1. Conditions affecting the vulva and vagina Dr Hiba Ahmed Suhail M.B. Ch. B./F.I.B.O.G. College of medicine University of Mosul

2. The importance of good history is vital to make the diagnosis in any patient presented with vulval symptoms ; the important area to cover are :
Presenting symptoms{ pain ; itching ; lump ; superfacial dyspareunia } whether symptom constant or intermittent; any triggering factors.
Previous treatment and the response.
Dermatological history { personal and family history }.
Gynecological history { any relation to menstruation; cervical smear abnormality }.
Any history of STD ;vaginal discharge or dyspareunia.
Any medical disease { IBD ; auto immune disease }.
Medication.

3. Examination:
It should be approached systematically including examination of eye ; oral cavity; skin scalp; nail; flexural site ; joint and local examination of the vulva; vagina and cervix.
Inguinal lymph node.

4. Investigations :
In some case diagnosis made on clinical appearance ; but investigations done to confirm the diagnosis:
Microbiological swab for viral bacterial and yeast culture if there is discharge or suspect STD.
Colposcopic examination of vagina and cervix.
Patch testing when there is possibility of allergic contact dermatitis.
Biopsy.

5. Treatment : Treat the underlying cause. Remove the allergin.
Topical or systemic therapy like steroid or immune suppressive agent.
Improve the hygiene.
Drugs ( antibiotics, antifungal , antiviral )

6. Conditions affecting vulva
Inflammation (eczema, psoriasis , lichen simplex , lichen planus and lichen sclerosis ).
Infection (viral , bacterial , fungal , parasite like lice and scabies and thread worm.
Vulvar ulcer ( aphthous , herpes gentalis , primary syphilis , Behcets disease , Lymph granuloma venereum , chancroid , T.B , Crohns disease and malignant ulcer ).
Vulval lump ( Bartholins cyst and abscess , vulval hematoma , cndylomata acuminata , lipoma , fibroma , hemangioma and inguino labial hernia malignant lump ).
Pruritis vulvae.
Vulval intraepithelial neoplasia ( VIN ).
Vulval cancer.

7. Pruritus vulvae
Many conditions can leading to pruritus and scratching :
Local causes like infection , inflammation , irritation by chemicals, urine in case of urinary incontinence, premalignant condition ( VIN ), malignancy (vulval cancer ).
Systemic disease such as Diabetes, hematological, renal and liver disease and lymphoma.
Psychological disorder .
Treatment:
Treat the underlying accordingly, remove any triggering factors, stop further skin damage by scratching ,topical steroid therapy.

8. Vulval lumps Bartholin’s cyst:
Bartholins glands is two glands located on both sides of the introitis and it is duct opens on the lower third of the labia minora on both side of the introitis.
When one or both the ducts of the gland are blocked for any reason like a thick secretion so retention of non infected mucous within the gland causing swelling which is usually painless apart from discomfort it is developed gradually it is not associated with vaginal discharge usually not tender unless when it change to abscess , it treated by marsupialisation.

9. Bartholins abscess:
it is presented usually as a unilateral painful and tender swelling due to pus collection with sign of inflammation, there is history of vaginal discharge.
The most common organism are gram negative gonococci in addition to other organism like strepto and staphelococci or anaerobic.
It treated by marsupialisation with antibiotics and pus send for culture and and biopsy if recurrence or in older woman .

10. Vulval Intra epithelial Neoplasia :
Is also un common pre invasive condition of the vulva.
VIN in younger woman is strongly associated with oncogenic HPV other risk factors is lichen sclerosis.
It may be asymptomatic the most common symptom is soreness, pruritus , it is most commonly affect labia minora and perineum and may extend to anal mucosa.
Lesion either multi focal and have a variety of appearances.
Diagnosis examination with good light , colposcopy and biopsy from lesion.
Lesion graded 1-3 , low grade lesion can observed , VIN3 lesion can be treated by local excision or laser vaporization.
Long term follow up is essential because there is high recurrence rate.

