Fig. 16.1
Anatomical extent of vulva, showing hair-bearing skin on mons pubis, lateral parts of labia majora, and perianal area
16.1.2 Colposcopic Definition
16.1.3 Histological Variation and Its Basis
Due to the different embryological origins of various vulvar parts, the histology also varies. Vulva has an ectodermal origin with keratinized stratified squamous epithelium which lacks glycogen in the epidermis and mesodermal dermis (with its reticular and papillary layer). In contrast, vestibule has an endodermal origin and is covered by nonkeratinized squamous epithelium, which is relatively thinner with abundant mucus-secreting glands [4]. Mons pubis, outer parts of labia majora, and perianal area are covered with hair follicle-bearing skin. The skin in this part has rich sebaceous glands along with sweat glands.
16.1.4 Basis of Colposcopy of Vulva
Colposcopic features depend on the specific parts of the vulva. It is widely variable for different vulvar parts and varies even from person to person. This is the reason behind the different appearances of histologically similar lesions in different parts of the vulva. The features are based on the fact that epithelial thickness directly affects the skin thickness, and hence its opacity thus obscuring the clear view of the underlying vascularity [4]. Moreover any pigmentation on the vulvar skin can also mask the clear view. This is in contrast to the colposcopy of the cervix where specific vascular patterns are pronounced and form a reliable colposcopic finding.
While acetowhitening is the most frequent colposcopic appearance along with leukoplakia, the atypical vessel pattern can be seen in invasive carcinoma [5].
Punctation and mosaic patterns are less common on most of the vulvar region except the inner parts of labia minora where the layer of keratin is thinner and in the vestibular part where the keratin is absent [4].
16.1.5 Indications for Colposcopy of Vulva
-
Pruritus vulvae to rule out subclinical papilloma infection, intraepithelial lesion (VIN), or early malignant lesion
-
Vulvodynia
-
Condyloma of cervix and/or vagina
-
Cervical or vaginal intraepithelial lesions (CIN/VAIN)
-
To delineate a visible lesion (VIN, cancerous growth, or Paget’s disease).
16.1.6 Contraindications
-
The use of local medication just before the procedure
-
Acute vulvar infection or presence of vulvitis
Any visible growth of a nonhealing ulcer on vulva must be biopsied to rule out tuberculosis and malignancy even in young patients.
16.1.7 Colposcopic Appearance of Vulva
The following points are to be looked for during vulvoscopy: [6]
-
Color changes
-
Topography
-
Surface contour
-
Angioarchitecture
16.1.7.1 Color Changes
Lugol’s iodine application shows a clearly demarcated vulvovaginal line (Fig. 16.3) owing to glycogenated vaginal epithelium. Due to the nonglycogenated nature of the vulvar epithelium, there is no role of iodine application in vulvoscopy. 5% acetic acid application results in acetowhite response extending a few millimeters lateral from vulvovaginal line, but it never involves the fourchette. There has been no correlation between the degree of acetowhitening and primary histopathology. A special note should be made of generalized depigmentation (due to loss of melanin as in vitiligo) or localized whiteness (due to transient loss of pigment as in a scar of a healed ulcer) [6].
Fig. 16.3
Vulva after Lugol’s iodine application showing demarcated iodine-positive vaginal epithelium from nonglycogenated keratinized vulvar epithelium
White lesions may be seen in non-neoplastic epithelial disorder, HPV lesion, and in VIN. To differentiate, biopsy is a must.
Red lesion on vulva is due to increased vascularity and vasodilatation as in infections (candidiasis) and inflammation (dermatitis and eczema), thinning of epidermis (in postmenopausal age-group), and neovascularization seen in malignancy. Diffused redness is suggestive of benign pathology, while an isolated red lesion is invariably a feature of neoplasia.
Dark lesion is due to melanin, which is a result of increased melanin production in epidermal melanocytes which is then extruded toward the papillary dermis as a result of a mechanism known as “melanin incontinence” leading to an occasional pigmented appearance of the VIN lesion. Thus dark lesions are seen in VIN, hyperpigmentation, nevi, lentigo, and malignant melanoma.
