BENIGN DISORDERS OF THE VULVA Rukset Attar, MD, PhD Department of Obstetrics and Gynecology.

BENIGN DISORDERS OF THE BENIGN DISORDERS OF THE VULVAVULVA

Rukset Attar, MD, PhDRukset Attar, MD, PhDDeparDeparttment ment of of

Obstetrics and GynecologyObstetrics and Gynecology

OrOriiggiinates from ectodermnates from ectoderm erithematouserithematous, ulcerative, proliferative and , ulcerative, proliferative and

hyperhyperkkeratotic lesions eratotic lesions Examined after application of Examined after application of 3-5% acetic acide3-5% acetic acide

or or 1% toluidin blue1% toluidin blue Colposcopy is time consumingColposcopy is time consuming Biopsy from multiple sites with Biopsy from multiple sites with Keyes biopsyKeyes biopsy

forcepsforceps

Benign Lesions of the VulvaBenign Lesions of the Vulva InflamatoryInflamatory

Dermatities ( contact, seboreic-intertrigo, psoriasis, Dermatities ( contact, seboreic-intertrigo, psoriasis, candidasis, tinea, infections of the major and minor candidasis, tinea, infections of the major and minor vestibular glands)vestibular glands)

Viral diseases ( HSV, HPV, Herpes Zoster, Viral diseases ( HSV, HPV, Herpes Zoster, Molluscum contagiosum)Molluscum contagiosum)

Ulcerative lesions ( Crohn, Behcet, venerial diseases, Ulcerative lesions ( Crohn, Behcet, venerial diseases, nonspes lesions-hydradenitis, folliculitis,etc) nonspes lesions-hydradenitis, folliculitis,etc)

TraumaticTraumatic hematomas hematomas lacerationslacerations

White White Depigmentation-vitiligo or leukodermaDepigmentation-vitiligo or leukoderma Hypercheratotic lesions( inflamatory,benign Hypercheratotic lesions( inflamatory,benign

neoplasms)neoplasms) Vulvar dystrophies (Lichen sclerosus, squamous cell Vulvar dystrophies (Lichen sclerosus, squamous cell

hyperplasia-hyperplastic dystrophy,mixt)hyperplasia-hyperplastic dystrophy,mixt)

Benign Lesions of the VulvaBenign Lesions of the Vulva

Benign neoplasmsBenign neoplasms Benign cystic tumorsBenign cystic tumors ( (Epidermal cysts, sebaceous Epidermal cysts, sebaceous

cysts, apocrine sweat gland cysts, Skene duct cyst, cysts, apocrine sweat gland cysts, Skene duct cyst, urethral diverticulum, inguinal hernia, Gartner's duct urethral diverticulum, inguinal hernia, Gartner's duct cyst, Bartholin's duct cyst and abscess)cyst, Bartholin's duct cyst and abscess)

Benign solid tumorsBenign solid tumors ( (Acrochordon, pigmented nevi, Acrochordon, pigmented nevi, leiomyoma, fibroma, lipoma, neurofibromas, granular leiomyoma, fibroma, lipoma, neurofibromas, granular cell myoblastoma)cell myoblastoma)

Vascular and lymphatic diseaseVascular and lymphatic disease ((Varicosities, Varicosities, hematoma, edema, granuloma pyogenicum, hematoma, edema, granuloma pyogenicum, hemangioma, lymphangioma)hemangioma, lymphangioma)

Vulvar manifestation of systemic diseaseVulvar manifestation of systemic disease ((Leukemia, dermatologic disorders Leukemia, dermatologic disorders (disseminated lupus erythematosus, pemphigus (disseminated lupus erythematosus, pemphigus vulgaris)vulgaris)

Infestations of the vulvaInfestations of the vulva ( (Pediculosis pubis, Pediculosis pubis, scabies, enterobiasis)scabies, enterobiasis)

Vascular and lymphatic diseaseVascular and lymphatic disease

varicosities varicosities hematoma hematoma edema edema granuloma pyogenicum(agranuloma pyogenicum(a variant of a capillary variant of a capillary

hemangioma. It usually is single, raised, and dull red. Its hemangioma. It usually is single, raised, and dull red. Its size seldom exceeds 3 cm. size seldom exceeds 3 cm. Pyogenic granuloma is Pyogenic granuloma is important because it tends to bleed easily if traumatizedimportant because it tends to bleed easily if traumatized. . Wide excisional biopsy is indicated to alleviate symptoms Wide excisional biopsy is indicated to alleviate symptoms and to rule out a malignant melanoma) and to rule out a malignant melanoma)

hemangiomahemangioma lymphangiomalymphangioma

Vulvar manifestation of systemic diseaseVulvar manifestation of systemic disease

leukemia leukemia dermatologic disordersdermatologic disorders (disseminated lupus (disseminated lupus

erythematosus, pemphigus vulgaris, contact dermatitis, erythematosus, pemphigus vulgaris, contact dermatitis, psoriasis) psoriasis)

obesityobesity Acanthosis nigricansAcanthosis nigricans is a benign hyperpigmented is a benign hyperpigmented

lesion characterized by papillomatous hypertrophy. It lesion characterized by papillomatous hypertrophy. It may be associated with an underlying may be associated with an underlying adenocarcinoma. adenocarcinoma.

IntertrigoIntertrigo is an inflammatory reaction involving the is an inflammatory reaction involving the genitocrural folds or the skin under the abdominal genitocrural folds or the skin under the abdominal panniculus. It is common in obese patients and panniculus. It is common in obese patients and results from persistent moistness of the skin surfaces. results from persistent moistness of the skin surfaces.

Vulvar manifestation of systemic diseaseVulvar manifestation of systemic disease

Diabetes MellitusDiabetes Mellitus Diabetic vulvitisDiabetic vulvitis. It is caused by a chronic vulvovaginal . It is caused by a chronic vulvovaginal

candidiasis candidiasis Necrotizing fasciitisNecrotizing fasciitis is seen most commonly in is seen most commonly in

diabetics. It is an uncommon, acute, rapidly diabetics. It is an uncommon, acute, rapidly spreading, frequently fatal spreading, frequently fatal polymicrobial infection of polymicrobial infection of the superficial fascia and subcutaneous fasciathe superficial fascia and subcutaneous fascia. It may . It may be seen following a surgical procedure such as an be seen following a surgical procedure such as an episiotomy or after minor trauma. It presents as an episiotomy or after minor trauma. It presents as an extremely painful, tender, and indurated region with extremely painful, tender, and indurated region with central necrosis and peripheral purplish erythema. central necrosis and peripheral purplish erythema. Treatment requires surgical debridement and Treatment requires surgical debridement and ssystemic antibiotics.ystemic antibiotics.

Behçet's syndromeBehçet's syndrome

Viral InfectionsViral Infections Herpes genitalisHerpes genitalis HPVHPV Herpes ZosterHerpes Zoster Molluscum ContagiosumMolluscum Contagiosum

Herpes Zoster Herpes Zoster

A painful eruption of groups of vesicles is distributed A painful eruption of groups of vesicles is distributed over an area of skin corresponding to the course of 1 or over an area of skin corresponding to the course of 1 or more peripheral sensory nerves. more peripheral sensory nerves.

The causative agent is The causative agent is varicella-zoster virusvaricella-zoster virus. . The lesion is commonly unilateral and not infrequently The lesion is commonly unilateral and not infrequently

attacks 1 buttock, 1 thigh, or 1 side of the vulva.attacks 1 buttock, 1 thigh, or 1 side of the vulva.

Molluscum ContagiosumMolluscum Contagiosum These benign epithelial These benign epithelial poxviruspoxvirus-induced tumors are -induced tumors are

dome-shaped, often umbilicated, and vary in size up to 1 dome-shaped, often umbilicated, and vary in size up to 1 cm. cm.

The lesions often are multiple and are mildly contagious.The lesions often are multiple and are mildly contagious. The microscopic appearance is characterized by The microscopic appearance is characterized by

numerous inclusion bodies numerous inclusion bodies (molluscum bodies)(molluscum bodies) in the in the cytoplasm of the cells. cytoplasm of the cells.

Each lesion can be treated by Each lesion can be treated by desiccation, freezing, or desiccation, freezing, or curettage and chemical cauterization of the basecurettage and chemical cauterization of the base..

