3. ANATOMICAL CONSIDERATION
Vulva includes mons veneris,
labia majora, labia minora,
clitoris, vestibule and
conventionally the perineum
Bounded anteriorly by the
mons veneris, laterally by
the labia majora and
posteriorly by the perineum
4. BLOOD SUPPLY OF VULVA
ARTERIAL SUPPLY
Branches of internal pudendal artery
Branches of femoral artery
VEINOUS SUPPLY
Internal pudendal vein
Vesical or vaginal venous plexus, and
Long saphenous vein
5. VULVAL ANATOMY: INNERVATION
Anterosuperior part is supplied by
the cutaneous branches from the
ilioinguinal and genital branch of
genitofemoral nerve (L1 and L2)
Posteroinferior part by the
pudendal branches from the
posterior cutaneous nerve of thigh
(S2,3,4)
9. BARTHOLIN’S CYST
Bartholin’s glands are the two pea sized (2 cm)
glands, located in the groove between the hymen and
the labia minora at 5 O’Clock and 7 O’Clock position
10. Swollen inflamed Vulva: Underlying
Bartholin’s abscess with inflammation of
the Vulva
•Painful swollen gland
•Fluctuant tender
•May have expressible
purulent discharge
•Located at the 5 and 7
o’clock position of the
vestibule.
•2% have adenocarcinoma
11. Treatment Bartholin’s Cyst or
Abscess
Consider antibiotics if extensive inflammation vulval tissues.
If small may settle, alternately for persistent cysts and or larger
cysts/absecess 2 options.-
1. First consider insertion of Word Catheter in OPD and prescribe
antibiotics. Allow free drainage remove catheter when settled
.Send swab for C&S
2. Marsupialization of Bartholin’s abscess or cyst alternative option
In Recurrent abscess or cyst consider excision Bartholin’s cyst/gland
In Older females tissue for histology sent as 2% risk adenocarcinoma
Antibiotics: Chlamydia cover with Doxycycline 100mg BD for 10 days
and broad spectrum cover with a Cephalopsporin 500mg TDS for 5-7
days or Metronidazole 400mg TDS for 5-7 days
12. SEBACEOUS CYST/EPIDERMAL INCLUSION CYST —
Common vulvar cyst
Location-anterior half of labia majora
multiple
formed by accumulation of the sebaceous material due to occlusion of the ducts.
If infected, treatment is done by antibiotics and surgical drainage/excision
CYST OF CANAL OF NUCK
Part of the processus vaginalis, which accompanied the round ligament and got
obliterated prior to birth may persist to form a cyst.
occupies the anterior part of the labium majus.
INGUINOLABIAL HERNIA
When the entire processus vaginalis remains patent-herniation of the abdominal
contents along the tract.
The hernia may be limited to the inguinal canal or may extend up to the anterior part
of the labium majus.
The contents of the sac - intestine or omentum. The swelling is reducible and impulse on
straining can be elicited. One should be conscious of the entity as casual surgical incision
on labial swelling may cause inadvertent injury to the gut.
13. VULVAL VARICOSITIES
predominantly seen during pregnancy and subside following
delivery.
Intolerable aching on standing.
Support pads and tights or T-bandage may be tried, If these
fails, treatment by injecting sclerosing fluids or high ligature of
the long saphenous vein may be of help.
ELEPHANTIASIS VULVAE
It is mainly due to consequence of lymphatic obstruction by
microfilaria (filariasis).
Plastic surgery may be tried to restore the normal anatomy
along with antifilarial treatment.
14. BENIGN TUMORS OF VULVA
FIBROMA,LIPOMA
,NEUROFIBROMA
Fibroma is the most common
benign solid tumor of the vulva
Vulval fibroma grow slowly.
malignant change is very low.
Surgical removal is necessary
as they produce discomfort
HYDRAADENOMA
arises from the sweat gland
in the vulva, usually located
in the anterior part of the
labia majora (38%).
benign lesion but its reddish
look and complex
adenomatous pattern on
histology ,may be confused
with adenocarcinoma.
Simple excision and biopsy is
adequate.
16. WHITE LESIONS OF VULVA RED LESIONS OF VULVA
The melanocytes loose their
ability to manufacture
melanin resulting in
depigmentation and
subsequent
white lesions
Lichen sclerosus
Squamous cell hyperplasia
Vitiligo
Albinism—enzyme deficiency
preventing normal formation
of melanin
Leukoderma
Intertrigo.
