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The Vulva.

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Presentation on theme: "The Vulva."— Presentation transcript:

1 The Vulva

2 Terminology

3 Normal Anatomy

4 Normal Anatomy

5 Symptoms your patients will tell you about
Pruritus (itch). General or just one spot Soreness: stinging / burning / pain Difficulty with sex Lumps

6 Causes of pruritus vulvae and/or pain
Candida albicans infection Irritant contact dermatitis Seborrhoeic dermatitis Psoriasis The three lichens: -Lichen simplex -Lichen sclerosus -Lichen planus

7 Candida albicans – vulvovaginal

8 Candida albicans – vaginal

9 Irritant contact dermatitis
Erythema Oedema Fissuring Soap, water, rubbing

10 Irritant contact dermatitis
Burn-like Glazed erythema Superficial erosions Oedema Faecal and urinary incontinence

11 Seborrhoeic dermatitis
Usually patient has it at other sites also Mons pubis and flexures May or may not be scaly Mild or absent symptoms

12 Seborrhoeic dermatitis

13 Causes of pruritus vulvae
Candida albicans infection Irritant contact dermatitis Seborrhoeic dermatitis Psoriasis The three lichens:

14 Vulval psoriasis

15 Vulval psoriasis

16 Causes of pruritus vulvae and /or pain
Candida albicans infection Irritant contact dermatitis Seborrhoeic dermatitis Psoriasis The three lichens: Lichen simplex Lichen sclerosus Lichen planus

17 Lichens All three cause similar skin change
The skin becomes thickened, pale, with increased skin markings [grooves]and fissures

18 Lichen Simplex Chronic irritation causes the skin change
Remove the irritant and the skin recovers

19 Lichen simplex Perineum - ?Candida Skin thickening Fissuring
Skin coloured Dyspigmentation common

20 Lichen simplex Unilateral, labium major
Due to rubbing because of intense itch Well-demarcated Skin thickening Increased skin markings Skin coloured Dyspigmentation common

21 Lichen sclerosus Probably an immune system disease
Itch: nil to very severe Soreness: nil to very severe Altered anatomy from tissue destruction Dyspareunia / apareunia because of symptoms or changed anatomy

22 The Itch of lichen sclerosus
Mainly the labia minora, clitoral hood and/or perineum Perianal in 50% Extragenital in 15%

23 Who gets Lichen Sclerosus
Most are 50 years or older but children and teenagers may be affected May have other associated autoimmune conditions 25% thyroid antibodies; 10% psoriasis

24 LS and VIN Lichen Sclerosus is associated with pre malignant change
VIN, Vulval Intraepithelial neoplasia VIN untreated may become SCC

25 Lichen sclerosus Distribution: figure of 8 with wings
Usually bilateral Colour – white,crinkly (‘cigarette-paper’) Sclerosis – firm

26 Lichen sclerosus White, like vitiligo Anatomic change
Loss of labia minora

27 Lichen sclerosus Distorted clitoral hood and labia minora
Postinflammatory white areas Postinflammatory brown pigmentation

28 Lichen sclerosus Resorption of labia minora
Fissures in the labial sulcus and onthe perineum

29 Lichen sclerosus Flattening of clitoral hood
Resorption of labia minora Haemorrhages

30 Lichen sclerosus Flattening of clitoral hood
Resorption of labia minora

31 Lichen sclerosus Severe introital narrowing
Splitting of posterior forchette

32 Lichen sclerosus Bridging / fusion / agglutination of left and right labia Ulceration

33 Lichen sclerosus Distortion of labia minora Ulceration Haemorrhage

34 Lichen sclerosus Ulcer right labium minor

35 Lichen sclerosus Hyperkeratosis Consider biopsy

36 LS in a teenager

37 Psoriasis + lichen sclerosus
Psoriasis less symptomatic but more impressive Psoriasis ‘outside’ Lichen sclerosus ‘inside’ Psoriasis does not alter anatomic features