Topical Topical imiquimod( aldara )imiquimod( aldara ) can be used as alternative can be used as alternative therapy therapy

Infestations of the VulvaInfestations of the Vulva Pediculosis PubisPediculosis Pubis

The crab louse The crab louse ((Phthirus pubisPhthirus pubis)) is transmitted through is transmitted through sexual contact or from shared infected bedding or sexual contact or from shared infected bedding or clothing. clothing.

intense pubic and anogenital itching.intense pubic and anogenital itching. minute pale-brown insects and their ova may be seen minute pale-brown insects and their ova may be seen

attached to terminal hair shafts. attached to terminal hair shafts. treatment consists of treatment consists of permethrin 1% cream, lindane permethrin 1% cream, lindane

1% shampoo, or pyrethrins with piperonyl butoxide1% shampoo, or pyrethrins with piperonyl butoxide. . LindaneLindane is not recommended for pregnant or lactating is not recommended for pregnant or lactating

women or for children younger than 2 years. women or for children younger than 2 years. Treat all contacts and sterilize clothing that has been Treat all contacts and sterilize clothing that has been

in contact with the infested area.in contact with the infested area.

Infestations of the VulvaInfestations of the Vulva

Scabies Scabies Sarcoptes scabieiSarcoptes scabiei itching and excoriation of the skin surfaces in the itching and excoriation of the skin surfaces in the

vicinity of minute skin burrows where parasites have vicinity of minute skin burrows where parasites have deposited ova. deposited ova.

The itch mite is transmitted, often directly, from The itch mite is transmitted, often directly, from infected persons.infected persons.

The patient should take a hot soapy bath, scrubbing The patient should take a hot soapy bath, scrubbing the burrows and encrusted areas thoroughly. the burrows and encrusted areas thoroughly.

Treatment consists of Treatment consists of permethrin cream (5%),permethrin cream (5%), which which should be applied to the entire body from the neck should be applied to the entire body from the neck down, with particular attention to the hands, wrists, down, with particular attention to the hands, wrists, axillae, breasts, and anogenital region. It should be axillae, breasts, and anogenital region. It should be washed off after 8–14 hours.washed off after 8–14 hours.


Alternatively, Alternatively, lindane (1%)lindane (1%) in the lotion or cream form in the lotion or cream form can be applied in a thin layer to all areas of the body can be applied in a thin layer to all areas of the body and washed off after 8 hours. and washed off after 8 hours.

All potentially infected clothing or bedding should be All potentially infected clothing or bedding should be washed or dry-cleaned. washed or dry-cleaned.

All contacts or persons in the family must be treated All contacts or persons in the family must be treated in the same way to prevent reinfection. in the same way to prevent reinfection.

Therapy should be repeated in 10–14 days if new Therapy should be repeated in 10–14 days if new lesions develop. lesions develop.


Enterobiasis (Pinworm, Seatworm)Enterobiasis (Pinworm, Seatworm) Apply ammoniated mercury ointment to the perianal Apply ammoniated mercury ointment to the perianal

region twice daily for relief of itching. region twice daily for relief of itching. Pinworms succumb to systemic treatment with Pinworms succumb to systemic treatment with

pyrantel pamoate, mebendazole, or pyrvinium pyrantel pamoate, mebendazole, or pyrvinium pamoate pamoate

Mycotic Infections of the VulvaMycotic Infections of the Vulva Fungal Dermatitis (Dermatophytoses)Fungal Dermatitis (Dermatophytoses)

Tinea crurisTinea cruris is a superficial fungal infection of the is a superficial fungal infection of the genitocrural area that is more common in men than in genitocrural area that is more common in men than in women. women.

The most common organisms are The most common organisms are Trichophyton Trichophyton mentagrophytesmentagrophytes and and Trichophyton rubrum.Trichophyton rubrum.

The initial lesions usually are located on the upper The initial lesions usually are located on the upper inner thighs and are well circumscribed, inner thighs and are well circumscribed, erythematous, dry, scaly areas that coalesce. erythematous, dry, scaly areas that coalesce.

Scratching causes lichenification and a gross Scratching causes lichenification and a gross appearance similar to neurodermatitis. appearance similar to neurodermatitis.

Mycotic Infections of the VulvaMycotic Infections of the Vulva

The diagnosis depends on microscopic examination The diagnosis depends on microscopic examination (as for (as for CandidaCandida) )

Culture on Culture on Sabouraud's mediumSabouraud's medium confirms the confirms the diagnosis. diagnosis.

Treatment with Treatment with 1% haloprogin, tolnaftate1% haloprogin, tolnaftate, or a similar , or a similar agent is effective. agent is effective.

Topical imidazoleTopical imidazole preparation at twice-daily preparation at twice-daily application for 2–3 weeks also is highly effectiveapplication for 2–3 weeks also is highly effective

Other Infections of the VulvaOther Infections of the Vulva ImpetigoImpetigo

is caused by the hemolytic is caused by the hemolytic S aureusS aureus or streptococci or streptococci.. The disease is autoinoculable and spreads quickly to The disease is autoinoculable and spreads quickly to

other parts of the body, including the vulva. other parts of the body, including the vulva. Thin-walled vesicles and bullae develop that display Thin-walled vesicles and bullae develop that display

reddened edges and crusted surfaces after rupture.reddened edges and crusted surfaces after rupture. The disease is common in children, particularly on the The disease is common in children, particularly on the

face, hands, and vulva.face, hands, and vulva. The patient must be isolated and the blebs incised or The patient must be isolated and the blebs incised or

crusts removed aseptically. crusts removed aseptically. Neomycin or bacitracinNeomycin or bacitracin should be applied twice daily should be applied twice daily

for 1 week. for 1 week. Bathing with an Bathing with an antibacterial soapantibacterial soap is recommended. is recommended.

Other Infections of the VulvaOther Infections of the Vulva

FurunculosisFurunculosis Vulvar folliculitis is caused by a Vulvar folliculitis is caused by a staphylococcal staphylococcal

infectioninfection of hair follicles. of hair follicles. Furunculosis occurs if the infection spreads into the Furunculosis occurs if the infection spreads into the

perifollicular tissues, producing a localized cellulitis.perifollicular tissues, producing a localized cellulitis. Minor infections can be treated by applications of Minor infections can be treated by applications of

topical antibiotic lotions. topical antibiotic lotions. Deeper infections can be brought to a head with hot Deeper infections can be brought to a head with hot

soaks, after which the pustules should be incised and soaks, after which the pustules should be incised and drained. drained.

Appropriate systemic antibiotics are warranted when Appropriate systemic antibiotics are warranted when extensive furunculosis is present.extensive furunculosis is present.


ErysipelasErysipelas Erysipelas is a rapidly spreading erythematous lesion of Erysipelas is a rapidly spreading erythematous lesion of

the skin caused by invasion of the superficial the skin caused by invasion of the superficial lymphatics by lymphatics by ββ-hemolytic streptococci.-hemolytic streptococci.

is extremely rare and is most commonly seen after is extremely rare and is most commonly seen after trauma to the vulva or a surgical procedure. trauma to the vulva or a surgical procedure.

Systemic symptoms of chills, fever, and malaise Systemic symptoms of chills, fever, and malaise Vesicles and bullae may appear, and erythematous Vesicles and bullae may appear, and erythematous

streaks leading to the regional lymph nodes are typical.streaks leading to the regional lymph nodes are typical. The patient should be given The patient should be given systemic (preferably systemic (preferably

parenteral) penicillin or tetracycline orallyparenteral) penicillin or tetracycline orally in large doses in large doses


HidradenitisHidradenitis Hidradenitis suppurativa is a refractory process of the Hidradenitis suppurativa is a refractory process of the

apocrine sweat glandsapocrine sweat glands, usually associated with , usually associated with staphylococci or streptococcistaphylococci or streptococci..

Treatment early in the disease consists of drainage Treatment early in the disease consists of drainage and administration of antibiotics based on organism and administration of antibiotics based on organism sensitivity testing. sensitivity testing.

Long-term therapy with Long-term therapy with isotretinoinisotretinoin may be may be considered. considered.

