This document discusses vaginal abnormalities and the role of colposcopy in assessing dyskariosis, VAIN, and carcinoma. It notes that the true incidence of VAIN is unknown, but it is less common than CIN and VIN. Colposcopy is useful for examining the vagina to detect abnormal lesions, though vaginal assessment is more difficult than cervical assessment due to the large surface area and rugose folds. Biopsies of any atypical vaginal epithelium are important for diagnosis. Management depends on the grade of VAIN, with VAIN I often requiring only observation, while VAIN II and III should typically be treated through methods like topical therapies, ablation, or excision.

1. Vaginal Abnormalities
Ayman Ewies
Consultant Gynaecologist
The Ipswich Hospital
24th April 2009

2. 2
Role of Colposcopy
 Assessment of:
1. Dyskariosis
2. VAIN
3. Carcinoma

3. 3
Incidence of VAIN
 True incidence is unknown:
– Extremely low since vagina lacks an active TZ.
 Less common than CIN and VIN.
 Screening is not indicated.
 Asymptomatic  discovered on investigating
abnormal cervical smears.

4. 4
Causes of VAIN
 Not clear – most likely certain types of HPV.
 Predisposing factors could be:
1. Immune status.
2. Smoking.
3. Radiation treatment.
 Its occurrence de novo without previous history of CIN is
rare.
– 1-2.5% of women with CIN have an extension of the
disease onto the vagina.

5. Histological Terminology of VAIN
It is not universally agreed
VAIN I Inner third of epithelium involved with atypia
VAIN II
Inner two-thirds of epithelium involved with atypia
VAIN III
Whole of the epithelium involved with atypia

6. 6
Malignant Potential
 VAIN I  regresses spontaneously in the majority of cases
(regression is less frequent when associated with CIN or
VIN).
 VAIN III  has a higher malignant potential than VaIN I.

7. Vaginoscopic Assessment

8. 8
Vaginoscopic Examination
 The same technique as for the cervix.
 Vaginal assessment is more difficult and takes longer:
1. Large surface.
2. No TZ.
3. Rugose folds.
 After hysterectomy, this even becomes more difficult
(especially at the angles) due to distortion with scarring !

9. 9
Vaginoscopic Examination
 The speculum needs to be rotated and gradually withdrawn
for complete assessment.
• The disposable transparent speculum may be useful.
 It is uncomfortable for women.
 Topical vaginal oestrogen is helpful in postmenopausal and
post irradiation women  helps thicken the epithelium 
accurate differential staining with Lugol’s iodine.
 The whole lower genital tract should be assessed i.e.
colposcopy and vulvoscopy should be performed.

10. 10
Vaginoscopic Parameters
 VAIN colposcopically and histologically has similar
features to CIN.
 Lesions are mostly confined to the upper 1/3 of the vagina;
however it can occur anywhere.
 The commonest sites are the lateral vaginal fornices.
 VAIN after hysterectomy commonly occurs at the vaginal
suture line and the vaginal angle.

11. 11
Vaginoscopic Parameters
 Lesions are usually multi-focal.
 Lesions may appear somewhat raised.
 After applying acetic acid  they appear white with
granular surface and distinct borders.
 Punctation is a more common feature than mosaicism.
 Abnormal epithelium appears yellow due to non-uptake
Lugol’s iodine.

12. 12
Vaginal Biopsies
 Biopsy of any atypical vaginal epithelium is essential.
 Multiple biopsies are often required.
 Methods:
1. Punch biopsy forceps.
2. Small loop.
3. CO2 laser.
 Haemostasis :
1. Silver nitrate
2. Monsel’s solution
3. Tampon pressure.

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Management of VAIN I
 Observation.
 Cytological and colposcopic assessment every 6 months.

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Management of VAIN II & III
 It should be treated.
 Treatment should be individualized
 Treatment options should be based on:
1. Lesion site & size.
2. Age.
3. Medical condition of the patient.
4. Resources & expertise.

15. 15
Management of VAIN II & III
 Medical:
1. Topical 5-Fluorouracil.
2. Oestrogen.
3. Intra-lesional interferon.
 Surgical – Ablation:
1. CO2 Laser.
2. Electro-diathermy.
3. Cryotherapy.
 Surgical – Excision:
1. CO2 Laser.
2. LLETZ.
3. Cold knife.
4. Vaginectomy: partial or total.
 Radiotherapy.

16. 16
Management of VAIN II & III
 Ideally, in those without a cervix, the lesion should be excised.
 Depth of destruction needs to be only 2-3 mm as the vagina does not
contain glands that may harbour the pre-invasive disease.
 Radiotherapy should be reserved for cases with (given the considerable
morbidity):
1. Multi-focal disease.
2. Resistance to other modalities.
 Failure of treatment is more often in those with:
1. Multi-focal disease.
2. Associated CIN or VIN.