Disorders of the Vagina and Vulva
- Lymph drainage occurs via the inguinal nodes which drain to the femoral and thence to the external iliac nodes of the pelvis
- This is the route of metastic spread from the vulva
Lichen simplex
- Presents with long history of vulval itching and soreness
- The labia are often thickened and inflamed with hyperpigmentation
- Treated with antihistamines and steroid creams
Lichen planus
- Irritation with flat papular, purple lesions in the anogenital region
- Can affect hair, nails and mucous membranes
- Treatment with steroid creams
Lichen sclerosis
- Vulva epithelium thinned with a loss of collagen
- May be of autoimmune origin and can co-exist with thyroid disease and vitiligo
- Mostly seen in menopause
- Pink/white papules with coalesce to form parchment like skin with fissures
- Atypical cells found in 5% of cases therefore important to biopsy
Vulval pain syndromes
- No evidence of organic vulval disease
- May be associated with infections, former use of oral contraceptives or psychosexual disorders
- Spontaneous generalised vulvar dysthesia is a burning pain which is more common in older women
- Vulvar dysthesia of the vestibule is seen in younger women and causes superficial pain upon using tampons or dyspareunia
- Treated by topical agents and tricyclics
Infections
- Herpes simplex
- Vulval warts (condylomata acuminate)
- Syphilis
- Donovanosis
- Candidiasis – more common in diabetes, pregnancy, with antibiotic use and when immunity is compromised
Bartholin’s gland cyst and abscess
- Bartholin’s gland sits behind the labia minora and secretes lubrication for coitus
- Blockage causes cyst formation
- Infection (generally with Staph or E.coli) causes abscess formation
- Treatment is with incision, drainage and marsupialization
Vaginal cysts
- Smooth and white, can be the size of a golf ball and are often mistaken for a prolapse
- May cause dyspareunia
Vaginal adenosis
- When columnar epithelium is found in the squamous epithelium of the vagina
- Commonly occurs in women whose mothers had diethylstilboestrol (to prevent miscarriage) in pregnancy
- Normally resolves but can develop into malignancy
Premalignant disease of the vulva (VIN)
- Graded I-III in a similar manner to CIN
- Becoming more common especially in young women
- Multifocal and can progress to invasive carcinoma in 5-10%
- Associated with HPV, smoking, lichen sclerosis and squamous hyperplasia of the vulva
- Generally presents with pain or puritus
Carcinoma of the vulva
- Accounts for 5% of genital cancers.
- Most common in age >60
- Mostly (95%) they are squamous cell carcinomas
- The rest are melanomas, basal cell carcinomas, adenocarcinomas and sarcomas
- Carcinomas can arise from VIN II or can arise de novo
Clinical features
- Patient may present with puritus, bleeding or discharge
- On examination there may be an ulcer or mass on the clitoris or labia majora
Staging
- Stage 1 tumour <2cm in diameter and no nodes are involved
- 1a stromal invasion <1mm
- 1b stromal invasion >1mm
- Stage II tumour >2cm in diameter and no nodes are involved
- Stage III tumour has spread beyond vulva or perineum to urethra, vagina or anus. Or nodes are involved in one side only
- Stage IV tumour in rectum, bladder, bone or distant metastases. And/or nodes are involved bilaterally
Prognosis
- 5 year survival in stage I is >90%
- Stage III-IV it is 40%
Vaginal Malignancies
Secondary vaginal carcinoma
- Common, arises from spread from the cervix, endometrium, vulva or GI tract
Primary vaginal carcinomas
- Account for 2% of genital tract malignancies
- Generally affects older women
- Usually squamous in origin
- Presentation with bleeding, discharge or ulceration
- Clear cell adenocarcinoma is most common in late teenage years, mostly due to maternal ingestion of diethylsilboestrol in pregnancy
- Survival rates are good with radical surgery and radiotherapy