DR.

SAIMA AZIZ SIDDIQUI

ASSISTANT PROFESSOR
OBSTETRICS &GNAECOLOGY(UNIT II)
DOW UNIVERISTY OF HEALTH SCIENCES.

OBJECTIVES
At the end of the lecture students should be able to:
Explain the anatomy of vulva.
Discuss clinical assessment; history & examination
Identify the normal Variants
Describe the pathology of Benign Tumors & Vulval intraepithelial
neoplasia.
Discuss the treatment of vulval carcinoma.

ANATOMY
VULVA includes
o Mons Pubis
o Labia majora
o Labia minora
o Clitoris
o Vestibule(of vagina)
o Bulb of vestibule
o Greater vestibular glands
 Tumors of vulva and vagina together account for less than 5% of
female genital tract cancers.

Many patients may presenting to gynaecology clinic have

dermatological problem rather than a gynaecological complaint. Thus it
is important to common skin conditions that affect vulva

CLINICAL ASSESSMENT
HISTORY

Sympathetic environment

Itching

Pain
Prescribed

Previous treatment OTC

Dermatological Psoriasis
Atopy

Gynaecological history

Relations with menstruation

History of cervical smear; CIN may be associated in patients with VIN

Sexual history

EXAMINATION

Examine in good light.

Approach systematically with general view of vulva, hair of labia

majora and Mons pubis.

Labia majora need to be separated for adequate visualization

 General view of hair

Skin colour, pigementary disturbance(vitiligo),inflammation

Skin texture; Abnormal thickness(Lichenification)

Skin surface; Integrity, excoriation, erosion

Palpation
Tenderness or underlying masses(cyst)
Examine labia minora and clitoral area
Vagina and cervix also to be examined in all mucocutaneous diseases and
VIN.
NORMAL VARIANTS
Angiokeratomas
Common
Usually seen on Labia
majora
Small red or purple vascular lesions with
overlyinghperkeratosis

HARTS LINE

Demarcates junction of keratinized and non keratinized epithelia of

labia minora
 VESTIBULAR PAPILLAE

Presence of filliform projections on inner labia minor and vestibule.

A common finding

Do not require treatment

Dewhurst text book of Obstetrics &Gynaecology- 8th edition

FORDYCE SPOTS

Small sebaceous papules on inner surfaces of Labia minora.

Can be seen on buccal mucosa as well

 NON-NEOPLASTIC DISORDERS

LICHEN SCLEROSUS
It is a destructive inflammatory condition with strong predilection for
genital skin.
Commonest condition affecting older women complaining of
prutitis(itch)

LICHEN SCLEROSUS
EPIDEMIOLOGY

Seen in both sexes, all sites & in all races but commonly affects white
women.
The peak ages for presentation are childhood and around or after the
menopause.
True incidence is unknown, prevalence has been estimated at
between 1 in 300 and a 1:1000 of the population

Dewhursts textbook of Obsterics&Gynaecology -7th edition.

Cause unknown; associated with autoimmune disorders, affecting

genetically predisposed individuals.

In a study 44% had significant auto-antibodies, 22% a family history

21% a further autoimmune disease

Affects vulva and peri-anal skin.

Dewhursts textbook of Obsterics&Gynaecology -7th edition.

LICHEN SCLEROSUS

Although there is undoubtedly an increased incidence of squamous cell

carcinoma in patients with lichen sclerosus. In practice the incidence is
well below 5%.
When pathological specimens of

squamous cell carcinoma are reviewed concomitant lichen sclerosus is

found in over 50 percent.

Dewhursts textbook of Obsterics&Gynaecology -7th edition

LICHEN SCLEROSUS
TREATMENT

Treatment of choice is super potent topicla corticosteroids; clobetasol

propionate.

Topical testosterone has no role.

The place of the newer non-steroidal anti-inflammatory

immunomodulatingtopicals (e.g. tacrolimus and pimecrolimus) is
debatable.

Inflammatroy disorder which can affect both skin and mucosal

surfaces.
 Cutaneous lesions are small purplish papules.

