Female Genital Diseases-1 PDF

Female genital diseases-1 BY HUSAMELDIN OMER MOHAMED OMER  Diseases of vulva Infectious vulvitis; The most important infectious agents are:- 1. Human papillomavirus (HPV), producing condylomata acuminata (warts) and vulvar intraepithelial neoplasia. 2. Herpes simplex...

Female genital diseases-1 BY HUSAMELDIN OMER MOHAMED OMER  Diseases of vulva Infectious vulvitis; The most important infectious agents are:- 1. Human papillomavirus (HPV), producing condylomata acuminata (warts) and vulvar intraepithelial neoplasia. 2. Herpes simplex genitalis (HSV 1 or 2), causing a vesicular eruption. 3. Gonococci producing suppurative infection of the vulvovaginal glands. 4. Syphilis, causing primary chancre at the site of inoculation. 5. Candida causing an itchy rash on the vulva and surrounding skin in combination with vaginal discharge. Complication: like abscess and Bartholin gland cyst. Bartholin cyst results from occlusion of the main ducts of the Bartholin glands. This cyst may get infected and change into an abscess. Inflammatory dermatoses of vulva Contact dermatitis of vulva; One of the common causes of vulva dermatitis is the reactive inflammatory response to an exogenous stimulus, which may be an irritant (contact irritant dermatitis like urine, certain chemicals…etc.) or an allergen (contact allergic dermatitis) Non-contact vulval dermatitis: Lichen sclerosus (older name: lichen sclerosus et atrophicus) A chronic inflammatory dermatosis that most often affects the genital areas in both sexes and characterized with itchy, smooth white to gray plaques. ❖ It thought to be an auto-immune disease and in women it most common and most extensive in postmenopausal years. ❖ Microscopically There is hyperkeratosis and the epidermis is thin with disappearance of rete ridges. The dermis shows Amorphous homogeneous degenerative changes with a degree of infiltration of chronic inflammatory cells at the mid dermis Lichen simplex chronicus (neurodermatitis): is a chronic itchy skin condition causing thickened skin at any area that have been injured before by repeated scratching and rubbing in response to an itchy primary stimulation that started by different causes. The condition begins as itchy skin that leads to repeated scratching and rubbing. This causes thickening of skin and moreover itchy stimulation. Microscopically there is acanthosis, hyperkeratosis and inflammatory cells infiltration of the dermis.  Lichen sclerosus Normal skin Lichen sclerosus  Lichen simplex chronicus Normal skin Lichen simplex chronicus Neoplasms of vulva: Benign tumors: Papillary hidradenoma: Arises from the apocrine sweat glands of vulva as a circumscribed nodule that most likely located in the labia. Microscopically It composed of irregularly shaped tubular structures and dilated duct-like structures with intraluminal papillary projections. These three structures are all lined by two layers. The inner layer is composed of columnar cells whereas the outer layer is formed of cuboidal cells Condyloma acuminatum:  Wart-like verrucous lesion.  Caused by human papilloma virus (HPV, type 6, or 11).  Occurs usually on the vulva, perineum, & vagina.  Composed of sessile or pedunculated epithelial proliferation of stratified squamous epithelial cells, some of which may show perinuclear cytoplasmic clearing. Malignant vulval tumors: Vulval intraepithelial neoplasia (VIN) ❖ Caused by HPV 16. ❖ Occurs in 4th or 5th decades. ❖ May progress to invasive carcinoma in the sixth decade. Invasive SCC  Histologically, it is usually well differentiated squamous cell carcinoma with keratin pearls or nests, and obvious intracellular bridges  Prognosis depends on the size, depth of invasion, and the state of lymph nodes. Paget’s disease of vulva:  Carcinoma in situ, mostly on labia majora.  Appears as a red crusted sharply demarcated area.  Composed of large anaplastic cells lying singly or in small clusters.  There is no underlying intra duct carcinoma (unlike breast). Other vulvar carcinomas include:  Basal cell carcinoma.  Adenocarcinoma of Bartholin glands or sweat glands.  Malignant melanoma.  Vaginal diseases Vaginal infectious inflammation  Common, causes vaginal discharge  Usually sexually transmitted.  The most important organisms are:  Gardenella vaginalis.  Neisseria gonorrhea.  Candida albicans  Trichomonas vaginalis.  