Benign conditions

of
the vulva and vagina

Dr. Amal Abdul Mahdi Alrahimi

5th yr.
The vulva is the term used to
describe the external female
genitalia, the sexual organs. It
includes the labia majora and minor,
clitoris and fourchette.
Many women who present with
vulval symptoms may have a
dermatological problem rather than
an infective or gynaecological
complaint.
Vulval skin has different
physiological properties when
compared to other regions of the
body.
Trans-epidermal water loss is twice
the amount in vulval suggests that
the stratum corneum, the
protective layer of vulval skin,
functions poorly as a skin barrier
and may explain why vulval skin is
more prone to irritancy.
The vulval vestibule is defined
anatomically as the area between the
lower end of the vaginal canal at the
hymenal ring and the labia minora.
 Assessment
A full history and clinical examination
(with optional vaginal swabs and
biopsies) are essential to make the
diagnosis.
The examination should be approached
systematically and should always be
carried out with a trained chaperone
present.
Good lighting and appropriate
magnification is essential
Vulval itching (pruritis)
The most common presenting
symptoms of benign vulval
conditions are itching, discomfort,
pain, discharge and dyspareunia
Women with vulval disease may
present at all ages but
preponderantly postmenopausal
women with benign dermatological
conditions.
Differential diagnosis of vulval complaints
Vulvar pruritus is frequent with
many dermatoses. Patients may
have been previously diagnosed with
psoriasis, eczema, or dermatitis at
other body sites.
Isolated vulvar pruritus may be
associated with a new medication.
Pathology may have multiple
etiologies (e.g. atrophic vaginitis and
vulvitis or lichen sclerosus)
Reduction in allergens
It`s advisable to discourage women
from washing with any soaps or
detergents (including feminine
washes), which disrupt the bacterial
balance of the vagina and can cause
a vulval dermatitis.
Water is preferable but some women
find olive (or other natural un-
perfumed) oils offer moisturization
and a better clean or with a few
drops of tea tree oil( perfumed)
Vulvar Care Recommendations
Avoid using gels, scented bath
products, cleansing wipes, and soaps,
as they may contain irritants
Use aqueous creams to clean the vulva
Avoid using a harsh washcloth to clean
the vulva
Dab the vulva gently to dry
Avoid wearing tight-fitting pants
 Select white cotton underwear. Worth
considering to the effect of sanitary
protection/pads for urinary incontinence.
Women may benefit from sourcing
unbleached, organic protection, washable
pads or the ‘Moon Cup’.
 Avoid washing undergarments in scented
washing detergents. Consider using a
multirinse process with cold water to
remove any remaining detergent
 Consider wearing skirts and no underwear
at home and at night to avoid friction and
aid drying
Recurrent use of antifungals
 The vulval and vaginal condition of candidal
infection or ‘thrush’ is commonly affects women
of reproductive age (diabetic or using HRT) where
oestrogen levels are high (and there is an
increased prevalence in pregnancy).
 It is uncommon in prepubescent girls and
postmenopausal women
 Other causes for irritation should be sought
rather than relying on readily available
antifungals.
 Candidal infection should be treated with a course
of 150 mg clotrimazole nightly over 3 consecutive
nights (Oral fluconazole is a second-line
treatment after clotrimozole ) in combination of
reduction of allergens is sufficient in most cases.
Lichen planus
is an autoimmune disorder affecting 1–
2% of the population (particularly in
people over 40) and affects the skin,
genitalia and oral and gastrointestinal
mucosa.
The characteristic cutaneous lesions are
small purplish papules, which may exhibit
a fine lace‐like network over their surface
Genital lesions can be longitudinal,
annular, ulcerative, hyperpigmented or
bullous and may cause vaginal stenosis
and resulting sexual dysfunction due to
pain and stenosis.
oral inspection should be performed if the
diagnosis is suspected
Aetiology is unknown but it is likely that it
is a T‐lymphocyte‐ mediated inflammatory
response to some form of antigenic insult.
There is a small
risk of SCC in
the classic and
hypertrophic
types.
Lichen sclerosus
is a destructive inflammatory skin condition
that affects mainly the anogenital area of
women, and is classically presents in
postmenopausal women.
The destructive nature of the condition is due
to underlying inflammation in the subdermal
layers of the skin, which results in
hyalinization of the skin.
It characteristically presents in a ‘figure of 8’
pattern around the vulva and anus,
hypopigmentation, loss of anatomy, vaginal
stenosis and cracking (particularly in the
posterior fourchette) but appearances can be
subtle in early-stage disease
It affects 1/300- 1/1000 women and
the cause is believed to be
autoimmune, infectious, hormonal, and
genetic etiologies
Many patients have other autoimmune
conditions, such as thyroid disease and
pernicious anaemia.
Prompt biopsy should be sent to
exclude pre-invasive and malignant
lesions. The characteristic clinical
picture and histologic findings typically
confirm the diagnosis.
 Lichen
Sclerosis
Curative therapies are not available or
lichen sclerosus and treatment goals are
symptom control and prevention of
anatomic distortion.
Treatment of both lichen planus and
sclerosus is by high-dose topical steroids
applying daily for 1 month, alternate days
for the second month and twice a week for
the third month.
If there is not complete resolution of
symptoms, biopsy is indicated.
Patients require long‐term follow‐up as
there is a small risk of malignancy
Vulval cysts
Bartholin’s cysts, Skene gland cysts and
mucous inclusion cysts can affect the
vulval area and cause a lump with or
without vulval discomfort. Most cysts are
small and
asymptomatic
except for
Minor
Discomfort
during sexual
contact
Small, asymptomatic Bartholin gland duct
cysts require no intervention except exclusion
o neoplasia in women older than 40 years.
With larger or infected cysts, however,
patients may complain of severe vulvar pain
that precludes walking, sitting, or sexual
activity
A symptomatic cyst may be managed with
one o several techniques. T ese include
incision and drainage (I&D),
marsupialization, and Bartholin gland
excision, which is done for recurrence.
Abscesses are treated with I&D or
marsupialization.
SKENE’S DUCT CYSTS
Skene’s glands, or paraurethral glands,
are located bilaterally on either side of
the urethral meatus.
Chronic inflammation of the Skene’s
glands can cause obstruction of the
ducts and result in cystic dilation of the
glands.
When conservative measures fail,
persistent or recurrent paraurethral
cysts can be treated with simple
marsupialization or excision.
 Position of
Bartholin's gland
and Skene`s gland
 Benign vaginal tumours
These are uncommon but occur within the
vaginal wall and include myoma, fibromyoma,
neurofibroma, papilloma, myxoma and
adenomyoma.
Cystic lesions may be found within the vagina,
usually laterally and occasionally extending
from the fornix down to the introitus.
These are usually of Gartner’s or Wolffian duct
origin. They may increase to such a size as to
interfere with coitus or tampon use.
They can usually be managed by de‐roofing,
but care must be taken in the fornices to
avoid large uterine and vesical vessels.
Vulvodynia
Vulvodynia is the condition of pain on
the vulva most often described as a
burning pain, occurring in the absence
of skin disease or infection of at least 3
to 6 months duration( without an
identifiable cause).
Its underlying cause is likely
multifactorial and variable among
individuals.
Women with vulvodynia may have
primary or secondary psychosexual
Vulvodynia can occur at any age, and
causes huge distress to sufferers. It is
essential to exclude physical causes such
as dermatitis.
Approximately one in 10 women with
vulvodynia will have spontaneous
remission
Some women can benefit from:
perineal massage may aid vulval
desensitization, reduce muscular spasm
Oils (such as coconut) may act as a barrier
and enable better lubrication for sexual
function.
Support to-regain their sex lives-by
someone with an empathetic ear who
appreciates the physical and
psychosexual aspects of their pain.
Medications for vulvodynia treatment
may be administered topically, orally,
or intra-lesionally, 5% lidocaine
ointment applied sparingly to the
vestibule 30 minutes prior to sexual
intercourse can significantly decrease
dyspareunia, and long-term use may
promote healing
Dyspareunia

