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 of the Vagina and Vulva

• 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

• Bartholinâ’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 of Vulva Carcinoma

• Patient may present with puritus, bleeding or discharge
• On examination there may be an ulcer or mass on the clitoris or labia majora

Staging of Vulva Carcinoma

• 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 of Vulva Carcinoma

• 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