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CHAPTER 13 Benign Diseases of the Female Reproductive Tract. Novak ’ s Gynecology page 399~412 OBGY R1 Lee eun suk . Vulvar Conditions. Neonatal Various developmental & congenital abnormalities Etiology Chromosomal abnormalities

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chapter 13 benign diseases of the female reproductive tract

CHAPTER 13 Benign Diseases of the Female Reproductive Tract

Novak’s Gynecology page 399~412

OBGY R1 Lee eun suk

vulvar conditions
Vulvar Conditions
  • Neonatal
    • Various developmental & congenital abnormalities
    • Etiology
      • Chromosomal abnormalities
      • Enzyme deficiencies (including 17- or 21- hydroxylase deficiency as causes of congenital adrenal hyperplasia)
      • Prenatal masculinization resulting from maternal androgen-secreting ovarian tumors
      • Drug exposures
vulvar conditions1
Vulvar Conditions
  • Neonatal
    • Ambiguous genitalia represents a social & potential medical emergency that is best handled by a team of specialists, which include urologists, neonatologists, endocrinologists & pediatric gynecologists
    • The issues of gender assignment & timing of surgical therapy are controversial and should be managed by clinicians with extensive experience in the field
vulvar conditions2
Vulvar Conditions
  • Neonatal
    • Careful inspection of the external genitalia of all female infants with gentle probing of the introitus & anus to determine the patency of the hymen or a possible imperforate anus
    • Congenital vulvar tumors
      • Strawberry hemangiomas : relatively superficial vascular lesions
      • Large cavernous hemangiomas
vulvar conditions3
Vulvar Conditions
  • Childhood
    • Vulvovaginitis is most common ginechological problem
    • Prepubertally, the vulva, vestibule, vagina are anatomically & histologically vulnerable to infection with bacteria
    • The phygical proximity of the vagina & vestibule to anus can result in bacterial overgrowth → primary vulvitis & secondary vaginitis
vulvar conditions4
Vulvar Conditions
  • Childhood - Lichen sclerosus
    • The cause is not well established
    • Cigarette paper appearance in a keyhole distribution (around vulva & anus)
    • Spontaneous regression through adrenarche & menarche
    • Medication
      • Progesterone in oil (400mg in 4 OZ. Of Aquaphor)
      • Betamethasone valerate (0.1% ointment, Valisone)
      • High-petency topical corticosteroids
      • Temovate(0.05%) cream
vulvar conditions6
Vulvar Conditions
  • Childhood - Labial agglutination
    • Result of chronic vulva inflammation from any cause
    • Treatment
      • Brief course (2 to 4 weeks) of estrogen cream
      • Agglutination (adhesion) will become thin as the result
      • Separation can often be perfomed with topical anesthetic
vulvar conditions7
Vulvar Conditions
  • Childhood
    • Urethral prolapse
      • Acute pain or bleeding
      • The presence of a mass may be noted
    • Vulvovaginal complaints of any sort in a young child should prompt the consideration of possible sexual abuse
      • Sexually transmitted infections may occur in prepubertal children
      • Sensitive but, direct questioning of the parent or caretaker & the child
vulvar conditions8
Vulvar Conditions
  • Adolescence
    • Various development abnormalities
      • Vaginal agenesis, imperforate hymen, transverse & longitudinal vaginal septa, vaginal and uterine duplications, hymenal bands & septa
      • A tight hymenal ring may discovered because of concerns about the ability to use tampons or initiate intercourse
        • Manual dilation : small relaxing incisions at 6 o’clock & 8 o’clock
        • This can be done in the office using local anesthesia but may require general anesthesia in operating room
    • The possibility of sexual abuse, incest, or involuntary intercourse should be considered for vulvovaginal complaints, STDs, or pregnancy
vulvar conditions9
Vulvar Conditions
  • Reproductive age women
    • Most related to a primary vaginits and a secondary vulvitis
    • Vaginal discharge → vulvar irritative symptoms or candida vulvutis
    • Vulvar symptoms : itching, pain, discharge, discomfort, burning, external dysuria, soreness, pain with intercourse or sexual activity
      • Itching is a very commom vulvar symptom
      • A variety of vulva conditions and lesions can present with pruritus
      • Burning with urination from noninfection causes may difficult to distinguish from a urinary tract infection
      • Some women can distinguish pain when the urine hits the vulvar area (an external dysuria) from burning pain (often suprapubic in locaion)
      • Urine culture
vulvar conditions10
Vulvar Conditions
  • Reproductive age women
    • Vulvar conditions classified by infectious or noninfectious causes
    • The diagnosis of some of these conditions is apparent form inspection alone (e.g., a skin tag)
    • Any lesions that appear atypical or in which the diagnosis is not clear should be analyzed by biopsy
vulvar conditions12
Vulvar Conditions
  • Reproductive age women
    • Pigmented vulvar lesions : benign nevi, lentigines, melanosis, seborrheic keratosis, & some vulvar intraepithelial neoplasias
    • 10% of white women have a pigmented vulvar lesion, some of lesions may be malignant or have the potential progression
    • The behavior of some nevocellular lesions (representing about 2%

