1. Vulval and vaginal benign
and malignant conditions
Dr. Muhabat Salih Saeid- MRCOG- London, UK.

2. Vulval anatomy
The 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.

4. Non-neoplastic epithelial
disorders
Classification:
2. Lichen sclerosis.
3. Squamous cell hyperplasia (formerly:
hyperplastic dystrophy).
4. Other dermatoses.
- lichen planus.
- psoriasis.
- seborrhoeic dermatitis
- inflammatory dermatoses.
- ulcerative dermatoses.

5. 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

6. 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

7. 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

11. Vulvar Psoriasis
 Physical Appearance
◦ Red moist lesions w/without scales
 Treatment: Topical corticosteroids

13. 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

15. Lichen Simplex Chronicus
 Physical Appearance
◦ Thickened white epithelium on
vulva
◦ Generally unilateral and localized
 Treatment: Medium potency
steroid twice daily prn

17. 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.

18. 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

19. 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 →
Bartholin's abscess.
 Rx: excision or
Marsupialization.

20. Bartholin's Abscess
Rx: drainage &
Marsupialization

22. Skene's Gland
• are found on each side
of urethra
• Normally neither seen
nor felt

23. Skenitis
May become swollen
and tender, particularly
with
GC or chlamydia
Rx: drainage.
Culture for GC, Chlamydia

24. 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.

25. (vulval intraepithelial neoplasia) VIN
Classification
 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).

26. VIN Dx & Rx
 Dx: colposce + biopsies
 Rx:
- low grade VIN: observation.
- VIN3: local excision or laser vaporization
- Topical immunomodulator: imiquimod

27. Vulval carcinoma

28. • 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.

29. 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.

30. PATHOLOGY
Primary 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 .

31. Vulval Carcinoma
Clinical 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.

32. A new FIGO staging based on surgical
findings in 1988, it is more accurate
as the involvement of groin nodes is
missed on clinical examination in up to
30% of cases and over diagnosis in 5%.

33. NEW FIGO STAGING OF
VULVA CARCINOMA
Stage 1 cm lesion 2 Confined to the vulva or perineum nodes
size Or less .histo-Logically negative
Stage 2 2cm lesion < Confined to the vulva or perineum nodes
size .histo-Logically negative
Stage 3 Tumor of any size spread to lower urethra
vagina anus +/- Unilateral metastasis
Stage 4 A : Involvement of
Upper urethra
Bladder mucosa
Rectal mucosa
Pelvic bone
Bilateral L.N.metastasis
B Distant metastases and / or pelvic nodes

34. 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 rectum
7. Hematogenous spread to bone or lung is rare
The lymph nodes are arranged in 5 groups in each
groin:

35. Clinical Features & Diagnosis
Most patients with invasive disease
complain 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

36. The major problem in invasive vulvar cancer
is delay between the first appearance of the
symptoms and referral to the gynecological
opinion 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.

37. On Examination
2. 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 noted
3. 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.

38. 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.

39. Benign Vaginal lesions

40. Symptoms of Vaginitis
 Abnormal vaginal discharge
 Pruritus
 Irritation
 Burning
 Soreness
 Odor
 Dyspareunia
 Bleeding
 Dysuria

41. Atrophic Vaginitis
 Pre-pubertal – lactating – postmenopausal
 Reduced endogenous estrogen
 Causing thinning of the vaginal epithelium
 Vaginal epithelium susceptible to trauma
and infection
 pH high

42. 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

44. 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

45. 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.

46. Vaginal Carcinoma
Clinical 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.

47. 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.