Benign diseases of the Benign diseases of the vulva, vagina and cervixvulva, vagina and cervix
The vulvaThe vulva
• Is the part of the female genital tract located between the genitocrural folds laterally, the mons pubis anteriorly, and the anus posteriorly.
• Embryologically, it is the result of the junction of the cloacal endoderm, urogenital ectoderm, and paramesonephric mesodermal layers.
• This hollow structure contains – LABIA MAJORA– LABIA MINORA– CLITORIS– VESTIBULE– URINARY MEATUS– VAGINAL ORIFICE– HYMEN– BARTHOLIN GLANDS– SKENE DUCTS.
The vulvaThe vulva
• Different epithelia, from keratinized squamous epithelium to squamous mucosa, cover the vulva.
• The labia minora are rich with sebaceous glands but have few sweat glands and no hair follicles.
• The epithelium of the vestibule is neither pigmented nor keratinized and contains eccrine glands.
BENIGN LESIONS OF THE VULVABENIGN LESIONS OF THE VULVA
• According to the International Society for the
Study of Vulvar Disease (ISSVD) in 1989:
– Inflammatory diseases.
– Blistering diseases.
– Pigmentary changes.
– Benign tumors, hamartomas and cysts
– Congenital malformations.
Inflammatory diseasesInflammatory diseases
1. Lichen sclerosus 2. Squamous cell hyperplasia (+/-
atypia) 3. Lichen simplex chronicus
(localized neurodermatitis) 4. Primary irritant dermatitis 5. Intertrigo 6. Allergic contact dermatitis 7. Fixed drug eruption 8. Erythema multiforme 9. Toxic epidermal necrolysis 10.Atopic dermatitis 11.Seborrheic dermatitis
12.Psoriasis 13.Reiter disease 14.Lichen planus 15.Lupus erythematosus 16.Darier disease 17.Aphthosis and Behçet
disease 18.Pyoderma gangrenosum 19.Crohn disease 20.Hidradenitis suppurativa 21.Fox-Fordyce disease 22.Plasma cell vulvitis 23.Vulvar vestibulitis
syndrome
Blistering diseasesBlistering diseases
1. Familial benign chronic
pemphigus (Hailey-
Hailey disease)
2. Bullous pemphigoid
3. Cicatricial pemphigoid
4. Pemphigus vulgaris
5. Erythema
multiforme
6. Epidermolysis
bullosa
Pigmentary changesPigmentary changes
1. Acanthosis nigricans
2. Lentigo
3. Melanocytic nevus
4. Postinflammatory
hyperpigmentation
5. Postinflammatory
hypopigmentation
6. Vitiligo
Benign tumors, hamartomas, and Benign tumors, hamartomas, and cystscysts
1. Bartholin cysts
2. Epidermal inclusion cyst (Dermoid
cyst)
3. Endometriosis
4. Hydrocele of the canal of Nuck
5. Skene duct cyst
6. Seborrheic keratosis
7. Acrochordon (fibroepithelial polyp)
8. Fibroma, fibromyoma, and
dermatofibroma
8. Hidradenoma
9. Lipoma
10.Chronic Inflammatory
swellings
11.Hemangioma
12.Lymphangioma
13.Angiokeratoma
14.Pyogenic granuloma
15.Sebaceous gland hyperplasia
16.Papillomatosis
BENIGN LESIONS OF THE VULVABENIGN LESIONS OF THE VULVA
• BARTHOLIN’s CYST
• ATROPHIC LICHEN (LICHEN SCLEROSUS ET
ATROPHICUS)
• SQUAMOUS HYPERPLASIA
• LICHEN SIMPLEX CHRONICUS
• HIDRADENOMA PAPILLIFERUM
Bartholin’s Cyst/AbscessBartholin’s Cyst/Abscess
• Medial to labia minor
• Blockage of duct following infection
– N. gonorrhea
– Staphylococci
– Anaerobes
• Thomas Bartholin
• Danish professor
• In 1652 he gave the first full
description of the human
lymphatic system.
MarsupalizationMarsupalization
lichenlichen
What is What is lichen?lichen?
A fungus, usually of the class Ascomycetes, that grows symbiotically with algae, resulting in a composite organism that characteristically forms a crustlike or branching growth on rocks or tree trunks.
In pathology….In pathology….
Any of various skin diseases
characterized by patchy eruptions of
small, firm papules.
Lichen Sclerosus et AtrophicusLichen Sclerosus et Atrophicus
• Most patients are post-menopausal women
• Stenosis of the introitus develops
Lichen Sclerosus et AtrophicusLichen Sclerosus et Atrophicus
Note the white, parchment-like or plaque-like lesion
Lichen Sclerosus et AtrophicusLichen Sclerosus et Atrophicus
• During early stages the patient may not have
symptoms.