of nevi) is not well established but has been linked to melanoma

    • Multiple hyperpigmented lesions of typical lentigo simplex and melanosis are common, and any areas with irregular borders

should be evaluated by biopsy

vulvar conditions13
Vulvar Conditions
  • Vulvar biopsy
    • A vulvar biopsy is essential in distinguishing benign from pre-malignant or malignant vulvar lesions lesions, especially because many types of lesions may have a somewhat similar appearance
      • Epidermal inclusion cyst, lentigo, bartholin duct obstruction, CIS,

melanocytic nevi, acrochordon, mucous cyst, hemangioma, post

inflammatory hyperpigmentation, seborreic keratosis, varicosities,

hidradenomas, verruca, basal cell ca, neurofibroma, ectopic tissue,

syringomas, & abscess

vulvar conditions14
Vulvar Conditions
  • Vulvar biopsy
    • Vulvar biopsies should be performed liberally to ensure these

lesions are diagnosed and treated appropriately

      • Biopsy is easily performed in the office using a local anesthetic

(1% lidocaine)

      • Punch biopsy Instruments, forceps, scissors, & a scalpel
      • Smaller biopsies unnecessary to place a suture
      • The biopsy sites will be painful for several days after procedure

→ 2% lidocaine jelly to be applied periodically and before urination

other vulvar conditions
Other Vulvar Conditions
  • Pseudofolliculitis
    • Occur in women who follow the increasingly popular practice of shving pubic hair to confirm to swimsuit
      • Inflmmatory reaction surrounding an ingrown hair
      • Comomly among individual with curly hair, particularly African Americans
other vulvar conditions1
Other Vulvar Conditions
  • Fox-Fordyce diseassse
    • A chronic, pruritic eruption of small papules or cysts formed by keratin-plugged apocrine glands
    • Commonly present over the lower abdomen, mons pubis, labia majora, & inner portions of the thighs
    • Hidradenitis suppurativa
      • Chronic condition involving the apocrine glands with the formation of multiple deep nodules, scar, pits, and sinuses in the axilla, vulva, & perineum
      • Treatment : antibiotics, estrogens or antiadrogen therapy, isotreinoin & steroids, surgical therapy with wide local excision
other vulvar conditions2
Other Vulvar Conditions
  • Acanthosis nigricans
    • Wide spread velvety pigmentation in skin folds
      • Particularly the axillae, neck, thighs, submammary area, vulva and surrounding skin
    • Association with hyperandrogenism & PCOS as such
      • Obesity, chronic anovulation, acne, glucose intolerance, and cardiovascular disease
vulvar conditions15
Vulvar Conditions
  • Intraepithelial neoplasia
    • Extramammary Paget’s disease of the vulva is an intraepithelial neoplasia containing vacuolated Paget’s cells
      • Moist, oozing ulcerations, eczematoid lesion with scaling and crusting
      • Biopsy to confirm the diagnosis is mandatory
    • Vulvar intraepithelial neoplasia
      • Associated with human pillomavirus infection
      • Increasing in frequency, particularly among young women
      • Suspicious vulvar lesions that are pigmented or discolored → biopsy
vulvar conditions16
Vulvar Conditions
  • Vulva tumors, cysts, and masses
    • Condyloma accuminata
      • Very commom vulvar lesions
      • Treated with topical therapies such as tri-and bichloroacetic acid
      • Other sexually transmitted organisms, such as the virus responsible for

molluscum contagiosum, the lesions of syphilis, and condyloma lata ,

may occasionally be mistaken

vulvar conditions17
Vulvar Conditions
  • Vulva tumors, cysts, and masses
    • Bartholin duct cysts
      • Common vulvar lesions
      • Occlusion of the duct with accumulation of mucus
      • Frequently asymtomatic
      • Infection of the gland

→ accumulation of purulent material

→ formation of a rapidly enlarging, painful, inflammatory mass

      • Inflatable bulb-tipped catheter described by Word is inserted through

a stab wound into the abscess

→The ballon of the catheter is inflated with 2 to 3 ml of saline

→The catheter remains in place for 4 to 6 weeks

→Epithelization of the tract & creation of a permanent gland opening

vulvar conditions18
Vulvar Conditions
  • Vulva tumors, cysts, and masses
    • Skene duct cysts
      • Cystic dilations of the Skene glands
      • Typically located adjacent tourethral meatus within the vulvar vestibule
      • Most small and asymtomatic
      • May enlarge & cause urinary obstruction → excision
vulvar conditions19
Vulvar Conditions
  • Vulva tumors, cysts, and masses
    • The symptom of painful intercourse (dyspareunia) may be caused