Due to infection
Includes-
Candidiasis
Allergic dermatitis
Melanosis
18. ETIOLOGY –
Traumatic (scratching)
autoimmune allergic (atopic)
nutritional (deficiency of folic acid, vitamin B12,riboflavine
achlorhydria, etc.)
infection (fungus)
metabolic or systemic (hepatic, hematological)
Autoimmune disorders like thyroid disease, pernicious
anemia . (asthma, eczema, hay fever)
Drugs:β-blockers, ACE inhibitors
Common allergens are: cosmetics, synthetic underwears
and fragrances.
19. Vulval assessment:
DETAILED HISTORY;
-Itching or pruritus
-Pain/ soreness (character, severity, radiation, relieving/exacerbating factors)
-Erythema (redness), Localised lesions, Any discharge
-Onset and progression of any pain tenderness or itching
-Sexual history including any previous STIs, sexual pain
-Hygiene/cleansing routine (check specific products ?allergy)
-Menopausal status
-Contraception including use of condoms or lubricants (impact on pain or itching)
-Cervical screening history and vaccination
-Medical, psychological (anxiety/depression), surgical and social history (e.g.
cigarettes)
-Psychosexual symptoms (e.g. vaginismus, loss of libido)
-Any lesions elsewhere on the body or history dermatoses (e.g. dermatitis, psoriasis)
-Any history atopy, chest infection, sore throat etc
-Current or recent medications
20. Vulval examination
Detailed vulvovaginal and general examination;
Inspect external/internal vagina then exam including bi-manual
Qualify the rash lesion(s); (erythema, petechiae, ulcer, type lesion, colour)
Tender non tender
Assess the quality of the surrounding skin
Hygiene
Identify any vaginal discharge
Cusco speculum exam; visualise cervix and vaginal walls (document tenderness)
Consider microscopy, wet mount (LM assess) and/or HVS and/or PID screen
Palpation vulva using swab; any pain tenderness, character, radiation
Check the anus and peri-anal skin
Consider vulvoscopy
General medical exam of the body skin remembering to look at the scalp and behind
the ears. Oral exam using tongue depressor identify and oral mucosal /gingival
lesions and tongue. Check elbows and behind the knees.
21. PROCEDURE-VULVAL BIOPSY
INDICATION -Biopsy is required if the woman
fails to respond to treatment or there is clinical
suspicion of VIN or cancer
The sites for biopsy are from the margins of
cracks and fissures and the sky blue areas left
behind after applying 1 percent aqueous toluidine
blue to the vulva and washing it off after 1 minute
with 1 percent acetic acid.
22. Vulval biopsy procedure:
Keyes Biopsy
Different sizes
LA cover
Only every biopsy the edge of
a lesion
Always take a clinical photo
were possible
Review histology and adjust
treatment as required
Refer to specialist
dermatologist if unclear
Discuss histology at MDT if
fails to respond to therapy
24. Lichen Sclerosus
Aetiology: All 1 in 300 females of all ages and 1 in 30 elderly women. Ratio F:M is 5:1
Location - The entire vulva is involved. Lesion encircles the vestibule. It is usually bilateral and
symmetrical .It does not involve the vestibule or extend into the vagina or anal canal
Presentation: White patch (leukoplakia) which coalesce leading to a paper-thin-like skin, stiff
labia with a constricted vaginal orifice and loss of architecture,Figure of ‘8’ appearance
Pathogenesis: Unknown (autoimmune?), autoantibodies to ECM protein.
Histology: Benign thin, flat squamous epidermal cells with fibrosis, degeneration of basal
epidermal cells . Hallmark at histology: Band of Fibrosis.
Symptoms: None (rare), itching (worse at night), sore, pain, dyspareunia (vulval stenosis),
constipation -peri-anal involvement.
Differential skin lesions: Can co-exist with LP and must exclude neoplastic lesions or VIN.(risk of
malignancy =1-4%
26. Management Lichen Sclerosus:
INIVESTIGATIONS;
1. Biopsy: mandatory if diagnosis
uncertain, atypical features
coexistent VIN or SCC is suspected
2. Investigation autoimmune disease:
If clinically indicated (e.g. T4 TSH)
is often asymptomatic
3. Skin swab:exclude co-existing
infection
4. Consider referral to dermatologist
or Vulval Clinic if chronic,
complicated or diagnosis unclear.
;
TREATMENT :
1. Recommended regimen: Ultra-potent
topical steroids (e.g. Clobetasol
proprionate (level evidence I A).