38 Lichen sclerosus: treatment
Ultrapotent topical steroid, usually clobetasol ointment Once daily until clear (one to three months) Then alternate days for the same duration Then once or twice per week long-term or PRN Explain to patient precisely where to apply the ointment

39 Lichen planus Less common More painful Just as destructive
More likely to be seen on other parts of the patient Two types: cutaneous and mucosal

40 Lichen planus: cutaneous type
Violaceous plaques Wickham’s striae Labia majora Irregular distribution

41 Lichen planus: mucosal type
May be very itchy More often very painful Very tender to touch Destructive – loss of clitoral hood, labia minora May cause introital narrowing More likely to involve vagina (unlike lichen sclerosus) May also affect oral mucosa Buccal mucosa, inner lips, tongue Desquamative gingivitis

42 Erosive lichen planus Red glistening painful mucosal patch
Loss of labia minora

43 Erosive Lichen Planus

44 Erosive lichen planus

45 Erosive lichen planus Mucosal disease may result in postinflammatory pigmentation

46 Erosive lichen planus Destruction of tissue Introital narrowing
Eaten-away appearance

47 Erosive lichen planus: treatment
Topical clobetasol daily May be required daily long-term Topical calcineurin inhibitors, e.g., pimecrolimus cream Oral prednisone Methotrexate Often symptoms respond better than signs

48 Plasma cell Vulvitis Much less common Much less destructive
Often asymptomatic

49 Plasma cell vulvitis Deeper red than LP More internal More patchy
Haemorrhagic More internal More patchy

50 Plasma cell vulvitis May extend periurethrally Contact bleeding

51 Plasma cell vulvitis: treatment
Topical antibiotic Clindamycin cream Metronidazole cream Hydrocortisone cream

52 Symptoms your patients will tell you about
Pruritus (itch). General or just one spot Soreness : stinging / burning / pain Difficulty with sex Lumps

53 Lumps that might not cause symptoms
Frightening things Not so frightening things

54 Pre malignant and Malignant lesions
Vulval intraepithelial neoplasia, VIN Invasive squamous cell carcinoma Melanoma

55 Vulval intraepithelial neoplasia
This is a pre malignant lesion Mild or no symptoms but does have signs Two types: Usual and Differentiated Usual VIN = HPV related Differentiated VIN = Lichen sclerosus or lichen planus related – more likely to become an aggressive SCC

56 HPV Human Papilloma Virus
Low risk and High risk, but HrHPV types are associated with cancers in many parts of the body: cervix, vagina, vulva, anal canal, mouth. Sexually transmitted Vaccine ENT surgeons now very interested

57 VIN

58 VIN

59 VIN

60 VIN + Lichen sclerosus

61 Invasive squamous cell carcinoma
Arises within VIN [HPV or lichen sclerosus] Irregular, hard nodule, often ulcerated May be multifocal Often aggressive

62 Invasive squamous cell carcinoma

63 Invasive squamous cell carcinoma

64 Melanoma Rare Not related to fair skin or sun exposure
Mild or no symptoms

65 Vulval melanoma

66 Melanoma

67 Less frightening things
You will often notice lumps or bumps Ask about them The patient may be waiting to see if you think its abnormal.

68 Sebaceous Cyst

69 Vaginal Wall prolapse

70 Prolapse

71 Varicosities

72 Genital Warts

73 Others Urethral caruncle Bartholin’s cyst Asymmetrical labia

74 Bartholins cyst

75 Urethral caruncle

76 It’s a very private area
Our perception of our vulva is effected by: Culture Religion Age Education Marital status Sexual experiences Facebook

77 Vulval Disease Most women present late, and very distressed
They often feel guilt or ashamed They always feel embarrassed They worry it’s an STI If there is a lump they think it’s a wart Results of surveys of the impact of vulva disease are alarming

78 Vulval disease Any one of the conditions I have discussed today, even the most innocuous will disrupt their sex lives no matter their age. Patients can become very socially isolated and their relationships severely altered. There is usually something we can do to help

79 Vulva Sign


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