11. Vulval cancer
Is a disease primarily of old age group years An increasing proportion presenting in women below 50 years so this diagnosis must always kept in mind Incidence remain steady 1% Histological type : Squamous cell carcinoma 90-95% Melanoma 2nd most common 5-10% Adenocarcinomas can arise from Bartholins and also in conjunction with Pagets disease Basal cell carcinomas }both are rare Verrucous carcinomas }

12. Aetiology:
Vulval intra epithelial neoplasm is associated with vulval ca and VIN3 is a pre invasive condition to vulval ca , HPV type 16 and 18 are found in 40 % of vulval ca and 80% - 90% of this ca found in women below 50 years.
Lichen sclerosis.
Pagets disease of vulva is a rare form of VIN.

13. Presentation : Assessment: Vulval sorness and itching.
Vulval mass ]asymptomatic
]painful
]bleeds
Enlarged groin mass.
Warty lesion.
Assessment:
When women presented with vulval symptoms ; a full clinical examination with palpation of groin Ln.
Full thickness biopsy from the lesion{excisional or incisional}under GA or LA for histopathological diagnosis and depth of invasion.
Cervical and vaginal examination for any co –existing lesion.
CT scan ;MRI to asses pelvic Ln involvement.

14. Pattern of spread :
Local involving urethra; vagina; rectum; perineum and pubic bone.
Lymphatic follows lymphatic drainage pattern of vulva ; including superficial inguinal Ln ; deep femoral Ln and pelvic Ln.
Hematogenous in advance and recurrent Ln.

15. Treatment : Surgery ;Radiotherapy ;Chemotherapy.
Surgery either radical local excision of lesion with 1 cm safe margin.
Radical vulvectomy with bilateral inguinal lymph adenectomy.
Radiotherapy For the vulval lesion or for regional lymph node

16. Conditions affecting vagina:
Vaginal discharge
Vaginal trauma.
Vaginal lump.
Vaginal atrophy.
Fistula.
Endometriosis.
Va IN.
Vaginal cancer.

17. Normal vaginal discharge:
The normal vaginal discharge consist of transudate through the vaginal wall ( contain no glands ) , cervical and endometrial gland secretion.
Normally its watery, or white in colour odourless varies in amount depending on hormonal status causing no itching.

18. Factors associated with increase vaginal discharge:
1) Physiological causes.
Mid cycle, pregnancy, use of oral contraceptive.
Cervical ectropion.
2) Vaginal infection ( candidiasis, bacterial vaginosis, and trichomonal infection, viral infection, gonococal infection ( only in prepubertal and postmenopausal )).
3) Atrophic vaginitis.
4) Vaginal trauma ( foreign bodies ).
5) Fistula.
6) Malignancy.

19. Vaginal trauma
This may follow: 1) Vaginal delivery 2) Chemical irritation ( douches , lubricants , topical intra vaginal preparations ). 3) Foreign bodies insertion ( articles by child or mentally retarded patient , tampons ). 4) Iatrogenic ( for induction of labour and abortion like laminaria ,catheter , vaginal packs during surgery, pessaries for prolapse treatment, local contraceptive device).

20. This may lead to alteration of vaginal PH and microbiology , damage of the epithelium , vaginal muscle wall resulting in to infection and bleeding, perforation of the vaginal and affect nearby organs like bladder and rectum causing fistula.
Presentation offensive profuse vaginal discharge, with abnormal vaginal bleeding.
Treatment:
It respond to with drwal of the causative agent, then treat condition accordingly.

21. Vaginal atrophy
Usually associated with decrease estradiol levels, it most often seen in:
Prepubertal
During lactation
Premenopausal woman
Post menopausal women
Using of anti estrogenic drugs

22. The normal protective thickness and PH of the vaginal epithelium depend on estrogen stimulation
Clinical presentation:
Vaginal bleeding .
Vaginal discharge.
Infection by local Gram positive or Gram negative organism.
Vaginal dryness.
Dyspareunia.

