1. Diseases of the Vulva Azza Alyamani Department of Obstet. & Gynecol.

2. Vulvo-vaginal problems are among 10 leading disorders encountered by primary care clinicians. * Benign lesions of the vulva are mentioned in three categories : 1. Epithelial conditions. 2. Benign neoplastic disorders. 3. Dermatologic disorders. * VIN * Cancer vulva

3. Benign Conditions
of the Vulva

4. (1) Epithelial Conditions
1) Lichen simplex .
2) Lichen sclerosis.
3) Lichen planus,
erosive lichen planus.

5. 1) Lichen Simplex “ squamous cell hyperplasia “
* it is a local thickening of the epithelium resulting
from a prolonged itching .
* symptoms :
pruritus and pain.
* signs :
white or reddish thickened ,leathery ,raised surface.
usually discrete lesion but may be multiple.
* treatment :
• moderate-strength steroid ointment.
• antipruritic agent.

6. lichen simplex

7. * it is a chronic progressive disease which constrict
2) Lichen Sclerosis
* it is a chronic progressive disease which constrict
and destroy the normal genital anatomy . In the
long term ,labia minora are lost ,labia majora
flatten ,clitoris becomes inverted .
* frequently found on the vulva of postmenopausal
women & can involve all the genital area from
mons to the anal area.

8. * combinations of lichen sclerosis & epithleal
hyperplasia or carcinoma are possible.
* symptoms:
intense pruritus , dyspareunia and burning pain.
* signs:
thin inelastic atrophic skin ,white with a crinkled ,
tissue paper appearance.

9. * diagnosis:
multiple biopsies is necessary.
it reveals a thin atrophic epithelium with
inflammatory cells lining the basement
membrane.
* treatment:
● potent topical steroids. 80% of lesions respond.
long term therapy with low potent steroids may
be necessary.
● other local treatments are: esrtogen cream and
anaesthetics.

10. lichen sclerosis advanced

11. 3) Lichen planus * it is a purplish ,polygonal papules that may
appear in their erosive form.
* it involve the vulva ,the vagina and the mouth
( vulval – vaginal –gingival syndrome ).
* symptoms:
vulval burning , severe dyspareunia when
vaginal stenosis develop in advanced stages.
* treatment:
topical and systemic steroids .

12. erosive lichen planus lichen planus
of vulva & vagina

13. (2) Benign Neoplastic condions
1) epidermal inclusion and sebaceous cysts.
2) vulvar varicosities.
3) fibromas and lipomas.
4) clitoromegaly.

14. 1) epidermal inclusion & sebaceous cysts
* they are nontender , mobile , spherical ,slow
growing cysts located below the epidermis.
* sebaceous cysts are firmer bec. they are
filled with dry caseous material.
* treatment :
most of inclusion cysts require no ttt. if they
are asymptomatic, or surgical excision.

15. 2) Vulval Varicosities Can enlarge especially during pregnancy
to cause discomfort and carry a possible
risks for rupture or thrombosis.

16. 3) Fibromas and Lipomas Fibromas:
* are the most common benign solid tumors
that arise in the deeper connective tissue
of the vulva.
* they are slow growing 1–10 cm in diameter,
but may become huge .
Lipomas:
* slow growing tumors composed of adipose
cells.

17. Vulval Fibroma

18. 4) Clitoromegaly * may develop after birth in response to
excessive androgen exposure . It is a sign
virillization.
* diagnosed when the clitorial length exceeds
30 mm or the width at the base exceeds
10 mm.

19. clitoromegaly

20. ( 3) Dermatologic Disorders
1) Psoriasis.
2) Behcet ′s syndrome.
3) Crohn ΄s disease .
4) Acanthosis nigricans .

21. 1) Psoriasis appears velvety but lack the characteristic
scaly patches found on the knees & elbows.

22. * ulcers in the vulval , oral and ocular areas.
2) Behcet ′s syndrome
* ulcers in the vulval , oral and ocular areas.
* genital lesions can result over time in a scarred
vulva.
* etiology : is unknown.
* diagnosis : based on the concurrence ulcers in
vulva ,mouth & ocular involvement ,the
recurrent nature of the disease and exclusion
of syphilis and Crohn’s disease.
* treatment : no effective ttt.

23. oral ulcer vulvar ulcer
Behcet′ s disease

24. * vulval ulcers can precede the development of GIT ulcerations .
3) Crohn’s disease
* vulval ulcers can precede the development
of GIT ulcerations .
* vulval ulcers are slit-like or knife – cut ulcers
with prominent edema. Draining sinuses and
fistulas to the rectum may occur.

25. 4) Acanthosis nigricans * most commonly found in the axilla or the
nape of the neck then vulva.
* characterized by its darky pigmented
velvety or warty surface .
* etiology : related to insulin resistance.

26. * uncommon 5 % of female genital tract malign.
Vulval Neoplasms
Introduction
* uncommon 5 % of female genital tract malign.
most tumors are squamous cell carcinomas ,may
be melanomas , adenocarcinomas and sarcomas.
* postmenopausal women ,mean age 65 years.
* a history of chronic vulval itching is common.

27. Two different etiologic types of vulval cancers :
Epidemiology
Two different etiologic types of vulval cancers :
1. A less common type:
* in younger women .
* related to HPV infection and smoking.
* commonly associated with VIN .

28. 2. The more common type: * in old women .
* unrelated to HPV infection or smoking.
* concurrent VIN is uncommon.
* long standing lichen sclerosis is common.
5% of patients have +ve serologic tests for
syphilis , lymphogranuloma venereum
and granuloma inguinale.

