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


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  • This condition believed to be an autoimmune disease. This condition affects the Pts are usually treating self for chronic yeast infections SKIN/NAILS/MUCOUS MEMBRANES:MOUTH ESOPHAGUS CUNJUNCTIVAE, BLADDER, NOSE, LARYNX, STOMACH, AND ANUS. Papulosquamous LP are usually intense papules with a violaceous hue. Hypertrophic LP is difficult to diagnose resembling squamous cell carcinoma.
  • Medications to avoid (may exacerbate condition) B-blockers, methyldopa, NSAID, ACE inhibitors, sulfonyluea, quinidine,
  • Lichen planus
  • Hypertrophic Lichen planus
  • Erosive lichen planus (less reponsive to therapy)
  • Vulvar psoriasis may be the only site affected. Or may have scalp/extensor surfaces of extremities/ trunck affected Other treatments if severe and involving other sites: emollients, tar, methotrexate, ultraviolet light etc.
  • Vulvar psoriasis
  • SSRI’s may help alleviate pruritus Treatment : AVOID causative factors PADS/SOAPS-avoid
  • Very similar to squamous cell hyperplasia and needs biopsy for diagnosis
  • Lichenification from lichen simplex chronicus
  • Marsupializationof Bartholin duct cyst. A vertical incision is made over the center of the cyst to dissect it free of mucosa. The cyst wall is everted and approximated to the edge of the vestibular mucosa with interrupted sutures.
  • The degree to which these symptoms are present depends upon the extent of inflammation
  • pH 5-7 d/t reduction in lactic acid production and decrease in lactobacilli decreasing h2o2 Normal vaginal pH 4-4.5 >4.5 BV/contaminant-sperm/lubricants Prepubertal small tear (treat with Vaseline/KY) R/O use of Perfumes, powders, soaps, deodorants, panty liners, spermicides and lubricants often contain irritant compounds. 6 In addition, tight-fitting clothing and long-term use of perineal pads or synthetic materials can worsen atrophic symptoms
  • External genitalia of a 67-year-old woman who is naturally menopausal for two years and is not on estrogen replacement therapy. Note loss of labial and vulvar fullness, pallor of urethral and vaginal epithelium, and decreased vaginal moisture.
  • Treatment w/ ½ applicator nightly for 1-2weeks usually resolves symptoms Treat with estrogen if not contraindicated (breast CA/endometrial CA etc…) 1/2g cream given 3x/w x6months had normal ultz, biopsy showed thickening. ESTRING= preferred local delivery. (is 1/10 th the amount of estrogen secreted by premenopausal women. Only 10% absorbed systemically (may still consider opposing progesterone Oral meds may be 25days or more if needed but will reoccur of D/C’d If no uterus then no progesterone is needed ½ the dose for the vaginal cream may be effective Consider progesterone w/any vaginal treatments 1g vag=100ug estrodiol (max 4g) 1g=.625mg conjugated estrogen
  • 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.