Urethral prolapse (Figure 9.1) may cause dysuria, but often is asymptomatic. Treatment: topical estrogen cream, hot sitz baths, and antibiotics may reduce inflammation and infection; surgical excision is rarely needed.
Urethral diverticulum is a sac or a pouch that connects with the urethra and may cause dysuria, dribbling incontinence urgency, or hematuria. Treatment: excision with layered closure or marsupialization.
Skenes. Duct, cyst, or abscess is an obstruction of the periurethral glands. Treatment: abscess requires incision and drainage.
Vulvar cysts and benign tumors
Bartholin cysts result from occlusion of the excretory duct. Treatment: most will resolve spontaneously with local care, but marsupialization is performed for large or recurrent lesions and abscess requires incision and drainage and often placement of a Word catheter.
Hernias (hydroceles, cysts) of the canal of Nuck are abnormal dilations of the peritoneum that accompany the round ligament through the inguinal canal and into the labia majora. Treatment: excision of the hernia sac.
Epidermal inclusion cysts are formed when a focus of epithelium is buried beneath the skin surface and becomes encysted. Treatment: expectant management or excision if symptomatic.
Non-neoplastic epithelial disorders
Candida vulvitis is a symmetric bright red rash, causes itching and burning. Treatment: topical imidazole, oral fluconazole.
Lichen sclerosus (Figure 9.1) is an atrophic change or thinning of the epidermis (onion skin, parchment like), more common in postmenopausal women. The main symptom, if any, is pruritus. Diagnosis can often be made by inspection alone, but biopsy is confirmatory. One percent annual risk of vulvar cancer. Treatment: topical testosterone or high-potency corticosteroids (clobetasol).
Squamous cell hyperplasia is a diagnosis of exclusion that represents a thickening of the epidermis and lichenification, and is a chronic scratch–itch cycle reaction to fungus or other vulvitis, allergens, or unknown stimuli. Pruritus and excoriations are often evident. Pathologic findings are non-specific. Treatment: management of the inciting cause and/or topical corticosteroids.
Lichen planus
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