Vulvo-vaginal problems are among 10 leading disorders encountered by primary care clinicians



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  • Vulvo-vaginal problems are among 10 leading

  • disorders encountered by primary care clinicians.

  • * Benign lesions of the vulva are mentioned in three

  • categories :

  • 1. Epithelial conditions.

  • 2. Benign neoplastic disorders.

  • 3. Dermatologic disorders.

  • * VIN

  • * Cancer vulva



  • Benign Conditions

  • of the Vulva



(1) Epithelial Conditions

  • (1) Epithelial Conditions

  • 1) Lichen simplex .

  • 2) Lichen sclerosis.

  • 3) Lichen planus,

  • erosive lichen planus.



1) Lichen Simplex

  • 1) Lichen Simplex

  • “ squamous cell hyperplasia “

  • * it is a local thickening of the epithelium resulting

  • from a prolonged itching .

  • * symptoms :

  • pruritus and pain.

  • * signs :

  • white or reddish thickened ,leathery ,raised surface.

  • usually discrete lesion but may be multiple.

  • * treatment :

  • • moderate-strength steroid ointment.

  • • antipruritic agent.





2) Lichen Sclerosis

  • 2) Lichen Sclerosis

  • * it is a chronic progressive disease which constrict

  • and destroy the normal genital anatomy . In the

  • long term ,labia minora are lost ,labia majora

  • flatten ,clitoris becomes inverted .

  • * frequently found on the vulva of postmenopausal

  • women & can involve all the genital area from

  • mons to the anal area.



* combinations of lichen sclerosis & epithleal

  • * combinations of lichen sclerosis & epithleal

  • hyperplasia or carcinoma are possible.

  • * symptoms:

  • intense pruritus , dyspareunia and burning pain.

  • * signs:

  • thin inelastic atrophic skin ,white with a crinkled ,

  • tissue paper appearance.



  • * diagnosis:

  • multiple biopsies is necessary.

  • it reveals a thin atrophic epithelium with

  • inflammatory cells lining the basement

  • membrane.

  • * treatment:

  • ● potent topical steroids. 80% of lesions respond.

  • long term therapy with low potent steroids may

  • be necessary.

  • ● other local treatments are: esrtogen cream and

  • anaesthetics.



lichen sclerosis advanced

  • lichen sclerosis advanced



3) Lichen planus

  • 3) Lichen planus

  • * it is a purplish ,polygonal papules that may

  • appear in their erosive form.

  • * it involve the vulva ,the vagina and the mouth

  • ( vulval – vaginal –gingival syndrome ).

  • * symptoms:

  • vulval burning , severe dyspareunia when

  • vaginal stenosis develop in advanced stages.

  • * treatment:

  • topical and systemic steroids .



erosive lichen planus lichen planus

  • erosive lichen planus lichen planus

  • of vulva & vagina



(2) Benign Neoplastic condions

  • (2) Benign Neoplastic condions

  • 1) epidermal inclusion and sebaceous cysts.

  • 2) vulvar varicosities.

  • 3) fibromas and lipomas.

  • 4) clitoromegaly.



1) epidermal inclusion & sebaceous cysts

  • 1) epidermal inclusion & sebaceous cysts

  • * they are nontender , mobile , spherical ,slow

  • growing cysts located below the epidermis.

  • * sebaceous cysts are firmer bec. they are

  • filled with dry caseous material.

  • * treatment :

  • most of inclusion cysts require no ttt. if they

  • are asymptomatic, or surgical excision.



2) Vulval Varicosities

  • 2) Vulval Varicosities

  • Can enlarge especially during pregnancy

  • to cause discomfort and carry a possible

  • risks for rupture or thrombosis.



3) Fibromas and Lipomas

  • 3) Fibromas and Lipomas

  • Fibromas:

  • * are the most common benign solid tumors

  • that arise in the deeper connective tissue

  • of the vulva.

  • * they are slow growing 1–10 cm in diameter,

  • but may become huge .

  • Lipomas:

  • * slow growing tumors composed of adipose

  • cells.





4) Clitoromegaly

  • 4) Clitoromegaly

  • * may develop after birth in response to

  • excessive androgen exposure . It is a sign

  • virillization.