29. Vulval Intraepithelial Neoplasia (VIN) 2 types of VIN :
1. squamous cell carcinoma in situ
VIN III or Bowen’s disease.
2. Adenocarcinoma in situ
VIN III or Paget’s disease.

30. Squamous cell carcinoma in situ: VIN III ( Bowen′s disease )
* mean age 45 years.
* symptoms:
50% asymptomatic.
itching is the most common symptom.
* signs:
most lesions are elevated ,white ,red ,pink ,
brown or grey in color.
20% of lesions are warty in appearance.

31. * diagnosis:
1.careful inspection of the vulva in bright
light and with the aid of a magnifying glass.
2. 5% acetic acid aceto white areas.

32. * treatment : 1. local superficial excision.
with margins of 5 mm are adequate.
2. skinning vulvectomy in extensive lesions.
3. laser therapy
if lesions involves the clitoris , labia minora
or perineal area.

33. Adenocarcinoma in situ
VIN III ( Paget′ s disease )
* occurs in white postmenopausal elderly women.
also occurs in the nipple area of the breast.
* 20% is associated with adenocarcinoma.
* symptoms:
itching and tenderness are common.
* signs:
well demarcated and eczematus with white
plaque like lesions.
* growth may progresses beyond the vulva to the
mons pubis ,buttocks & thighs.

34. * diagnosis histologically: adenocarcinoma in situ characterized by
large ,pale , pathognomonic Paget’ s cells,
typically located both in the epidermic and
in the adnexal structures.
* treatment:
1. local superficial excision.
with margins 5-10 mm.
2. laser therapy
in recurrences which are common.

35. Paget′ s disease

36. A. Squamous cell carcinoma
Invasive Cancer Vulva
A. Squamous cell carcinoma
* 90% of vulval cancers.
* symptoms:
• vulval lump or ulcer.
• long standing pruritus.
* signs:
• raised ,ulcerated ,pigmented or warty lesion.
however , ulceration is usually an early sign.
• most lesions occur on labia majora and labia
minora. Less common sites , the clitoris
or the perineum.
• 5% of lesions are multifocal.

37. squamous cell carcinoma of vulva

38. * spread : • direct extension
to adjacent structures as the vagina , urethra
and anus.
• lymphatic embolisation
inguino femoral nodes.
= initially to the superficial inguinal LN.
= then to deep femoral LN. located medial
to the femoral vein, LN of Cloquet′s is
the most common of this group.
=then spread occurs to pelvic nodes
especially the external iliac LN.

39. = LN metastases occurs 50% in cancer vulva.
5% of patients have metastases to pelvic
LN , usually 3 or more +ve unilateral
inguino femoral LN.
• hematogenous
occurs late to the lungs , liver and bone rarely
in the absence of lymphatic metastases.

40. FIGO Staging of Cancer Vulva
Tumor limited to the vulva or perineum or both ,and
2 cm or < in diameter ,and no nodal metastases.
as above + stromal invasion < 1mm.
as above + stromal invasion > 1 mm.
> 2 cm in diameter ,and no nodal metastases.
Tumor of any size with :
• adjacent spread to the urethra &/or vagina &/or
anus
• unilateral regional LN. metastasis or combination.
Stage I Ia Ib
Stage II
Stage III

41. Tumor invades any of the following pelvic :
upper urethra ,bladder mucosa ,rectal
mucosa ,pelvic bone or bilateral regional
node metastasis ,or a combination.
Any distant metastasis including pelvic
lymph nodes.
Stage IV
IVa
IVb

42. Management A) Early vulval cancer * Stage I a the midline lesions .
( penetration depth < 1mm below the basement
membrane & no nodal metastases )
radical local excision é surgical margins
1cm, patient do not need groin dissection.
* Stage I b & Stage II
( penetration > 1mm )
radical local excision +ipsilateral inguinal
femoral lymphadenectomy if the lesion is
unilateral and bilateral groin dissection in
the midline lesions .

43. B) Advanced vulval cancer
* Stage III
( involves the proximal urethra ,anus or rectovaginal
septum )
radical vulvectomy which includes a bowel,
urinary stroma or rectovaginal septum.
+ bilateral groin dissection.
Preoperative radiation or chemo-radiation should be
used to shrink the 1ry tumor ,followed by more
conservative surgical excision.

44. C) Positive lymph nodes
Radiation
used with > one nodal mico metastasis (<5mm),
or evidence of extra nodal spread .
postoperative radiation to both groins
and to the pelvis.
Prognosis:
= it correlate significantly with LN status.
with –ve nodes have a 5-ys survival rate is 90%.
with +ve nodes have a 5-ys survival rate is 50%.
= patient with no involved node have a good
prognosis regardless of stage.

45. Malignant Melanoma * the 2nd most common vulvar cancer.
* may arise de novo or from a preexisting nevus.
commonly involve labia minora or clitoris.
* occurs in postmenopausal white women.
* diagnosis :
any pigmented lesion of the vulva requires
excisional biopsy for histopathology.
* usually smaller lesions and tend to metastasized
early.

46. malignant melanoma of the vulva

47. * prognosis: correlates to the depth of penetration into the
dermis. The 5-ys survival rate is 30%.
* superficial lesion radical local excision alone
with margins of 1 cm, is adequate.
* deeper lesions 1 mm or > radical local
excision + ipsilateral inguinal femoral
lymphadenectomy.
* adjuvant therapy:
= nonspecific immuno stimulants.
= chemotherapy.
= vaccines.

48. Thank You