Vulva & Vagina Pathology

Question 1

Vulva

Answer 1

• skin & mucosa external to the hymen

- lined by squamous epithelium

Question 2

Vagina

Answer 2

• Canal leading to the cervix

- Mucosa lined by non-keratinizing squamous epithelium

Question 3

Infectious agents to the Vulva/Vagina

Answer 3

1. Normal bacterial flora
2. Yeast, fungi (candida)
3. Trichomonas vaginalis
4. Molluscum contagiosum
5. Herpes Simplex Virus

Question 4

Herpes Simplex Virus Infection (HSV Type 2)

Answer 4

– Involves the vulva, vagina, and cervix
– Symptoms seen 3 to 7 days after sexual relations
– Painful red papules and vesicles in the vulva and vagina that progress to ulcers
– Vesicles contain viral particles
– Heal spontaneously but latent infections may remain in nerve ganglia
– Two-thirds of women suffer a recurrence
– Danger: TRANSMISSION DURING BIRTH

Histo: Ulcer; Multinucleated Cells with cleared out cytoplasm

Question 5

Trichomonas vaginalis

Answer 5

• Flagellated ovoid protozoan transmitted by sexual contact.
  - Clinical symptoms: Yellow, frothy vaginal discharge or vulvovaginal discomfort, painful urination or painful intercourse

Question 6

Molluscum contagiosum

Answer 6

- Poxvirus infection of the skin and
mucous membranes
- Transmitted by direct contact of
charted articles (towels)
- Incubation period about 6 weeks.
- Clinical symptoms:  Small papules on the skin; may be seen in the genital area

Histo: Large eiosinophilic inclusions in the vulva

Question 7

Inflammatory Dermatologic Disorders of the Vulva

Answer 7

1. Lichen sclerosis

2. Lichen simplex chronicus

Question 8

Lichen Sclerosis

Answer 8

Clinical:  Smooth white plaques.
- thinning of the epidermis
- Fibrosis/Sclerosis of the dermis
- Seen mostly in postmenopausal women
- Benign, but INCREASED RISK in developing squamous cell carcinoma of the vulva

Question 9

Lichen Simplex Chronicus

Answer 9

• Squamous Cell Hyperplasia of the vulvar epithelium, WITH THICKENED EPIDERMIS
• Clinically appears as leukoplakia (white area)
• Associated with chronic irritation/scratching
• Benign, WITHOUT increased risk of squamous cell carcinoma

Question 10

Bartholin Cyst

Answer 10

• Bartholin gland: Gland present on each side of the vaginal canal and produces a mucus like fluid
• Infection may produce inflammation and an
  abscess.
• When symptomatic may be a large cysts
  (3-5 cm)
• Treatment: drained and excised

Question 11

Condyloma Acuminatum

Answer 11

• Benign raised or warlike lesions seen in the perineal, perianal, vulva, vagina,
  cervix, and penis.
  - Caused by human papillomavirus (HPV) types 6 and 11.

Histology:
– Hyperkeratosis, acanthosis (thickening of the epidermis).
– HPV cytopathic effect “koilocytic atypia”
(nuclear atypi that is wrinkled like a raisin, and perinuclear vacuolization).
- Not considered precancerous but may be
associated with vulvar intraepithelial neoplasia (VIN).

Question 12

Vulvar intraepithelial neoplasia

VIN

Answer 12

• Dysplasia of the squamous epithelial cells of the vulva
• Premalignant lesions (noninvasive) of the vulva, due to high -risk HPV types 16 and 18
• Most commonly in sexually active 40-50 yo woman
• Does not invade the underlying stroma
• reversible

Question 13

Invasive Squamous Cell Carcinoma of the Vulva (Vulvar carcinoma)

Answer 13

• Invasion of dysplastic epithelium into the
  underlying stroma.
• prognosis is determined by the size of
  the tumor, depth of invasion, involvement of
  lymphatic vessels, and regional lymph
  nodes.

2 etiologies:

1. Vulvar Intraepithelial Neoplasia (1,2,3) caused by HPV 16 and 18 (40-50 yo)
2. Inflammatory vulvar disorders such as lichen sclerosus, that is unassociated with HPV infection (older patients).

Question 14

Extramammary Paget Disease

Answer 14

• IN SITU adenocarcinoma in the epithelium of
  the vulva and perianal regions.
• Clinical: Pruritic, red, crusted lesions on the
  labia majora.
• Histology: Cluster of large clear cells with
  paler staining cytoplasm in the squamous
  epithelium
• May not be associated with underlying carcinoma (vs. Paget disease of the nipple, which is almost always associated with underlying carcinoma)

Question 15

Adenosis

Answer 15

• During normal development, squamous epithelium of the lower 2/3 vagina grows upward to replace columnar epithelium of the upper 1/3 vagina; there are NO ADNEXAL STRUCTURES in the vaginal stroma
• Adenosis is the focal persistence of the columnar epithelium in the upper 1/3 vagina
• Normally present in a small percentage of adult women, but 30% to 90% of women exposed to DES in utero.
• Clinically: Red, granular area in the vagina.
• Histo: Columnar, glandular epithelium similar to that of the endocervix.

Question 16

Clear Cell Adenocarcinoma of the Vagina

Answer 16

• Malignant proliferation of GLANDS with clear cytoplasm

- associated with DES-associated vaginal adenosis

Question 17

Vaginal Carcinoma

Answer 17

• Carcinoma arising from squamous epithelium lining of the vaginal mucosa
• related to HPV 16 & 18
• precursor lesions referred to as VAGINAL INTRAEPITHELIAL NEOPLASA (VAIN 1,2,3)

Question 18

Sarcoma botyroides (Embryonal
Rhabdomyosarcoma)

Answer 18

• Uncommon vaginal tumor in infants and
  children less than 5 years of age
• Malignant mesenchymal proliferation of immature skeletal muscle
• Gross features: Bulky mass that fills the
  vagina (bunch of grapes)
• Histo: Small to oval nuclei crowded into a “cambium layer”; deep, loose fibromyxomatous edematous stroma