Antiandrogen therapyAntiandrogen therapy with with cyproterone acetate or cyproterone acetate or ethinyl estradiolethinyl estradiol may be an alternate but highly may be an alternate but highly effective treatment.effective treatment.


Severe chronic infections may not respond to medical Severe chronic infections may not respond to medical therapy, and the involved skin and subcutaneous tissues therapy, and the involved skin and subcutaneous tissues must be removed down to the deep fascia. must be removed down to the deep fascia.

This may necessitate a filet and curettage or a complete This may necessitate a filet and curettage or a complete vulvectomy. vulvectomy.

The area generally will not heal after a primary closure; The area generally will not heal after a primary closure; therefore, therefore, the wound must be left open and allowed to the wound must be left open and allowed to heal by secondary intention, or a split-thickness graftheal by secondary intention, or a split-thickness graft may be placed. may be placed.

Squamous cell carcinomaSquamous cell carcinoma is rarely associated with is rarely associated with hidradenitis suppurativa. hidradenitis suppurativa.


Tuberculosis (Vulvovaginal Lupus Vulgaris)Tuberculosis (Vulvovaginal Lupus Vulgaris) is manifested by chronic, minimally painful, exudative is manifested by chronic, minimally painful, exudative

"sores" that are tender, reddish, raised, moderately "sores" that are tender, reddish, raised, moderately firm, and nodular, with central "apple jelly"-like firm, and nodular, with central "apple jelly"-like contents contents

wet compresses of wet compresses of aluminum acetate solution aluminum acetate solution (Burow's solution)(Burow's solution) are helpful. are helpful.

systemic antituberculosis therapysystemic antituberculosis therapy should be given. should be given.

Vulvar Nonneoplastic Epithelial DisordersVulvar Nonneoplastic Epithelial Disorders Vulvar dystrophiesVulvar dystrophies was previously used to define the was previously used to define the

nonneoplastic epithelial disorders of the vulva. nonneoplastic epithelial disorders of the vulva. As characterized by the International Society for the As characterized by the International Society for the

Study of Vulvovaginal Disease (ISSVD), these lesions Study of Vulvovaginal Disease (ISSVD), these lesions include include lichen sclerosuslichen sclerosus (previously lichen sclerosus et (previously lichen sclerosus et

atrophicus),atrophicus), squamous cell hyperplasiasquamous cell hyperplasia (previously hyperplastic (previously hyperplastic

dystrophy), and dystrophy), and mixtmixt

Vulvar Nonneoplastic Epithelial DisordersVulvar Nonneoplastic Epithelial Disorders

These lesions present classically with intense pruritus These lesions present classically with intense pruritus with or without pain and vulvar epithelial changes. with or without pain and vulvar epithelial changes.

Differentiating from among these disorders and ruling Differentiating from among these disorders and ruling out an underlying malignant process require out an underlying malignant process require histopathologic diagnosis.histopathologic diagnosis.

The risk of an underlying malignancy is The risk of an underlying malignancy is less than 5%.less than 5%. Patients must be reexamined periodically, and one Patients must be reexamined periodically, and one

should not hesitate to take additional biopsy should not hesitate to take additional biopsy specimens. specimens.


Lichen sclerosusLichen sclerosus Thin, white, wrinkled tissue, with a cigarette-paper Thin, white, wrinkled tissue, with a cigarette-paper

appearance appearance Clobetasol propionate(dermovate)Clobetasol propionate(dermovate) 0.05% twice daily for 3 0.05% twice daily for 3

monthsmonths 2% testosterone cream 2% testosterone cream twice daily for 3 monthstwice daily for 3 months 1.25% topical progesterone 1.25% topical progesterone twice daily for 3 months 9 esp twice daily for 3 months 9 esp

for children-discontinue for 1 year at puberty and for children-discontinue for 1 year at puberty and menapaosal women)menapaosal women)

Intralesional triamcinolone injection5 mg in 2 ml or 10 mg in Intralesional triamcinolone injection5 mg in 2 ml or 10 mg in 1 ml injection 0.1 ml at diff sites with 22 gauge spinal needle1 ml injection 0.1 ml at diff sites with 22 gauge spinal needle

surgerysurgery


Squamous cell hyperplasiaSquamous cell hyperplasia Circumscribed, single or multifocal Circumscribed, single or multifocal Raised white lesion on vulva or adjacent tissue (generally of Raised white lesion on vulva or adjacent tissue (generally of

labia majora and clitoris)labia majora and clitoris) Medium-potency topical steroids twice daily ( kenocort-A, Medium-potency topical steroids twice daily ( kenocort-A,

locacortene)- not eff then high-potency topical locacortene)- not eff then high-potency topical steroids(dermovate) twice daily when satisfactory relief steroids(dermovate) twice daily when satisfactory relief established then hydrocortisone established then hydrocortisone

With benadryl at bedtime and white cotton glovesWith benadryl at bedtime and white cotton gloves Intralesional triamcinolone injection5 mg in 2 ml or 10 mg in Intralesional triamcinolone injection5 mg in 2 ml or 10 mg in

1 ml injection 0.1 ml at diff sites with 22 gauge spinal needle1 ml injection 0.1 ml at diff sites with 22 gauge spinal needle surgerysurgery


Lichen simplex chronicusLichen simplex chronicus Thickened white epithelium on vulva Thickened white epithelium on vulva Generally unilateral and localizedGenerally unilateral and localized Medium-potency topical steroids twice a dailyMedium-potency topical steroids twice a daily

Benign Cystic TumorsBenign Cystic Tumors Epidermal CystEpidermal Cyst

epithelial cells-may result from traumatic suturing of epithelial cells-may result from traumatic suturing of skin fragments during closure of the vulvar mucosa skin fragments during closure of the vulvar mucosa and skin after trauma or episiotomy. and skin after trauma or episiotomy.

most epidermal cysts arise from occlusion of most epidermal cysts arise from occlusion of pilosebaceous ducts. pilosebaceous ducts.

These cysts usually are small, solitary, and These cysts usually are small, solitary, and asymptomatic.asymptomatic.

Benign Cystic TumorsBenign Cystic Tumors

Sebaceous CystsSebaceous Cysts develops when the sebaceous gland's duct becomes develops when the sebaceous gland's duct becomes

occluded and accumulation of the sebaceous material occluded and accumulation of the sebaceous material occurs. occurs.

are frequently multiple and almost always involve the are frequently multiple and almost always involve the labia majora. labia majora.

are generally asymptomatic; however, acutely are generally asymptomatic; however, acutely infected cysts may require incision and drainage.infected cysts may require incision and drainage.


Apocrine Sweat Gland Cysts Occlusion of the ducts with keratin results in an

extremely pruritic, microcystic disease called Fox-Fordyce disease.

Chronic infection in the apocrine glands, usually with staphylococci or streptococci, results in multiple painful subcutaneous abscesses and draining sinuses. This condition is called hidradenitis suppurativa, which is generally treated with a broad-spectrum antibiotic.

Hidradenoma and syringoma are included in a diverse group of benign cystic or solid tumors of apocrine sweat gland origin present as small subcutaneous and asymptomatic tumors.


Bartholin's Duct Cyst and AbscessBartholin's Duct Cyst and Abscess Obstruction of the main duct of Bartholin's gland Obstruction of the main duct of Bartholin's gland

results in retention of secretions and cystic dilatation. results in retention of secretions and cystic dilatation. Infection is an important cause of obstruction; Infection is an important cause of obstruction;

however, other causes include inspissated mucus and however, other causes include inspissated mucus and congenital narrowing of the duct. congenital narrowing of the duct.

Secondary infection may result in recurrent abscess Secondary infection may result in recurrent abscess formation.formation.

The gland and duct are located deep in the posterior The gland and duct are located deep in the posterior third of each labium majus. third of each labium majus. Enlargement in the Enlargement in the postmenopausal patient may represent a malignant postmenopausal patient may represent a malignant process (although the incidence is < 1%), and biopsy process (although the incidence is < 1%), and biopsy should be consideredshould be considered


Other Other Skene duct cystSkene duct cyst urethral diverticulumurethral diverticulum An An inguinal herniainguinal hernia Occlusion of a persistent processus vaginalis (canal Occlusion of a persistent processus vaginalis (canal

of Nuck) may cause a cystic tumor or of Nuck) may cause a cystic tumor or hydrocelehydrocele. . Dilatation of the mesonephric duct vestiges produces Dilatation of the mesonephric duct vestiges produces

lateral vaginal wall cysts, lateral vaginal wall cysts, Gartner's duct cystGartner's duct cyst.. Supernumerary mammary tissue that persists in the Supernumerary mammary tissue that persists in the

labia majora may form a cystic or solid tumor or even labia majora may form a cystic or solid tumor or even an adenocarcinoma; engorgement of such tissue in an adenocarcinoma; engorgement of such tissue in the pregnant patient can be symptomatic. the pregnant patient can be symptomatic.

