Dr.

Zainab Abdul Ameer

M.B.CH.B - F.I.C.O.G.
Embryologically:
Presenting features:
1.vulval pruritus
2.vulval pain, burning
3.lump
4.superficial dyspareunia
5.vulval ulcer
 HISTORY
1.A complete history of potential causes of vulvar
irritation, including creams, powders, soaps, type
of underwear, and cleansing techniques, should
be reviewed.
2. Sexual activity needs evaluation.
3.The use of :
 feminine hygiene products (eg, douching, soaps,
perfumes)
 medications (eg, pessaries, diaphragms, oral
contraceptive pills, antibiotics) can alter the
normal vaginal flora.
 EXAMINATION
A physical examination including :
1. inspection using magnifying glass of :
 all mucosal and skin surfaces, because many skin
conditions, such as psoriasis, seborrheic dermatitis,
pemphigus, and lichen planus, can affect the vulva.
 evaluation of vaginal discharge.
2. a colposcopy examination (i.e., “vulvoscopy,”
“vaginoscopy” is preferred, especially if a biopsy is to be
taken
 Investigations
In the initial assessment of a woman with vulval symptoms;
consider Investigation if clinically indicated for:
1. autoimmune disease
2. thyroid disease
3. diabetes mellitus may be associated with vulvar pruritus
or pain as a consequence of vulvovaginal candidiasis or, in
advanced cases, as a result of neuropathic pain.
4. sexually transmitted infections
5. Skin swab - to exclude secondary infection
6. Elevated serum levels of biliary salts, such as in biliary stasis or
primary biliary cirrhosis, may cause vulvar pruritus.
7. CBC=Hematologic disorders such as polycythemia or lymphoma
may be associated with systemic symptoms, including vulvar
pruritus
 8-Vulvar Biopsy
1. if the woman fails to respond to treatment
2. there is clinical suspicion of VIN or cancer.
3. Any vulva lesion :
 enlarging
 Pigmented lesions(changed color )
 changed appearance.
 raised lesions
 lesion associated white or thickened areas.
 ulcer or erosions persist.
with a punch biopsy forceps (Keyes) under local
anesthesia as an outpatient procedure.
Monsel’s solution (ferric subsulfate) is applied to control
bleeding
 Vulvar biopsy
Contraindications
1.Infected site
2.Coagulopathy
3.Allergy to local anesthetic
 VULVAL LICHEN SCLEROSUS
 It is an inflammatory dermatosis of
unknown a etiology.
 It affects the skin of the anogenital region in
postmenopausal women.
 There is an increased frequency of other
autoimmune disorders in females .
 incidence of is 3% .
 VULVAL LICHEN SCLEROSUS
Symptomes
This chronic disease often has the episodes of
spontaneous remissions and exacerbations
• vulva and perianal pruritus
• Dyspareunia if introital narrowing
• vaginal soreness
• Urinary symptoms including dysuria
 VULVAL LICHEN SCLEROSUS
Complications
 squamous cell carcinoma (SCC). <5%.
 VIN
 ( due to active disease or to the use of
potent topical steroid ) Reactivation of
latent viruses infections( Herpes simplex
virus (HSV) or Human papillomavirus
(HPV)
Signs:

1. Pale, white atrophic areas

affecting the vulva
2. thickened, fissures ,crinkled,
skin
3. Loss of architecture manifest
as loss of the labia minora
and/or midline fusion.
4. localised or in a ‘figure of eight’
distribution including the
perianal area
5. in atypical cases can be
hyperkeratotic
Dx:
the diagnosis can usually be made clinically
a biopsy should be performed mandatory
 Rx: treatment must then be individualized.
1.If asymptomatic no treatment is required
2.Daily Emollients Ointment base used as a soap
substitute.
3.She should avoid chemical or mechanical irritants
on the vulvar skin
4.Topical steroids Ointment according to severity
of itching then tapering(as clobetasol
propionate 0.05% )
5.reviewed at three months
Surgery:
Perineoplasty may be needed.:
• Vaginal dilatation
• surgical release of adhesions
 Lichen planus (LP)
Etiology
 It is an inflammatory condition of unknown
pathogenesis but it is probably an immunological
response by activated T cells.
 It is seen between 30 and 60 years of age.
 can affect :
1. the vulval skin(hair and nails, causing a scarring
alopecia and nail dystrophy)
2. oral cavity
3. genital mucous membranes
Clinical features
Symptoms
1. Can be asymptomatic
2. vulvovaginal pruritus
3. Soreness (burning pain)
4. Dyspareunia
5. Urinary symptoms
6. a blood-stained vaginal discharge.
7. postcoital bleeding.
8. Vaginal erosions can produce adhesion
 Signs
classified into three main
clinical presentation:
1. erosive(most common)=raw
red “erosions” on the vulva
with white lacy patterns
(known as Wickham striae).
vulvo-vaginal gingival
syndrome (VVG)
2. Papulosquamous=small
purple lesions
3. Hypertrophic=thickened
lesions
Diagnosis
1. The diagnosis is made on the characteristic
clinical appearance and involvement of the
vagina excludes LS
2. Biopsy should be performed if indicated
3. Histology =
 Lichen planus (LP)
Treatment
The risk of malignancy is low.
1) Topical steroids such as (clobetasol 0.05%)
2) Oral steroids can be used for severe flares
3) Vaginal corticosteroids:
4) Follow up At 3 months to assess response to treatment.
5) Surgical vulvo-vaginal adhesiolysis: for severe adhesions
 Vulval eczema (dermatitis)
1) Vulval allergic dermatitis
2) Vulval Contact(irritant) dermatitis (more frequent than
allergic)
3) seborrheic :in
 some immune disorders (e.g. HIV)
 neurological and psychiatric diseases (e.g. Parkinson’s
disease, epilepsy, depression)
 stress reactions
Symptoms
1. Vulval itch
2. Soreness

