Vulvar Lesions: Diagnosis and Treatment

• A review of the development and anatomy of the female genital tract is fundamental to understanding of its diseases
• The diseases are common and include complications of pregnancy, infections, tumors, and hormonally induced abnormalities

Infections

• A large variety of organisms can infect the female genital tract
• Some infections with microorganisms are very common
• Other infections are major causes of infertility
• Some organisms are implicated in preterm deliveries, stillbirths, and neonatal infections
• Viruses account also for considerable morbidity
• Many of these infections are sexually transmitted

Infections of the Lower Genital Tract

• Genital HSV infection is common and may involve the vulva, vagina, or cervix
• HSVs are DNA viruses that include two serotypes, HSV-1 and HSV-2
• About one-third of newly infected individuals are symptomatic
• Lesions typically develop 3 to 7 days after transmission
• Vesicles and ulcers contain numerous viral particles
• The lesions heal spontaneously in 1 to 3 weeks
• HSV infections persist indefinitely
• Transmission of HSV takes place mainly during the active phase but occasionally may occur during the latent phase
• Condoms and antiviral therapies reduce the risk of transmission
• The gravest consequence of HSV infection is transmission to the neonate during birth
• The diagnosis is based on typical clinical findings and HSV detection

Other Lower Female Genital Tract Infections

• Molluscum contagiosum is a cutaneous or mucosal lesion caused by poxvirus
• Infections are common in young children and in sexually active adults
• The diagnosis is based on the characteristic clinical appearance of pearly, dome-shaped papules with a dimpled center
• Fungal infections are extremely common - symptomatic candidiasis is typically a result of a disturbance in the vaginal microbial ecosystem
• The diagnosis is made by finding the pseudospores or filamentous fungal hyphae in wet KOH mounts of the discharge or on Papanicolaou (Pap) smear
• Trichomonas vaginalis is a large, flagellated ovoid protozoan that is usually transmitted by sexual contact
• The vaginal and cervical mucosa typically has a fiery-red appearance, with marked dilation of cervical mucosal vessels
• Gardnerella vaginalis is a gram-negative coccobacillus that is implicated as the main cause of bacterial vaginosis
• Ureaplasma urealyticum and Mycoplasma hominis species account for some cases of vaginitis and cervicitis
• Chlamydia trachomatis infections mainly take the form of cervicitis
• Chlamydia is one of the causes of pelvic inflammatory disease

Pelvic Inflammatory Disease (PID)

• PID is an infection that begins in the vulva or vagina and spreads upward to involve structures in the female genital system
• Neisseria gonorrhoeae continues to be a common cause of PID - the most serious complication of gonorrhea in women
• Chlamydia infection is another well-recognized cause of PID
• Infections after spontaneous or induced abortions and normal or abnormal deliveries are also important causes of PID
• The initial infection most commonly involves the endocervical mucosa
• acute complications of PID include peritonitis and bacteremia
• The chronic sequelae of PID include infertility and tubal obstruction, ectopic pregnancy, pelvic pain, and intestinal obstruction
• PID infections are usually readily controlled with antibiotics

Vulva

• Diseases of the vulva aggregate to only a small fraction of gynecologic practice
• Many inflammatory diseases that affect skin elsewhere on the body do so on the vulva
• It is more prone to superficial infections than skin elsewhere on the body
• Most skin cysts and skin tumors can also occur in the vulva
• We will discuss vulvar disorders that are relatively specific and common

Bartholin Cyst

• Infection of the Bartholin gland produces an acute inflammation (adenitis, resulting in an abscess)
• Bartholin duct cysts are relatively common, occur at all ages, and result from by an inflammatory process
• can become large, up to 3 to 5 cm in diameter, and produce pain and local discomfort
• Bartholin duct cysts are either excised or opened permanently

Lichen Sclerosus

• Presents as smooth, white plaques or macules that in time may enlarge and coalesce
• characterized by marked thinning of the epidermis, degeneration of the basal epithelial cells, excessive keratinization, sclerotic changes of the superficial dermis, and a bandlike lymphocytic infiltrate occurs in all age groups - most common in postmenopausal women
• may have a slightly increased chance of developing squamous cell carcinoma of the vulva

Squamous Cell Hyperplasia

• caused by rubbing or scratching of the skin to relieve pruritus
• Clinically it presents as leukoplakia
• histological examination reveals thickening of the epidermis (acanthosis) and hyperkeratosis. is not considered premalignant