• Some patients develop intractable pruritus
• Burning and pain are less likely manifestations.
• Figure-of-8 or keyhole configuration.
• In late stages normal architecture may be lost
– atrophy of the labia minora, constriction of the vaginal orifice
(kraurosis), synechiae, ecchymoses, fissures.
• Squamous cell carcinoma develops in 3-6% cases
Lichen Sclerosus et AtrophicusLichen Sclerosus et Atrophicus
• Thinning of the surface epithelium with some hyperkeratosis.
Lichen Sclerosus et AtrophicusLichen Sclerosus et Atrophicus
• Etiology – Unknown. A higher prevalence of the disease in
postmenopausal women suggests hormonal factors, but this has not been confirmed.
– Studies identifying an infection are inconclusive – Weakly linked to autoimmune diseases and
genetic factors– Local factors (eg, trauma, friction, chronic
infection and irritation) – Recurrence near vulvectomy scars has been
observed.
Lichen Sclerosus et AtrophicusLichen Sclerosus et Atrophicus
• Treatment
– Potent topical corticosteroids
– Testosterone propionate is ineffective
and has many adverse effects
– Close follow-up -----epithelial cancer.
Squamous HyperplasiaSquamous Hyperplasia
Associated with a response to hormonal
influences or exposure to exogenous
irritants
Precursor of squamous cell CA if cells are
atypical
Squamous Hyperplasia Squamous Hyperplasia
• This lesion produces hyperplastic thickening of the superficial squamous epithelium.
• This lesion is a precursor of squamous cell carcinoma of the vulva
Squamous Hyperplasia Squamous Hyperplasia
• Note the keratin horn cysts and the infiltrate of inflammatory cells at the base of the lesion.
Squamous HyperplasiaSquamous Hyperplasia
• ITCHING is a common symptom.
• If hyperkeratosis is not prominent, lesions may
appear as reddish plaques.
• The clitoris, labia minora, and inner aspects of the
labia majora are more commonly affected.
• Extensive lesions may result in stenosis of the
vaginal introitus.
Squamous HyperplasiaSquamous Hyperplasia
• Etiology
– Repetitive scratching or rubbing from
irritants
– Treatment is aimed at halting the
itch-scratch-itch cycle.
Squamous HyperplasiaSquamous Hyperplasia
• Treatment – The same as lichen sclerosus
– General attention to proper hygiene.
– If the skin is moist or macerated, aluminum acetate 5% solution applied 3-4 times daily for 30-60 minutes is beneficial.
– Systemic antihistamines or tricyclic antidepressants
– Refractory lesions, intralesional injections of triamcinolone acetonide may be an alternative.
lichen simplex chronicuslichen simplex chronicus
• Hyperkeratotic, usually ill-
defined, grayish, thickened,
and sometimes excoriated
lesion.
• Usually located over the labia
majora.
• Hyperpigmentation.
• Itching is always present and
may be intense.
lichen simplex chronicuslichen simplex chronicus
• Lichen simplex chronicus of the vulva is the end stage of
the itch-scratch-itch cycle. • The initial stimulus to itch may be:
– Underlying seborrheic dermatitis.
– Intertrigo
– Tinea.
– Psoriasis.
– In most cases, the underlying cause is not evident and may have been transient vulvitis or vaginal discharge.
• Any itching disease of the vulva may become secondarily lichenified.
lichen simplex chronicuslichen simplex chronicus
• Epidermal and epithelial hyperplasia, • Hyperkeratosis.• Fibrotic vertical streaks of collagen between the
hyperplastic rete are present.
lichen simplex chronicuslichen simplex chronicus
• Treatment
– Includes removal of irritants and/or allergens
– Topical application of mild-to-high–potency corticosteroids.
– Avoid soaps and cleansing agents other than aqueous cream.
– Discourage excessive cleaning of the genital area; use of hot
water; overheating; and wearing of synthetic, rough, and/or
tight clothing.
• Lichen simplex chronicus may be associated with
underlying diseases (eg, Paget disease, Bowen disease)
Lichen planusLichen planus
• Three types:
– Papulosquamous– Erosive – Hypertrophic
• Malignancy is possible in long-standing and ulcerative lichen planus.
Lichen planusLichen planus
• The papulosquamous form: – Occurring as part of a
generalized disease – Is the most common and is
characterized by:• Flat-topped• Polyhedral, • Violaceous, shiny, and itchy
papules located on keratinized skin of the labia and mons pubis. Delicate and whitish reticulated papules may be present on the mucosa, but no atrophy or scarring is observed.
