Vulvar Lesions

Vulvar Lesions
Presentation by:Anna Mae Smith, MPAS, PA-C
Lock Haven University

Anatomy
* Mons pubis
* labia majora and minora
* clitoris
* vestibule
* urethral meatus
* It covers and protects the entrance to the vagina, vestibule, and urethra.

Vulvar Hygiene
* use mild, nondrying soap
* washing underwear with mild soap and rinsing well
* 100% cotton underwear
* avoid extra layers and tight slacks (unneeded medicines, tinted toilet tissue, all "feminine hygiene" products), excessive sweating without aeration, and public pools and hot tubs
* It is important to be keenly conscious of what "aggravates" the skin.
* A dermatologic cliche is to "dry wet lesions" (soaks and compresses) and "moisturize dry lesions" (creams and ointments).

Vulvar Cancer
* 4th most common site of gynecologic neoplasia
* Squamous neoplasia most common type of neplasia
* HPV (16,18) infections are most commonly associated with squamous cell changes of the vulva, vagina & cervix. However the vulva tends to be more resistant to oncogenesis

Histopathology of Vulvar Neoplasia
* Squamous
* Malignant melanoma
* Sarcoma
* Basal Cell
* Adenocarcinoma
* Paget’s Disease
* Undifferentiated


Classification of VIN
* VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia
* VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia
* VIN III - Severe dysplasia, carcinoma in situ, Bowen’s Dz; hyperplastic vulvar dystrophy with severe stypia


Spread of vulvar Ca
* Local growth with extension to the perineum, anus, urethra, vagina & pelvic bone
* Lymphatics - inguinal & femoral nodes to the external iliac, common iliac, & para-aortic chains

Paget’s Disease
* presents with extreme pruritus and soreness, usually of long duration
* red or bright pink, desquamated, exzematoid areas among scattered, raised, white patches of hyperkeratosis
* borders are well demarcated and raised

Basal Cell Carcinoma
* very rare
* associated with a long history of pruritus
* occurs over the anterior two-thirds of the labia majora, with slightly elevated margins
* appears as condyloma
* does not respond to treatment for HPV

Invasive Squamous Cell Carcinoma
* occurs when a woman is in her 60s and 70s
* presents with ulceration, friability, or induration of surrounding tissues

Sarcoma
* occurs in women of all ages
* rapidly expanding, painful mass

Diethylstilbestrol (DES) Exposure
* used extensively in US during the 1940s and early 1950s to prevent miscarriage and premature births
* studies during the late 1950s proved its ineffectiveness
* DES use continued through 1971
* estimated 2 million women were exposed in utero

DES Exposure Sequelae
* structural changes
* vaginal adenosis shows columnar epithelium on or beneath the vaginal mucosa; it is self-limiting and gradually disappears
* clear-cell adenocarcinoma of the cervix or vagina may develop (incidence rises at age 15, and median age at diagnosis is 19 years
* increased incidences of:

Lesions
* Often present with prurutis
* Elevated above the skin
* Gray, white , red or pigmented
* May also look verrucous
* INVASIVE- all the above plus ulcerated & bleeding

Treatments
* Local - laser
* Invasive - total vulvectomy & nodes

Vulvar Lesions
* RED - neoplasm, inflammation, or atrophy
* Inflammation-
o Fungi - most common cause of red, nonulcerative, infectious lesion of the vulva
o Folliculitis - secondary to Staph. Aureus may cause painful, itchy vulva
Vulvar Lesions/ RED
* Noninfectious
* Vestibular adenitis
* Psoriasis
* Seborrheic Dermatitis

White Lesions/ Leukoplakia
* Hyperkeratosis
* Depigmentation
* Absolute or relative avascularity

Vulvar Dystrophy
* Benign epithelial disorders
* Lichen Sclerosis 70%, vulvar hyperplasia accounts for the rest
* Biopsy is mandatory of any white lesion!!!
* VIN - neoplastic, premalignant lesion

Depigmented disorders
* Vitiligo - inherited, autosomal dominant
* Often progressive & often associated with increased incidence of
o Addison’s disease
o Thyroiditis
o DM
o Lymphoma
o Pernicious anemia

Intertrigo
* Nonspecific hyperkeratotic epithelial reaction to inflammation in the skin folds

DARK Lesions
* Usually secondary to increase in melanocytes or melanin production
* Must biopsy any dark lesion of the vulva!
* Lentigo - most common - freckle - no malignant potential
* Nevi - moles. Localized collections of neural crest cells which are usually present from birth
* Asymptomatic and rarely become malignant
* 30% of all malignant melanomas develop from nevi
* Neoplasms
* Reactive Hyperpigmentation
* Seborrheic keratosis

Ulcerative Lesions
* VIRAL - HSV - 48 hrs to 7 days after initial contact
* Bacterial - Syphillis, Granuloma inguinal, pyoderma, cutaneous TB
* Inflammatory/noninfectious

Tumors < 1cm
* Inflammation - condyloma acuminata(HPV) Molluscum contagiosum
* Cysts- epidermal inclusion, vestibular gland, mesonephric duct
* Neoplasia - VIN, hemangioma, hidradenoma, neurofibroma, syringoma
* Other - Accessory breast tissue, acrocordon, endometriosis, Fox-Fordyce Dz., Pilonidal sinus
Tumors > 1 cm

* Inflammatory - Bartholin’s cyst/abscess, lymphogranuloma venereum
* Neoplasm - fibroma, lipoma, verrucous carcinoma, sq. cell carcinoma
* Hernia, Edema
* Hematoma
* Other - skin tag, epidermal cysts, neurofibromatosis, accessory breast tissue

Vulvar Dysplasia.ppt