Benign Solid TumorsBenign Solid Tumors AcrochordonAcrochordon

An acrochordon is a flesh-colored, soft polypoid tumor An acrochordon is a flesh-colored, soft polypoid tumor of the vulvar skin that has been called a of the vulvar skin that has been called a fibroepithelial fibroepithelial polyppolyp or simply a or simply a skin tag.skin tag.

The tumor does not become malignant and is of no The tumor does not become malignant and is of no clinical importance, unless it becomes traumatized, clinical importance, unless it becomes traumatized, causing bleeding. causing bleeding.

Simple excision biopsy in the office is ordinarily Simple excision biopsy in the office is ordinarily adequate therapyadequate therapy..

Benign Solid TumorsBenign Solid Tumors

Pigmented NevusPigmented Nevus Leiomyoma, FibromaLeiomyoma, Fibroma, and , and Lipoma Lipoma NeurofibromaNeurofibroma - may be solitary, solid tumors of the vulva - may be solitary, solid tumors of the vulva

or associated with generalized neurofibromatosis or associated with generalized neurofibromatosis (Recklinghausen's disease)-(Recklinghausen's disease)-They arise from the neural They arise from the neural sheath and usually are small lesions of no consequence sheath and usually are small lesions of no consequence

Benign Solid TumorsBenign Solid Tumors

Granular Cell Myoblastoma (Schwannoma)-Granular Cell Myoblastoma (Schwannoma)-is usually a is usually a solitary, painless, slow-growing, infiltrating but benign solitary, painless, slow-growing, infiltrating but benign tumor of neural sheath origin, most commonly found in tumor of neural sheath origin, most commonly found in the tongue or integument, although approximately 7% the tongue or integument, although approximately 7% involve the vulva. The usual picture consists of small involve the vulva. The usual picture consists of small subcutaneous nodules 1–4 cm in diameter. With subcutaneous nodules 1–4 cm in diameter. With increasing size, they erode through the surface and increasing size, they erode through the surface and result in ulcerations that may be confused with cancer. result in ulcerations that may be confused with cancer. The margins of the tumor are indistinct, and wide local The margins of the tumor are indistinct, and wide local excision is necessary to completely excise the cells excision is necessary to completely excise the cells extending into contiguous tissues. The area of resection extending into contiguous tissues. The area of resection must be periodically re-examined and secondary must be periodically re-examined and secondary excision performed promptly if recurrence is suspectedexcision performed promptly if recurrence is suspected

Vulvar Pain SyndromeVulvar Pain Syndrome Vulvar pain in the absence of relevant, visible physical Vulvar pain in the absence of relevant, visible physical

findings is termed findings is termed vulvodynia.vulvodynia. The patient suffering from vulvodynia describes her The patient suffering from vulvodynia describes her

symptoms as burning, rawness, irritation, dryness, and symptoms as burning, rawness, irritation, dryness, and hyperpathia (pain provoked by very light touch).hyperpathia (pain provoked by very light touch).

Approximately 16% of the female population has Approximately 16% of the female population has experienced vulvodynia and approximately 1.5% experienced vulvodynia and approximately 1.5% currently suffer from the disorder. currently suffer from the disorder.

Vulvodynia has been classified into Vulvodynia has been classified into generalized generalized vulvodynia (provoked or unprovoked)vulvodynia (provoked or unprovoked) and and localized localized vulvodynia (provoked and unprovoked).vulvodynia (provoked and unprovoked).

a detailed history and examination are important to help a detailed history and examination are important to help determine the etiology and to direct the diagnosis and determine the etiology and to direct the diagnosis and treatment.treatment.

Vulvar Pain SyndromeVulvar Pain Syndrome--EtiologyEtiology

InfectionsInfections Bartholin's gland abscess, vulvovaginal candidiasis, Bartholin's gland abscess, vulvovaginal candidiasis,

herpes, herpes zoster, human papillomavirus, herpes, herpes zoster, human papillomavirus, molluscum contagiosum, trichomoniasis molluscum contagiosum, trichomoniasis

Trauma Trauma Sexual assault, prior vaginal deliveries, hymenectomySexual assault, prior vaginal deliveries, hymenectomy

Systemic IllnessSystemic Illness Behçet's disease, Crohn's disease, Sjögren's Behçet's disease, Crohn's disease, Sjögren's

syndrome, systemic lupus erythematosussyndrome, systemic lupus erythematosus NeoplasiaNeoplasia

Vulvar intraepithelial neoplasia and invasive Vulvar intraepithelial neoplasia and invasive squamous cell carcinomasquamous cell carcinoma


Allergens/toxic medicationsAllergens/toxic medications Soaps, sprays, douches, antiseptics, suppositories, Soaps, sprays, douches, antiseptics, suppositories,

creams, laser treatment, podophyllin, trichloroacetic creams, laser treatment, podophyllin, trichloroacetic acid, 5-fluorouracilacid, 5-fluorouracil

Dermatologic conditionsDermatologic conditions Allergic and contact dermatitis, eczema, hidradenitis Allergic and contact dermatitis, eczema, hidradenitis

suppurativa, lichen planus, lichen sclerosus, suppurativa, lichen planus, lichen sclerosus, pemphigoid, pemphigus, psoriasis, squamous cell pemphigoid, pemphigus, psoriasis, squamous cell hyperplasia hyperplasia

Urinary tract syndromesUrinary tract syndromes Interstitial cystitis and urethral syndromeInterstitial cystitis and urethral syndrome


NeurologicNeurologic Referred pain from urethra, vagina, and bladder;Referred pain from urethra, vagina, and bladder; dysesthesias secondary to herpes zoster, spinal disk dysesthesias secondary to herpes zoster, spinal disk

problems; problems; specific neuralgias (pudendal, genitofemoral)specific neuralgias (pudendal, genitofemoral)

PsychologicalPsychological Sexual/physical abuse historySexual/physical abuse history

Localized Provoked VulvodyniaLocalized Provoked Vulvodynia was formerly known as was formerly known as vulvar vestibulitisvulvar vestibulitis//clitorodynia.clitorodynia. The vestibule is the nonpigmented, nonkeratinized The vestibule is the nonpigmented, nonkeratinized

squamous epithelium of the vulva between the labia minora squamous epithelium of the vulva between the labia minora and the hymenand the hymen

generally affects women in their 20s and 30s who complain generally affects women in their 20s and 30s who complain of introital dyspareunia. of introital dyspareunia.

present as persistent vaginal discharge and burningpresent as persistent vaginal discharge and burning. . is characterized by 3 criteria: is characterized by 3 criteria:

introital pain on vestibular or vaginal entry (entry introital pain on vestibular or vaginal entry (entry dyspareunia), dyspareunia),

vestibular erythema or inflammation of the vestibule, vestibular erythema or inflammation of the vestibule, commonly involving the posterior fourchette, and commonly involving the posterior fourchette, and

vestibular tenderness—pressure from a cotton-tipped vestibular tenderness—pressure from a cotton-tipped applicator at the vestibule reproduces the pain. applicator at the vestibule reproduces the pain.

Localized Provoked VulvodyniaLocalized Provoked Vulvodynia

Patients should be instructed on proper vulvar hygiene Patients should be instructed on proper vulvar hygiene (cotton underwear, keeping area dry, avoidance of (cotton underwear, keeping area dry, avoidance of constrictive garments and irritating agents). constrictive garments and irritating agents).

