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Diseases of the Vagina Azza AlYamani Prof. Obstet. & Gynecol. PowerPoint PPT Presentation


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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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Diseases of the Vagina Azza AlYamani Prof. Obstet. & Gynecol.

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Diseases of the vagina azza alyamani prof obstet gynecol l.jpg

Diseases of the Vagina Azza AlYamaniProf.Obstet. & Gynecol.


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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

hair follicles.


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Benign Conditions


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Structural and Benign Neoplastic

Conditions :

(1)Urethral diverticula

* 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.

=dyspareunia.

*treatment :

*urethral dilatation or

*surgical excision of the diverticulum.


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(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.

*teatment :

by marsupialization.


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Bartholin′ s cyst


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*Bartholin abscess

* 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.


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(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.


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(5) vaginal adenosis

* multiple mucus – containing vaginal cysts

rarely give symptoms.

* common in daughters of women who took

di ethyl stilboesterol ( DES) during

pregnancy.

(6) Prolapse

as ; cystocele , rectocele and enterocele.


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cystocele


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(7) Fistula

as ; vesico vaginal , recto vaginal and

uretero vaginal fistulas. They may result from

obstetric or surgical trauma , invasive cancer and

radiation therapy.

(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.


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Erosive lichen planus


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(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.


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Gartener’s cyst


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In summary

Benign Conditions:

1. urethral diverticula.

2. Bartholin’s cysts & abscess.

3. inclusion cysts.

4. endomeriotic cysts.

5. vaginal adenosis.

6. prolapse.

7. fistula.

8. erosive lichen planus.

9. Gartner’s duct cyst.


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Vaginal intraepithelial neoplasia(VAIN)


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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

risk.


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*Diagnosis by:

=Pap smear is abnormal.

=colposcopy.

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.

=vaginal biopsy

directed by colposcopy & Lugol′s iodine.


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* management

=vaginal vault lesion

surgical excision to exclude invasive cancer.

=multifocal lesions

laser therapy or topical 5 fluorouracil.

=extensive disease

total vaginectomy and neovagina using a

split thickness skin graft.


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In summary

VAIN

diagnosis:

1. Pap smear.

2. colposcopy.

3. vaginal biopsy.

management :

1.vaginal vault lesion.

2. multifocal lesions.

3. extensive disease.


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Vaginal Cancer

Squamous Cell Carcinoma

Clear Cell Adenocarcinoma

rare cancer


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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

earlier.

*50% of lesions are in the upper1/3 of

vagina on the posterior wall.


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*Symptoms:

= vaginal bleeding.

= vaginal discharge.

= urinary symptoms.

*examination:

ulcerative , exophytic and infiltrative

growth patterns.


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Squamous cell carcinoma of vagina


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*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.

=hematogenous

is uncommon until the disease is advanced.


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Staging

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.


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FIGO staging of Vaginal Cancer


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Management

1. Radiotherapyor chemo radiotherapy

are the main methods of treatment for 1ry

vaginal cancer.

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.


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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.


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* 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.


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*Treatment :

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.


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Thank you


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