diseases of the vagina azza alyamani prof obstet gynecol l.
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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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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.

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.


*treatment :

*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.

*teatment :

by marsupialization.

*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.

(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


(6) Prolapse

as ; cystocele , rectocele and enterocele.

(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.

(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.


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.

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


*Diagnosis by:

=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.

=vaginal biopsy

directed by colposcopy & Lugol′s iodine.

* 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.


In summary



1. Pap smear.

2. colposcopy.

3. vaginal biopsy.

management :

1.vaginal vault lesion.

2. multifocal lesions.

3. extensive disease.

Vaginal Cancer

Squamous Cell Carcinoma

Clear Cell Adenocarcinoma

rare cancer

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

growth patterns.

*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

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.

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.

*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.