1. Vulvar Lesions
A.MALIBARY, M.D.

2. Anatomy Mons pubis Labia majora and minora Clitoris Vestibule
Urethral meatus
It covers and protects the entrance to the vagina, vestibule, and urethra.

3. Vulvar Hygiene Use mild, nondrying soap
Washing underwear with mild soap and rinsing well
100% cotton underwear
Avoid extra layers and tight slacks (unneeded medicines, tinted toilet tissue, all "feminine hygiene" products), excessive sweating without aeration, and public pools and hot tubs

4. Vulvar Hygiene
It is important to be keenly conscious of what "aggravates" the skin.
A dermatologic cliche is to "dry wet lesions" (soaks and compresses) and "moisturize dry lesions" (creams and ointments).

5. Vulvar Cancer 4th most common site of gynecologic neoplasia
Squamous neoplasia most common type of neplasia
HPV (16,18) infections are most commonly associated with squamous cell changes of the vulva, vagina & cervix. However the vulva tends to be more resistant to Oncogenesis
Cigs are linked to the development of lower genital tract neoplasms

6. Vulvar Dysplasia
Clinically, all these lesions appear as either red or white patches. These lesions are frequently multiple.

7. Carcinoma in situ

8. Histopathology of Vulvar Neoplasia
Squamous %
Malignant melanoma %
Sarcoma %
Basal Cell %
Adenocarcinoma %
Paget’s Disease %
Undifferentiated %

9. Classification of VIN
VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia
VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia
VIN III - Severe dysplasia, carcinoma in situ, Bowen’s Dz; hyperplastic vulvar dystrophy with severe atypia

10. Spread of vulvar Ca
Local growth with extension to the perineum, anus, urethra, vagina & pelvic bone
Lymphatics - inguinal & femoral nodes to the external iliac, common iliac, & para-aortic chains

11. Paget’s Disease
Presents with extreme pruritus and soreness, usually of long duration
Red or bright pink, desquamated, exzematoid areas among scattered, raised, white patches of hyperkeratosis
Borders are well demarcated and raised

12. Paget’s Disease

14. Basal Cell Carcinoma Very rare
Associated with a long history of pruritus
Occurs over the anterior two-thirds of the labia majora, with slightly elevated margins

15. Verrucous Carcinoma Appears as condyloma
Does not respond to treatment for HPV

16. Invasive Squamous Cell Carcinoma
Occurs when a woman is in her 60s and 70s
Presents with ulceration, friability, or induration of surrounding tissues

17. Sarcoma
Occurs in women of all ages
Rapidly expanding, painful mass

18. Diethylstilbestrol (DES) Exposure
Used extensively in US during the 1940s and early 1950s to prevent miscarriage and premature births
Studies during the late 1950s proved its ineffectiveness
DES use continued through 1971
Estimated 2 million women were exposed in utero

19. DES Exposure Sequelae structural changes
transverse vaginal and cervical ridges (cocks combs, collars, and pseudopolyps)
abnormally shaped uterine cavity
uterine hypoplasia
vaginal adenosis shows columnar epithelium on or beneath the vaginal mucosa; it is self-limiting and gradually disappears
clear-cell adenocarcinoma of the cervix or vagina may develop (incidence rises at age 15, and median age at diagnosis is 19 years
increased incidences of:
spontaneous abortion
ectopic pregnancy
premature cervical dilation
premature rupture of membranes

20. Lesions Often present with prurutis Elevated above the skin
Gray, white , red or pigmented
May also look verrucous
INVASIVE- all the above plus ulcerated & bleeding

21. Treatments
Local - laser
Invasive - total vulvectomy & nodes

22. Vulvar Lesions RED - neoplasm, inflammation, or atrophy Inflammation-
Fungi - most common cause of red, nonulcerative, infectious lesion of the vulva
Folliculitis - secondary to Staph. Aureus may cause painful, itchy vulva

23. Vulvar Lesions/ RED Noninfectious
Reactive vulvitis - secondary to physical or chemical irritants such as detergents, dyes perfumes, spermicides, lubricants, hygiene sprays, podophyllin, saliva, semen. Mechanical trauma from scratching!
Treatment - Burrow’s solution soaks x 30 mins tid; steroid cream, po antihistamines

24. Noninfectious , cont’d Vestibular adenitis Psoriasis
Seborrheic Dermatitis

25. White Lesions/ Leukoplakia
Hyperkeratosis
Depigmentation
Absolute or relative avascularity

26. Vulvar Dystrophy Benign epithelial disorders
Lichen Sclerosis 70%, vulvar hyperplasia accounts for the rest
Biopsy is mandatory of any white lesion!!!

27. White lesions continued
VIN - neoplastic, premalignant lesion

28. Classification of VIN
VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia
VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia
VIN III - Severe dysplasia, carcinoma in situ, Bowen’s Dz; hyperplastic vulvar dystrophy with severe atypia

29. Depigmented disorders
Vitiligo - inherited, autosomal dominant
Often progressive & often associated with increased incidence of
Addison’s disease
Thyroiditis DM
Lymphoma
Pernicious anemia

30. Intertrigo
Nonspecific hyperkeratotic epithelial reaction to inflammation in the skin folds

31. DARK Lesions
Usually secondary to increase in melanocytes or melanin production
Must biopsy any dark lesion of the vulva!
Lentigo - most common - freckle - no malignant potential
flat, well circumscribed

32. Dark Lesions cont’d
Nevi - moles. Localized collections of neural crest cells which are usually present from birth
Asymptomatic and rarely become malignant
30% of all malignant melanomas develop from nevi
Biopsy all changes, bleeding, change I color, ulceration, sudden growth, satellite lesions

33. Dark Lesions cont’d Neoplasms Reactive Hyperpigmentation
Seborrheic keratosis

34. Ulcerative Lesions
VIRAL - HSV - 48 hrs to 7 days after initial contact
Bacterial - Syphillis, Granuloma inguinal, pyoderma, cutaneous TB
Inflammatory/noninfectious -
Behcet’s Disease - oral & genital ulcers
Crohn’s Dz.
Pemphigus & Pemphigoid

35. Inflammatory/noninfectious
Hidradenitis Suppurativa
Neoplastic

36. Tumors < 1cm
Inflammation - condyloma acuminata(HPV) Molluscum contagiosum
Cysts- epidermal inclusion, vestibular gland, mesonephric duct
Neoplasia - VIN, hemangioma, hidradenoma, neurofibroma, syringoma
Other - Accessory breast tissue, acrocordon, endometriosis, Fox-Fordyce Dz., Pilonidal sinus

37. Tumors > 1 cm
Inflammatory - Bartholin’s cyst/abscess, lymphogranuloma venereum
Neoplasm - fibroma, lipoma, verrucous carcinoma, sq. cell carcinoma
Hernia, Edema
Hematoma
Other - skin tag, epidermal cysts, neurofibromatosis, accessory breast tissue