Diseases of the Vulva

Chapter 8 Diseases of the Vulva



Vulval Dermatoses 156
Classification 156

Lichen Sclerosus 157

Benign Tumours of the Vulva 158

Vulval Intraepithelial Neoplasia 159
Vulval Intraepithelial Neoplasia (VIN) 159

Paget’s Disease of the Vulva (Adenocarcinoma In Situ) 159

Carcinoma of the Vulva 160
Aetiology 160

Histology 160

Clinical Features 160

Lymphatic Spread 161

Surgical Treatment 162

Complications 164

Radiotherapy and Chemotherapy 164

Prognosis of Vulval Carcinoma 164

Diseases of the Urethra 165
Prolapse of the Urethral Mucosa 165

Caruncle 165

Urethrocele 165


Vulval dermatoses


Vulval dermatoses is the term applied to non-infective non-neoplastic diseases of the vulval skin. Their management has evolved into a multidisciplinary approach involving specialist nursing staff, dermatologists and gynaecologists. Specialist clinics may have direct referrals, but the symptoms of itching, soreness and dyspareunia will usually take the patient in the first place to the gynaecologist.



image

Normal vulva



Classification


The following classification is recommended by the International Society for the Study of Vulvar Disease (ISSVD – 2004).


Non-neoplastic disorders of the vulva
lichen sclerosus

lichen planus

other dermatoses

Vulval intraepithelial neoplasia (VIN)
VIN, usual type
(i) warty

(ii) basaloid

(iii) mixed

VIN, differentiated type
Paget’s disease


Lichen sclerosus


Lichen sclerosus is a common condition found in postmenopausal women complaining of vulval itch. Premenopausal women may also be affected, as well as men and children. The aetiology is unknown, but it appears to be associated with autoimmune disorders.


It is most commonly seen in the vulvo-perineal skin of women, but can affect skin in any region of the body.



image


Appearance


The disease starts as a flat pinkish-white macula. As it progresses, there is atrophy of the labia as well as clitoral recession with loss of normal architecture. With further deterioration, labial fusion and perineal fissuring occur. Scratching may induce lichenification (thickening).



Histology


There is atrophic thinning of the epidermis with some hyalinisation of the dermis. The keratinised layer is thickened, giving a whitened appearance (‘leukoplakia’).



image


Differential Diagnosis of Vulval Itch


Lichen planus, lichen simplex, candidiasis, VIN, psoriasis.



Management



Ultrapotent steroid such as clobetasol propionate (suggested regimen)



Apply once daily 4 weeks.

Apply alternate days for 4 weeks.

Apply twice weekly for 4 weeks.

NB maintenance/interval treatment with clobetasol at previous minimal effective frequency.


Soap substitute

There is an extremely limited role for vulval surgery in the management of this condition, unless there is suspected malignancy.


If asymptomatic, no treatment is required.



Malignant Associations


A recent estimate suggests that 5% of women with lichen sclerosus will develop invasive cancer.



Benign tumours of the vulva


The complaint is usually of a ‘lump’ or ‘swelling’ at the vaginal introitus. (In many cases, the patient may mistake prolapse of various types for tumour growth.)


Cyst of Bartholin’s gland This is the commonest simple tumour of the vulva. Caused by obstruction of the duct, the cyst often becomes infected and requires surgical treatment (see p. 133).


Sebaceous cyst of the vulva occurs in the hair-bearing vulval tissue. The cyst may become infected and cause pain. The cyst contains whitish, cheesy sebaceous material. If painful, it can be removed.


image

Vulval haematoma is a result of direct violence or wounding (it is most commonly found with childbirth). Treatment is by incision, evacuation and drainage if the patient is symptomatic.


Lipoma, fibroma and myoma

Related posts:

  1. Physiology of the Reproductive Tract
  2. Gynaecological Infections
  3. Diseases of the Cervix
  4. Abnormalities of Menstruation

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Jun 4, 2016 | Posted by in GYNECOLOGY | Comments Off on Diseases of the Vulva

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