Various regimens are used. The most
common is daily use for 1-month,
alternate days 1-month, x2 weekly
for 1-month , review at three
months. Then use as required
2. Alternative regimens: Ultra-potent
topical steroid with antibacterial
/antifungal(Clobetasol with
neomycin/nystatin), alternative
preparation that combats secondary
infection (e.g. Fucibet cream)
27. Refractory LS: New and novel
therapies
•Topical calcineurin inhibitors (e.g topical tacrolimus 0.1%)
•Avocado and soya beans extracts
•Methyl aminolevulinate photodynamic therapy (MAL-PDT)
•Cyclopsporin
•Methotrexate (dosing e.g. Methylprednisolone 1g for 3 days
then 15mg once weekly for 6 months)
•Retinoids (e.g. elretinate)
•Surgical excision,CO2 laser vaporisation
Cryotherapy and laser ablation –rarely needed
31. Lichen Simplex Chronicus (squamous
hyperplasia)
Presentation: White patches (leukoplakia)
with thick leathery vulval skin.
Symptoms:itching (intractable pruritus –
night )
Pathogenesis: Benign hyperplasia of the
vulvar epithelium secondary to rubbing
and scratching due to pruritus.
Histology: Hyperkeratosis, no nuclear
atypia.
Hallmark at histology: hyperkeratosis
Differential skin lesions: Can co-exist must
exclude neoplastic lesions or VIN.
Biopsy: If fails to respond to therapy or
suspicious lesions.
The initial stimulus itch may be due to;
-Underlying seborrrhoeic dermatitis
-Intertrigo
-Tinea
-Psoriasis
Any itching disease of the vulva may
become secondarily lichenified
Psychological factors may play a role -some
specialists may use the term
neurodermatitis
Main stay of treatment is to avoid any
irritants, antihistaminics,ultrapotent topical
steroids (clobetasol) is helpful to break the
itch-scratch cycle.
32. Vulval Psoriasis
Psoriasis is a chronic, inflammatory
epidermal skin disease
It is the 3rd most common
dermatoses of genital skin where it
may affect the pubic area, vulva, skin
folds and buttocks.
The appearance of vulvar psoriasis is
often symmetrical and can vary from
silvery, scaling patches adjacent to
the outer parts of the labia majora to
moist greyish plaques or glossy red
plaques without scaling in the skin
folds.
Most genital psoriatic lesions
represent plaque-type
The diagnosis of psoriasis is based on
appearance
Treatment: Topical preparations
and UV light are most often used.
- Moisturize
- Emollients can cover and
protect the skin
- Low strength topical steroids
-Topical Vitamin D preparations
- Coal tar preparations
- UV light (risk burns with excess)
Refractory psoriasis may require
systemic medications: Calcineurin
inhibitors: Tacrolimus and
Pimecrolimus
Topical cyclosporin may also be
considered 3rd line.
33. Vulvo-Vaginal Candidiasis (VVC)
Differential diagnoses includes: BV,
dermatitis, allergic reactions, HS
infection and lichen sclerosis
Investigations: empirical treatment
can be considered based on the
history. Vaginal vulval swabs should be
taken if symptoms are persistent or
recurrent
TREATMENT-
-TOPICAL -clotrimazole ,fenticonazole
,miconazle –cream ,pessary
intravaginal cream
-ORAL –Fluconazole 150mg single
dose and itraconazole 200 mg twice
daily x 1 day
34. Irritant Contact Dermatitis (ICD)
Irritant Contact Dermatitis (ICD) is
a common problem and vulvar
irritation is a frequent complaint
among women
It occurs after exposure/contact
with exogenous irritants
Unlike ACD, irritant (ICD) reactions
are not typically vesicular or
bullous
There is often sparing of the
inguinal creases where the
offending agent is not as capable
of contacting the skin
ETIOLOGY-Local irritants as
perfumed soap ,deodorant
,bubble bath ,tight cothin,urie
,faeces
Sodium lauryl sulfate (SLS) is an
anionic detergent and surfactant
used as a foaming agent in many
soaps and shampoos –been
implicated in induction of
dermatitis
Differential diagnosis-vulvar
candidiasis
TREATMENT
-Avoid local cause
-Oral antihistamincs
-Topical steroids
35. Allergic Contact Dermatitis (ACD):
ACD a type IV delayed hypersensitivity reaction
Itching is a prominent feature of ACD, which can be somewhat
helpful in distinguishing from ICD, in which pain is often a
primary
Characteristic appearance of ACD - erythema, oedema, and
possible vesicles or bullae with weeping
contact irritants predisposing to ACD-some antibiotics
,antifungals,all corticosteroids ,nail polish ,body fluids
Because topical corticosteroids are commonly used to treat a
variety of vulvar dermatoses, it’s important to keep in mind
their potential for inducing comorbid ACD
37. Extra-mammary Pagets (risk of
adenocarcinoma)
Age-seen in postmenopausal women
Presentation: florid eczematous with erythema and
excoriation
Symptoms: None, itching, soreness
Differential skin lesions: Can co-exist must exclude
neoplastic lesions or VIN.
