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Vulvar Lesions

Vulvar Lesions

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Vulvar Lesions

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  1. Vulvar Lesions A.MALIBARY, M.D.

  2. Anatomy • Mons pubis • Labia majora and minora • Clitoris • Vestibule • Urethral meatus • It covers and protects the entrance to the vagina, vestibule, and urethra.

  3. Vulvar Hygiene • Use mild, nondrying soap • Washing underwear with mild soap and rinsing well • 100% cotton underwear • Avoid extra layers and tight slacks (unneeded medicines, tinted toilet tissue, all "feminine hygiene" products), excessive sweating without aeration, and public pools and hot tubs

  4. Vulvar Hygiene • It is important to be keenly conscious of what "aggravates" the skin. • A dermatologic cliche is to "dry wet lesions" (soaks and compresses) and "moisturize dry lesions" (creams and ointments).

  5. Vulvar Cancer • 4th most common site of gynecologic neoplasia • Squamous neoplasia most common type of neplasia • HPV (16,18) infections are most commonly associated with squamous cell changes of the vulva, vagina & cervix. However the vulva tends to be more resistant to Oncogenesis • Cigs are linked to the development of lower genital tract neoplasms

  6. Carcinoma in situ

  7. Histopathology of Vulvar Neoplasia • Squamous 86% • Malignant melanoma 5% • Sarcoma 2% • Basal Cell 1.5% • Adenocarcinoma 1% • Paget’s Disease 1% • Undifferentiated 4%

  8. Classification of VIN • VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia • VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia • VIN III - Severe dysplasia, carcinoma in situ, Bowen’s Dz; hyperplastic vulvar dystrophy with severe atypia

  9. Spread of vulvar Ca • Local growth with extension to the perineum, anus, urethra, vagina & pelvic bone • Lymphatics - inguinal & femoral nodes to the external iliac, common iliac, & para-aortic chains

  10. Paget’s Disease • Presents with extreme pruritus and soreness, usually of long duration • Red or bright pink, desquamated, exzematoid areas among scattered, raised, white patches of hyperkeratosis • Borders are well demarcated and raised

  11. Paget’s Disease

  12. Basal Cell Carcinoma • Very rare • Associated with a long history of pruritus • Occurs over the anterior two-thirds of the labia majora, with slightly elevated margins

  13. Verrucous Carcinoma • Appears as condyloma • Does not respond to treatment for HPV

  14. Invasive Squamous Cell Carcinoma • Occurs when a woman is in her 60s and 70s • Presents with ulceration, friability, or induration of surrounding tissues

  15. Sarcoma • Occurs in women of all ages • Rapidly expanding, painful mass

  16. Diethylstilbestrol (DES) Exposure • Used extensively in US during the 1940s and early 1950s to prevent miscarriage and premature births • Studies during the late 1950s proved its ineffectiveness • DES use continued through 1971 • Estimated 2 million women were exposed in utero

  17. DES Exposure Sequelae • structural changes • transverse vaginal and cervical ridges (cocks combs, collars, and pseudopolyps) • abnormally shaped uterine cavity • uterine hypoplasia • vaginal adenosis shows columnar epithelium on or beneath the vaginal mucosa; it is self-limiting and gradually disappears • clear-cell adenocarcinoma of the cervix or vagina may develop (incidence rises at age 15, and median age at diagnosis is 19 years • increased incidences of: • spontaneous abortion • ectopic pregnancy • premature cervical dilation • premature rupture of membranes

  18. Lesions • Often present with prurutis • Elevated above the skin • Gray, white , red or pigmented • May also look verrucous • INVASIVE- all the above plus ulcerated & bleeding

  19. Treatments • Local - laser • Invasive - total vulvectomy & nodes

  20. Vulvar Lesions • RED - neoplasm, inflammation, or atrophy • Inflammation- • Fungi - most common cause of red, nonulcerative, infectious lesion of the vulva • Folliculitis - secondary to Staph. Aureus may cause painful, itchy vulva

  21. Vulvar Lesions/ RED • Noninfectious • Reactive vulvitis - secondary to physical or chemical irritants such as detergents, dyes perfumes, spermicides, lubricants, hygiene sprays, podophyllin, saliva, semen. Mechanical trauma from scratching! • Treatment - Burrow’s solution soaks x 30 mins tid; steroid cream, po antihistamines

  22. Noninfectious , cont’d • Vestibular adenitis • Psoriasis • Seborrheic Dermatitis

  23. White Lesions/ Leukoplakia • Hyperkeratosis • Depigmentation • Absolute or relative avascularity

  24. Vulvar Dystrophy • Benign epithelial disorders • Lichen Sclerosis 70%, vulvar hyperplasia accounts for the rest • Biopsy is mandatory of any white lesion!!!

  25. White lesions continued • VIN - neoplastic, premalignant lesion

  26. Classification of VIN • VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia • VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia • VIN III - Severe dysplasia, carcinoma in situ, Bowen’s Dz; hyperplastic vulvar dystrophy with severe atypia

  27. Depigmented disorders • Vitiligo - inherited, autosomal dominant • Often progressive & often associated with increased incidence of • Addison’s disease • Thyroiditis • DM • Lymphoma • Pernicious anemia

  28. Intertrigo • Nonspecific hyperkeratotic epithelial reaction to inflammation in the skin folds

  29. DARK Lesions • Usually secondary to increase in melanocytes or melanin production • Must biopsy any dark lesion of the vulva! • Lentigo - most common - freckle - no malignant potential • flat, well circumscribed

  30. Dark Lesions cont’d • Nevi - moles. Localized collections of neural crest cells which are usually present from birth • Asymptomatic and rarely become malignant • 30% of all malignant melanomas develop from nevi • Biopsy all changes, bleeding, change I color, ulceration, sudden growth, satellite lesions

  31. Dark Lesions cont’d • Neoplasms • Reactive Hyperpigmentation • Seborrheic keratosis

  32. Ulcerative Lesions • VIRAL - HSV - 48 hrs to 7 days after initial contact • Bacterial - Syphillis, Granuloma inguinal, pyoderma, cutaneous TB • Inflammatory/noninfectious - • Behcet’s Disease - oral & genital ulcers • Crohn’s Dz. • Pemphigus & Pemphigoid

  33. Inflammatory/noninfectious • Hidradenitis Suppurativa • Neoplastic

  34. Tumors < 1cm • Inflammation - condyloma acuminata(HPV) Molluscum contagiosum • Cysts- epidermal inclusion, vestibular gland, mesonephric duct • Neoplasia - VIN, hemangioma, hidradenoma, neurofibroma, syringoma • Other - Accessory breast tissue, acrocordon, endometriosis, Fox-Fordyce Dz., Pilonidal sinus

  35. Tumors > 1 cm • Inflammatory - Bartholin’s cyst/abscess, lymphogranuloma venereum • Neoplasm - fibroma, lipoma, verrucous carcinoma, sq. cell carcinoma • Hernia, Edema • Hematoma • Other - skin tag, epidermal cysts, neurofibromatosis, accessory breast tissue