Benign disorders of the vulva and vagina

Question 1

Lichen simplex

Answer 1

AKA chronic vulval dermatitis
Severe intractable pruritis, especially at night
Inflamed and thickened with hypo and hyperpigmentation
Typically labia majora
Symptoms exacerbated by chemical or contact dermatitis and are sometimes linked to stress or low iron stores
Vulval biopsy if diagnosis in doubt
Avoid irritants (eg soap)
Emollients, moderate steroids and antihistamines

Question 2

Lichen planus

Answer 2

May affect skin anywhere but especially mucosal surfaces eg mouth and genitals
Flat, popular, purplish lesions
Can be erosive
Pain rather than pruritis
May be autoimmune related; not related to hormone status
Treatment with high-potency steroid cream

Question 3

Lichen sclerosis

Answer 3

Thin vulval epithelium with loss of collagen
May be autoimmune (40% have or develop another autoimmune condition)
Throid disease and vitiligo may co-exist
Typically postmenopausal
Severe pruritis, worse at night
Scratching may cause bleeding, skin splitting, pain, discomfort and dyspareunia
Pink-white papules which coalesce to form parchment like skin with fissures
Inflammatory adhesions can form
Vulval carcinoma can develop in 5% cases
Vulval biopsy to exclude carcinoma and confirm diagnosis
Ultra-potent topical steroids

Question 4

Vulvar dysaesthesia (vulvodynia) or the vulval pain syndromes

Answer 4

Diagnoses of exclusion, no organic vulval disease
Provoked vs spontaneous
Local vs generalised
Associated with history of genital tract infections, former use of oral contraceptives and psychosexual disorders
Spontaneous generalised vulvar dysaesthesia: burning pain more common in older patients
Superficial dysaesthesia of the vestibule: superficial dyspareunia/pain using tampons more common in younger women; introital damage must be excluded
Topical agents seldom helpful
Amitriptyline or gabapentin sometimes used

Question 5

Infections

Answer 5

Herpes simplex, vulval warts, syphilis and donovanosis
Candidiasis. More common in diabetics, obese, pregnancy, when antibiotics have been used or when immunity is compromised. Irritation and soreness of vulva and anus. Topical or oral antifungals

Question 6

Bartholin’s cyst and abscess

Answer 6

Gland behind labia minora
Blockage causes cyst formation
Infection (Staph or E. coli) => abscess. Acutely painful and a large tender red swelling evident. Incision and draining and incision sutured open to prevent re-formation

Question 7

Introital damage

Answer 7

Commonly follows childbirth
Overtightening, bad perineal repair or extensive scar tissue
Superficial dyspareunia
Symptoms often resolve with time
If introitus too tight, vaginal dilators or surgery

Question 8

Vaginal cysts

Answer 8

Congenital cysts commonly arise in vagina
Smooth, white, can be as large as a golf ball
May be mistaken for prolapse
Seldom cause symptoms
If dyspareunia, should be excised

Question 9

Vaginal adenosis

Answer 9

Columnar epithelium in normal squamous epithelium of vagina
Women whose mothers received diethlstilboestrol in pregnancy
Usually spontaneously resolves
May turn malignany
Women with DES exposure in utero screened annually by colposcopy
May also occur secondary to trauma