Biopsy: Biopsy from edge of lesion
Pathogenesis: Arises from sweat glands and 10% patients
have underlying sweat gland adenocarcinoma.
Histology:paget’s cell-IHC shows, PAS+ (mucin secreting
cells), Keratin + (intermediate fillaments), S100-.
The gastrointestinal, urinary tract and the breasts should
be checked
TREATMENT-Surgical excision to exclude adenocarcinoma
,photodynamic therapy and topical imiquimod
38. CONDYLOMA ACUMINATUM (GENITAL WARTS )
Presentation: Numerous often large white warty
neoplasms of vulvar skin
Symptoms: None, itching
The disease is transmitted sexually
Pathogenesis: Usually benign genital warts caused
by HPV (subtypes 6,11).
Histology: Koilocytosis (clear halo around raisin
like nuclei, a viral effect) in papillomatosis
formations . Usually benign but rarely progress to
squamous cell cancer.
Differential skin lesions: Can co-exist ,must
exclude neoplastic lesions or VIN.
Biopsy: If fails to respond to therapy or suspicious
lesions.
Treatment-25% TCA,podophyllin ,cryosurgery
,electrodiathermy ,CO2 laser,interferon
41. VULVODYNIA
Chronic pain syndrome that affects the vulvar area and
occurs without an identifiable cause affecting up to
16% women
Symptoms typically include a feeling of burning or
irritation. For diagnosis symptoms must last at least 3
months. (BURNING VULVA SYNDROME )
The exact cause - unknown but is believed to be
multifactorial- including genetics, immunology, and
possibly diet.
Diagnosis is by ruling out other possible causes that
may include biopsy of the area.
43. TREATMENT OF VVD (VULVODYNIA )
General measures: Minimizing exposure to contact irritants
Topical agents: Local Anaesthetic (LA): Topical lidocaine gels or ointments-
for provoked VVD making penetrative sex possible, applied 15–20 mins
prior to sex.
Oral analgesics: Paracetamol, NSAIDs
TCADs: Effective particularly for unprovoked VVD.
Dosage: Amitriptyline -Start 10 mg OD increasing weekly until pain
controlled . Average dose 60 mg divided daily up to 100 mg-For 3-6 months
Other drugs:Gabapentin and Pre-gabalin at increasing dosages.
Combining medication with Psychosexual counselling, physiotherapy and
dietary advice significantly improves pain free outcome rates.
However, The optimal drug treatment for VVD remains unclear due to a
lack of well-conducted trials
Surgical removal of the vestibule also has a better outcome when other
measures have been tried
Only a minority of patients may be suitable for surgery
46. INTRODUCTION -
Vulvar squamous intraepithelial lesions (SIL), previously referred to as vulvar intraepithelial neoplasia (VIN)
Group of premalignant conditions of the vulva
No routine screening methods available
The prevalence of vulvar SIL is higher in premenopausal women –Avg age of diagnosis-46 years
There is increased prevalence of associated CIN (10–80%)
It is often related with STD such as condyloma accuminata, herpes simplex virus II, gonorrhea, syphilis or
Gardnerella vaginalis
HPV 16, 18, 31, 35 have been found to be associated with VIN lesions
Location-The interlabial grooves, posterior fourchette, and perineum
47.
48.