Lichen planusLichen planus
• The erosive form:– Involves the mucous membranes of the mouth and
vulvovaginal area and may be locally destructive, leading to atrophy and scarring.
– Synonyms include erosive vaginal lichen planus, desquamative inflammatory vaginitis, vulvovaginal-gingival syndrome, and ulcerative lichen planus.
–Itching is rare, but pain, burning, and irritation occur and may be responsible for dyspareunia and dysuria.
Lichen planusLichen planus
• The rare hypertrophic form:– Resembling lichen sclerosus,
manifests with extensive white scarring of the periclitoral area with variable degrees of hyperkeratosis.
– It may be very itchy. – Extensive vaginal involvement may
result in a malodorous discharge. – Large denuded areas may become
adherent, causing stenosis of the vaginal introitus and dyspareunia.
– Marked atrophy may develop with time.
ID/CCID/CC A 75 year old woman visits her A 75 year old woman visits her
gynecologistgynecologist
for a routine checkup and is found to for a routine checkup and is found to
havehave
white spots on her genitaliawhite spots on her genitalia
HPIHPI She complains of slight outer She complains of slight outer
vaginal itching but denies any vaginal itching but denies any
postmenopausal bleeding, vaginal postmenopausal bleeding, vaginal
discharge, or drug intakedischarge, or drug intake
PEPE Hypochromic macules on labia Hypochromic macules on labia
majora extending to perineum and majora extending to perineum and
inner thighs in patchy distribution inner thighs in patchy distribution
with scale formation; skin is with scale formation; skin is
thickenedthickened
PruritPrurituus vulvas vulva
• Causes:– General
– Local
– Psychosomatic
– Idiopathic
• General Examination
• Local examination:– Smears
– Culture and sensitivity
– BIOPSY: KEYE’s Dermatological knife
BENIGN LESIONS OF THE VaginaBENIGN LESIONS OF THE Vagina
• CYSTIC SWELLINGS
• SOLID TUMORS
• ATROPHIC VAGINITIS
• VAGINAL ADENOSIS
Cystic swellingsCystic swellings
• Gartner’s Cyst
– Dilatation of the Gartner’s (Wollfian) duct
– Anterior and lateral vaginal walls
• Epithelial inclusion cysts
• Endometrioma
• Uretheral diverticulum
Solid TumorsSolid Tumors
• Fibromyoma
• Condyloma accuminata
• Bilharzial polyps
Atrophic vaginitisAtrophic vaginitis
• Thinning and atrophy of vaginal
epithelium
• Most common in postmenopausal
women with low estrogen levels
• Dyspareunia and vaginal spotting
(differential includes uterine
cancer)
Vaginal AdenosisVaginal Adenosis
• Persistent Mullerian columnar
epithelium in the anterior
wall and upper 1/3 of vagina
• Manifestation of maternal
DES exposure
• Red, granular patches
• Precursor of clear cell
adenocarcinoma
Vaginal AdenosisVaginal Adenosis
• Note the red granular patches on the vaginal mucosa on the left. The slide on the right shows glandular development.
• Most patients are 7-35 years of age
BENIGN LESIONS OF THE cervixBENIGN LESIONS OF THE cervix
• CERVICITIS• EROSION• POLYPS
Inflammatory Lesions of the CervixInflammatory Lesions of the Cervix
• Cervicitis (acute)
• Symptoms: backache, bearing-down feeling
in the pelvis, dull pain in the lower part of
the abdomen, urinary tract symptoms
Erosion of the CervixErosion of the Cervix
• Characterized by columnar epithelium replacing squamous
epithelium, grossly resulting in an erythematous area
• Causes:
– Physiological:
– Cervicitis: Acute or Chronic
– Hormonal therapy
Erosion of the CervixErosion of the Cervix
• Erosion of the cervix following delivery. A normal cervix is on the left
Erosion of the CervixErosion of the Cervix
•SMEAR
– If infection---- Treat cause
– IF CIN ------ Manage according to stage
Chronic CervicitisChronic Cervicitis
• Chronic inflammation, sometimes ulceration with
repair, atypia or dysplasia, nabothian cysts from
endocervical glands
• Backache is a common symptom
Chronic CervicitisChronic CervicitisNabothian CystsNabothian Cysts
• Endocervical glands blocked by inflammation or scarring.
Chronic CervicitisChronic Cervicitis
• Chronic inflammation underlies an area of cervical dysplasia
Endocervical PolypsEndocervical Polyps
Postcoital bleeding and
irregular vaginal spotting
• Inflammatory
proliferations of cervical
mucosa; not true
neoplasms
• Soft; may protrude
through the cervical os
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