Benign diseases of the vulva, vagina and cervix

Benign diseases of the Benign diseases of the vulva, vagina and cervixvulva, vagina and cervix

The vulvaThe vulva

• Is the part of the female genital tract located between the genitocrural folds laterally, the mons pubis anteriorly, and the anus posteriorly.

• Embryologically, it is the result of the junction of the cloacal endoderm, urogenital ectoderm, and paramesonephric mesodermal layers.

• This hollow structure contains – LABIA MAJORA– LABIA MINORA– CLITORIS– VESTIBULE– URINARY MEATUS– VAGINAL ORIFICE– HYMEN– BARTHOLIN GLANDS– SKENE DUCTS.

The vulvaThe vulva

• Different epithelia, from keratinized squamous epithelium to squamous mucosa, cover the vulva.

• The labia minora are rich with sebaceous glands but have few sweat glands and no hair follicles.

• The epithelium of the vestibule is neither pigmented nor keratinized and contains eccrine glands.

BENIGN LESIONS OF THE VULVABENIGN LESIONS OF THE VULVA

• According to the International Society for the

Study of Vulvar Disease (ISSVD) in 1989:

– Inflammatory diseases.

– Blistering diseases.

– Pigmentary changes.

– Benign tumors, hamartomas and cysts

– Congenital malformations.

Inflammatory diseasesInflammatory diseases

1. Lichen sclerosus 2. Squamous cell hyperplasia (+/-

atypia) 3. Lichen simplex chronicus

(localized neurodermatitis) 4. Primary irritant dermatitis 5. Intertrigo 6. Allergic contact dermatitis 7. Fixed drug eruption 8. Erythema multiforme 9. Toxic epidermal necrolysis 10.Atopic dermatitis 11.Seborrheic dermatitis

12.Psoriasis 13.Reiter disease 14.Lichen planus 15.Lupus erythematosus 16.Darier disease 17.Aphthosis and Behçet

disease 18.Pyoderma gangrenosum 19.Crohn disease 20.Hidradenitis suppurativa 21.Fox-Fordyce disease 22.Plasma cell vulvitis 23.Vulvar vestibulitis

syndrome

Blistering diseasesBlistering diseases

1. Familial benign chronic

pemphigus (Hailey-

Hailey disease)

2. Bullous pemphigoid

3. Cicatricial pemphigoid

http://medic.med.uth.tmc.edu/slnk/slnkimg/00001122.jpg

4. Pemphigus vulgaris

5. Erythema

multiforme

6. Epidermolysis

bullosa

http://www.dermnet.com/image.cfm?passedArrayIndex=8&moduleID=5&moduleGroupID=73

Pigmentary changesPigmentary changes

1. Acanthosis nigricans

2. Lentigo

3. Melanocytic nevus

4. Postinflammatory

hyperpigmentation

5. Postinflammatory

hypopigmentation

6. Vitiligo

Benign tumors, hamartomas, and Benign tumors, hamartomas, and cystscysts

1. Bartholin cysts

2. Epidermal inclusion cyst (Dermoid

cyst)

3. Endometriosis

4. Hydrocele of the canal of Nuck

5. Skene duct cyst

6. Seborrheic keratosis

7. Acrochordon (fibroepithelial polyp)

8. Fibroma, fibromyoma, and

dermatofibroma

8. Hidradenoma

9. Lipoma

10.Chronic Inflammatory

swellings

11.Hemangioma

12.Lymphangioma

13.Angiokeratoma

14.Pyogenic granuloma

15.Sebaceous gland hyperplasia

16.Papillomatosis

BENIGN LESIONS OF THE VULVABENIGN LESIONS OF THE VULVA

• BARTHOLIN’s CYST

• ATROPHIC LICHEN (LICHEN SCLEROSUS ET

ATROPHICUS)

• SQUAMOUS HYPERPLASIA

• LICHEN SIMPLEX CHRONICUS

• HIDRADENOMA PAPILLIFERUM

Bartholin’s Cyst/AbscessBartholin’s Cyst/Abscess

• Medial to labia minor

• Blockage of duct following infection

– N. gonorrhea

– Staphylococci

– Anaerobes

• Thomas Bartholin

• Danish professor

• In 1652 he gave the first full

description of the human

lymphatic system.

MarsupalizationMarsupalization

lichenlichen

What is What is lichen?lichen?

A fungus, usually of the class Ascomycetes, that grows symbiotically with algae, resulting in a composite organism that characteristically forms a crustlike or branching growth on rocks or tree trunks.