The initial conservative approach to therapy includes The initial conservative approach to therapy includes topical estradiol with twice-daily application, 5% lidocaine topical estradiol with twice-daily application, 5% lidocaine ointment daily, calcium citrate 400 mg 3 times daily to ointment daily, calcium citrate 400 mg 3 times daily to decrease the urinary oxalate crystal concentration, oral decrease the urinary oxalate crystal concentration, oral antifungal therapy using fluconazole 150 mg weekly, and antifungal therapy using fluconazole 150 mg weekly, and pelvic floor therapy with biofeedbackpelvic floor therapy with biofeedback. .

Localized Provoked VulvodyniaLocalized Provoked Vulvodynia

The injectable forms of therapy include The injectable forms of therapy include intralesional intralesional interferon injectioninterferon injection to treat possible HPV, trigger point to treat possible HPV, trigger point injections with long-acting injectable anesthetics, and injections with long-acting injectable anesthetics, and injection of botulism toxin to treat vaginismus as the injection of botulism toxin to treat vaginismus as the source of vulvodynia. source of vulvodynia.

The surgical treatment of localized provoked vulvodynia The surgical treatment of localized provoked vulvodynia in the form of in the form of vulvar vestibulectomyvulvar vestibulectomy with vaginal with vaginal advancement is most effective (70% success rate) in advancement is most effective (70% success rate) in patients who have been refractory to more conservative patients who have been refractory to more conservative therapies. therapies.

Generalized Unprovoked VulvodyniaGeneralized Unprovoked Vulvodynia was formerly known as pudendal neuralgia. was formerly known as pudendal neuralgia. Its etiology is unknown. Its etiology is unknown. The pain involves a larger surface area than that of The pain involves a larger surface area than that of

localized vulvodynia. localized vulvodynia. The average patient is in her 40s. The average patient is in her 40s. The typical patient complains of intermittent or constant The typical patient complains of intermittent or constant

burning sensation with periods of unexplained relief burning sensation with periods of unexplained relief and/or flares. The diagnosis is made by exclusion. and/or flares. The diagnosis is made by exclusion.

Infections and dermatosis should be ruled out.Infections and dermatosis should be ruled out.

Generalized Unprovoked VulvodyniaGeneralized Unprovoked Vulvodynia

A test for allodynia and hyperalgesia using a cotton-A test for allodynia and hyperalgesia using a cotton-tipped swab should be performed. tipped swab should be performed.

It is believed to be a neuropathic pain, but other organic It is believed to be a neuropathic pain, but other organic causes, including pudendal nerve entrapment, pudendal causes, including pudendal nerve entrapment, pudendal nerve injury due to child birth, referred pain from nerve injury due to child birth, referred pain from ruptured disk, neuropathic viruses such as herpes ruptured disk, neuropathic viruses such as herpes simplex or varicella-zoster, and neurologic disease such simplex or varicella-zoster, and neurologic disease such as multiple sclerosis, are possible.as multiple sclerosis, are possible.

Generalized Unprovoked VulvodyniaGeneralized Unprovoked Vulvodynia

Treatment of generalized unprovoked vulvodynia is Treatment of generalized unprovoked vulvodynia is mostly unsuccessful. mostly unsuccessful.

The patient should be counseled on elimination of The patient should be counseled on elimination of irritants and on self-care. irritants and on self-care.

Topical local anesthetics, tricyclic antidepressants, or Topical local anesthetics, tricyclic antidepressants, or anticonvulsants such as gabapentin can be tried. anticonvulsants such as gabapentin can be tried.

If the patient is refractory to such treatment, acupuncture If the patient is refractory to such treatment, acupuncture or referral to a pain center may be attempted.or referral to a pain center may be attempted.

BENIGN DISORDERS OF VAGINA BENIGN DISORDERS OF VAGINA AND VULVOVAGINITISAND VULVOVAGINITIS

Rukset Attar, MD, PhDRukset Attar, MD, PhDDeparDeparttment ment of of

Obstetrics and GynecologyObstetrics and Gynecology

Benign Disorders of Vagina Benign Disorders of Vagina

Vulvovaginitis Vulvovaginitis Benign cystsBenign cysts Congenital anomaliesCongenital anomalies

Mullerian anomaliesMullerian anomalies Hymenal SeptumHymenal Septum Hymen imperforatusHymen imperforatus

Causes of Vulvovaginitis

InfectiousInfectious Vulvovaginal candidiasis Vulvovaginal candidiasis Bacterial vaginosis Bacterial vaginosis Bacterial infections Bacterial infections Trichomoniasis Trichomoniasis Viral infections Viral infections Desquamative inflammatory vaginitis (clindamycin Desquamative inflammatory vaginitis (clindamycin

responsive) responsive) Secondary bacterial infection associated with foreign body Secondary bacterial infection associated with foreign body Atrophic vaginitis Atrophic vaginitis ParasiticParasitic

Causes of Vulvovaginitis

NoninfectiousNoninfectious Atrophic vaginitis Atrophic vaginitis Allergic vaginitis Allergic vaginitis Foreign body Foreign body Desquamative inflammatory vaginitis (steroid Desquamative inflammatory vaginitis (steroid

responsive) responsive) Collagen vascular disease Collagen vascular disease Behçet's syndrome Behçet's syndrome Pemphigus syndromesPemphigus syndromes

CandidiasisCandidiasis

75% of women will experience an episode of 75% of women will experience an episode of vulvovaginal candidiasis. vulvovaginal candidiasis.

Candida albicansCandida albicans is the most common is the most common CandidaCandida species species causing symptomatic candidiasis in approximately 90% causing symptomatic candidiasis in approximately 90% of cases of cases

C albicansC albicans frequently inhabits the mouth, throat, large frequently inhabits the mouth, throat, large intestine, and vagina normally. intestine, and vagina normally.

Clinical infection may be associated with a systemic Clinical infection may be associated with a systemic disorder (diabetes mellitus, human immunodeficiency disorder (diabetes mellitus, human immunodeficiency virus [HIV], obesity), pregnancy, medication (antibiotics, virus [HIV], obesity), pregnancy, medication (antibiotics, corticosteroids, oral contraceptives), and chronic corticosteroids, oral contraceptives), and chronic debilitation.debilitation.


presents with intense vulvar pruritus; a white curdlike, presents with intense vulvar pruritus; a white curdlike, cheesy vaginal discharge; and vulvar erythema. A cheesy vaginal discharge; and vulvar erythema. A burning sensation burning sensation

Diagnosis is based on demonstration of candidal mycelia Diagnosis is based on demonstration of candidal mycelia and a normal vaginal pH 4.5.and a normal vaginal pH 4.5.

Identification of Identification of C albicansC albicans requires finding filamentous requires finding filamentous forms (pseudohyphae) of the organism when vaginal forms (pseudohyphae) of the organism when vaginal secretions are mixed with 10% KOH solution. secretions are mixed with 10% KOH solution.

The gold standard for its diagnosis is a vaginal culture.The gold standard for its diagnosis is a vaginal culture.


Chemicals and dyesChemicals and dyes 1% Gentian violet (once per week)1% Gentian violet (once per week) Boric acid Boric acid

Polyenes—Polyenes— Nystatin-have been largely replaced by imidazoles. Nystatin-have been largely replaced by imidazoles.

Imidazole Imidazole clotrimazole and oral agents such as ketoconazole clotrimazole and oral agents such as ketoconazole

(mostly used as topical agents and are effective (mostly used as topical agents and are effective against against C albicans.C albicans.

A single 150-mg oral dose of fluconazole A single 150-mg oral dose of fluconazole Inclusion of a topical steroid Inclusion of a topical steroid

Bacterial infectionsBacterial infections Gardnerella vaginalisGardnerella vaginalis Neisseria gonorrhoeae Neisseria gonorrhoeae ChlamydiaChlamydia Mycoplasma hominis Mycoplasma hominis Ureaplasma urealyticum.Ureaplasma urealyticum.

Bacterial VaginosisBacterial Vaginosis The most common cause of symptomatic bacterial The most common cause of symptomatic bacterial

infection in reproductive-age women. infection in reproductive-age women. In bacterial vaginosis the normal vaginal flora is altered. In bacterial vaginosis the normal vaginal flora is altered. The concentration of the hydrogen peroxide–producing The concentration of the hydrogen peroxide–producing

lactobacilli is decreased lactobacilli is decreased There is overgrowth of There is overgrowth of Gardnerella vaginalis, MobiluncusGardnerella vaginalis, Mobiluncus

spp., anaerobic gram-negative rods (spp., anaerobic gram-negative rods (PrevotellaPrevotella spp., spp., PorphyromonasPorphyromonas spp., spp., BacteroidesBacteroides spp.), and spp.), and PeptostreptococcusPeptostreptococcus spp spp

Bacterial VaginosisBacterial Vaginosis

Presents as a Presents as a "fishy" vaginal discharge"fishy" vaginal discharge, which is more , which is more noticeable following unprotected intercourse. noticeable following unprotected intercourse.

