1. Benign diseases of the vulva, vagina and cervix

2. The vulva
Is 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 contains
LABIA MAJORA
LABIA MINORA
CLITORIS
VESTIBULE
URINARY MEATUS
VAGINAL ORIFICE
HYMEN
BARTHOLIN GLANDS
SKENE DUCTS.

4. The vulva
Different 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.

5. BENIGN 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 cysts
Congenital malformations.

6. Inflammatory diseases
Lichen sclerosus
Squamous cell hyperplasia (+/- atypia)
Lichen simplex chronicus (localized neurodermatitis)
Primary irritant dermatitis
Intertrigo
Allergic contact dermatitis
Fixed drug eruption
Erythema multiforme
Toxic epidermal necrolysis
Atopic dermatitis
Seborrheic dermatitis
Psoriasis
Reiter disease
Lichen planus
Lupus erythematosus
Darier disease
Aphthosis and Behçet disease
Pyoderma gangrenosum
Crohn disease
Hidradenitis suppurativa
Fox-Fordyce disease
Plasma cell vulvitis
Vulvar vestibulitis syndrome

7. Blistering diseases
Familial benign chronic pemphigus (Hailey-Hailey disease)
Bullous pemphigoid
Cicatricial pemphigoid

8. Pemphigus vulgaris
Erythema multiforme
Epidermolysis bullosa

9. Pigmentary changes Acanthosis nigricans Lentigo Melanocytic nevus
Postinflammatory hyperpigmentation
Postinflammatory hypopigmentation
Vitiligo

10. Benign tumors, hamartomas, and cysts
Hidradenoma
Lipoma
Chronic Inflammatory swellings
Hemangioma
Lymphangioma
Angiokeratoma
Pyogenic granuloma
Sebaceous gland hyperplasia
Papillomatosis
Bartholin cysts
Epidermal inclusion cyst (Dermoid cyst)
Endometriosis
Hydrocele of the canal of Nuck
Skene duct cyst
Seborrheic keratosis
Acrochordon (fibroepithelial polyp)
Fibroma, fibromyoma, and dermatofibroma

11. BENIGN LESIONS OF THE VULVA
BARTHOLIN’s CYST
ATROPHIC LICHEN (LICHEN SCLEROSUS ET ATROPHICUS)
SQUAMOUS HYPERPLASIA
LICHEN SIMPLEX CHRONICUS
HIDRADENOMA PAPILLIFERUM

12. Bartholin’s Cyst/Abscess
Medial to labia minor
Blockage of duct following infection
N. gonorrhea
Staphylococci
Anaerobes

14. Thomas Bartholin
Danish professor
In 1652 he gave the first full description of the human lymphatic system.

15. Marsupalization

16. lichen

17. What 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.

18. In pathology….
Any of various skin diseases characterized by patchy eruptions of small, firm papules.

19. Lichen Sclerosus et Atrophicus
Most patients are post-menopausal women
Stenosis of the introitus develops

20. Lichen Sclerosus et Atrophicus
Note the white, parchment-like or plaque-like lesion

21. Lichen Sclerosus et Atrophicus
During early stages the patient may not have symptoms.
Some patients develop intractable pruritus
Burning and pain are less likely manifestations.
Figure-of-8 or keyhole configuration.
In late stages normal architecture may be lost
atrophy of the labia minora, constriction of the vaginal orifice (kraurosis), synechiae, ecchymoses, fissures.
Squamous cell carcinoma develops in 3-6% cases

22. Lichen Sclerosus et Atrophicus
Thinning of the surface epithelium with some hyperkeratosis.

23. Lichen Sclerosus et Atrophicus
Etiology
Unknown. A higher prevalence of the disease in postmenopausal women suggests hormonal factors, but this has not been confirmed.
Studies identifying an infection are inconclusive
Weakly linked to autoimmune diseases and genetic factors
Local factors (eg, trauma, friction, chronic infection and irritation)
Recurrence near vulvectomy scars has been observed.

24. Lichen Sclerosus et Atrophicus
Treatment
Potent topical corticosteroids
Testosterone propionate is ineffective and has many adverse effects
Close follow-up -----epithelial cancer.

