Diseases of the Vagina Azza AlYamani Prof. Obstet. & Gynecol. Anatomy of the vagina * it is a flattened muscular tube extending from the hymenal ring at the introitus up to the fornices . It is about 8 cm in length. * the posterior fornix ( Douglus pouch ) allows
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Anatomy of the vagina
* it is a flattened muscular tube extending from
the hymenal ring at the introitus up to the
fornices . It is about 8 cm in length.
* the posterior fornix (Douglus pouch) allows
easy access to the peritoneal cavity from the
the vagina by culdocentesis or colpotomy.
* its epithelium is non-keratinized squamousin
type normally devoid of mucous glands and
Structural and Benign Neoplastic
* small sac-like projections in the anterior vaginal
wall along the posterior urethra, it may or may not
communicate with the urethra.
it can cause :
= recurrent urinary tract infections.
*urethral dilatation or
*surgical excision of the diverticulum.
(2) Bartholin’s cyst
* it is the most common vulvo vaginal mass. It
presents as swelling postrolateral in the introitus
usually unilateral , 3cm in diameter. It is not
infected but can be symptomatic.
* after 40 y. it is necessary to palpate the base of
the cyst to rule out carcinoma.
Bartholin′ s cyst
* infection of the gland may result from blockage
and accumulation of purulent material and a
large painful inflammatory mass can develop.
* The treatment
by incision of the abscess and left drain in place
for 2-4 weeks.
(3) Inclusion cysts
* result from infolding of the vaginal epithelium,
located in the posterior or lateral wall of the
lower 1/3 of the vagina.
* They are most frequently associated with
lacerations from delivery or surgery. They are
treated by surgical excision.
(4) Endometriotic cysts
* are endometriotic implants located in the upper
1/3 of the vagina.
* presents as black cysts which may bleeds at the
time of menstruation.
* they are most common in an episiotomy wound.
(5) vaginal adenosis
* multiple mucus – containing vaginal cysts
rarely give symptoms.
* common in daughters of women who took
di ethyl stilboesterol ( DES) during
as ; cystocele , rectocele and enterocele.
as ; vesico vaginal , recto vaginal and
uretero vaginal fistulas. They may result from
obstetric or surgical trauma , invasive cancer and
(8) Erosive lichen planus
erythematous papules involve vagina as well
as vulval vestibule . Condylomaacuminata ,flat
warts ( HPV) and herpes simplex infections can
be found in the vaginal vault.
Erosive lichen planus
(9) Gartner’s duct cyst
* aregenerally thick-walled , soft cystsresulting
from embryonic remnants. Gartner′s cyst
arise from the remnant of the Wolffian duct .
* they vary in size from 1 – 5cm , found on the
antero lateral walls in the upper ½ of the
vagina and more laterally in the lower vagina.
* most of them are asymptomatic.
* require no intervention.
if ttt is required , marsupialization is
effective and safer than excision.
1. urethral diverticula.
2. Bartholin’s cysts & abscess.
3. inclusion cysts.
4. endomeriotic cysts.
5. vaginal adenosis.
8. erosive lichen planus.
9. Gartner’s duct cyst.
Vaginal Intraepithelial Neoplasia (VAIN)
VAIN or carcinoma in situ :
* much less common than CIN and VIN.
* occurs in the upper 1/3 of the vagina.
* caused by HPV infection or after irradiation
for cervical cancer .
* women with past history of in situ or
invasive ca.cx or ca. vulva are at increased
=Pap smear is abnormal.
findings are similar to cervical lesions.
abnormal epithelial proliferation and
maturation above the basement membrane.
VAIN I : inner 1/3 .
VAIN II: inner 2/3 .
VAIN III: full thickness involvement.
directed by colposcopy & Lugol′s iodine.
=vaginal vault lesion
surgical excision to exclude invasive cancer.
laser therapy or topical 5 fluorouracil.
total vaginectomy and neovagina using a
split thickness skin graft.
1. Pap smear.
3. vaginal biopsy.
1.vaginal vault lesion.
2. multifocal lesions.
3. extensive disease.
Squamous Cell Carcinoma
Clear Cell Adenocarcinoma
Squameous Cell Carcinoma
of the Vagina
* uncommon tumor.
* mean age 60 – 70 years.
*30% have a history of insitu or invasive
cervical cancer that was treated at least 5ys
*50% of lesions are in the upper1/3 of
vagina on the posterior wall.
= vaginal bleeding.
= vaginal discharge.
= urinary symptoms.
ulcerative , exophytic and infiltrative
*pattern of spread:
=direct invasion to bladder ,urethra or rectum
or progressive lateral extension to the
pelvic side wall.
=lymphatic to the obturator ,internal iliac
and external iliac nodes.
lesions in the lower vagina drains to the
inguino femoral nodes.
is uncommon until the disease is advanced.
is made clinically by:
* chest X-ray.
* pelvic & abdominal CT.
* MRI for metastatic spread & bulky pelvic
and para aortic lymph nodes.
* PET (position emission tomography)
to look for metastatic disease.
1. Radiotherapyor chemo radiotherapy
are the main methods of treatment for 1ry
2. Radical surgery has a limited role :
*Radical hysterectomy + radical
vaginectomy+ pelvic lymphadenectomy,
for stage 1 in the posterior fornix.
*Pelvic exenteration with creation of a
neovagina ,if LN. are free.
Clear Cell Adenocarcinoma
*An association between in utero exposure
to di ethyl stilbesterol (DES) and the latter
development of clear cell carcinoma in the
vagina was reported in 1971.
*Vaginal adenosis (columnar epithelium) is
the most common anomaly ,present in 30%
of exposed females.
* this tissue behaves similarly to the columnar
epithelium of the cervix & is replaced initially by
immature metaplasticsquamous epithelium.
* the risk for developing a clear cell
adenocarcinoma following DES exposure in utero
is only 1/1000 .
* the mean age is 19years, rare before 14y.
few cases reported in women in their 40s & 50s.
for early tumor , radical hysterectomy and
vaginectomy ( cereation of neovagina) or
radiation therapy is effective.
*The 5-year survival rate is 80%, which is
better than that for squameous cell carcinoma
of the vagina.