Erosive lichen planus; HLA DQ B1 0201 allelle implicated in specific

subtype of erosive mucosal LP, the VVG syndrom which affects vulva
vagna and gingiva.

Commonest form affecting genital skin. Vulval lesions affect inner

labia minora and vestibule where erythema and erosion occur. A lacy
white edge is seen Wickham striae

Malignancy has been reported in hypertrophic and classic types but

not in VVG syndrome.

Dewhursts textbook of Obstetrics &Gynaecology- Eighth edition

LICHEN PLANUS

LICHEN PLANUS
TREATMENT

Clobetasol propionate.

Emollients

INDICATIONS FOR BIOPSY

Difficulty in establishing clinical diagnosis.

All blistering disorders.

All pigmented lesions.

 Inflammatory lesions that do not respond to as expected to anti-
inflammatory drugs.

Persistently erosive lesions.

CYSTIC TUMORS

Bartholins Cyst
Arise from duct of Bartholins gland which is located in subcutaneous
tissue belwo lower third of labium majus.
Often infection supervenes and a painful abscess forms.
TREATMENT:Incision and marsupilization and antibiotic therapy.
 SOLID TUMORS

Commonest are condylomataacuminata(Warts) presenting as small

papules.

Clinical warts appear as tiny, cauliflower-like, raised lesions around the

opening of the vagina or inside the vagina.

Anogenital warts are caused by Human papilloma virus; more than 100
genotypes but commonly caused by 6,11

SYMPTOMS

Irritation and soreness especially around anus.

Disruption of urine flow and

Vulval Warts

TREATMENT
Depends on number, morphology, distribution of warts and patient
preference and pregnancy status.
NON KERATINIZED SOFT WARTS: podophyllin, Trichloracetic acid.
KERATIZED WARTS: Cryotherapy, excision, electrocautery.
Immiquimod; as 5% cream, it is immune response modifier.
Induces cytokine response, suitable for both keratinized and Non
keratinized warts.It is contraindicated in pregnancy.
 5 Flourouracil-5% cream, may cause sever local side effects.
Teratogenic so not inidcated in pregnancy.

VULVAL INTRAEPITHELIAL NEOPLASIA

VIN
Intraepithelial disease often presents wihpruritis vulvae, but 20-45%
are asymptomatic
Lesions ae often raised above surrounding skin And have rough
surface.
Colour variable; white , red or dark brown.
Full extent of abnormality is only apparent after 5 % acetic acid
application

Adequate biopsies must be taken from abnormal areas.

TREATMENT: Difficult

Consideration of young age of patients is important, as 40 percent of

women with VIN are younger than 41 years.

Spontaneous regression is possible in women with a variant

bowenoidPapillosis.

In patients younger than 50 years close observation with repeated

biopsies to keep a check on progression to invasive disease.
After exclusion of invasive disease flourianted topical steroids may
offer symptomatic relief.
Excision biopsy; if the lesion is small.
 Skinning vulvectomy; If the disease is multifocal or covers a wide
area skin graft may be necessary.
VULVAL CANCER
Cancer of vulva is rare & it accounts for <1% of all & 7 % of all
Gynaecological cancers diagnosed in female.

Incidence rate in U.K: 2.4 per 100000 of female population.

Incidence is 2-3 times higher in underdeveloped countries.

Its a disease of older age group; mostly occurs in women after

menopause with peak incidence between 65 and 75 years.

Dewhursts textbook of Obstetrics &Gynaecology- Eighth edition

An increasing proportion with disease presenting in women <50 yrs.

Rates of around 1 per 100000 in those aged 25 -44 years, rising to 3

per 100000 in those aged 45-64 years.

Peak at 13.2 per 100000 in 65 years or older.

The most common symptoms are a persistent itch or pain in the vulval
area.

1)Obstetrics&Gynaecology; An evidence based text for MRCOG- Second

edition
2)Dewhursts textbook of Obstetrics &Gynaecology. Eighth edition
AETIOLOGY

Certain preexisting vulvaldermatoses are associated with Vulval

carcinoma.