  • * diagnosed when the clitorial length exceeds

  • 30 mm or the width at the base exceeds

  • 10 mm.



clitoromegaly

  • clitoromegaly



( 3) Dermatologic Disorders

  • ( 3) Dermatologic Disorders

  • 1) Psoriasis.

  • 2) Behcet ′s syndrome.

  • 3) Crohn ΄s disease .

  • 4) Acanthosis nigricans .



1) Psoriasis

  • 1) Psoriasis

  • appears velvety but lack the characteristic

  • scaly patches found on the knees & elbows.



2) Behcet ′s syndrome

  • 2) Behcet ′s syndrome

  • * ulcers in the vulval , oral and ocular areas.

  • * genital lesions can result over time in a scarred

  • vulva.

  • * etiology : is unknown.

  • * diagnosis : based on the concurrence ulcers in

  • vulva ,mouth & ocular involvement ,the

  • recurrent nature of the disease and exclusion

  • of syphilis and Crohn’s disease.

  • * treatment : no effective ttt.



oral ulcer vulvar ulcer

  • oral ulcer vulvar ulcer

  • Behcet′ s disease



3) Crohn’s disease

  • 3) Crohn’s disease

  • * vulval ulcers can precede the development

  • of GIT ulcerations .

  • * vulval ulcers are slit-like or knife – cut ulcers

  • with prominent edema. Draining sinuses and

  • fistulas to the rectum may occur.



4) Acanthosis nigricans

  • 4) Acanthosis nigricans

  • * most commonly found in the axilla or the

  • nape of the neck then vulva.

  • * characterized by its darky pigmented

  • velvety or warty surface .

  • * etiology : related to insulin resistance.



Vulval Neoplasms

  • Vulval Neoplasms

  • Introduction

  • * uncommon 5 % of female genital tract malign.

  • most tumors are squamous cell carcinomas ,may

  • be melanomas , adenocarcinomas and sarcomas.

  • * postmenopausal women ,mean age 65 years.

  • * a history of chronic vulval itching is common.



Epidemiology

  • Epidemiology

  • Two different etiologic types of vulval cancers :

  • 1. A less common type:

  • * in younger women .

  • * related to HPV infection and smoking.

  • * commonly associated with VIN .



2. The more common type:

  • 2. The more common type:

  • * in old women .

  • * unrelated to HPV infection or smoking.

  • * concurrent VIN is uncommon.

  • * long standing lichen sclerosis is common.

  • 5% of patients have +ve serologic tests for

  • syphilis , lymphogranuloma venereum

  • and granuloma inguinale.



Vulval Intraepithelial Neoplasia (VIN)

  • Vulval Intraepithelial Neoplasia (VIN)

  • 2 types of VIN :

  • 1. squamous cell carcinoma in situ

  • VIN III or Bowen’s disease.

  • 2. Adenocarcinoma in situ

  • VIN III or Paget’s disease.



Squamous cell carcinoma in situ:

  • Squamous cell carcinoma in situ:

  • VIN III ( Bowen′s disease )

  • * mean age 45 years.

  • * symptoms:

  • 50% asymptomatic.

  • itching is the most common symptom.

  • * signs:

  • most lesions are elevated ,white ,red ,pink ,

  • brown or grey in color.

  • 20% of lesions are warty in appearance.



  • * diagnosis:

  • 1.careful inspection of the vulva in bright

  • light and with the aid of a magnifying glass.

  • 2. 5% acetic acid aceto white areas.



* treatment :

  • * treatment :

  • 1. local superficial excision.

  • with margins of 5 mm are adequate.

  • 2. skinning vulvectomy in extensive lesions.

  • 3. laser therapy

  • if lesions involves the clitoris , labia minora

  • or perineal area.



Adenocarcinoma in situ

  • Adenocarcinoma in situ

  • VIN III ( Paget′ s disease )

  • * occurs in white postmenopausal elderly women.

  • also occurs in the nipple area of the breast.

  • * 20% is associated with adenocarcinoma.

  • * symptoms:

  • itching and tenderness are common.

  • * signs:

  • well demarcated and eczematus with white

  • plaque like lesions.

  • * growth may progresses beyond the vulva to the

  • mons pubis ,buttocks & thighs.