Exophytic or Wartlike Lesions

• caused by infection or reactive conditions of unknown etiology
• Condyloma acuminatum (papillomavirus-induced)
• benign vulvar squamous papillomas are benign exophytic proliferations covered by nonkeratinized squamous epithelium that develop on vulvar services
• The etiology of fibroepithelial polyps and squamous papillomas is unknown

Condyloma Acuminatum

• benign genital warts caused by low-risk HPV
• may be solitary, but are more frequently multifocal/involve the vulvar, perineal, and perianal regions
• consist of papillary, exophytic, treelike cores of stroma covered by thickened squamous epithelium
• not precancerous lesions
• HPV vaccines provide excellent protection against infection by low-risk HPV & genital warts

Vulvar Intraepithelial Neoplasia and Vulvar Carcinoma

• Carcinoma of the vulva is an uncommon malignant neoplasm/represents ~3% of all genital cancers in the female
• ~two-thirds occur in women >60 years of age
• Squamous cell carcinoma is the most common histologic type
• Basaloid and warty carcinomas are related to infection with high-risk HPVs, most commonly HPV-16
• keratinizing squamous cell carcinomas are unrelated to HPV infection + more common/occur in older women
• classic VIN occurs mainly in reproductive age women
• Risk factors for VIN are the same as those with cervical squamous intraepithelial - young age at first intercourse, multiple sexual partners, male partner with multiple sexual partners
• is frequently multicentric
• Keratinizing squamous cell carcinoma occurs most often in individuals with long-standing lichen sclerosus or squamous cell hyperplasia/ is not related to HPV

Morphology for the types of VIN explained

• lesions of classic VIN may be discrete and white (hyperkeratotic) or slightly raised and pigmented
• basaloid carcinoma consist of nests and cords of small,tightly packed cells that lack maturation and resemble the basal layer of the normal epithelium
• warty carcinoma is characterized by exophytic, papillary architecture and prominent koilocytic atypia
• Differentiated VIN is characterized by marked atypia of the basal layer of the squamous epithelium and normal-appearing differentiation

Further details on risk of cancer

• dependent on duration and extent of disease/the immune status of the patients
• characterized by direct invasion

Glandular Neoplastic Lesions

• vulva contains modified apocrine sweat glands
• the vulva may be involved by two tumors with counterparts in the breast, papillary hidradenoma and extramammary Paget disease

Extramammary Paget Disease

• similar to Paget Disease of the Breast
• Treatment - wide local incision
• if invasion develops, the prognosis is poor

Morphology

• intraepithelial proliferation of malignant cells
• cells display apocrine, eccrine, and keratinocyte differentiation/ presumably arise from multipotent cells found within the mammary gland-like ducts of the vulvar skin

Key Concepts for Vulva

• ~30% of vulvar cancers are caused by infection with high-risk HPVs
• Most vulvar cancers (~70%) are not related to HPV + develop in a background of lichen sclerosus or squamous cell hyperplasia from the premalignant lesion

Vagina

• remarkable resistant to diseases that affect nearby structures
• Primary lesions of the vagina are rare/serious, so are briefly discussed here

Developmental Anomalies

• Septate (double), vagina is an uncommon anomaly that arises from a failure of müllerian duct fusion and is accompanied by a double uterus
• Small patches of residual glandular epithelium may persist into adult life + recognized as vaginal adenosis

Premalignant and Malignant Neoplasms of the Vagina

• main are the spread from cervical carcinoma
• may involve leimyomas and hemangiomas
• Infants may also have a rare malignancy — called embryonal rhabdomyosarcoma

Vaginal Intraepithelial Neoplasia and Squamous Cell Carcinoma

• associated with high-risk HPV infection, most common -previous carcinoma w/ cervix/vulva

Cervix

• anatomically the cervix consists of the external vaginal portio (ectocervix) and the endocervical canal
• epithelium converges centrally at a small opening that leads to the endocervical canal
• The replacement of the glandular epithelium by advancing squamous epithelium is a process called squamous metaplasia
• The unique epithelial environment of the cervix renders it highly susceptible to infection with HPV

Inflammations

• Production of estrogens stimulates maturation and formation @ squamous mucosa and formation of vacuole in the squamous cells of the cervical
• The low pH, bacteriotoxic H2O2 inhibits the growth of organism and produce low pH vaginal environment

Endocervical Polyps

• common benign exophytic growths that arise within the endocervical canal
• are of irregular vaginal spotting, simple curettage of surgical excision is curative

Premalignant and Malignant Neoplasma of the Cervix

• carcinoma is most 4th common worldwide(570k new cases)
• No form better documents the effective screening than cancer, detects low stage and prevent progression
• high-risk are by far the most common factor in The cervix cancer
• The genital infections most common and asymptomatic
• HPV in 20-24 age, reduces when women have monoamorous
• viral replication HPV E6/7 proteins is needed