In pathology….In pathology….

Any of various skin diseases

characterized by patchy eruptions of

small, firm papules.

Lichen Sclerosus et AtrophicusLichen Sclerosus et Atrophicus

• Most patients are post-menopausal women

• Stenosis of the introitus develops


Note the white, parchment-like or plaque-like lesion


• During early stages the patient may not have

symptoms.

• Some patients develop intractable pruritus

• Burning and pain are less likely manifestations.

• Figure-of-8 or keyhole configuration.

• In late stages normal architecture may be lost

– atrophy of the labia minora, constriction of the vaginal orifice

(kraurosis), synechiae, ecchymoses, fissures.

• Squamous cell carcinoma develops in 3-6% cases


• Thinning of the surface epithelium with some hyperkeratosis.


• Etiology – Unknown. A higher prevalence of the disease in

postmenopausal women suggests hormonal factors, but this has not been confirmed.

– Studies identifying an infection are inconclusive – Weakly linked to autoimmune diseases and

genetic factors– Local factors (eg, trauma, friction, chronic

infection and irritation) – Recurrence near vulvectomy scars has been

observed.


• Treatment

– Potent topical corticosteroids

– Testosterone propionate is ineffective

and has many adverse effects

– Close follow-up -----epithelial cancer.

Squamous HyperplasiaSquamous Hyperplasia

Associated with a response to hormonal

influences or exposure to exogenous

irritants

Precursor of squamous cell CA if cells are

atypical

Squamous Hyperplasia Squamous Hyperplasia

• This lesion produces hyperplastic thickening of the superficial squamous epithelium.

• This lesion is a precursor of squamous cell carcinoma of the vulva

Squamous Hyperplasia Squamous Hyperplasia

• Note the keratin horn cysts and the infiltrate of inflammatory cells at the base of the lesion.


• ITCHING is a common symptom.

• If hyperkeratosis is not prominent, lesions may

appear as reddish plaques.

• The clitoris, labia minora, and inner aspects of the

labia majora are more commonly affected.

• Extensive lesions may result in stenosis of the

vaginal introitus.


• Etiology

– Repetitive scratching or rubbing from

irritants

– Treatment is aimed at halting the

itch-scratch-itch cycle.


• Treatment – The same as lichen sclerosus

– General attention to proper hygiene.

– If the skin is moist or macerated, aluminum acetate 5% solution applied 3-4 times daily for 30-60 minutes is beneficial.

– Systemic antihistamines or tricyclic antidepressants

– Refractory lesions, intralesional injections of triamcinolone acetonide may be an alternative.

lichen simplex chronicuslichen simplex chronicus

• Hyperkeratotic, usually ill-

defined, grayish, thickened,

and sometimes excoriated

lesion.

• Usually located over the labia

majora.

• Hyperpigmentation.

• Itching is always present and

may be intense.


• Lichen simplex chronicus of the vulva is the end stage of

the itch-scratch-itch cycle. • The initial stimulus to itch may be:

– Underlying seborrheic dermatitis.

– Intertrigo

– Tinea.

– Psoriasis.

– In most cases, the underlying cause is not evident and may have been transient vulvitis or vaginal discharge.

• Any itching disease of the vulva may become secondarily lichenified.


• Epidermal and epithelial hyperplasia, • Hyperkeratosis.• Fibrotic vertical streaks of collagen between the

hyperplastic rete are present.


• Treatment

– Includes removal of irritants and/or allergens

– Topical application of mild-to-high–potency corticosteroids.

– Avoid soaps and cleansing agents other than aqueous cream.

– Discourage excessive cleaning of the genital area; use of hot

water; overheating; and wearing of synthetic, rough, and/or

tight clothing.

• Lichen simplex chronicus may be associated with

underlying diseases (eg, Paget disease, Bowen disease)

Lichen planusLichen planus

• Three types:

– Papulosquamous– Erosive – Hypertrophic

• Malignancy is possible in long-standing and ulcerative lichen planus.


• The papulosquamous form: – Occurring as part of a

generalized disease – Is the most common and is

characterized by:• Flat-topped• Polyhedral, • Violaceous, shiny, and itchy

papules located on keratinized skin of the labia and mons pubis. Delicate and whitish reticulated papules may be present on the mucosa, but no atrophy or scarring is observed.


• The erosive form:– Involves the mucous membranes of the mouth and

vulvovaginal area and may be locally destructive, leading to atrophy and scarring.