16.1.7.2 Topography
Acetowhitening beyond normal limits or isolated acetowhite areas are abnormal findings. It can be unifocal, multifocal, or with a multisite involvement [6].
16.1.7.3 Surface Contour
The surface contour is mentioned in the context of the level of surrounding skin and can be differentiated into:
-
Raised above the skin surface – papule, pustule, proliferative, vesicular
-
At the level of the skin – acetowhitening, pigmentation, macula
-
Below the level of the skin – ulcer or erosion.
In reproductive age-group females, papillary and villiform features (also called micropapillomatosis) are present in contrast to those in postmenopausal and prepubertal age-groups. These micropapillomatosis may be mildly acetowhite. They may sporadically merge and can be misinterpreted as HPV infection.
According to the International Federation for Cervical Pathology and Colposcopy (IFCPC) colposcopic terminology of the vulva, the definitions of primary lesion types are mentioned in Tables 16.1 and 16.2 [7].
Table 16.1
Definition of primary vulvar lesions
|
Term |
Definition |
|---|---|
|
Macule |
Small (<1.5 cm) area of color change; no elevation and no substance on palpation |
|
Patch |
Large (>1.5 cm) area of color change; no elevation and no substance on palpation |
|
Papule |
Small (<1.5 cm) elevated and palpable lesion |
|
Plaque |
Large (>1.5 cm) elevated, palpable, and flat-topped lesion |
|
Nodule |
A large papule (>1.5 cm) often hemispherical or poorly marginated; may be located on the surface of, within, or below the skin; may be cystic or solid |
|
Vesicle |
Small (<0.5 cm) fluid-filled blister; fluid is clear |
|
Bulla |
Large (>0.5 cm) fluid-filled blister; fluid is clear |
|
Pustule |
Pus-filled blister; fluid is white or yellow |
Table 16.2
IFCPC (2011) terminology of the vulva; definitions of secondary morphology presentation [8]
|
Term |
Definition |
|---|---|
|
Eczema |
A group of inflammatory diseases that are characterized by the presence of itchy, poorly marginated red plaques with minor evidence of microvesiculation and/or subsequent surface disruption |
|
Lichenification |
Thickening of the tissue and increased prominence of skin markings. Scale may or may not be detectable in vulvar lichenification. Lichenification may be bright red, dusky red, white, or skin-colored in appearance |
|
Excoriation |
Surface disruption (notably excoriations) occurring as a result of the “itch-scratch” cycle |
|
Erosion |
A shallow defect in the skin surface; absence of some, or all, of the epidermis down to the basement membrane; the dermis is intact |
|
Fissure |
A thin linear erosion of the skin surface |
|
Ulcer |
Deeper defect; absence of the epidermis and some, or all, of the dermis |
16.1.7.4 Angioarchitecture
Due to the presence of surface keratinization, the terminal vessels are rarely visible. However atypical vessels and prominence of vessels may be features in invasive cancers. Punctation and mosaic patterns are evaluated in the same manner as in the colposcopic evaluation of cervix.
Various types of lesions cannot be differentiated on the basis of gross appearance and distribution of lesions on vulva. Vulvoscopy only helps in localizing the lesion for biopsy or mapping the extent of the lesion during excision.
16.1.8 Colposcopic Terminology of Vulvar Lesions
The IFCPC in 2011 has suggested the clinical/colposcopic terminology of the vulva (including the anus) (Table 16.3) [8].
Table 16.3
IFCPC 2011 terminology of vulva (including anus)
|
Normal findings |
Micropapillomatosis | ||
|
Sebaceous glands (Fordyce spots) | |||
|
Vestibular redness | |||
|
Abnormal findings |
Lesion type |
Lesion color |
Secondary morphology |
|
Macule |
Skin-colored |
Eczema | |
|
Patch |
Red |
Excoriation | |
|
Papule |
White |
Purpura | |
|
Plaque |
Dark |
Scarring | |
|
Nodule |
Ulcer | ||
|
Cyst |
Erosion | ||
|
Vesicle |
Fissure | ||
|
Bulla |
Wart | ||
|
Pustule | |||
|
Miscellaneous findings |
Trauma | ||
|
Malformation | |||
|
Suspicion of malignancy |
Gross neoplasm
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