Cervical Intraepithelial Neoplasia (Squamous Intraepithelial Lesions)

• Three tier to a two-tiered system called CIN I, II, or III
• LSIL does not progress into invasive and is actually regressed
• There are two tiers on both the LSIL & HSIL level

Body of Uterus and Endometrium

• The uterus has two major components: the myometrium and the endometrium
• The most common of which comes from the endocrine gland that regulates fertility

Endometrial Histology Int he Menstrual Cycle

• Is a dynamic response to steroid from the ovaries via signal from pituitary/hypothalamus
• Used to diagnosis hormones, assess status and determine aetiology like blood and in fertility

Functional Endometrial Disorders

• Can be cause thru well defined pathos like ectopics endometrial polyos
• But, the endo can require all involvement from pituitary & ovarian balance
• Also, endometrial stems are identify the regeneration by contribution
• Dysfunctional uterine and other blendings the result of cycles from anovulation

Anovulatory Cycle

• From hormonal imbalances
• Are rare but can be endocrine disorders
• Involves a stimulus from excessive estrogen

Endometriosis and Adenyosis

• Endo is when etopic tissues are outside of the uterus such as pelvic and peritoneum, it's all based on the size of the site outside uterus
• Dysmenorrhea/pelvic pain affects 3 and 4th/decade and will require mutations to be prevent
• The endo is like a tumor ability of the surface/gross is that the uterus
• the metaplastic theory suggest from mesoeuithliem
• Retro menstrual theory the origination theory through tube

Inability if E/Tosis

• Releases ProI f/angio factors to immune by facrophages & vegf
• Andro production aroids normal stem levels
• Tends to show less involvement of the lumen & tube compared infection and it within layers
• They have serosa/ ligaments and perotineium all involved

Endometrial Polyps

• Exophytic and sessile, the 4th with endo epithelium
• stromal cells will involve chromosome rearangementa

Endometrial Hyperplasia

• cause by abnormal proliferation in terms relative or increases ratio within glands
• Has abnormal blood if is non - typ vs type I or II

Adenosarcoma

• Endo presents commonly by the tumor like most but will be benign glands shape
• Is usually at the 4/5 decade

Body of Uterus and Endometrium

• Carcinoma will develop out of the step wise aquation of tumor genes+on cogenes
• Type I or II will most common and aquire and more and less mutations
• PI3K/AKT or other factors will play

Endometrial Adenocarcinoma

• Take form from localized polyps/invovlement lining itself:
• Metrial invasion direct extension the adjunct structure organs
• Has 3 Histo grades -
• Diffentiated
• Mediator:
• Poor
• The uterus+cancer will be taken out

Ovaries

• Functional cyst/ benign tumors and come from neoplastic
• The epithelium/germ cells/sex-stroma will have their roles and can be ovarian related
• Are not uncommon, Auto - immune can cause oohoritits
• Has cysts from follicles+ or rupture but there is a seal-like structure

Morp

• will be multi, like the cycle and size of a tumor
• Luteal cyst is another form that happens
• Pcos another one from cyclystic ovaries, hormone

Tuumur

• Can be Benign, Borderline or Malignant and will have 3 types to orginate/affect from tissue's such germ or tumor

Serous Tumor

• Has cystic neoplasm, the maligant has been found
• The tum also consist in the cells that need that serous that ither bening/mali - in terms to stage & outcome factor
• It is hard detect because it is mostly outside the ovaries already

Much Tum

• More than half will affect women
• That will happen in all the cycle of a partum

Enotmetrious Tu

• Account to half for another type of cancer out there
• It must be a part/involve to more with
• the serous factor

Class Tumor

• It comes transitional the cells that can be related to tumor

Cell Tumor

• Stroma is with more gonads
• In the center to the edge of the surface
• The fibrona will cause a Meigs syndrom e
• Can be related to a stroma w/ cell tumors

Sertroli Cell Tumors

• Has some cells related to the granulosa, all different will play out
• It and they may cause certain effects

Gestational and Placental Disorders

• Most have been seen as caused for Fetus death-congenital malformation etc
• These all are related with understanding in selected events and situations
• An extra area will occur if there is trophoblast
• And infection play a role either by birthing or blood related
• And those lead in some fashion with endothelial
• The morp has multiple parts

Explore vulvar lesion diagnosis, including lichen sclerosus and squamous cell hyperplasia. Learn about key features, distinctions, and treatment considerations. Understand the long-term implications and underlying causes of these conditions.