by many different vulvovaginal conditions

    • A careful sexual history & examination of the vulvar area is essential
    • Vulvodynia
      • Unexplained vulva pain, sexual dysfunction, & psychological disability
    • Vulva vestibulitis
      • Pain during intercourse, primarily during entry
      • Tender areas surrounding the vulvar vestibule and hymenal ring
      • Recent studies have failed to demonstrate a consistent relationship

with any genital infectious organism, cllmydia, donorrhea, Trichomonas,

mycoplasma, Ureaplasma, Gardnerella, candida, human papillomavirus

vulvar conditions20
Vulvar Conditions
  • Vulvar ulcers
    • Caused by a number of STDs : herpes simplex virus, syphilis,

lymphogranuloma venereum & granuloma inguinale

    • Chron’s disease
      • Abscesses, fistulae, sinus tracts, fenestrations, and other scarring
    • Behcet’s disease
      • Genital and oral ulcerations with ocular inflammation
      • The cause & the most effective therapy are not well established
    • Lichen planus
      • Oral & genital ulcerations
      • Typically desquamative vaginitis with vestibule erosion
      • Topical and systemic steroids
vulvar conditions21
Vulvar Conditions
  • Post menopausal women - vulvar dystrophies
    • Vulvar epithelial growth that produce a number of nonspecific gross changes
    • Malignant potential is less than 5%
    • At particular risk is the patient cellular atypia on initial
    • Squamous hyperplasia
      • Most common in postmenopausal women
      • Pruritus is the most symptoms
      • Lesion appears thickened, hyperkeratotic & there may be exocoriation
      • Biopsy → evaluate the presence of atypia & exclude malignancy
      • fluorinated corticosteroid ointment 2 times s day for 6 weeks
      • New lesions recur → biopsy & additional 6 weeks of treatment
vulvar conditions22
Vulvar Conditions
  • Post menopausal women - vulvar dystrophies
    • Lichen sclerosis
      • Most common white lesion of the vulva
      • Can occur at any age, although it is most common among post

menopause and prepubertal girls

      • Symptoms : pruritus, dyspareunia, & burning
      • Decreased subcutaneous fat→ vulvar atrophy, with small or abscent

labia minora, thin labia majora, & sometimes phimosis of the prepuce

      • Pale surface with a shiny, crinkled pattern, with fissures & excoriation
      • The lesions is symmetric and extends to the perineal & perianal area
      • The diagnosis is confirmed by biopsy & invasive cancer is rare
      • Treatment : ultrapotent topical steroid ( 0.05% clobestasol)
vulvar conditions23
Vulvar Conditions
  • Post menopausal women – urethral lesions
    • Urethral caruncles and prolapse of the urethral mucosa
    • Can be treated with topical or systemic estrogen preparations
vaginal conditions
Vaginal Conditions
  • Vaginal discharge
    • One of the most common vaginal symptoms
    • Vaginal candidiasis, chlamydia cervicitis, bacterial vaginosis, & cervical carcinoma cause vaginal discharge
    • Other noninfectious causes of discharge
      • Retained foreign body-tampon, pessary
      • Ulcerations-tampon induced, lichen planus
      • Malignancy-cervical, vaginal
      • Postmenopausal atropic vaginitis, postradiation vulvovaginitis
vaginal conditions1
Vaginal Conditions
  • Pediatric
    • Sexual abuse should always be considered in prepubertal children

with vaginal discharge

    • Routine STD cultures in girls with a history of sexual abuse

Vaginal culture for gonorrhea and chlamydia should be performed

    • Vulvovaginitis
      • Usually caused by multiple organisms in perineal area
      • Single organism, streptococcus or Shigella, may be causative
      • Treatment

→ Hygienic and cleansing measures

→ Short-term (<4 weeks) course of topical estrogens

& broad-spectrum antibiotics

vaginal conditions2
Vaginal Conditions
  • Adolescence and older
    • Toxic shock syndrome (TSS)
      • Associated with tampon use

& vaginal Staphylococcus aureus-produced exotoxins

      • Fever, hypotension, a diffuse erythroderma with desquamation of the palms & soles, plus involvement of at least three major organ systems
      • Vagina : mucous membrane inflammations
vaginal conditions3
Vaginal Conditions
  • Adolescence and older
    • Fibroepithelial polyps
      • Polypoid folds of connective tissue, capillaries, and stroma covered by vaginal epithelium
      • Excision
    • Cysts of embryonic origin
      • From mesonephric, paramesonephric & urogenital sinus epithelium
    • Gartner’s duct cysts
      • Mesonephric origin
      • Usually present on lateral vaginal wall
vaginal conditions4
Vaginal Conditions
  • Adolescence and older
    • Vaginal adenosis
      • The presence of epithelial-lined glands within the vagina
      • Associated with in utero exposure to diethylstilbestrol
      • No therapy is necessary
    • Bulging lesion of the vagina & vulvar area
      • Associated with symptoms of pressure or discomfort
      • Most common cause : cystocele, rectocele, or urethrocele