Benign lesion of the vulva and vagina

Behcets syndrome- a multisystemic inflammatory disorder that predominantly affect the venous system and it is characterized by a triple symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis.

Herpes simplex- ulcer usually found in mouth and vulva.

Syphilis- painless ulcer.

Chancroid (H. ducreyi)

Granuloma inguinale (Klebsiella granulomatis)

Bartholin cyst/abscess-

• The Bartholin ducts are 2cm ducts found at 5 and 7 o’clock at introitus.
• They can become obstructed due to gonococcal infection or trauma from mediolateral episiotomy
• When the Bartholin’s gland duct orifice becomes obstructed, the glands produce a build-up of mucus. This build-up leads to a cystic dilatation of the duct and cyst formation. Infection of this cyst is likely to result in Bartholin’s gland abscess.
• Swelling may be up to 1—8 cm in diameter.
• Often affect reproductive age women; if > 40 years, rule out adenocarcinoma.
• Causes pain, superficial dyspareunia.
• Treatment is drainage by marsupialization, insertion of a word catheter for 3—4 weeks. Using incision and drainage can cause recurrence. The cyst can also be excised in recurrent cases or in patients older than 40 years.

Sebaceous cysts

• Caused by blocking of the duct of multiple sebaceous glands of the hair-bearing surface of the vulva.
• Painless, involves the labia majora
• May become secondarily infected
• Treatment is by surgical excision if > 0.5—1cm

Cyst of canal of Nuck

• Benign painful or painless swelling in the inguinal region and sometimes to the labia majora. A developmental disorder; normally, the canal of Nuck is obliterated in the first year of life.
• Corresponds to encysted hydrocele in males. Cystic dilation can extend from the labia majora to the inernal inguinal ring.
• Treatment is by surgical excision.

Endometriosis

• Presence of normal endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity.
• Commoner on episiotomy site, healed laceration scar, site of Bartholin’s surgery.
• Present with vulva pain, dyspareunia, enlarging mass painful during menstruation.
• Treatment is complete surgical removal of affected areas or by laser vaporization.

Other types of cysts include epidermal inclusion cyst and clitoridal cyst.

Urethral mucosa prolapse

• Complete evagination of mucosa through external meatus.
• Common between 3—11 years, mostly seen in girls under 5 years.
• Presents as bloody stain on underwear or dysuria.
• Treatment
• Medical: analgesic, sitz bath, topical estrogen cream, amoxicillin and flagyl. Most resolve in 2 weeks and recurrence is not common.
• Surgical:
• Excision- catheterize post-op under GA.
• Ligation around a Foley catheter.
• Cryotherapy
• Electrocautery

Urethral caruncle

• Small fleshy outgrowth of the distal edge of urethral mucosa.
• Ectropion off posterior urethral wall.
• Commoner in postmenopausal women.
• Present with post-menopausal vaginal bleeding, dysuria, frequency.
• Treatment
• No treatment necessary if asymptomatic
• Cryosurgery
• Laser therapy
• Excision

Fibromata

• Treatment is excision.

Lipomata

• Treatment is surgical excision.

Hidradenomata

• Sweat gland tumor.
• Usually found in in labia majora and perineum.
• Treatment is by excision.

Hemangiomata

Nevi

Verrucous lesions- rare, usually occurs in the mouth and occasionally on the genitals or feet. Typically develops at sites of chronic irritation and inflammation. Often seen in people who smoke, chew tobacco or drink a lot of alcohol.

Pappilomata- small wartlike growth on the skin or mucus membrane caused by HPV.

Molluscum contagiosum- caused by poxvirus. Produces painless benign raised lesions.

von Recklihausen’s disease- Neurofibromatosis type 1.

Mainly caused by C. albican.

Risk factors include DM, HIV, pregnancy, prolonged drug use e.g. antibiotics, OCP, steroids, chronic debilitation.

Presents with intense pruritus with cheesy, curdlike discharge, erythema and burning sensation. Whitish plaques adherent to the vaginal wall with excoriation of vulva skin.

Treatment

• Control underlying disease.
• Discontinue antibiotics
• Avoid douching, non-absorbent underwear
• Drugs: topical antifungal
• Clotrimazole pessary 500mg nocte × 1/52
• Fluconazole 150mg p.o. stat
• Itraconazole 200mg p.o. bd × 1/7
• Ketoconazole 200mg p.o. bd × 5/7
In pregnancy: Nystatin pessary nocte × 1/52

Caused by trichomonal vaginalis- a flagellated protozoa.

Usually sexually transmitted.

Itchy burning sensation, dyspareunia, frothy vaginal discharge which may be white, green or brownish; frothy due to gaseous fermentation by a commensal aerogenic streptococcus. Vulva edema, less erythema than candida. pH 5—6.

Treatment is with metronidazole for both partners.

Overgrowth of bacteria: Gardrenella vaginalis, anerobes (Mobilincus sp, Bacteroides), and Mycoplaspla hominis.

Risk factors: sexually active, IUCD, low socioeconomic status, previous STD.

Profuse, thin, homogenous grey/white/yellow malodorous discharge, fishy smell due to amines. Minimal or no pruritus, pH > 7.0.

Risk factor in post abortal sepsis, preterm delivery, SPROM, chorioamnionitis, postpartum endometritis.

Treatment

• Metronidazole p.o. 500 mg bd x 1/52 or 2gm stat.
• Clindamycin cream 5g PV nocte x 1/52.
• Clindamycin 300 mg bd x 1/52.
• In pregnancy:
• Metronidazole 250 mg tds x 1/52 or metronidazole 2gm stat.
• Clindamycin 300 mg bd x 1/52.

Due to Neisseria gonorrhea.

Painful vulva swelling, dysuria, purulent discharge 2—7 days or longer after coitus with infected partner.

Intracellular diplococcic on microscopy.

Culture on Thayer-Martin plate, transfer swabs in Stuart’s transport medium.

Treatment is with procaine penicillin, ampicillin, augmentin, or erythromycin.

Post-menopause:

• Mainly due to atrophic vaginitis. Rule out cancer via EUA, then give topical steroids.

Prepubertal:

• Poor hygiene, estrogen lack, non-specific vulvovaginitis.
• Rule out sexual abuse in specific vulvovaginitis.
• Parasites such as pinworm, threadworm.
• Emphasize perineal hygiene.

Hemorrhage

Pain

Urinary retention

Secondary infection

Transmission of infection- HIV, Hepatitis

Anemia

Death

Keloid, clitoral cyst

Sexual dysfunction

Recurrent UTI

Renal failure

Acquired gynetresia with hematocolpos

Obstructed labor

Psychological disorders