Vaginal neoplasia Vaginal intraepithelial neoplasia: VaIN is defined by the presence of squamous cell atypia without invasion. The disease is classified according to the depth of epithelial involvement. VaIN 1 and 2 involve the lower one-third and two-thirds of the epithelium, respectively. VaIN 3 involves all the thickness of the epithelium. It related to HPV infection Invasive vaginal squamous cell carcinoma ❖ Primary vaginal squamous cell carcinoma is uncommon ❖ Vast majority is HPV-associated and preceded with VaIN 3  Occur mainly between 60 & 70 years of age.  The tumor may be plaque-like or fungating. Clear cell adenocarcinoma ❖ Very rare tumor that occurs historically in young women whose mothers were treated by diethylstilbesterol during pregnancy (stopped now) ❖ Composed of glands lined by vacuolated clear cells Embryonal rhabdomyosarcoma ❖ Rare Polypoid tumor, in young female children Clear cell adenocarcinoma  Disease of the cervix Infectious cervicitis: ❖ Extremely common ❖ The most common organisms are Chlamydia trachomatis, N. gonorrhoeae, and Trichomonas vaginalis ❖ Either to be chronic or acute, and the acute cervicitis often results in purulent discharge ❖ Cervicitis is sometimes not caused by infection, for example it may be due to chemical irritation or mechanical trauma. ❖ In chronic cervicitis the cervical tissue is infiltrated by chronic inflammatory cells. ❖ Chronic cervicitis causes metaplasia of the endocervical columnar epithelium into squamous epithelium and this metaplasia may cause obstruction of the cervical gland crypts and formation of Nabothian cysts. Chronic cervicitis Endocervical polyps:  Common lesions that occur at any age. The are usually small, but can reach large size  Composed of core of connective tissue stroma containing blood vessels. This core is covered by endocervical glandular epithelium or metaplastic squamous epithelium.  No definite, known etiologic factors, although the role of chronic inflammation has been hypothesized  The stroma may contain acute or chronic inflammatory cells.  Usually have no malignant potential. Cervical intraepithelial neoplasia (CIN):  Caused by Human Papilloma Virus (HPV).  Usually begins at the squamo-columnar junction in adolescent age  There is squamous metaplasia, maturation and cytologic atypia.  Nuclear atypia include: hyperchromasia, pleomorphism, increased mitotic activity and increased nuclear cytoplasmic (N/C) ratio. the squamo-columnar junction CIN is graded into:  CIN I: the lower 1/3rd of epithelium shows dysplasia (mild dysplasia).  CIN II: the lower 2/3rd of epithelium shows dysplasia (moderate dysplasia)  CIN III: more than 2/3rd to full epithelial thickness is occupied by the atypical cells (severe dysplasia). These changes appear to last for years before invasion occurs (about 10 years). Grades of CIN Invasive squamous cell carcinoma of the cervix: The peak incidence is around 45 years, usually in multipara and it is usually preceded by CIN 3. Advanced tumors can cause pain, bleeding, painful intercourse. Predisposing factors:  Early full sexual activity  High parity or multipara (≥5 pregnancies of ≥20 weeks)  Infection by herpes simplex type II and HPV,  High and prolonged level of estrogen.  Cervical SCC Gross appearance Grossly, usually show one of the following forms: Polypoid (the commonest). Or Ulcerative or Infiltrative within the wall of the cervix. Microscopically, The main morphological variants include; Keratinizing Keratin pearls, abundant keratohyaline granules and intercellular bridges, large, hyperchromatic nuclei with coarse chromatin and inconspicuous nucleoli Nonkeratinizing Polygonal cells forming sheets or nests with intercellular bridges but not keratin pearls Papillary Thin or broad papillae with fibrovascular cores lined by multilayered epithelium Basaloid Well defined nests of immature basaloid cells Squamous cell carcinoma, cervix Stages of SCC of the cervix:  Stage I: carcinoma confined to the cervix.  Stage II: carcinoma reaching to the upper part of vagina.  Stage III: carcinoma reaching the pelvic wall or lower 1/3rd of vagina.  Stage IV: carcinoma reaching the urinary bladder and rectum with distant metastases. Other malignant tumors of the cervix Adenocarcinoma (classic type0. Adenosquamous carcinoma. Clear cell adenocarcinoma. Small cell carcinoma Sarcomas Melanoma Effects and complications of cancer cervix:  Spread:  Local to the surrounding structures,  Lymphatic to the regional lymph nodes e.g. iliac, sacral & hypogastric,  Blood spread to liver, lungs and bone.  Vesico-vaginal and recto-vaginal fistulas.  Pyometria.