Vulva and vagina

Question 1

What part of the female genitalia are between the labia minora and the hymen (surrounding the vaginal & urethral opening)?

Answer 1

Vestibule

Question 2

Describe the histological appearance of the vaginal lining:

Answer 2

Squamous epithelium

Question 3

What is the lymphatic drainage of the vagina?

Answer 3

Inguinal lymph nodes (which drain into the femoral and external iliac nodes)

Question 4

Give 3 causes of vulval pruritus (vulval itching):

Answer 4

1) Infection:
- Candidiasis (+ discharge) -> in DM, HIV
- Vulvar warts
- Pubic lice, scabies
2) Dermatological:
- Eczema, psoriasis
- Lichen simplex, lichen sclerosus
- Contact dermatitis
3) Neoplasia:
- Carcinoma
- VIN (premalignant)

(other vulval symptoms apart from pruritus include: soreness & burning, superficial dyspareunia (pain on penetration))

Question 5

What causes severe pruritus of the labia major often causing inflammation and/or hypo/hyperpigmentation?

Answer 5

Lichen simplex

Question 6

What is the treatment for lichen simplex/planus/sclerosus?

Answer 6

Rx = steroid cream

Question 7

What is dermatological condition is common and affects all mucosal surfaces, has purplish lesions and can be erosive (=pain> pruritus)?

Answer 7

Lichen planus

Question 8

What dermatological disorder is associated with AI conditions and causes thinning of vulvar skin?

Answer 8

Lichen sclerosus

Question 9

List 4 common infections of the vulva:

Answer 9

• Herpes simplex
• Vulvar warts
• Syphilis
• Donovanosis (klebsiella granulomatis)
• Candidiasis

Question 10

What is the common treatment for syphilis and donovanosis?

Answer 10

Antibiotics

Question 11

What is the common Rx for candidiasis?

Answer 11

Antifungal treatment

Question 12

What is a Bartholins gland cyst/abscess and how is it formed?

Answer 12

Gland secreating lubricating mucus behind the labia minora.

If duct blockage is present -> cyst -> infected with E coli -> abscess

Question 13

What is marsupialization?

Answer 13

Surgical technique of cutting into an abscess and then leaving it open so that it can continue to drain/heal from the inside out.

Question 14

What is the vaginal interoitus?

Answer 14

The opening to the vagina

Question 15

What is characterised by columnar epithelium metaplasia within squamous epithelium of the vagina? When is it usually found?

Answer 15

Vaginal adenosis.

Usually in women whos mothers received DES (di-ethyl-stilboestrol) during pregnancy.

Question 16

What is treatement/observation is performed in those with vaginal adenosis/DES exposure in utero?

Answer 16

Annual colposcopy screening - risk of clear cell carcinoma of the vagina

Question 17

What is Vulvar Intraepithelial Neoplasia (VIN)?

Answer 17

Presence of atypical cells in the vulvar epithelium.

Usually multifocal:

• Warty lesions
• Hyperkeratosis
• Pigmented plaques
• erosions
• Nodules

Question 18

What age bracket does usual VIN typically affect? And what is it associated with?

Answer 18

35-55yo.

Associations: HPV-16, CIN, smoking, immunosuppression

Question 19

If one has usual type VIN, what are they at risk of?

Answer 19

Squamous cell carcinoma

Question 20

What type of VIN is usually present in older women?

Answer 20

Differentiated VIN

Question 21

What is differentiated VIN associated with?

Answer 21

Unifocal: ulcer or single plaque.

Association: lichen sclerosis

Question 22

What are those with differentiated VIN more at risk of than in usual VIN?

Answer 22

^ risk of keratinising squamous cell carcinoma

Question 23

What is the typical presentation of VIN?

Answer 23

Pruritus and pain

Question 24

What is the Rx of VIN?

Answer 24

Depending on disease progression:

• Low: Emollients + topical steroids -> take biopsy
• High: Surgical excision -> biopsy: histology -> 15% women have invasive disease

Question 25

What is the most common form of carcinoma of the vulva?

Answer 25

Squamous cell carcinoma (95%).
usually seen in post-menopausal women.

(only represents 5% of gynae cancers however)

Question 26

What is vulval squamous cell carcinoma associated with ?

Answer 26

VIN, lichen sclerosis, immunosuppression, smoking, Paget’s disease.

Question 27

Give 2 features of vulvar carcinoma:

Answer 27

Pruritus

Discharge/bleeding

Question 28

What may you see on O/E in vulvar carcinoma?

Answer 28

• Ulcer or mass on the labia majora/clitoris

- ^Ingluinal LN

Question 29

Describe the staging of vulvar carcinomas:

Answer 29

Stage 1 (50% present with this) - Confined to vulva/perineum, no LN

Stage 2 - Any size by adjacent spread (urethra, vagina, anus), no LN

Stage 3 - any size +ve LN

Stage 4 - Distal invasion (upper urethra, upper vagina, rectum, bladder, bone or distal mets)

Question 30

What Ix should be performed for someone with suspected vulva carcinoma?

Answer 30

• Biopsy -> establish histology and staining

- Assess fitness for surgery

Question 31

What is the Rx for those with vulval carcinoma?

Answer 31

Stage 1 - wide local excision

Other stages - wide local excision + sentinel LN biopsy (SLNB)

Question 32

What is/why is sentinel lymph node biopsy performed?

Answer 32

Radioactive isotope + blue dye is injected into the tumour -> sentinel LN identified & biopsied for mets.

If no sentinel lymph node is found or if +ve -> complete ingunialfemoral lymphadenectomy.

A sentinel lymph node is the one to which the primary tumour first mets to.

Question 33

What is the treatment of vaginal carcinoma?

Answer 33

Radiotherapy and radical surgery. (rare)

Question 34

In utero exposure to DES (miscarriage prevention in 1950-1970) can cause why type of vaginal/vulval carcinoma?

Answer 34

Clear cell carcinoma.