– Synonyms include erosive vaginal lichen planus, desquamative inflammatory vaginitis, vulvovaginal-gingival syndrome, and ulcerative lichen planus.

–Itching is rare, but pain, burning, and irritation occur and may be responsible for dyspareunia and dysuria.


• The rare hypertrophic form:– Resembling lichen sclerosus,

manifests with extensive white scarring of the periclitoral area with variable degrees of hyperkeratosis.

– It may be very itchy. – Extensive vaginal involvement may

result in a malodorous discharge. – Large denuded areas may become

adherent, causing stenosis of the vaginal introitus and dyspareunia.

– Marked atrophy may develop with time.

ID/CCID/CC A 75 year old woman visits her A 75 year old woman visits her

gynecologistgynecologist

for a routine checkup and is found to for a routine checkup and is found to

havehave

white spots on her genitaliawhite spots on her genitalia

HPIHPI She complains of slight outer She complains of slight outer

vaginal itching but denies any vaginal itching but denies any

postmenopausal bleeding, vaginal postmenopausal bleeding, vaginal

discharge, or drug intakedischarge, or drug intake

PEPE Hypochromic macules on labia Hypochromic macules on labia

majora extending to perineum and majora extending to perineum and

inner thighs in patchy distribution inner thighs in patchy distribution

with scale formation; skin is with scale formation; skin is

thickenedthickened

PruritPrurituus vulvas vulva

• Causes:– General

– Local

– Psychosomatic

– Idiopathic

• General Examination

• Local examination:– Smears

– Culture and sensitivity

– BIOPSY: KEYE’s Dermatological knife

BENIGN LESIONS OF THE VaginaBENIGN LESIONS OF THE Vagina

• CYSTIC SWELLINGS

• SOLID TUMORS

• ATROPHIC VAGINITIS

• VAGINAL ADENOSIS

Cystic swellingsCystic swellings

• Gartner’s Cyst

– Dilatation of the Gartner’s (Wollfian) duct

– Anterior and lateral vaginal walls

• Epithelial inclusion cysts

• Endometrioma

• Uretheral diverticulum

Solid TumorsSolid Tumors

• Fibromyoma

• Condyloma accuminata

• Bilharzial polyps

Atrophic vaginitisAtrophic vaginitis

• Thinning and atrophy of vaginal

epithelium

• Most common in postmenopausal

women with low estrogen levels

• Dyspareunia and vaginal spotting

(differential includes uterine

cancer)

Vaginal AdenosisVaginal Adenosis

• Persistent Mullerian columnar

epithelium in the anterior

wall and upper 1/3 of vagina

• Manifestation of maternal

DES exposure

• Red, granular patches

• Precursor of clear cell

adenocarcinoma

Vaginal AdenosisVaginal Adenosis

• Note the red granular patches on the vaginal mucosa on the left. The slide on the right shows glandular development.

• Most patients are 7-35 years of age

BENIGN LESIONS OF THE cervixBENIGN LESIONS OF THE cervix

• CERVICITIS• EROSION• POLYPS

Inflammatory Lesions of the CervixInflammatory Lesions of the Cervix

• Cervicitis (acute)

• Symptoms: backache, bearing-down feeling

in the pelvis, dull pain in the lower part of

the abdomen, urinary tract symptoms

Erosion of the CervixErosion of the Cervix

• Characterized by columnar epithelium replacing squamous

epithelium, grossly resulting in an erythematous area

• Causes:

– Physiological:

– Cervicitis: Acute or Chronic

– Hormonal therapy


• Erosion of the cervix following delivery. A normal cervix is on the left


•SMEAR

– If infection---- Treat cause

– IF CIN ------ Manage according to stage

Chronic CervicitisChronic Cervicitis

• Chronic inflammation, sometimes ulceration with

repair, atypia or dysplasia, nabothian cysts from

endocervical glands

• Backache is a common symptom

Chronic CervicitisChronic CervicitisNabothian CystsNabothian Cysts

• Endocervical glands blocked by inflammation or scarring.

Chronic CervicitisChronic Cervicitis

• Chronic inflammation underlies an area of cervical dysplasia

Endocervical PolypsEndocervical Polyps

Postcoital bleeding and

irregular vaginal spotting

• Inflammatory

proliferations of cervical

mucosa; not true

neoplasms

• Soft; may protrude

through the cervical os

Benign diseases of the vulva, vagina and cervix

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