49. Vulvar LSIL is a benign lesion and is not considered a premalignant lesion.
HSILs can be subdivided based on their morphologic and histologic features
as-BASALOID SUBTYPE and WARTY (CONDYLOMATOUS) SUBTYPE
dVIN includes lesions that are not associated with HPV but are associated
with vulvar dermatoses, mainly lichen sclerosus
dVIN and HSIL are neoplastic (premalignant) changes, with dVIN accounting
for 2 to 29 percent of such changes and HSIL comprising the rest
HSIL occurs much more frequently than dVIN
dVIN is more likely to progress to invasive carcinoma-80 percent of
keratinizing vulvar cancers
50. RISK FACTORS AND PREVENTION
RISK –
Human papillomavirus (HPV):high-risk types (16, 18, 31)
can be found to be a/w HSIL
Cigarette smoking
Immunodeficiencies –more common in women with HIV
infection
Vulvar dermatosis –such as Lichen sclerosis
PREVENTION –
The quadrivalent and 9-valent HPV vaccines
Encourage to stop using tobacco
Earlier detection and proactive management of vulvar
dermatosis
51. CLINICAL PRESENTATION -
Asymptomatic
Vulvar pruritus –Most common ,Other potential
symptoms are vulvar pain, burning,or dysuria,bleeding
from vulvar ulcer
Vulvar lesion/lump
Persistent abnormal cervical cytology with no
abnormality identified on cervical biopsy- multicentric
origin, which is actually representative of disease in other
nearby genital tract sites (such as the vulva, vagina, and
anus)
52. DIAGNOSTIC EVALUATION
HISTORY –Risk factors assessment
LOCAL EXAMINATION reveals a lesion with white, grey, pink or dull red color.
Lesions look rough, raised from the surface and often multifocal
APPLICATION OF 5 PERCENT ACETIC ACID turns VIN lesions white with
punctuation and mosaic patterns,best seen with a colposcope.
Cytologic screening of the vulva is not useful and unreliable.
Confirmation of diagnosis is done by biopsy.-Usually 3–5 mm diameter
dermal punch is taken under LA . Larger biopsy when required may be taken
using a scalpel. Multiple site biopsies are useful.
A complete pelvic examination is to be done
To exclude vaginal or cervical neoplasia, cytologic evaluation has to be
performed.
53. SURGERY-
Local excision—Wide local excision with 1 cm margin is reserved in young
patient with localized lesion
Laser therapy—CO2 laser vaporization -It gives better cosmetic results
with lower recurrence rate.
Skinning vulvectomy is less commonly done.
Simple vulvectomy—It is employed in diffuse type especially in
postmenopausal women - Long-term follow-up is needed as the risk of
recurrence is high (40–70%)
TREATMENT
Differentiated VIN — For women with dVIN, we recommend surgical
excision rather than ablation or pharmacologic therapy
54. Alternatives treatment
TOPICAL THERAPIES-
IMIQUIMOD
Imiquimod cream (Aldara) is a topical immune response modifier –
applied to individual lesions
Dosing-thin layer of cream 3-5 times per week (alternate days
)for 16 weeks
INDICATION-
initial treatment for recurrent vulvar HSIL
patients with clitoral lesions who prefer to avoid excision and
ablation, provided that they are able to comply with a long
treatment course (typically 16 weeks)
TOPICAL FLUOROURACIL -only rarely used and as a last resort
when other therapies have failed
55. POSTTREATMENT SURVEILLANCE
GYNECOLOGIC EXAMINATION
every six months for five years and then annually
COLPOSCOPY AND BIOPSIES -if the patient
exhibits symptoms and/or examination findings
concerning for additional disease
57. INTRODUCTION
Vulvar cancer is
uncommon, accounting
for only 2%–5% of
gynecologic malignancies
Squamous cell carcinoma
(SCC) of the vulva, the
most common subtype
Median age 68yrs
58. PATHOGENESIS
Two independent pathways of vulvar carcinogenesis
are:-
Mucosal HPV (Human Papilloma Virus) infection
&
Chronic inflammatory (vulvar dystrophy)
59. The risk of developing vulvar cancer is increased by
the following:-
Older age
Precancerous changes (dysplasia) in vulvar tissues
Lichen sclerosus, which causes persistent itching and
scarring of the vulva
Human papillomavirus (HPV) infection
Cancer of the vagina or cervix
Heavy cigarette smoking
Chronic granulomatous disease (a hereditary disease that
impairs the immune system)
60. PATHOLOGY
Sites: The commonest site is labium majus followed by
clitoris and labium minus. Anterior two-third are
commonly affected.
Naked Eye
1. Ulcerative: The features are raised everted edges,
sloughing base with surrounding induration. This is
common.
2. Hypertrophic: The overlying skin may be intact or it
ulcerates sooner or later. This is rare.
61. SPREAD-
DIRECT:
Occurs to the urethra, vagina, rectum and even to pelvic
bones.
LYMPHATICS:
It is the commonest method of spread
About 50 percent of the lymph glands are involved by the
time of presentation
HEMATOGENOUS: This is rare but may occur in advanced
cases.
