Female Genital Diseases - Vulva Quiz

Female Genital Diseases - Vulva

• Infectious Vulvitis: Important infectious agents include:
  • Human papillomavirus (HPV): Produces condylomata acuminata (warts) and vulvar intraepithelial neoplasia.
  • Herpes simplex genitalis (HSV 1 or 2): Causes a vesicular eruption.
  • Gonococci: Cause suppurative infection of the vulvovaginal glands.
  • Syphilis: Causes a primary chancre at the inoculation site.
  • Candida: Causes an itchy rash on the vulva and surrounding skin.

Complications of Vulva

• Abscess and Bartholin Gland Cyst:
  • Bartholin cysts result from the occlusion of Bartholin gland ducts.
  • These cysts can become infected and turn into abscesses.

Inflammatory Dermatoses of Vulva

• Contact Dermatitis: A common cause of vulvar dermatitis, resulting from a reactive inflammatory response to exogenous stimuli.
  • Irritants like urine, chemicals, or allergens can cause contact irritant or allergic dermatitis.

Non-Contact Vulval Dermatitis

• Lichen Sclerosus: A chronic inflammatory dermatosis affecting genital areas in both sexes.

  • Characterized by itchy, smooth white to gray plaques.
  • Primarily affects women and usually becomes most extensive in postmenopausal years.
  • Microscopically shows hyperkeratosis and a thinned epidermis with a loss of rete ridges. The dermis demonstrates changes.

• Lichen Simplex Chronicus (Neurodermatitis): A chronic itchy skin condition.

  • Results from thickened skin in areas subjected to repeated scratching and rubbing.
  • Microscopically, acanthosis, hyperkeratosis, and inflammatory cell infiltration of the dermis are evident.

Neoplasms of Vulva—Benign Tumors

• Papillary Hidradenoma: Arises from apocrine sweat glands, often located on the labia.
  • Microscopically composed of irregular tubular structures, dilated duct-like structures with intraluminal papillary projections.
  • Structures are lined by two layers; an inner layer of columnar cells and an outer layer of cuboidal cells.

Conditionally Acuminatum

• Wart-like verrucous lesion caused by HPV types 6 or 11.
• Usually occurs on the vulva, perineum, or vagina.
• Composed of sessile or pedunculated epithelial proliferation of stratified squamous epithelial cells, some showing perinuclear cytoplasmic clearing.

Malignant Vulvar Tumors

• Vulvar Intraepithelial Neoplasia (VIN): Caused by HPV 16.

  • Occurs most commonly in the 4th or 5th decades.
  • May progress to invasive carcinoma in the sixth decade.

• Invasive Squamous Cell Carcinoma (SCC):

  • Histologically, usually well-differentiated squamous cell carcinoma with keratin pearls or nests and prominent intracellular bridges.
  • Prognosis depends on tumor size, depth of invasion, and lymph node status.

• Paget's Disease of Vulva:

  • Carcinoma in situ, mostly located on the labia majora.
  • Appears as a red crusty, sharply demarcated area.
  • Composed of large anaplastic cells, often lying singly or in small clusters.
  • There is no underlying intraductal carcinoma.

• Other Vulvar Carcinomas: Include basal cell carcinoma, adenocarcinoma of Bartholin glands or sweat glands, and malignant melanoma.

Vaginal Diseases

• Vaginal Infectious Inflammation: Common causes of vaginal discharge are usually sexually transmitted.

  • Important organisms include: Gardenella vaginalis, Neisseria gonorrhoeae, Candida albicans, and Trichomonas vaginalis.

• Vaginal Intraepithelial Neoplasia (VaIN): Defined by squamous cell atypia without invasion.

  • Classified by the depth of epithelial involvement; VaIN 1 and 2 affect the lower one-third and two-thirds of the epithelium respectively. VaIN 3 involves all epithelium thickness and is related to HPV infection.

• Invasive Vaginal Squamous Cell Carcinoma: Uncommon.

  • Vast majority are HPV-associated and preceded by VaIN 3.

• Clear Cell Adenocarcinoma: Very rare, often in women whose mothers were treated with diethylstilbestrol.

  • Composed of glands lined by vacuolated clear cells. Typically between ages of 60-70.

• Embryonal Rhabdomyosarcoma: Extremely rare, predominantly in young females.

Cervical Diseases

• Infectious Cervicitis: Extremely common, caused by Chlamydia trachomatis, N. gonorrhoeae, and Trichomonas vaginalis.

  • Can be chronic or acute, acute often results in purulent discharge.
  • Cervicitis can sometimes be non-infectious, caused by chemical or mechanical irritation.

• Chronic Cervicitis: Cervical tissue infiltrated by chronic inflammatory cells.

  • Leads to metaplasia of endocervical columnar epithelium into squamous epithelium.

• Endocervical Polyps: Common, but can grow large.

  • Composed of connective tissue stroma with blood vessels covered by endocervical or metaplastic squamous epithelium.
  • Usually benign and asymptomatic.

• Cervical Intraepithelial Neoplasia (CIN): Caused by HPV.

  • Usually begins at the squamo-columnar junction in adolescents.
  • Characterized by squamous metaplasia, maturation, and cytologic atypia.
  • Nuclear atypia includes hyperchromasia, pleomorphism, increased mitotic activity, and an increased nuclear-cytoplasmic ratio.

• CIN Grades:

  • CIN I: Mild dysplasia (lower ⅓ of epithelium).
  • CIN II: Moderate dysplasia (lower ⅔ of epithelium).
  • CIN III: Severe dysplasia (more than ⅔ to full thickness of epithelium).

• Invasive Squamous Cell Carcinoma of Cervix:

  • Peak incidence around 45 years, usually in multipara.
  • Preceded by CIN 3.
  • Symptoms include pain, bleeding, and painful intercourse.
  • Predisposing factors include early full sexual activity, high parity, infection by HPV and herpes simplex type II, high and prolonged levels of estrogen.

• Gross Appearance of Cervical SCC: Often shows as polypoid (most common), ulcerative, or infiltrative lesions within the cervix.

• Microscopically, cervical Carcinoma: Shows keratinizing keratin pearls and abundant keratohyaline granules, intercellular bridges, large, hyperchromatic nuclei (coarse chromatin).

• Nonkeratinizing variant: Shows polygonal cells forming sheets or nests with intercellular bridges, but no keratin pearls.

• Papillary variant: Shows thin or broad papillae, with fibrovascular cores lined by multilayered epithelium.

• Basaloid variant: Shows well-defined nests of immature basaloid cells.

• Stages of Cervical SCC:

  • Stage I: Confined to the cervix.
  • Stage II: Reaches the upper part of the vagina.
  • Stage III: Reaches the pelvic wall or lower ⅓ of the vagina.
  • Stage IV: Reaches the urinary bladder or rectum, with distant metastases.

• Other Malignant Tumors of the Cervix: Adenocarcinoma (classic type), adenosquamous carcinoma, clear cell adenocarcinoma, small cell carcinoma, sarcomas, and melanomas are less common.

• Effects/Complications of Cervical Cancer: Includes spread to surrounding structures, regional lymph nodes (iliac, sacral, hypogastric), and distant sites (liver, lungs, bone), as well as vesico-vaginal and recto-vaginal fistulas and pyometria.