The patient complains of a malodorous, nonirritating The patient complains of a malodorous, nonirritating discharge, and examination reveals homogeneous, discharge, and examination reveals homogeneous, gray-gray-white secretionswhite secretions with a pH of 5.0–5.5. with a pH of 5.0–5.5.

A transient "fishy" odor can be released on application of A transient "fishy" odor can be released on application of 10% KOH10% KOH to the vaginal secretions on a glass slide. to the vaginal secretions on a glass slide.

A wet mount of the vaginal secretions using normal A wet mount of the vaginal secretions using normal saline under microscopy demonstrates the characteristic saline under microscopy demonstrates the characteristic clue cells, decreased lactobacilli, and few white blood clue cells, decreased lactobacilli, and few white blood cellscells. .


Gram stain reveals a large number of small gram-Gram stain reveals a large number of small gram-negative bacilli and a relative absence of lactobacilli.negative bacilli and a relative absence of lactobacilli.

Gram stain provides a more sensitive (93%) and specific Gram stain provides a more sensitive (93%) and specific (70%) diagnosis than does wet mount. (70%) diagnosis than does wet mount.

Treatment in nonpregnant women include Treatment in nonpregnant women include metronidazole 500 mg orally twice daily for 7 days, metronidazole 500 mg orally twice daily for 7 days,

metronidazole gel 0.75% (1 full applicator, 5 g) metronidazole gel 0.75% (1 full applicator, 5 g) intravaginally once or twice daily for 5 days, or intravaginally once or twice daily for 5 days, or

clindamycin cream 2% (1 full applicator, 5 g) clindamycin cream 2% (1 full applicator, 5 g) intravaginally at bedtime for 7 days. intravaginally at bedtime for 7 days.

Alternative regimens include metronidazole 2 g orally Alternative regimens include metronidazole 2 g orally in a single dose, clindamycin 300 mg orally twice daily in a single dose, clindamycin 300 mg orally twice daily for 7 days, or clindamycin ovules 100 g intravaginally for 7 days, or clindamycin ovules 100 g intravaginally once at bedtime for 3 days. once at bedtime for 3 days.


Pregnant women, the recommended treatmentPregnant women, the recommended treatment metronidazole 250 mg orally 3 times daily for 7 days.metronidazole 250 mg orally 3 times daily for 7 days. Alternatively, clindamycin 300 mg orally twice daily for Alternatively, clindamycin 300 mg orally twice daily for

7 days can be given. 7 days can be given. Possible management strategies for recurrent vaginosis Possible management strategies for recurrent vaginosis

includes use of condoms, longer treatment periods, includes use of condoms, longer treatment periods, prophylactic maintenance therapy, oral or vaginal prophylactic maintenance therapy, oral or vaginal application of yogurt containing lactobacillus acidophilus, application of yogurt containing lactobacillus acidophilus, intravaginal planting of other exogenous lactobacilli, and intravaginal planting of other exogenous lactobacilli, and hydrogen peroxide douches. hydrogen peroxide douches.

Neisseria GonorrhoeaeNeisseria Gonorrhoeae Up to 85% of women are asymptomatic Up to 85% of women are asymptomatic In acute disease, patients present with a copious In acute disease, patients present with a copious

mucopurulent dischargemucopurulent discharge, and Gram's stain reveals gram-, and Gram's stain reveals gram-negative diplococci within leukocytes. negative diplococci within leukocytes.

However, diagnosis should be confirmed with a culture However, diagnosis should be confirmed with a culture or with nucleic acid amplification. or with nucleic acid amplification.

The specimen is collected from the endocervix. The specimen is collected from the endocervix. Cultures may also be taken from the urethra, rectum, Cultures may also be taken from the urethra, rectum,

and mouth. and mouth.

Neisseria GonorrhoeaeNeisseria Gonorrhoeae

An estimated 15–20% of women with lower tract disease An estimated 15–20% of women with lower tract disease will develop upper tract disease presenting with will develop upper tract disease presenting with salpingitis, tubo-ovarian abscess, and peritonitis. salpingitis, tubo-ovarian abscess, and peritonitis.

Ectopic pregnancy and infertility may result. Ectopic pregnancy and infertility may result. If active infection is present during delivery, the newborn If active infection is present during delivery, the newborn

may develop conjunctivitis by contamination during may develop conjunctivitis by contamination during vaginal delivery vaginal delivery

Neisseria GonorrhoeaeNeisseria Gonorrhoeae

Treatment of uncomplicated gonococcal infections of the Treatment of uncomplicated gonococcal infections of the cervix consists of ceftriaxone 125 mg IM in a single cervix consists of ceftriaxone 125 mg IM in a single dose. Cefixime 400 mg orally in a single dose, dose. Cefixime 400 mg orally in a single dose, ciprofloxacin 500 mg orally in a single dose, ofloxacin ciprofloxacin 500 mg orally in a single dose, ofloxacin 400 mg orally in a single dose, or levofloxacin 250 mg 400 mg orally in a single dose, or levofloxacin 250 mg orally in a single dose are other recommended regimens. orally in a single dose are other recommended regimens.

Spectinomycin 2 g IM in a single dose can be given to Spectinomycin 2 g IM in a single dose can be given to patients sensitive to cephalosporins and quinolones.patients sensitive to cephalosporins and quinolones.

Treatment of Treatment of Chlamydia trachomatisChlamydia trachomatis infection should be infection should be considered considered

Chlamydia TrachomatisChlamydia Trachomatis present with a present with a mucopurulent cervicitismucopurulent cervicitis, dysuria, and/or , dysuria, and/or

postcoital bleeding postcoital bleeding can also cause an ascending infection, salpingitis, in 20–can also cause an ascending infection, salpingitis, in 20–

40% of untreated patients. More than 50% of upper tract 40% of untreated patients. More than 50% of upper tract infections may be caused by infections may be caused by C trachomatis,C trachomatis, leading to leading to tubal occlusion, ectopic pregnancy, or infertility. tubal occlusion, ectopic pregnancy, or infertility. C C trachomatistrachomatis also can cause neonatal conjunctivitis if also can cause neonatal conjunctivitis if untreated and atypical cytologic findings on untreated and atypical cytologic findings on Papanicolaou smear. Papanicolaou smear. C trachomatisC trachomatis may present as may present as lymphogranuloma venereum (LGV), which most lymphogranuloma venereum (LGV), which most commonly affects the vulvar tissues. Retroperitoneal commonly affects the vulvar tissues. Retroperitoneal lymphadenopathy may be present lymphadenopathy may be present

Chlamydia TrachomatisChlamydia Trachomatis

Can be identified by culture (50–90% sensitivity), a direct Can be identified by culture (50–90% sensitivity), a direct fluorescent antibody (50–80% sensitivity) and enzyme fluorescent antibody (50–80% sensitivity) and enzyme immunoassay (40–60% sensitivity), or most recently immunoassay (40–60% sensitivity), or most recently using nucleic acid amplification tests (polymerase chain using nucleic acid amplification tests (polymerase chain reaction or ligase chain reaction, 60–100% sensitivity) reaction or ligase chain reaction, 60–100% sensitivity)

Azithromycin 1 g orally in a single dose or doxycycline Azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily for 7 days. 100 mg orally twice daily for 7 days.

Erythromycin base 500 mg orally 4 times daily for 7 Erythromycin base 500 mg orally 4 times daily for 7 days, days,

Ofloxacin 300 mg orally twice daily, or Ofloxacin 300 mg orally twice daily, or Levofloxacin 50 mg once daily for 7 days are alternative Levofloxacin 50 mg once daily for 7 days are alternative

regimens. Doxycycline, levofloxacin, and ofloxacin regimens. Doxycycline, levofloxacin, and ofloxacin should be avoided in pregnancy and during lactation.should be avoided in pregnancy and during lactation.