25. Squamous Hyperplasia
Associated with a response to hormonal influences or exposure to exogenous irritants
Precursor of squamous cell CA if cells are atypical

26. Squamous Hyperplasia
This lesion produces hyperplastic thickening of the superficial squamous epithelium.
This lesion is a precursor of squamous cell carcinoma of the vulva

27. Squamous Hyperplasia
Note the keratin horn cysts and the infiltrate of inflammatory cells at the base of the lesion.

28. Squamous 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.

29. itch-scratch-itch cycle.
Squamous Hyperplasia
Etiology
Repetitive scratching or rubbing from irritants
Treatment is aimed at halting the
itch-scratch-itch cycle.

30. Squamous 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 antidepressants
Refractory lesions, intralesional injections of triamcinolone acetonide may be an alternative.

31. lichen 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.

32. lichen simplex chronicus
Lichen simplex chronicus of the vulva is the end stage of
the itch-scratch-itch cycle.
The initial stimulus to itch may be:
Underlying seborrheic dermatitis.
Intertrigo
Tinea.
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.

33. lichen simplex chronicus
Epidermal and epithelial hyperplasia,
Hyperkeratosis.
Fibrotic vertical streaks of collagen between the hyperplastic rete are present.

34. lichen simplex chronicus
Treatment
Includes removal of irritants and/or allergens
Topical 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)

35. Lichen planus Three types:
Papulosquamous
Erosive
Hypertrophic
Malignancy is possible in long-standing and ulcerative lichen planus.

36. Lichen planus The papulosquamous form:
Occurring as part of a generalized disease
Is the most common and is characterized by:
Flat-topped
Polyhedral,
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.

37. Lichen 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.

38. Lichen 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.

39. ID/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

40. Pruritus vulva Causes: General Examination Local examination: General
Psychosomatic
Idiopathic
General Examination
Local examination:
Smears
Culture and sensitivity
BIOPSY: KEYE’s Dermatological knife

41. BENIGN LESIONS OF THE Vagina
CYSTIC SWELLINGS
SOLID TUMORS
ATROPHIC VAGINITIS
VAGINAL ADENOSIS

42. Cystic swellings Gartner’s Cyst Epithelial inclusion cysts
Dilatation of the Gartner’s (Wollfian) duct
Anterior and lateral vaginal walls
Epithelial inclusion cysts
Endometrioma
Uretheral diverticulum

43. Solid Tumors
Fibromyoma
Condyloma accuminata
Bilharzial polyps

44. Atrophic vaginitis Thinning and atrophy of vaginal epithelium
Most common in postmenopausal women with low estrogen levels
Dyspareunia and vaginal spotting (differential includes uterine cancer)

45. Vaginal Adenosis
Persistent Mullerian columnar epithelium in the anterior wall and upper 1/3 of vagina
Manifestation of maternal DES exposure
Red, granular patches
Precursor of clear cell adenocarcinoma

46. Vaginal Adenosis
Note the red granular patches on the vaginal mucosa on the left. The slide on the right shows glandular development.
Most patients are 7-35 years of age

47. BENIGN LESIONS OF THE cervix
CERVICITIS
EROSION
POLYPS

48. Inflammatory Lesions of the Cervix
Cervicitis (acute)
Symptoms: backache, bearing-down feeling in the pelvis, dull pain in the lower part of the abdomen, urinary tract symptoms

51. Erosion of the Cervix
Characterized by columnar epithelium replacing squamous epithelium, grossly resulting in an erythematous area
Causes:
Physiological:
Cervicitis: Acute or Chronic
Hormonal therapy

53. Erosion of the Cervix
Erosion of the cervix following delivery. A normal cervix is on the left

54. SMEAR Erosion of the Cervix If infection---- Treat cause
IF CIN  Manage according to stage

55. Chronic Cervicitis
Chronic inflammation, sometimes ulceration with repair, atypia or dysplasia, nabothian cysts from endocervical glands
Backache is a common symptom

56. Chronic Cervicitis Nabothian Cysts
Endocervical glands blocked by inflammation or scarring.

57. Chronic Cervicitis
Chronic inflammation underlies an area of cervical dysplasia

58. Endocervical Polyps Postcoital bleeding and irregular vaginal spotting
Inflammatory proliferations of cervical mucosa; not true neoplasms
Soft; may protrude through the cervical os