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

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VULVODYNIA

VULVODYNIA
Clinical Aspects and Research Initiative
Presentation by:Gloria A. Bachmann, M.D. and Nidhi Gupta, M.D.
Women’s Health Institute, UMDNJ-Robert Wood Johnson Medical School


Defining Vulvodynia
The International Society for Study of Vulvovaginal Diseases (ISSVD) defines vulvodynia as ‘chronic vulvar discomfort, characterized by the woman’s complaint of burning, stinging, irritation or rawness’

Types of Vulvar Pain
* PAIN from an IDENTIFIABLE ETIOLOGY
* VULVODYNIA

Pain from an Identifiable Etiology
* Infections such as chronic vulvovaginitis caused by Candida or other pathogens
* Dermatoses and Dermatitis that involve the vulva such as Lichen Sclerosus, Lichen Planus, irritants and allergic dermatitis
* Vaginismus

Vulvodynia: Vulvar Vestibulitis Subtype
* Friedrich’s criteria diagnostic:
* 1. Severe pain on vestibular touch or attempted vaginal entry.
* 2. Tenderness to pressure localized within the vulvar vestibule
* 3. Physical findings confined to vestibular erythema of various degrees
* Pain is provoked and localized
* Commonly seen in women aged 50 years or less

Dysesthetic Vulvodynia Subtype
* Pain is constant and may be felt beyond the confines of vulvar vestibule
* Usually pain is unprovoked
* Diagnosed mainly in women who are peri- or postmenopausal

Vulvodynia: Prevalence Statistics
* Harvard-based study (n=16,000) estimates a 16% life time prevalence*
* UMDNJ-based study estimates:

Vulvodynia: Demographics
* Older data suggest the highest prevalence in white women
* Accounts for 10 million doctor visits/year
* Upwards of 14 million women are affected in their lifetime
* Recent data suggest Hispanic women 80% more likely to have vulvar pain than other racial groups

Etiology: Vulvar Vestibulitis Subtype
* Prior vulvovaginal Candidiasis
* Hypersensitivity to chemicals
* Human Papilloma virus infection
* High levels of urinary oxalates
* Neurological dysfunction

Candida Etiology: Vulvar Vestibulitis Subtype
* In 1989 Ashman and Ott proposed cross reaction between Candida albicans antigens and self-antigen in vulvovaginal tissue
* Affected tissue has locally elevated concentrations of inflammatory cells and pro-inflammatory cytokines
* These suggest a hyper-immune response, possibly from persistent antigen from the Candida

Proposed Etiologies: Vulvar Vestibulitis Subtype
* Calcium oxalate crystals in urine may act as irritant to the vulva
* Reduced estrogen receptor expression causing alteration in vulvar sensation*
* CNS etiology, similar to other regional pain syndromes

Proposed Inflammatory Etiology: Vulvar Vestibulitis Subtype
* An inflammatory event releases cytokines that sensitize nociceptors in the nerve fibers of the vulva*
* Increased intraepithelial nerve endings in vestibulitis patients have been reported. Prolonged neuronal firing sensitizes neurons in dorsal horn of spinal cord, with subsequent abnormal interpretation as pain from touch**

Etiology: Dysesthetic Vulvodynia Subtype
* Etiology not definitively known
* Childhood trauma and OCP’s possible contributors
* Sympathetic pain loops caused by repeated irritation/trauma leads to continuous vulvar symptoms*

Vulvodynia: Assessment of the Patient
* OB/GYN history
* Detailed pelvic exam to exclude pathology
* Vaginal culture (in selected cases)
* Pap smear

Vulvodynia: Assessment of the Patient

* Vaginal pH
* Urinanalysis for oxalate content (select cases)
* Biopsy of abnormal vulvar areas
* Psychosocial assessment

Vulvodynia: Assessment of Pain Intensity
Clinician Assessment:
* Q–tip test
* Vulvalagesiometer- A device developed at McGill University for nominal scale vulvar pain measurement*
* Vulvar Algesiometer- Developed by Curnow to quantify pain by nominal scale**

Vulvodynia: Assessment of Pain Intensity
Patient Assessment:
* McGill-Melzack Pain Questionnaire- 78 pain words grouped in 20 subclasses of 3-5 descriptive words*
* Subclasses are grouped in four sections, sensory, affective, evaluative and miscellaneous.
* Provides information on timeline, location and a quantitative measure of clinical pain.