Definition: pain during or after sexual

intercourse, which can be classified as
superficial affecting the vagina, clitoris
or labia, or deep with pain
experienced within the pelvis.
superficial dyspareunia: consider a
biopsy of lower genital tract lesions
and swabs; A psychosexual history
should be considered.
Deep dyspareunia associated with
pathology such as endometriosis or pelvic
inflammatory disease (PID). consider
transvaginal ultrasound scan (TVS),
swabs and laparoscopy.
On many occasions, despite appropriate
investigations, no cause can be found and
psychological support should be offered.
Risk factors include female genital
mutilation (FGM), suspected PID and
endometriosis, peri/postmenopausal
status, depression or anxiety states and
history of sexual assault.
Treatment:
Superficial dyspareunia: treat any
identifiable cause;
Deep dyspareunia: treat as for chronic
pelvic pain.
Psychosexual dysfunction
Primary psychosexual dysfunction
describes sexual difficulties where there
may be psychosomatic pain.
Secondary psychosexual dysfunction
describes sexual difficulties resulting from
pain or emotional issues.
Female genital mutilation(FGM)
FGM is defined as:
Any procedure
involving partial or
total removal of the
external genitalia
and/or injury to the
female genital organs
whether for cultural,
religious or other non-
therapeutic reasons
FGM is frequently performed in girls
from the age of 8 onwards without
analgesia or adequate sterility.
FGM is a practice that has far
reaching implications to women’s
health in the acute and chronic
timeframe. These implications are
physical, psychological and
psychosexual and may, in the worst
case scenario, lead to renal failure
from urinary obstruction and
infection.
The four main types of FGM are
 Type 1 Clitoroidectomy: excision of prepuce
(clitoral hood) with or without the removal of
the clitoris.
 Type 2 Excision of clitoris and partial or total
removal of the labia minora.
 Type 3 Excision of part or all of the external
genitalia and stitching/narrowing of the vagina
–infundibulation.
 Type 4 Piercing the clitoris, cauterization,
cutting the vagina, inserting corrosive
substances.
This also includes any plastic surgery
procedures done as an adult.
These are four degrees of FGM
practiced in different geographical
areas:
Reversal of infundibulation-
deinfundibulation
Deinfundibulation should be performed with
adequate analgesia to avoid flashbacks to the
FGM procedure (local anaesthetic can be used.
The incision should be made along the vulval
incision scar and the urethra identified before
surgery commences to reduce damage.
All women should have prior screening for UTI
and appropriate antibiotic therapy be given, as
bladder obstruction and urinary infection rates
are high.
A fine absorbable suture should be used and
prophylactic antibiotics considered.
Depending on the type of FGM, it
may be necessary to perform midline
episiotomy for safe delivery.
However, what is far preferable is to
enquire early in the pregnancy and
refer to a specialist centre for
deinfundibulation.
It is illegal to resuture (which many
women request) an FGM