* diagnosis

  • * diagnosis

  • histologically:

  • adenocarcinoma in situ characterized by

  • large ,pale , pathognomonic Paget’ s cells,

  • typically located both in the epidermic and

  • in the adnexal structures.

  • * treatment:

  • 1. local superficial excision.

  • with margins 5-10 mm.

  • 2. laser therapy

  • in recurrences which are common.



Paget′ s disease

  • Paget′ s disease



Invasive Cancer Vulva

  • Invasive Cancer Vulva

  • A. Squamous cell carcinoma

  • * 90% of vulval cancers.

  • * symptoms:

  • • vulval lump or ulcer.

  • • long standing pruritus.

  • * signs:

  • • raised ,ulcerated ,pigmented or warty lesion.

  • however , ulceration is usually an early sign.

  • • most lesions occur on labia majora and labia

  • minora. Less common sites , the clitoris

  • or the perineum.

  • • 5% of lesions are multifocal.





* spread :

  • * spread :

  • • direct extension

  • to adjacent structures as the vagina , urethra

  • and anus.

  • • lymphatic embolisation

  • inguino femoral nodes.

  • = initially to the superficial inguinal LN.

  • = then to deep femoral LN. located medial

  • to the femoral vein, LN of Cloquet′s is

  • the most common of this group.

  • =then spread occurs to pelvic nodes

  • especially the external iliac LN.



= LN metastases occurs 50% in cancer vulva.

  • = LN metastases occurs 50% in cancer vulva.

  • 5% of patients have metastases to pelvic

  • LN , usually 3 or more +ve unilateral

  • inguino femoral LN.

  • • hematogenous

  • occurs late to the lungs , liver and bone rarely

  • in the absence of lymphatic metastases.



FIGO Staging of Cancer Vulva

  • FIGO Staging of Cancer Vulva





Management

  • Management

  • A) Early vulval cancer

  • * Stage I a

  • ( penetration depth < 1mm below the basement

  • membrane & no nodal metastases )

  • radical local excision é surgical margins

  • 1cm, patient do not need groin dissection.

  • * Stage I b & Stage II

  • ( penetration > 1mm )

  • radical local excision +ipsilateral inguinal

  • femoral lymphadenectomy if the lesion is

  • unilateral and bilateral groin dissection in

  • the midline lesions .



B) Advanced vulval cancer

  • B) Advanced vulval cancer

  • * Stage III

  • ( involves the proximal urethra ,anus or rectovaginal

  • septum )

  • radical vulvectomy which includes a bowel,

  • urinary stroma or rectovaginal septum.

  • + bilateral groin dissection.

  • Preoperative radiation or chemo-radiation should be

  • used to shrink the 1ry tumor ,followed by more

  • conservative surgical excision.



C) Positive lymph nodes

  • C) Positive lymph nodes

  • Radiation

  • used with > one nodal mico metastasis (<5mm),

  • or evidence of extra nodal spread .

  • postoperative radiation to both groins

  • and to the pelvis.

  • Prognosis:

  • = it correlate significantly with LN status.

  • with –ve nodes have a 5-ys survival rate is 90%.

  • with +ve nodes have a 5-ys survival rate is 50%.

  • = patient with no involved node have a good

  • prognosis regardless of stage.



Malignant Melanoma

  • Malignant Melanoma

  • * the 2nd most common vulvar cancer.

  • * may arise de novo or from a preexisting nevus.

  • commonly involve labia minora or clitoris.

  • * occurs in postmenopausal white women.

  • * diagnosis :

  • any pigmented lesion of the vulva requires

  • excisional biopsy for histopathology.

  • * usually smaller lesions and tend to metastasized

  • early.



malignant melanoma of the vulva

  • malignant melanoma of the vulva



* prognosis:

  • * prognosis:

  • correlates to the depth of penetration into the

  • dermis. The 5-ys survival rate is 30%.

  • * superficial lesion radical local excision alone

  • with margins of 1 cm, is adequate.

  • * deeper lesions 1 mm or > radical local

  • excision + ipsilateral inguinal femoral

  • lymphadenectomy.

  • * adjuvant therapy:

  • = nonspecific immuno stimulants.

  • = chemotherapy.

  • = vaccines.





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