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Vulvar Lesions

Vulvar Lesions. A.MALIBARY, M.D. Anatomy. Mons pubis Labia majora and minora Clitoris Vestibule Urethral meatus It covers and protects the entrance to the vagina, vestibule, and urethra. Vulvar Hygiene. Use mild, nondrying soap Washing underwear with mild soap and rinsing well

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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

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