M Hominis and U UrealyticumM Hominis and U Urealyticum May cause infertility, spontaneous abortion, postpartum May cause infertility, spontaneous abortion, postpartum

fever, nongonococcal urethritis in men, and possibly fever, nongonococcal urethritis in men, and possibly salpingitis and pelvic abscess. salpingitis and pelvic abscess.

The most effective treatment is doxycycline 100 mg The most effective treatment is doxycycline 100 mg orally twice daily for 10 days.orally twice daily for 10 days.

Trichomonas VaginitisTrichomonas Vaginitis Trichomonas vaginalisTrichomonas vaginalis is a unicellular flagellate is a unicellular flagellate

protozoan protozoan T vaginalisT vaginalis organisms are larger than polymorphonuclear organisms are larger than polymorphonuclear

leukocytes but smaller than mature epithelial cells. leukocytes but smaller than mature epithelial cells. T vaginalisT vaginalis infects the lower urinary tract in both women infects the lower urinary tract in both women

and menand men A persistent vaginal discharge is the principal symptom A persistent vaginal discharge is the principal symptom

with or without secondary vulvar pruritus.with or without secondary vulvar pruritus. The discharge is profuse, extremely frothy, greenish, and The discharge is profuse, extremely frothy, greenish, and

at times foul-smelling.at times foul-smelling.

Trichomonas VaginitisTrichomonas Vaginitis

The pH of the vagina usually exceeds 5.0. The pH of the vagina usually exceeds 5.0. The labia minora may become edematous and tender.The labia minora may become edematous and tender. Urinary symptoms may occur; however, burning with Urinary symptoms may occur; however, burning with

urination is most often associated with severe vulvitis.urination is most often associated with severe vulvitis. Examination of the vaginal epithelium and cervix shows Examination of the vaginal epithelium and cervix shows

generalized vaginal erythema with multiple small generalized vaginal erythema with multiple small petechiae, the so-called petechiae, the so-called strawberry spotsstrawberry spots, which may be , which may be confused with epithelial punctation.confused with epithelial punctation.


Wet mount with normal saline reveals an increase in Wet mount with normal saline reveals an increase in polymorphonuclear cells and characteristic motile polymorphonuclear cells and characteristic motile flagellates in 50–70% of culture-confirmed cases (Fig flagellates in 50–70% of culture-confirmed cases (Fig 37–3). 37–3).

Papanicolaou smears have a sensitivity of approximately Papanicolaou smears have a sensitivity of approximately 60% and may yield false-positive results. 60% and may yield false-positive results.

Culture is the gold standard, providing 95% sensitivity Culture is the gold standard, providing 95% sensitivity and 100% specificity. and 100% specificity.

DNA probes and monoclonal antibodies may assist with DNA probes and monoclonal antibodies may assist with accurate diagnosis.accurate diagnosis.


MetronidazoleMetronidazole is the only Food and Drug Administration is the only Food and Drug Administration (FDA)-approved treatment in the United States, with cure (FDA)-approved treatment in the United States, with cure rates of approximately 90–95%. A single-dose regimen rates of approximately 90–95%. A single-dose regimen of 2 g may assure compliance. of 2 g may assure compliance.

Other regimens include a 500-mg tablet orally twice daily Other regimens include a 500-mg tablet orally twice daily for 7 days. for 7 days.

In resistant cases, which most likely are related to In resistant cases, which most likely are related to reinfection, oral metronidazole can be repeated after 4–6 reinfection, oral metronidazole can be repeated after 4–6 weeks if the presence of trichomonads has been weeks if the presence of trichomonads has been confirmed and the white blood cell count and differential confirmed and the white blood cell count and differential are normal. are normal.

Viral InfectionsViral Infections The viruses that affect the vulva and vagina are The viruses that affect the vulva and vagina are

Herpesvirus (herpes simplex, varicella-zoster, and Herpesvirus (herpes simplex, varicella-zoster, and cytomegalovirus) cytomegalovirus)

Poxvirus (molluscum contagiosum) and Poxvirus (molluscum contagiosum) and Papovavirus typesPapovavirus types

HerpesvirusHerpesvirus Infection occurs through direct contact with secretions or Infection occurs through direct contact with secretions or

mucosal surfaces contaminated with the virus. mucosal surfaces contaminated with the virus. The virus enters the skin through cracks or other lesions The virus enters the skin through cracks or other lesions

but can enter through an intact mucosa. but can enter through an intact mucosa. The virus initially replicates in the dermis and epidermis.The virus initially replicates in the dermis and epidermis. Incubation time is 2–7 days. Incubation time is 2–7 days. Prodromal symptoms of tingling, burning, or itching may Prodromal symptoms of tingling, burning, or itching may

occur shortly before vesicular eruptions appear. occur shortly before vesicular eruptions appear. The vesicles erode rapidly, resulting in painful ulcers The vesicles erode rapidly, resulting in painful ulcers

distributed in small patches, or they may involve most of distributed in small patches, or they may involve most of the vulvar surfacesthe vulvar surfaces

HerpesvirusHerpesvirus

Bilateral inguinal adenopathy may be present. Bilateral inguinal adenopathy may be present. Dysuria or other urinary symptoms may develop, Dysuria or other urinary symptoms may develop,

including urinary retention. including urinary retention. Approximately one-third of patients demonstrate Approximately one-third of patients demonstrate

systemic manifestations such as fever, malaise, systemic manifestations such as fever, malaise, headaches, and myalgia. headaches, and myalgia.

In other cases the primary infection is asymptomatic.In other cases the primary infection is asymptomatic. Lesions may persist for 2–6 weeks with no subsequent Lesions may persist for 2–6 weeks with no subsequent

scarringscarring


Approximately 85% of patients develop immunoglobulin Approximately 85% of patients develop immunoglobulin (Ig)M antibodies to type II virus within 21 days of (Ig)M antibodies to type II virus within 21 days of exposure. exposure.

Serologic tests are best used to determine whether the Serologic tests are best used to determine whether the patient has been infected in the past. patient has been infected in the past.

A 4-fold or higher increase in neutralizing complement A 4-fold or higher increase in neutralizing complement fixation antibody titers between acute and convalescent fixation antibody titers between acute and convalescent sera may be useful to document a primary infection. sera may be useful to document a primary infection.

Only 5% of patients with recurrent infection demonstrate Only 5% of patients with recurrent infection demonstrate a 4-fold or higher rise in antibody titer. a 4-fold or higher rise in antibody titer.

New type-specific serologic tests for herpes simplex New type-specific serologic tests for herpes simplex virus are available. virus are available.


The incidence of neonatal simplex virus infection ranges from 1 in 5000 to 1 in 20,000 live births.

Infection in the newborn is associated with a 60% mortality rate, and at least half of the survivors have significant neurologic and/or ocular sequelae.

The risk of infection to an infant born vaginally in a mother with active primary genital infection is 40–50%; for recurrent infection the risk is 5%.

Suppressive antiviral therapy may be initiated at 36 weeks to decrease the need for cesarean section

Human PapillomavirusHuman Papillomavirus is responsible for is responsible for condyloma acuminatacondyloma acuminata of the vagina, of the vagina,

cervix, vulva, perineum, and perianal areas as well as for cervix, vulva, perineum, and perianal areas as well as for dysplasia and cancer. dysplasia and cancer.

Condylomatous vaginitis causes a rough vaginal surface, Condylomatous vaginitis causes a rough vaginal surface, demonstrating white projections from the pink vaginal demonstrating white projections from the pink vaginal mucosa. mucosa.

Vaginal discharge and pruritus are the most common Vaginal discharge and pruritus are the most common symptom with florid condylomas. symptom with florid condylomas.

Postcoital bleeding may occur. Postcoital bleeding may occur. No specific symptoms are related to the other types of No specific symptoms are related to the other types of

condylomas. condylomas.

Human PapillomavirusHuman Papillomavirus

TreatmentTreatment Bichloroacetic acid (BCA) or trichloroacetic acid (TCA), Bichloroacetic acid (BCA) or trichloroacetic acid (TCA),

50–80% solution, 50–80% solution, Xylocaine 1% gel can be applied Xylocaine 1% gel can be applied around the wart to prevent damage to adjacent skin. around the wart to prevent damage to adjacent skin. Repeat weekly as necessary.Repeat weekly as necessary.

