Vulvar Lesions

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Vulvar Lesions

• Anna Mae Smith, MPAS, PA-C
• Lock Haven University
• Physician Assistant Program

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Anatomy

• Mons pubis
• labia majora and minora
• clitoris
• vestibule
• urethral meatus
• It covers and protects the entrance to the
  vagina, vestibule, and urethra.

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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

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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).

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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

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Carcinoma in situ
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Histopathology of Vulvar Neoplasia

• Squamous
  86
• Malignant melanoma 5
• Sarcoma
  2
• Basal Cell
  1.5
• Adenocarcinoma 1
• Pagets Disease 1
• Undifferentiated 4

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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,
  Bowens Dz hyperplastic vulvar dystrophy with
  severe stypia

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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

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Pagets 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

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Pagets Disease
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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

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Verrucous Carcinoma

• appears as condyloma
• does not respond to treatment for HPV

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Invasive Squamous Cell Carcinoma

• occurs when a woman is in her 60s and 70s
• presents with ulceration, friability, or
  induration of surrounding tissues

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Sarcoma

• occurs in women of all ages
• rapidly expanding, painful mass

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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

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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

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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

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Treatments

• Local - laser
• Invasive - total vulvectomy nodes

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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

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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 - Burrows solution soaks x 30 mins
  tid steroid cream, po antihistamines

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Noninfectious , contd

• Vestibular adenitis
• Psoriasis
• Seborrheic Dermatitis

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White Lesions/ Leukoplakia

• Hyperkeratosis
• Depigmentation
• Absolute or relative avascularity

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Vulvar Dystrophy

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

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White lesions continued

• VIN - neoplastic, premalignant lesion

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Depigmented disorders

• Vitiligo - inherited, autosomal dominant
• Often progressive often associated with
  increased incidence of
• Addisons disease
• Thyroiditis
• DM
• Lymphoma
• Pernicious anemia

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Intertrigo

• Nonspecific hyperkeratotic epithelial reaction to
  inflammation in the skin folds

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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

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Dark Lesions contd

• 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

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Dark Lesions contd

• Neoplasms
• Reactive Hyperpigmentation
• Seborrheic keratosis

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Ulcerative Lesions

• VIRAL - HSV - 48 hrs to 7 days after initial
  contact
• Bacterial - Syphillis, Granuloma inguinal,
  pyoderma, cutaneous TB
• Inflammatory/noninfectious -
• Behcets Disease - oral genital ulcers
• Crohns Dz.
• Pemphigus Pemphigoid

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Inflammatory/noninfectious

• Hidradenitis Suppurativa
• Neoplastic

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Tumors

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

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Tumors 1 cm

• Inflammatory - Bartholins cyst/abscess,
  lymphogranuloma venereum
• Neoplasm - fibroma, lipoma, verrucous carcinoma,
  sq. cell carcinoma
• Hernia, Edema
• Hematoma
• Other - skin tag, epidermal cysts,
  neurofibromatosis, accessory breast tissue