2The vulvaIs the part of the female genital tract located between the genitocrural folds laterally, the mons pubis anteriorly, and the anus posteriorly.Embryologically, it is the result of the junction of the cloacal endoderm, urogenital ectoderm, and paramesonephric mesodermal layers.This hollow structure containsLABIA MAJORALABIA MINORACLITORISVESTIBULEURINARY MEATUSVAGINAL ORIFICEHYMENBARTHOLIN GLANDSSKENE DUCTS.
4The vulvaDifferent epithelia, from keratinized squamous epithelium to squamous mucosa, cover the vulva.The labia minora are rich with sebaceous glands but have few sweat glands and no hair follicles.The epithelium of the vestibule is neither pigmented nor keratinized and contains eccrine glands.
5BENIGN LESIONS OF THE VULVA According to the International Society for the Study of Vulvar Disease (ISSVD) in 1989:Inflammatory diseases.Blistering diseases.Pigmentary changes.Benign tumors, hamartomas and cystsCongenital malformations.
17What is lichen?A fungus, usually of the class Ascomycetes, that grows symbiotically with algae, resulting in a composite organism that characteristically forms a crustlike or branching growth on rocks or tree trunks.
18In pathology….Any of various skin diseases characterized by patchy eruptions of small, firm papules.
19Lichen Sclerosus et Atrophicus Most patients are post-menopausal womenStenosis of the introitus develops
20Lichen Sclerosus et Atrophicus Note the white, parchment-like or plaque-like lesion
21Lichen Sclerosus et Atrophicus During early stages the patient may not have symptoms.Some patients develop intractable pruritusBurning and pain are less likely manifestations.Figure-of-8 or keyhole configuration.In late stages normal architecture may be lostatrophy of the labia minora, constriction of the vaginal orifice (kraurosis), synechiae, ecchymoses, fissures.Squamous cell carcinoma develops in 3-6% cases
22Lichen Sclerosus et Atrophicus Thinning of the surface epithelium with some hyperkeratosis.
23Lichen Sclerosus et Atrophicus EtiologyUnknown. A higher prevalence of the disease in postmenopausal women suggests hormonal factors, but this has not been confirmed.Studies identifying an infection are inconclusiveWeakly linked to autoimmune diseases and genetic factorsLocal factors (eg, trauma, friction, chronic infection and irritation)Recurrence near vulvectomy scars has been observed.
24Lichen Sclerosus et Atrophicus TreatmentPotent topical corticosteroidsTestosterone propionate is ineffective and has many adverse effectsClose follow-up -----epithelial cancer.
25Squamous HyperplasiaAssociated with a response to hormonal influences or exposure to exogenous irritantsPrecursor of squamous cell CA if cells are atypical
26Squamous HyperplasiaThis lesion produces hyperplastic thickening of the superficial squamous epithelium.This lesion is a precursor of squamous cell carcinoma of the vulva
27Squamous HyperplasiaNote the keratin horn cysts and the infiltrate of inflammatory cells at the base of the lesion.
28Squamous Hyperplasia ITCHING is a common symptom. If hyperkeratosis is not prominent, lesions may appear as reddish plaques.The clitoris, labia minora, and inner aspects of the labia majora are more commonly affected.Extensive lesions may result in stenosis of the vaginal introitus.
29itch-scratch-itch cycle. Squamous HyperplasiaEtiologyRepetitive scratching or rubbing from irritantsTreatment is aimed at halting theitch-scratch-itch cycle.
30Squamous Hyperplasia Treatment The same as lichen sclerosus General attention to proper hygiene.If the skin is moist or macerated, aluminum acetate 5% solution applied 3-4 times daily for minutes is beneficial.Systemic antihistamines or tricyclic antidepressantsRefractory lesions, intralesional injections of triamcinolone acetonide may be an alternative.
31lichen simplex chronicus Hyperkeratotic, usually ill-defined, grayish, thickened, and sometimes excoriated lesion.Usually located over the labia majora.Hyperpigmentation.Itching is always present and may be intense.
32lichen simplex chronicus Lichen simplex chronicus of the vulva is the end stage ofthe itch-scratch-itch cycle.The initial stimulus to itch may be:Underlying seborrheic dermatitis.IntertrigoTinea.Psoriasis.In most cases, the underlying cause is not evident and may have been transient vulvitis or vaginal discharge.Any itching disease of the vulva may become secondarily lichenified.
33lichen simplex chronicus Epidermal and epithelial hyperplasia,Hyperkeratosis.Fibrotic vertical streaks of collagen between the hyperplastic rete are present.
34lichen simplex chronicus TreatmentIncludes removal of irritants and/or allergensTopical application of mild-to-high–potency corticosteroids.Avoid soaps and cleansing agents other than aqueous cream.Discourage excessive cleaning of the genital area; use of hot water; overheating; and wearing of synthetic, rough, and/or tight clothing.Lichen simplex chronicus may be associated with underlying diseases (eg, Paget disease, Bowen disease)
35Lichen planus Three types: PapulosquamousErosiveHypertrophicMalignancy is possible in long-standing and ulcerative lichen planus.
36Lichen planus The papulosquamous form: Occurring as part of a generalized diseaseIs the most common and is characterized by:Flat-toppedPolyhedral,Violaceous, shiny, and itchy papules located on keratinized skin of the labia and mons pubis. Delicate and whitish reticulated papules may be present on the mucosa, but no atrophy or scarring is observed.
37Lichen planus The erosive form: Involves the mucous membranes of the mouth and vulvovaginal area and may be locally destructive, leading to atrophy and scarring.Synonyms include erosive vaginal lichen planus, desquamative inflammatory vaginitis, vulvovaginal-gingival syndrome, and ulcerative lichen planus.Itching is rare, but pain, burning, and irritation occur and may be responsible for dyspareunia and dysuria.
38Lichen planus The rare hypertrophic form: Resembling lichen sclerosus, manifests with extensive white scarring of the periclitoral area with variable degrees of hyperkeratosis.It may be very itchy.Extensive vaginal involvement may result in a malodorous discharge.Large denuded areas may become adherent, causing stenosis of the vaginal introitus and dyspareunia.Marked atrophy may develop with time.
39ID/CC. A 75 year old woman visits her gynecologist ID/CC A 75 year old woman visits her gynecologist for a routine checkup and is found to have white spots on her genitalia HPI She complains of slight outer vaginal itching but denies any postmenopausal bleeding, vaginal discharge, or drug intake PE Hypochromic macules on labia majora extending to perineum and inner thighs in patchy distribution with scale formation; skin is thickened
40Pruritus vulva Causes: General Examination Local examination: General PsychosomaticIdiopathicGeneral ExaminationLocal examination:SmearsCulture and sensitivityBIOPSY: KEYE’s Dermatological knife
41BENIGN LESIONS OF THE Vagina CYSTIC SWELLINGSSOLID TUMORSATROPHIC VAGINITISVAGINAL ADENOSIS
42Cystic swellings Gartner’s Cyst Epithelial inclusion cysts Dilatation of the Gartner’s (Wollfian) ductAnterior and lateral vaginal wallsEpithelial inclusion cystsEndometriomaUretheral diverticulum