62. LYMPHATIC SPREAD
Primarily by embolization and only at a late stage-by permeation to fill the lymphatic channels
Contralateral metastases -(25%) as the lymphatics of the vulva cross the midline
Lymphatics of the clitoris, anus and rectovaginal septum may drain directly into the pelvic lymph nodes
When the ipsilateral nodes are not involved -contralateral groin node spread is very unlikely.
Sequential pattern. The lymphatics of labia → superficial inguinal lymph nodes → deep inguinal lymph
nodes → pelvic nodes
Pelvic nodes are secondarily involved in about 20 percent--obturator, external iliac, hypogastric and
common iliac.
Involvement of pelvic nodes, bypassing the inguinal lymph nodes, is less than 3 percent.
BILATERAL LYMPH NODE INVOLVEMENT :Directly related to the site(Midline structure) , size of the lesion and
the depth of stromal invasion
Regional lymph nodes are assessed clinically , by using MRI , sentinel node lymphoscintigraphy ,
ultrasound and PET
63. DEPTH OF STROMAL INVASION AND GROIN LYMPH
NODE INVOLVEMENT IN SQUAMOUS CELL CARCINOMA
OF VULVA:
DEPTH OF INVASION
(MM)
PERCENT OF POSITIVE
NODES
<1 0
1-2 7.5
2.1-3 10
3.1-5 30
65. CLINICAL FEATURES
SYMPTOMS
Asymptomatic
Pruritus vulvae
Swelling with or without offensive
discharge
Difficulty in urination
Vulval ulceration
Bleeding
Inguinal mass
Pain
SIGNS
Possible signs of vulvar cancer
include bleeding or itching.
A lump or growth on the vulva
Changes in the vulvar skin, such as
color
Changes or growths that look like a
wart or ulcer.The ulcer has a
sloughing base with raised, everted
and irregular edges and bleeds on
touch
Tenderness in the vulvar area
„Inguinal lymph nodes of one or
both the sides may be enlarged and
palpable„
Clinical examination of the pelvic
organs,including the cervix, vagina,
urethra and rectum
66. DIAGNOSIS
Basic blood tests –CBC ,LFT/RFT
When a definite growth is present, the biopsy is to be taken from the
margin
Chest x ray, chest CT,Cystourethroscopy, Proctoscopy CT/MRI scan (for
nodes) may be needed
Whole body PET/CT if recurrence/metastasis is suspected
In cases of vulval dystrophy-multiple areas usually from the persistent red
areas or from stained areas following toluidine blue test are biopsied
Consider HPV testing
Consider HIV testing
68. PROGNOSIS
STAGE SURVIVAL
I 90-100%
II 65-75%
III 35-45%
IV 20-30%
SURVIVAL BY NODE STATUS
(5 YEARS)
Negative nodes 80-100%
Positive inguinal
femoral lymph
nodes
30-50%
Positive pelvic
lymph nodes
10-20 %
69. CAUSES OF DEATH
Uremia—from ureteric obstruction due to enlarged
common iliac and paraaortic nodes
„Rupture of the femoral vessels by the overlying involved
inguinal lymph glands
„Sepsis
70. MANAGEMENT
PROPHYLACTIC
Adequate therapy for non-neoplastic epithelial disorders of
the vulva
Adequate therapy for persistent pruritus vulvae in
postmenopausal women
Frequent use of multiple biopsies in conservative treatment of
VIN
Liberal use of simple vulvectomy in postmenopausal women
with VIN where follow-up facilities are not available
71. DEFINITIVE TREATMENT
SURGERY (wide local excision,Modified radical
vulvectomy with or without B/L inguinal
Lymph dissection or sentinel lymph node
biopsy)
RADIOTHERAPY
CHEMORADIATION
NEOADJUVANT CHEMOTHERAPY
72. TYPES OF SURGERY
EXCISION-The cancer and an edge (margin) of normal, healthy skin (usually at least ½ inch) around it and a
thin layer of fat below it are excised . This is sometimes called wide local excision. If extensive (a lot of
tissue is removed), it may be called a simple partial vulvectomy.
SKINNING VULVECTOMY—removes the top layer of skin .This is an option for treating extensive VIN, but
this operation is rarely done.
SIMPLE VULVECTOMY—removes multiple layers of skin and superficial subcutaneous tissue
PARTIAL VULVECTOMY/MODIFIED RADICAL HYSTERECTOMY —removes a part of the vulva, as well as
deep subcutaneous tissue and lymph nodes
COMPLETE RADICAL VULVECTOMY--the entire vulva and deep tissues, including the clitoris, are removed.
A complete radical vulvectomy rarely needed.
