Disorders Of The Vulva

Disorders of the vulva Vulva is covered in keratinising squamous epithelium Vaginal mucosa is non keratising Presentation Usually pruritis, soreness or noticing of masses/colour change/ulceration/raised areas by self or partner O/E Check nail beds for pitting & extensor surfaces (psoriasis) Check flexor surfaces for dermatitis & lichen planus (+ mouth) Examine vulva under good light +/- colposcopy Simple compaints Urethral Caruncle Polyploidal outgrowth from edge of urethra most commonly seen post menopause Tissue is soft, red, smooth & is eversion of urethral mucosa Can be asymptomatic or cause dysuria, frequency, urgency and focal tenderness Is suspicious then excision will exclude urethtral carcinoma (very rare) Bartholin’s Cysts In greater vesitbular (Bartholin’s glands) in sub-cut tissue in lower 1/3 of labia majorum Open via ducts to the vestibule between hymenal orifice & labia minora Secrete mucus, esp at intercourse Blocked duct à retention cyst – can be incised & drained under GA with repair by marsupialization Small cysts Usually inclusion (epithelium trapped in epidermis) or sebaceous (multiple, mobile, non tender, white/yellow filled with creamy substance) Cysts in episiotomy scar can be tender & need excision Infected cysts need excision & drainage Moles Usually asymptomatic. 10% of malignant melanomas in women are on vulva Any change (other than darkening at puberty) is therefore cause for removal Fibroma & Lipoma – benign, mobile tumours of fibrous tissue & fat Hydradenoma – rare tumour of swear gland near surface. Haematoma Most commonly following vaginal delivery (also operations, blunt trauma). Usually severe pain & require evacuation under GA Simple Atrophy Vaginal, vulval & clitoral atrophy are common with ageing Thinning of skin can à dysuria & superficial dyspareunia Introital stenosis can make intercourse impossible (helped by moisturiser / topical oestrogen) Ulcers Apthous – yellow base Herpetic – exquisitely painful multiple ulcers Syphilitic – indurated & painless Crohns – like knife cuts in skin Behcets – a chronic painful syndrome with apthous genital ulcers & ocular ulceration Tropical – lymphogranuloma venereum, chancroid, granuloma inguinale Lichen Planus / Stevens-Johnson syndrome Lichen sclerosis Chronic, recurrent condition, can present at any age (more common in older age) Autoimmune condition (common with others eg thyroid, DM, pernicious anaemia, SLE etc) Is non-neoplastic but can co-exist with VIN & some links with vulval squamous Ca (follow-up 6-12 monthly) Presentation – mainly itching, also dyspareunia/pain Histology - Dermis is thin with loss of rete ridges. Hyalinized layer with layer of inflammatory cells beneath) O/E – skin appears white, thin & crinkly (can be thickened if also hyperplasia). Clitoral or labial adhesions cause narrowing of introitus Treatment – initial with Dermovate (potent steroid cream) then hydrocortisone as symptoms lessen Squamous cell hyperplasia Thickened hyperkeratotic skin with white itchy plaques (severe pruritis). Diagnosis by biopsy and treatment as for lichen sclerosis Allergic/irritant dermatosis Can be irritant (non immunological) or allergy (immunological). Red inflamed vulva with features of eczema Temporary relief with vulval moisturisers (emulsiderm), emollients (topical aq cream) & topical corticosteroids (1 month of dermovate). If no response à biopsy to confirm diagnosis Psoriasis Red dry popular rash which extends to thigh. Bleeds when “silvery scales” are removed Often moist so exlude candida Treatment with topical coal tar preparations, UV light or steroid creams Intertrigo with Candida Moist inflammatory dermatitis occurring in any body fold (due to rubbing) Increased incidence in overweight & occlusive clothing Skin is sore, macerated, red, inflamed & cracked Encourage weight loss, hygiene, ventilation, stockings & cotton (rather than nylon & tights), talc, zinc astringents or barrier preparations may be helpful. If candida should be treated. If no candida steroid creams may help with inflammation Lichen Planus Chronic popular rash with dark blue hue involving vulva & flexor surfaces (can affect oral mucosa) Usually idiopathic but can be drug related Treat with topical steroids or UV light & should resolve in 2 yrs. AVOID surgery Pruritus Intense itching with desire to scratch Topical steroids will reduce inflammation & lessen itching Avoid soaps etc, dry area with hairdryer Vulvodynia Discomfort – burning, stinging, irritation, rawness May be some response to low-dose tricyclics Vulval Intraepithelial neoplasia (VIN) Squamous (Bowen’s disease / Bowenoid papulosis) Classified to grade I to III (similar to CIN) – HPV may be involved Many asymptomatic, some itching or pain. Some notice lesions – popular or rough surfaced (resemble warts) or macular with indistinct borders. White areas = hyperkeratosis, pigmentation common. Multifocal in < 40yrs, unifocal in post menopausal. Diagnosis by biopsy – check cervix @ same time Management – may regress but 5% risk of progression to higher grade & to vulval Ca. 10% VIN III go to carcinoma in lifetime of patient Treatment indicated in >45yrs, immunosuppressed, multifocal neoplasia & if invasion found on biopsy. . Options include imiquimod, laser therapy or surgical excision. Non-squamous (Pagets disease) Uncommon. Poorly demarcated, often multifocal eczematoid lesion assoc with adenoCa at distant site. Treatment by wide local excision Vulval Carcinoma 90% squamous cell carcinoma, 5% malignant melanomas, Remainder = bartholins, basal cell, sarcomas etc Usually in 60yrs+. Associated with smoking & immunocompromised Presentation – long standing vulval irritation / pruritus. Some will have history of lichen scleosis. Lump/ulcer common. Focal necrosis may cause pain Diagnosis – histology from biopsy Spread – usually if >1mm beyond BM à to inguinal nodes à external iliac nodes. Clitoral lesions can drain to internal iliac nodes Management – excision or vulvectomy. Check groin nodes & remove is suspicious. Wound should be drained for 7-10 days under suction. Pelvic node radiotherapy may be required. High risk of wound breakdown, infection & venous TED. Prognosis – recurrence unlikely if 10mm margin achieved but if epithelium is unstable can recur. Recurrence is managed surgically although radiotherapy may also help.