Podophyllin 10–25% in tincture of benzoin Podophyllin 10–25% in tincture of benzoin Cryosurgery, Cryosurgery, electrosurgery, electrosurgery, simple surgical excision, simple surgical excision, laser vaporizationlaser vaporization Podofilox 0.5% solution or gel Podofilox 0.5% solution or gel Imiquimod 5% cream (topically active immune enhancer Imiquimod 5% cream (topically active immune enhancer

that stimulates production of interferon and other that stimulates production of interferon and other cytokines)cytokines)

Atrophic VaginitisAtrophic Vaginitis Prepubertal, lactating, and postmenopausal women lack Prepubertal, lactating, and postmenopausal women lack

the vaginal effects of estrogen production. the vaginal effects of estrogen production. The pH of the vagina is abnormally high, and the The pH of the vagina is abnormally high, and the

normally acidogenic flora of the vagina may be replaced normally acidogenic flora of the vagina may be replaced by mixed flora. by mixed flora.

The vaginal epithelium is thinned and more susceptible The vaginal epithelium is thinned and more susceptible to infection and trauma. to infection and trauma.

Although most patients are asymptomatic, many Although most patients are asymptomatic, many postmenopausal women report vaginal dryness, postmenopausal women report vaginal dryness, spotting, presence of a serosanguineous or watery spotting, presence of a serosanguineous or watery discharge, and/or dyspareunia. discharge, and/or dyspareunia.

Atrophic VaginitisAtrophic Vaginitis

Treatment includes intravaginal application of estrogen Treatment includes intravaginal application of estrogen cream. Approximately one-third of the vaginal estrogen cream. Approximately one-third of the vaginal estrogen is systemically absorbed; therefore, this treatment may is systemically absorbed; therefore, this treatment may be contraindicated in women with a history of breast or be contraindicated in women with a history of breast or endometrial cancer. endometrial cancer.

The estradiol vaginal ring, which is changed every 90 The estradiol vaginal ring, which is changed every 90 days, may provide a more preferable route of days, may provide a more preferable route of administration for some women, or administration for some women, or

Estradiol hemihydrate (Vagifem) 1 tablet intravaginally Estradiol hemihydrate (Vagifem) 1 tablet intravaginally daily for 2 weeks and then 2 times per week for at least daily for 2 weeks and then 2 times per week for at least 3–6 months may be less messy. 3–6 months may be less messy.

Systemic estrogen therapy should be considered if there Systemic estrogen therapy should be considered if there are no contraindications.are no contraindications.

Foreign BodiesForeign Bodies Treatment involves removal of the foreign body. Treatment involves removal of the foreign body. Rarely, antibiotics are required for ulcerations or cellulitis Rarely, antibiotics are required for ulcerations or cellulitis

of the vulva or vagina. of the vulva or vagina. Dryness or ulceration of the vagina secondary to use of Dryness or ulceration of the vagina secondary to use of

menstrual tampons is transient and heals spontaneously.menstrual tampons is transient and heals spontaneously.

Desquamative Inflammatory VaginitisDesquamative Inflammatory Vaginitis The cause is unknown. The cause is unknown. Patients complain of a profuse purulent vaginal Patients complain of a profuse purulent vaginal

discharge, vaginal burning or irritation, dyspareunia, and discharge, vaginal burning or irritation, dyspareunia, and occasional spotting. occasional spotting.

The process is patchy and usually localized to the upper The process is patchy and usually localized to the upper half of the vagina. half of the vagina.

The purulent discharge contains many immature The purulent discharge contains many immature epithelial and pus cells without any identifiable cause.epithelial and pus cells without any identifiable cause.

Vaginal erythema is present and synechiae may develop Vaginal erythema is present and synechiae may develop in the upper vagina, causing partial occlusionin the upper vagina, causing partial occlusion

Desquamative Inflammatory VaginitisDesquamative Inflammatory Vaginitis

Treatment often is unsatisfactory but has included local Treatment often is unsatisfactory but has included local application of estrogen, antibiotics (particularly application of estrogen, antibiotics (particularly clindamycin cream 2% 5 g intravaginally daily for 7 clindamycin cream 2% 5 g intravaginally daily for 7 days), and corticosteroids. days), and corticosteroids.

Noninfectious VaginitisNoninfectious Vaginitis Chemical vaginitisChemical vaginitis secondary to multiple irritating secondary to multiple irritating

offenders, including topical irritants (sanitary supplies, offenders, including topical irritants (sanitary supplies, spermicides, feminine hygiene supplies, soaps, spermicides, feminine hygiene supplies, soaps, perfumes), allergens (latex, antimycotic creams), and perfumes), allergens (latex, antimycotic creams), and possibly excessive sexual activity can cause pruritus, possibly excessive sexual activity can cause pruritus, irritation, burning, and vaginal discharge. irritation, burning, and vaginal discharge.

The etiology may be confused with vulvovaginal The etiology may be confused with vulvovaginal candidiasis. candidiasis.

The offending agent should be removed for treatment. The offending agent should be removed for treatment. A short course of A short course of corticosteroid treatmentcorticosteroid treatment may be used may be used

along with sodium bicarbonate along with sodium bicarbonate sitz bathssitz baths and and topical topical vegetable oils.vegetable oils.

Cervical Mucorrhea or Vaginal Epithelial Cervical Mucorrhea or Vaginal Epithelial DischargeDischarge

CervicitisCervicitis due to cervical polyps or cervical or vaginal due to cervical polyps or cervical or vaginal cancer can cause a mucopurulent discharge and cancer can cause a mucopurulent discharge and bleeding. bleeding.

Excessive Excessive cervical ectropioncervical ectropion may cause excessive may cause excessive discharge of cervical mucus from normal endocervical discharge of cervical mucus from normal endocervical cells. cells.

Vaginal adenosisVaginal adenosis (the presence of the metaplastic (the presence of the metaplastic cervical or endometrial epithelium within the cervical or endometrial epithelium within the vaginalvaginal wall)wall) may cause the same type of clear, mucoid-type may cause the same type of clear, mucoid-type discharge with no associated symptoms.discharge with no associated symptoms.

Excessive desquamation of the vaginal epitheliumExcessive desquamation of the vaginal epithelium may may produce a diffuse gray-white pasty vaginal discharge, produce a diffuse gray-white pasty vaginal discharge, which may be confused with candidiasis which may be confused with candidiasis

Cervical Mucorrhea or Vaginal Epithelial Cervical Mucorrhea or Vaginal Epithelial DischargeDischarge

Vaginal pH is normal. Vaginal pH is normal. Microscopic evaluation shows normal bacterial flora, Microscopic evaluation shows normal bacterial flora,

mature vaginal squamae, and no increase in the number mature vaginal squamae, and no increase in the number of leukocytes. of leukocytes.

Excessive but normal vaginal discharge should be Excessive but normal vaginal discharge should be treated with reassurance and, if required at times, with treated with reassurance and, if required at times, with cryosurgery or carbon dioxide treatment of the cervix.cryosurgery or carbon dioxide treatment of the cervix.

Continuous use of a tampon should be avoided. Continuous use of a tampon should be avoided.

Parasitic InfectionParasitic Infection Pinworms (Pinworms (Enterobius vermicularisEnterobius vermicularis) and ) and Entamoeba Entamoeba

histolyticahistolytica Trophozoites of Trophozoites of E histolyticaE histolytica may be demonstrated on may be demonstrated on

wet-mount preparations or occasionally on a wet-mount preparations or occasionally on a Papanicolaou smear. Papanicolaou smear.

The parasite is generally detected by pressing a strip of The parasite is generally detected by pressing a strip of adhesive cellulose tape to the perineum. adhesive cellulose tape to the perineum.

The tape is then adhered to a slide, allowing the double-The tape is then adhered to a slide, allowing the double-walled ova to be identified under the microscope. walled ova to be identified under the microscope.

BENIGN DISORDERS OF THE VULVA Rukset Attar, MD, PhD Department of Obstetrics and Gynecology.

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Transcript of BENIGN DISORDERS OF THE VULVA Rukset Attar, MD, PhD Department of Obstetrics and Gynecology.