VULVAR RECONSTRUCTION-secondary intention ,split skin grafts and flap coverage
PELVIC EXENTERATION
73. Modified radical vulvectomy
THREE INCISION TECHNIQUE is preferred -(i) Vulval
incision, (ii) Groin incision one on either side
Groin incision is a crescent-shaped one, starting about
2–4 cm medial and about 2 cm below the
anteriorsuperior iliac spine. The incision curves
graduallydownwards above the inguinal ligament
medially to the superficial inguinal ring or about 2 cm
below and 2 cm medial to the pubic tubercle. A strip of
skin (2–4 cm) width is excised
Vulval incision –
Outer incision—an elliptical incision is made commencing
anteriorly on the mons pubis → encircling
laterally along the medial side of labiocrural
fold → posteriorly across the mid-line of
perineum
Inner incision — passes around the introitus and
anterior to urethra
74. COMPLICATIONS ASSOCIATED WITH VULVAL AND
INGUINAL LYMPH NODE SURGERY
wound breakdown
wound infection
deep vein thrombosis and pulmonary embolism
pressure sores
introital stenosis
urinary incontinence
rectocele
faecal incontinence
inguinal lymphocyst
lymphoedema
hernia
psychosexual complications
75. FIGO STAGING OF CARCINOMA OF VULVA-
The depth of invasion is defined as the measurement of the tumor from the epithelial–stromal
junction of the adjacent most superficial dermal papilla to the deepest point of invasion
77. PRINCIPLES OF SURGERY: SURGICAL STAGING
Staged using the American Joint Committee on Cancer (AJCC) and (FIGO) staging systems
Involves complete surgical resection of the primary vulvar tumor(s) with at least 1-cm
margins and either a unilateral or bilateral inguinofemoral lymphadenectomy, or an SLN
biopsy in selected patients
Inguinofemoral lymphadenectomy removes the LNs superficial to the inguinal ligament,
within the proximal femoral triangle, and deep to the cribriform fascia
LN status is the most important determinant of survival
The current standard involves resection of the vulvar tumor and LNs through 3 separate
incisions
The choice of vulvar tumor resection technique depends on the size and extent of the primary
lesion and may include radical local excision and modified radical vulvectomy
(NCCN-2018)
78. PRINCIPLES OF SURGERY (NCCN-2018)
For a primary vulvar tumor located within 2 cm from or crossing the vulvar midline,
a bilateral inguinofemoral lymphadenectomy or SLN biopsy is recommended
Locally advanced disease- neoadjuvant radiation with concurrent platinum-based
radiosensitizing chemotherapy
If a complete response is not achieved, surgical resection of the residual disease is
recommended
The management of bulky inguinofemoral LNs in the setting of an unresectable or
T3 primary vulvar lesion –
1) primary cytoreductive surgery followed by platinum-based chemosensitizing
radiation to the bilateral groins and primary vulvar tumor
2) platinum-based chemosensitizing radiation to the bilateral groins and primary
vulvar tumor alone
79. INGUINOFEMORAL SENTINEL LYMPH NODE BIOPSY
Alternative standard-of-care approach to lymphadenectomy in select women with SCC of the
vulva
Eligibility criteria for SLNB
● Tumor diameter <4 cm
● >1 mm depth of invasion
● No palpable groin lymph node
● Unifocal disease
Inguinal lymphadenectomy is a/w a high rate of postoperative morbidity; 20%–40% have wound
complications and 30%–70% -risk for lymphedema
The radiocolloid most commonly injected is technetium-99m sulfur colloid-2 hr prior to
procedure
Dye most commonly used is Isosulfan Blue 1%-intradermally in the operating room within 15–30
minutes of initiating the procedure.
Performed prior to the excision of the vulvar tumor, so as not to disrupt the lymphatic network
A complete inguinofemoral lymphadenectomy is recommended if an ipsilateral SLN is not
identified
If ipsilateral SLN is positive, the contralateral groin should be evaluated surgically and/or treated
with EBRT
80. PRINCIPLES OF RADIATION
THERAPY
INDICATION
As adjuvant therapy following initial surgery,
As part of Primary therapy in
1. locally advanced disease,
2. for secondary therapy/palliation in recurrent/metastatic
diseases
Tumor-directed EBRT is directed to the vulva and/or
inguinofemoral, external, and internal iliac nodal regions.
Brachytherapy can sometimes be used as a boost to
anatomically amenable primary tumors
82. CHEMORADIATION
INDICATIONS
Anorectal, urethral, or bladder involvement (in an
effort to avoid colostomy and urostomy)
Disease that is fixed to the bone
Gross inguinal or femoral node involvement
(regardless of whether a debulking lymphadenectomy
was performed)
83.