Vulvodynia: Differential Diagnosis
Exclude other pain causes:

o Vaginitis, Candida, urethritis, interstitial cystitis, Herpes, Bartholin adenitis
o Vulvar Dermatoses and Dermatitis such as eczema
o Vaginismus, entry and deep dyspareunia
o Atrophic Vulvo-Vaginitis

Vulvodynia: Diagnosis
“Diagnosis made after thorough evaluation fails to identify pain etiology”

Vulvodynia: Management
Vulvar Vestibulitis Subtype:
* Non-Pharmacologic
* Pharmacologic
* Surgical

Dysesthetic Vulvodynia Subtype:
* Non-Pharmacologic- Not recommended
* Pharmacologic
* Surgical- Not recommended

NonPharmacologic Management: Vulvar Vestibulitis Subtype
* Patient education and counseling
* Physical therapy and biofeedback
* Life-style modification
* Application of ice and local anesthetics to the vulvar region as needed

NonPharmacologic Management: Vulvar Vestibulitis Subtype
Low Oxalate Diet
* Oxalate is a metabolic breakdown product from certain food types
* Oxalates excreted in urine as crystals
* Vulvar surface contact with oxalate crystals causes irritation and burning
* Low oxalate diet (with calcium citrate supplementation) may be beneficial

NonPharmacologic Management: Vulvar Vestibulitis Subtype
Calcium Citrate and the Low Oxalate Diet
* Surface electromyographic biofeedback data suggest persistent vulvar injury leads to chronic reflex pain, resulting in increased muscle tension*
* Pelvic floor muscle instability may be present
* If pelvic floor abnormalities present, physical therapy often beneficial

Biofeedback: Vulvar Vestibulitis Subtype
Physical Therapy: Vulvar Vestibulitis Subtype
* Physical therapy reduces muscle tension and spasm, decreasing pain levels by 40-60% *
* Physical therapist can retrain dysfunctional pelvic floor muscles

Physical Therapy: Vulvar Vestibulitis Subtype
Physical therapy components:
* Pelvic floor exercise
* Myofascial release
* Trigger point pressure
* Massage
Medical Management: Vulvar Vestibulitis Subtype
* Topical estrogens:
* Topical estrogen creams useful for women with thin vaginal epithelium and/or lose of vulvar adipose tissue
* Can be used with other pharmacologic agents
* Tricyclic antidepressants (Amitriptyline-10mg hs: dose up to 150mg daily)
* Fluconazole
* Gabapentin (anticonvulsant), Venlafaxine-efficacy not proven
* Selective serotonin receptor inhibitors (SSRIs)-efficacy not proven
* Corticosteroids: (topical and injections)
* Topical anesthetics (nitroglycerin & lidocaine)
* Alpha Interferon injections
* Capsaicin cream (immune response modifier)
* Excision of affected vulvar area to remove neural hyperplasia
* Surgery reserved for non- responders to conservative treatments
* Data suggest a success rate varying from 40-100%
* Long term data lacking
* Types: focal excision, vestibuloplasty, vestibulectomy and perineoplasty
* Vestibulectomy excises a U shaped area of the vestibule from 5mm lateral to the urethra and the posterior fourchette
* Perineoplasty excises the vestibule from below and lateral the urethral meatus to the anal canal with the vaginal mucosa undermined 1-2cm.

Pharmacologic Management: Dysesthetic Vulvodynia Subtype
* Amitriptyline: first line therapy
* Other tricyclic antidepressants- desipramine and imipramine-may be effective *
* Selective serotonin reuptake inhibitors efficacy not proven

Vulvodynia.ppt

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Pathology and Neoplasia

Pathology and Neoplasia

1. Describe the pathogenesis and epidemiology of the common nonmalignant neoplasms that affect the external and internal genitalia.
2. Describe the role of oncogenes in the pathogenesis of premalignant lesions of the external and internal genitalia.


Lesions of the Vulva
* Dermatological conditions
* VIN
* Condyloma acuminatum

Condyloma
* Nevus
* Psoriasis
* Seborrheic Dermatosis
* Hidradenitis Suppurativa
* Lichen planus
* Lichen Sclerosis
* Lichen Simplex Chronicus
* Urethral Diverticulum or Caruncle
* Cysts
* Trauma
* Vaginal intraepithelial neoplasia (VAIN)
* Condyloma
* Urethral Diverticulum
* Urethral Caruncle
* Dysontogenetic cysts
* VAIN

Lesions of the Cervix
* Polyps
* Nabothian Cysts-mucous retention cysts, translucent/opaque, caused by normal healing process or cervix
* Fibroids
* Cervical intraepithelial neoplasia (CIN)
* Condyloma
* CIN
* Polyps
* Fibroids

Lesions of the Uterus
* Intravenous leiomyomatosis
* Leiomyomatosis peritonealis disseminata
* Fibroids
* Adenomatoid Tumors
* Paratubal Cysts
* Functional cysts
* Theca lutein cysts
* Tumors
* Fibroma
* Dermoid (Mature Teratoma)
* Brenner’s Tumor (transitional cell tumor)

References
* Comprehensive Gynecology/ Morton A. Stenchever…et al. 4th edition. 2001.
* Precis: an update in obstetrics and gynecology. Gynecology 2nd edition. Oncology 2nd edition.
* Obstetrics and gynecology: principles for practice. Ling, Duff. 2000.
* Urogynecology and reconstructive pelvic surgery. Walters, Karram. 2nd edition. 1999.

Pathology and Neoplasia.ppt

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