditions, it is important to be evaluated
by a physician to get a proper diagnosis.
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28. Thank you
The End
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29. References
• Liu MM: Fibromyoma of the vagina. Eur J
Obstet Gynecol Reprod Biol 29: 321, 1988
• Dhaliwal LK, Das I, Goplan S: Recurrent
leiomyoma of the vagina. Int Gynecol Obstet
37: 281, 1992
• Young SB, Rose PG: Vaginal fibromyomata:
Two cases with preoperative assessment,
resection, and reconstruction. Obstet Gynecol
78: 972, 1991
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