gynaecology.Vulval and vaginal benign and malignant conditions.(dr.mahabat)Presentation Transcript
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: 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.
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
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
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
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
Lichen Simplex Chronicus Physical Appearance ◦ Thickened white epithelium on vulva ◦ Generally unilateral and localized Treatment: Medium potency steroid twice daily prn
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.
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
Bartholin Duct CystMost 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.
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, posterior V. wall & other parts of the vulva. Arise from perineal skin buried at obstetrical injuries. Usually symptomless. Rx: excision.
(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).
• 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.
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.
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 .
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.
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%.
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
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:
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
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.
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.
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.
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
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.
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.
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.