23. On examination Diagnosis
Vagina is often pale , thin , punctate hemorrhagic spots and echemosis loss of rugal fold of vagina.
Diagnosis
It suspect in hypo estrogenic women presented with previously mentioned symptoms.
Vaginal PH > 4.5 .
Vaginal infection is not identified usually on wet mount preparation.

24. Treatment Local ( intra vaginal ) estrogen cream.
Hormonal replacement therapy may be given
symptoms respond to short term therapy but recur on dis continuation , but change in tissues require long term therapy ( 3-4 months ).

25. Fistula
It is an abnormal tract connecting between genital tract epithelium and other epithelial tissue.
Trauma ( foreign body in the vagina ).
Child birth ( obstructed labour , tear in vagina or episiotomy or in adequate repair ).
Gynecological surgery ( fistula involving bladder, ureter, and rectum ).
Malignancy.
Cohn's disease.

26. Benign Vaginal tumours
Uncommon , occur within vaginal wall , it include myoma, fibroma, neurofibroma, papilloma, myxoma, adenomyoma , vaginal adenosis and remenent of mesonephric duct.

27. Endometriosis
Deposition of the endometriosis can be found beneath the vaginal epithelium following surgery or episiotomy.
They may cause vaginal bleeding or pain.
Easily identified while bleeding or having bluish appearance if not bleed.
Treated by:
Drug.
Laser vaporization.
Excision.

28. Vaginal Intraepithelial Neoplasia VaIN:
It is pre invasive disease of vagina
Extremely rare ( 150 times less than CIN ) , because the vaginal epithelium is more stable so it affected for the lesser extend by oncogenic HPV.
In 70 % of VaIN there will be CIN.
The risk factors is similar to that of CIN.
Most common cause is oncogenic HPV (16,18and 33), and in utero exposure to DES.
It graded 1-3.
Diagnosed by Pap smear , colposcopy and biopsy
Treatment low grade lesion can observed , high grade lesion can be treated by surgical excision , destructive procedure , radiotherapy is also an alternative in woman not suitable for surgery

29. Vaginal cancer : Is account for 1-2% of all gynecological tumour.
Age between years.
Histological type :
Squamous cell ca about 85% usually located in the upper posterior half of vagina.
Adeno carcinomas commonly in young age group.
Melanoma[rare].
Sarcoma[rare].
Clear cell ca [due to in utero exposure to DES diethylstilbestrol].
Metastatic tumour from cervix ; uterus ; ovary and choriocarcinoms.

30. Aetiology : Presentations :
As in cervical and vulval ca ; HPV virus especially type 16 and 18 play a role in pre invasive vaginal intra epithelial neoplasia VaIN which is frequently seen with CIN either as an isolated lesion or as a lateral extension of CIN.
Presentations :
Asymptomatic because of the elasticity of vaginal wall ; tumour may reach large size before they symptomatic.
Bloody vaginal discharge [most common].
Post coital bleeding.

31. Diagnosis Speculum examination.
Colposcopic examination of the cervix and vagina with 5%acetic acid.
Full thickness biopsy of the lesion to confirm the diagnosis and for staging [ which depend on depth of invasion].
MRI of pelvis to determine the extend of tumor and spread to pelvic Ln.

32. Staging of vaginal cancer :
Stage I invasive cancer confined to the vaginal mucosa.
Stage II subvaginal extension not involving the pelvic side wall.
Stage III extends to pelvic side walls.
Stage IVa extends to mucosa of bladder &rectum
Stage IVb spread beyond the pelvis.

33. Treatment : Five year survival rates:
Radiotherapy [external and internal radiation] and has advantage of vaginal preservation.
Vaginal cancer is treated with surgery [ local excision or excision with hysterectomy ].
Five year survival rates:
Stage 1 is 80%-90%
Stage 2 is 60%
Stage 3 is 40%
Stage 4 is 10%