84. PRIMARY TREATMENT- STAGE WISE
EARLY-STAGE (STAGE I/II)
LOCALLY ADVANCED (STAGE III/IVA/IVB WITH
PELVIC CONFINED DISEASE)
DISTANT METASTATIC DISEASE (EXTRAPELVIC
STAGE IVB) NCCN-2018
National Comprehensive Cancer
Network
85. NCCN GUIDELINES 2018 VULVAR CANCER (SQUAMOUS
CELL CARCINOMA)-EARLY STAGE
IF WIDE LOCAL RESECTION PATHOLOGY REVEALS TUMOR IN AGGREGATE
OF ≥1 MM INVASION, THEN ADDITIONAL SURGERY MAY BE WARRANTED.
86. primary risk factors include: close tumor margins, lymphovascular
invasion, tumor size, depth of invasion, and pattern of invasion
(spray or diffuse
87. IF IPSILATERAL GROIN IS POSITIVE, THE CONTRALATERAL GROIN SHOULD EVALUATED
SURGICALLY AND/OR TREATED WITH EBRT
88. LOCALLY ADVANCED (STAGE III/IVA/IVB WITH PELVIC CONFINED DISEASE)
LARGER T2 TUMORS: >4 CM
AND/OR INVOLVEMENT OF THE
URETHRA, VAGINA, OR ANUS.
Causative Organisms: Although Gonococcus is
always in mind but more commonly other pyogenic
organisms such as Escherichia coli, Staphylococcus,
Streptococcus, or Chlamydia trachomatis or mixed
types (polymicrobial) are involved
the end results of acute Bartholinitis are:
(i) Complete resolution (ii) Recurrence (iii) Abscess
(iv) Cyst formation.
MARSUPIALISATION -incision is made on
the inner aspect of the labium minus just outside the
hymenal ring. The incision includes the vaginal wall
and the cyst wall. The cut margins of the either side
are to be trimmed off to make the opening an elliptical
shape and of about 1 cm in diameter. The edges of
the vaginal and cyst wall are sutured by interrupted
catgut, thus leaving behind a clean circular opening
Bartholins abcess-Bartholin’s abscess is the end result of acute bartholinitis.
The duct gets blocked by fibrosis and the
exudates pent up inside to produce abscess
Rest is imposed. Pain is relieved by
analgesics and daily sitz bath. Systemic antibiotic—
ampicillin 500 mg orally 8 hourly or tetracycline in
chlamydial infection is effective. Abscess should be
drained at the earliest opportunity before it bursts
spontaneously.
In case of recurrent Bartholin’s abscess, excisionX
should be done in the quiescent phase after the
infection is controlled.
lipschutZ ulcEr: The lesion affects mainly the
labia minora and introitus. In acute state, there may
be constitutional upset with lymphadenopathy. The
causative agent may be Epstein-Barr virus. Treatment
is with antiseptic lotions and ointment.
Vulvar skin disorders,TCA-tricloro acetic acid
Provoked (sexual, nonsexual, or both) 2 Unprovoked 3 Mixed (provoked and unprovoked
Surgical excision of the vestibule may be considered in patients with local provoked vulvodynia (vestibulodynia) after other measures have been tried.
Research shows combining medication with psychotherapy, physiotherapy and dietary advice significantly improves pain free outcome rates
Colposcopy
Visible vulvar lesion
Persistent symptoms consistent with vulvar SIL but no visible lesions
Persistent abnormal cervical cytology with no cervical intraepithelial
neoplasia on biopsy
women with vulvar HSIL in whom there is no
concern for invasive disease and who have multifocal disease or have lesions
involving the clitoris, urethra, anus, and/or vaginal introitus, ablative therapy
may be the best option to preserve vulvar anatomy
primary risk factors include: close tumor margins, lymphovascular invasion, tumor size, depth of invasion, and pattern of invasion (spray or diffuse). Nodal
involvement (as an indicator of lymphovascular space invasion) may also impact selection of adjuvant therapy to the primary site.
If ipsilateral groin is positive, the contralateral groin should be evaluated surgically and/or treated with EBRT. In select cases of a single, small-volume, unilateral,positive inguinal node with a well-lateralized primary tumor diameter ≤2 cm and depth of invasion ≤5 mm and with a clinically negative contralateral groin examination,a contralateral groin dissection or radiation may be omitted