Signs
1. Erythema
2. Lichenification and excoriation
3. Fissuring
 Treatment
1.Avoidance of precipitating factor
2.Use of emollient soap substitute
3.Topical corticosteroid - depend on severity
4.A combined preparation containing
antifungal and/or antibiotic may be
required if secondary infection
5.Consider SSRI or antihistamine
 Genital psoriasis
Etiology:
 Psoriasis is a chronic inflammatory epidermal skin
disease affecting approximately 2% of the general
population.
 Genital psoriasis may present as part of plaque or
flexural psoriasis
 Genital psoriasis
Clinical features
Symptoms
Pruritus
Soreness
Dyspareunia
Signs
1. Well-demarcated brightly
erythematous plaques in the
vulva
2. Scaling is rare
3. Fissuring
4. Involvement of other sites, e.g.
scalp, umbilicus, nails
5. Secondary candidiasis and
streptococcal infection can
occur
Diagnosis=

The diagnosis is generally clinical as the

signs are characteristic.
Treatment
1. Avoidance of irritating factors.
2. Use of emollient soap substitute.
3. Topical corticosteroids – weak to moderately potent
topical steroids are preferred
4. antifungal and/or antibiotic may be required if
secondary infection is suspected and if there is active
fissuring
5. Systemic treatment may be required for severe and
extensive psoriasis.
 Lichen simplex chronicus
1. severe intractable vulval pruritus
2. erythema, swelling and lichenification.
3. Lichenified means the skin has become thickened
and leathery. This often results from frequently
rubbing or scratching the skin
4. associated with atopic eczema or psoriasis, where
chronic scratching leads to lichenification i.e.
thickened, slightly scaly, pale or earthy-coloured skin
with accentuated markings.
 Lichen simplex chronicus
Investigations : Skin biopsy for confirmation.
Hyperkeratosis
treatment is to
1. avoid any irritants
2. use of prescribed emollients and soap
substitutes
3. a sedating antihistamine (e.g. 10-50 mg 3
Hydroxyzine per day), may be prescribed for
reducing itch and its impact on sleep
4. ultrapotent topical steroids (clobetasol)
 Vulvar
intraepithelial
neoplasia (VIN)
 premalignant condition
 squamous intraepithelial lesions (SIL)
(previously vulvar intraepithelial
neoplasia (VIN)
Previous classifications
 squamous intraepithelial lesions
(SIL)

It is now classified as :

1. low grade (low-grade squamous intraepithelial
lesions, LSIL)
2. high grade (high-grade squamous intraepithelial
lesions, HSIL)
3. differentiated type (dVIN)
 Aetiology
LSIL=
 they have no malignant potential
 it may regress spontaneously
HSIL
 is associated with (HPV) infection, Type 16, 18,
31, 33, 35
 presents in younger women .
dVIN
 is associated with vulval lichen sclerosus and less
commonly lichen planus (particularly the
hypertrophic type)
 presents in an older age group.
 Clinical Features
Symptoms
1.Asymptomatic
2.Pruritus, burning
3. Pain
4.Dysuria
5.Discharge/bleeding
6.Vulvar ulcer
7.Difficult sexuality
8.Warty growth/lumpBurning
 Signs= very variable
HSIL =
 Younger patient with intermittent symptoms Solitary
white lesions
 erythematous or pigmented plaques, warty in
appearance.
dVIN=
 Older patient with chronic symptoms
 Multifocal may be difficult to differentiate from the
underlying lichen sclerosus (LS) but resistant to
treatment.
 They can be hyperkeratotic, erosive or ulcerated.
Complications
1.vulval squamous cell carcinoma
higher in the dVIN group 50% compared to HSIL
10%

