Vulval skin is an extension of general skin surfaces

and it is important in the history to ask about

general skin problems as this might point towards

the diagnosis, for example psoriasis or eczema can

synchronously affect the vulva and the limbs. The

history should focus on the presenting complaint. It

is important to discuss current methods of skin care

(e.g. use of scented products which can

aggravate symptoms), which topical treatments

are being used (e.g. some creams such as

antifungal can aggravate the problem) and the

impact of the symptoms on sexual functioning.

Treatment should be given based on a

correct diagnosis and empirical

treatment should be discouraged

because of the potential side effects of

treatment. Good skin care of the vulva

is essential, with an avoidance of

scented and over-the-counter

products as these can produce

unnecessary irritation on the skin.

Vulval pruritus Vulval pain Superficial dyspareunia

Infections, e.g. candidiasis,

Trichomonas vaginalis

Infections, e.g. candidiasis Skin conditions, e.g. lichen

sclerosus

(causes vulval splitting)

Skin conditions, e.g. lichen

sclerosis, eczema, VIN

Skin conditions, e.g. lichen

sclerosis, eczema, VIN

Vulvodynia

Contact dermatitis Vulvodynia Vulval fissures

Skin bridges of the vulva

Vulvar lichen sclerosis (VLS) is a

chronic, inflammatory skin

condition of the vulva that

most commonly affects

postmenopausal women. It

can affect men, women, and

children on any area

Symptoms are insidious or

aggressive onset

Treatment: Topical Ultra potent

Corticosteroids.

Topical Calcineurin Inhibitors

Vulvodynia is a chronic type of pain that

affects the vulvar area and occurs without

an identifiable cause or visible pathology.

There are two subtypes of vulvodynia:

provoked vestibulodynia (also referred to

as vulvar vestibulitis syndrome) and

generalized vulvodynia. Vulvodynia is

classified according to the site of the pain

as generalized or localized.

Symptoms of herpes simplex virus infection include watery blisters in the skin or mucous membranes of the mouth, lips or genitals. Lesions heal with a scab characteristic of herpetic disease. Sometimes, the viruses cause very mild or atypical symptoms during outbreaks.

HSV replication

types of cysts:

1-Inclusion cysts : They are usually very small and located in the lower back of the vaginal wall.

2-Bartholin's gland cysts: are fluid-filled cysts that form on the Bartholin's glands. These glands sit on either side of the opening to the vagina and produce the fluid that lubricates the vaginal lips (labia).

3-Gartner's duct cysts: occur when ducts in a developing embryo don't disappear. These remaining ducts can form vaginal cysts later in life.

4-Müllerian cysts

Diagnosis is limited to visual assessment.

Treatment is

recommended for all

women with VIN. Wide

local excision is

recommended when

cancer is suspected. When

occult invasion is not a

concern, VIN can be treated with surgical

therapy, laser ablation, or

medical therap. (topical

imiquimod 5%).

Types

Squamous cell

carcinoma

Melanoma

Basal cell carcinoma

Vulvar cancer can

be caused by other

lesions such

as adenocarcinoma

or sarcoma

FIGO’s staging of carcinoma of the vulva

IA Tumor confined to the vulva or perineum, ≤ 2cm in size with stromal invasion ≤ 1mm, negative nodesIB Tumor confined to the vulva or perineum, > 2cm in size or with stromal invasion > 1mm, negative nodesII Tumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodesIIIA Tumor of any size with positive inguino-femoral lymph nodes

(i) 1 lymph node metastasis greater than or equal to 5 mm(ii) 1-2 lymph node metastasis (is) of less than 5 mm

IIIB (i) 2 or more lymph nodes metastases greater than or equal to 5 mm(ii) 3 or more lymph nodes metastases less than 5 mm

IIIC Positive node(s) with extracapsular spreadIVA (i) Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone

(ii) Fixed or ulcerated inguino-femoral lymph nodesIVB Any distant metastasis including pelvic lymph nodes

TreatmentThe extent of the surgery is dictated

by the anatomical staging. Surgery is

a mainstay of therapy and usually

accomplished by use of a radical

vulvectomy, removal of vulvar tissue

as well as the removal of as inguinal

and femoral lymph nodes as

possible (known as

complete inguinofemoral

lymphadenectomy

Vaginal disease

The main vaginal problem is infection which is covered

previously, Genital infections in gynecology. Bacterial

(bacterial vaginosis), fungal (Candida albicans) and

protozoal (Trichomonas vaginalis) infections can produce

vaginal inflammation and discharge. Microbiological swabs

will confirm the diagnosis and the symptoms should soon

resolve. Few skin conditions affect the vagina. Worthy of

mention is erosive lichen planus of the vagina which is an

autoimmune inflammatory skin condition that causes

vaginal pain, inflammation and if untreated vaginal

stenosis.

Treatment is usually with vaginal trainers (to stretch

the narrowing) and intravaginal steroids.

Conditions affecting the vulva, such as lichen

sclerosis and eczema, do not affect the vagina.

Intraepithelial neoplasia can affect the genital

tract (CIN and VIN) as discussed above

Treatment can involve cauterization, surgical

excision, radiotherapy and observational follow

up depending on the patient, grade of disease

and size of the lesion. VAIN assessment and

treatment can be complicated and is best

managed by specialist teams. There is a risk of

vaginal cancer in untreated patients, but this risk

remains unclear.

This is a rare cancer that accounts for around 250 new cases a year. The cause remains unknown, although the risk factors are likely to be similar to cervical cancer. The disease frequently presents at an advanced stage in the absence of symptoms with early disease.

FIGO Nomenclature

FIGO Nomenclature

Stage IThe carcinoma is limited to the vaginal wall.

Stage II

The carcinoma has involved the subvaginal tissue but

has not extended to the pelvic wall.Stage III

The carcinoma has extended to the pelvic wall.Stage IV

The carcinoma has extended beyond the true pelvis or

has involved the mucosa of the bladder or rectum;

bullous edema as such does not permit a case to be

allotted to stage IV.

IVa - Tumor invades bladder and/or rectal mucosa

and/or direct extension beyond the true pelvis.

IVb - Spread to distant organs.

FIGO staging and prognosis of vaginal cancer