Vulval intraepithelial neoplasia is often found in association with vulval

cancer.
 (VIN III) is a pre invasive condition, its risk of progression is highly
variable

In women previously treated for VIN, risk is between 7 & 8 percent.

Whereas in untreated women progression rate was found to be 80 %
over 10 years.

Obstetrics &Gynaecology; An evidence based text for MRCOG- Second

edition

Approximately 40 percent of all vulval cancers are associated with

HPV type 16 and about 80 -90 % of these vulval cancers develop in
women under the age of 50 years.

Smoking may e an important co-factor in the development of HPV

related VIN and is linked with lower survival rate for women with
carcinoma Vulva.

Obstetrics &Gynaecology; An evidence based text for MRCOG- Second

edition

HISTOLOGICAL TYPES OF VULVAL CARCINOMA

Squamous Cell Carcinoma- 90 percent

Verrucuous carcinoma
Basal cell carcinoma
Malignant Melanoma
Adenocarcinoma- exceedingly rare
Carcinoma of Bartholins gland. Rare
Sarcomas- Rare
Metastatic tumours from cervix, endometrium, and renal carcinoma.
Pagets disease.
 PRESTING SYMPTOMS
Pruritis. 71%

Vulval lump swelling 58%

Vulval ulceration 28%

Bleeding. 26%

Vulval soreness 23%

Urinary tract symptoms 14%

Discharge 13%

SPREAD OF VULVAL CANCER

Spreads both locally and through lymphatics to Superficial inguinal

lymph nodes.

LOCAL SPREAD; Vagina, perineum, urethera, anal canal, clitoris. Skin

beyond vulva may be involved i.e Mons Pubis and thighs.

In late disease; bone involvement.

Lymphatic involvement of superficial inguinal, deep inguinofemoral and

pelvic lymph nodes.

Central vulvar structures drain bilaterally

Lateral structures drain to ipsilateral nodes.

 Hematogenous spread is uncommon.

DIAGNOSIS

Examination; palpation of groin nodes.

Full thickness biopsy which must include interface between normal
tissue and cancer.

Cervix must be examined to exclude cervical cancer.

CT or MRI of pelvis; if suspicion of inguinal node enlargement.
 TREATMENT

Treatment depends on site, size of lesion and relation to important

funtionalstructures

EARLY STAGE VULVAL CANCER

Surgery is the mainstay of treatment.

Primary lesion should be excised with 1cm of disease free margin.

Depth of invasion is the best predictor of risk of nodal involvement.

Microinvasivedisease(depth <1mm) wide local excision is sufficient.

LATERAL TUMORS; (2 cm lateral to a central line between clitoris and

anus) require ipsilateral lymph node dissection.

ADVANCED STAGE TUMORS;

When cancer has extended beyond vulva chemo and radiotherapy can be
used to shrink tumor volume in order to preserve sphincter function.
Triple incision technique is employed but with involvement of skin bridge
between tumour and lymph node a radical vulvectomy with en bloc
dissection should be considered.

Obstetrics and Gynaecology; An evidence based text for MRCOG. Second

edition

OTHER VULVAL CANCERS

Basal cell carcinomas and Verrucous carcinomas Wide

local excision as these are superficially invasive(depth <1mm)

Malignant melanoma Wide local excision

TREATMENT
Neoadjuvant Radiotherapy
Pre-operatively to shrink primary tumor size before surgery,
concomitantly with 5 flourouracil.
Adjuvant radiotherapy
i)Considered postoperatively in patients with close or positive tumor
margin.
ii)Nodal involvement with metastatic disease.

Radical Chemoradiotherapy with curative intent-

65 GyRadiotherpay with concurrent 5 Flourouracil or Cisplatin;
alternative to surgery in advanced squamous cell carcinoma.

TREATMENT RELATED MORBIDITY

SURGERY:

Wound break down.

Wound infection.

Lymphoedema.
KEY POINTS
Most vulval cancers present with soreness, pruritis or presence of a
mass or ulcer.
All suspicious lesions should be biopsied.
Primary spread is local and inguinofemoral.
Status of lymph node is a major determinant of clinical outcome.
Invasion > 1mm is associated with increasing rates of lymph node
involvement.

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