2. Recurrent disease 30%

 Diagnosis
Biopsy.
 Multiple biopsies may be required as there is a
risk of missing invasive disease
 histology =
HSIL – There is disruption of the architecture,
high nuclear-to-cytoplasmic ratios

dVIN –acanthosis ,irregular elongation and

anastomoses of the rete ridges.
 Treatment
1. followed up by gynecological oncologists.
2. All patients with VIN should be referred
colposcopy to exclude CIN and VIN. If there are
any peri-anal lesions, referral for anoscopy is
recommended
3. dVIN=
 surgical excision is recommended, depending
on the extent of disease
 partial vulvectomy
4. HSIL=
 Local excision is the recommended
treatment for well circumscribed lesions
 Ablative techniques - laser therapy has
been used(BUT similar recurrence rates to
excision)
 Imiquimod
5. Annual vulvar exams mandatory
 adenocarcinoma in situ
(pagets disease)
clinical features:
1. Pruritus
2. often presented as red crusted plaque
with sharp edges
 adenocarcinoma in situ(pagets disease)
Diagnosis
 by biopsy
 1/3 of patient there is associated with
underlying adenocarcinoma.
 adenocarcinoma in situ(pagets disease)

Treatment
is very wide local excision to exclude
adenocarcinoma
of a skin appendage.
 Vulval pain
defines vulvodynia as ‘vulvar discomfort,
most often described as burning pain,
occurring in the absence of relevant visible
findings or a specific, clinically identifiable,
neurologic disorder’
Vulvodynia is categorized:

 generalized :occurs without a

trigger (constant burning )
 localized; has trigger –pain at the
opening to vagina or pain to
touch to clitoris
History
 When did the pain begin? A precipitating event?
 Was the onset gradual or sudden?
 Describe the pain and its intensity.
 Aggravating factors? Is it provoked or unprovoked?
 Relieving factors? Prior therapy?
 Associated symptoms? Urinary? GI? Dermatologic?
 Does pain lessen quality of life? Limit activities?
frequently felt at the introitus at penetration during
sexual intercourse
 Diagnosis
1. Clinical diagnosis made on history and
examination
2. May have pain with the touch of Q-tip
which is often called the (cotton swab
test )
3. Important to be examined and rule out
possible causes of pain and get swabs
for infection
1) Avoidance of irritating factors
2) Use of emollient soap substitute
3) Topical local anesthetics e.g. 5% lidocaine ointment
or 2% lidocaine gel 15-20 minutes prior to penetrative
sex
4) Vaginal training
5) Vaginal transcutaneous electrical nerve stimulation
6) Cognitive behaviour therapy
7) Pain modifiers –such as tricyclic antidepressants
8) Surgery – Modified vestibulectomy may be
considered in cases where other measures have been
unsuccessful
 Bartholin Gland Duct cyst
Obstruction of the main
duct of Bartholin’s gland
results in retention of
secretions and cystic
dilatation.
cause of obstruction:
1. Infection
2. mucus changes
3. congenitally narrowed
ducts.
asymptomatic Bartholin gland duct cysts require
no intervention except exclusion neoplasia in
women older than 40 years so do Bartholin
gland excision

If symptomatic :managed with one o several

techniques.
• incision and drainage (I&D)
• Marsupialization
• Bartholin gland excision
 Malignancy

1. Enlargement in the postmenopausal patient may

reflect a malignant process (incidence is <1%), and
biopsy should be considered.
2. Most are squamous carcinomas or adenocarcinomas
3. in women older than 40 years, drainage o the cyst and
biopsy o cyst wall sites adequately excludes malignancy

4. Treatment : Bartholin gland excision

 Bartholin Gland Duct absess
Secondary infection may result in abscess
formation.
Symptoms :
1. Pain
2. tenderness
3. Dyspareunia
4. difficulty in walking with adducted thighs.

Signs:
The surrounding tissues become edematous and
inflamed.
A fluctuant, tender mass is usually palpable
 Treatment
1. Primary treatment consists of drainage of the infected
cyst or abscess by incision should be made in the
vestibule, close to the original orifice of the Bartholin’s
gland duct.
 Marsupialization: suture the cyst walls to the
surrounding tissue to keep it open.
 insertion of a Word catheter (an inflatable bulb-tipped
catheter provides a route for continued drainage by
preventing the incision from closing
2. Procedure done under Antibiotics cover =
Eg.
 Trimethoprim-sulfamethoxazole +/- metronidazole
 Trimethoprim-sulfamethoxazole +/- amoxicillin-
clavulanate
The end of lecture
‫اﻟﻧﺟﺎح واﻟﺗوﻓﯾﻖ‬