Benign diseases of the

vulva, vagina and cervix

 The vulva
Is the part of the female genital tract located between the
genitocrural folds laterally, the mons pubis anteriorly, and the anus
posteriorly.
Embryologically, it is the result of the junction of the cloacal
endoderm, urogenital ectoderm, and paramesonephric mesodermal
layers.
This hollow structure contains
LABIA MAJORA
LABIA MINORA
CLITORIS
VESTIBULE
URINARY MEATUS
VAGINAL ORIFICE
HYMEN
BARTHOLIN GLANDS
SKENE DUCTS.
 The vulva
Different epithelia, from keratinized squamous epithelium
to squamous mucosa, cover the vulva.
The labia minora are rich with sebaceous glands but
have few sweat glands and no hair follicles.
The epithelium of the vestibule is neither pigmented nor
keratinized and contains eccrine glands.
 BENIGN LESIONS OF THE VULVA

According to the International Society for the Study of

Vulvar Disease (ISSVD) in 1989:
Inflammatory diseases.

Blistering diseases.

Pigmentary changes.

Benign tumors, hamartomas and cysts

Congenital malformations.
 Inflammatory diseases
1. Lichen sclerosus
2. Squamous cell hyperplasia (+/- atypia)
3. Lichen simplex chronicus (localized
neurodermatitis)
4. Primary irritant dermatitis
5. Intertrigo
6. Allergic contact dermatitis
7. Fixed drug eruption
8. Erythema multiforme
9. Toxic epidermal necrolysis
10.Atopic dermatitis
11.Seborrheic dermatitis
12.Psoriasis
13.Reiter disease
14.Lichen planus
15.Lupus erythematosus
16.Darier disease
17.Aphthosis and Behet disease
18.Pyoderma gangrenosum
19.Crohn disease
20.Hidradenitis suppurativa
21.Fox-Fordyce disease
22.Plasma cell vulvitis
23.Vulvar vestibulitis syndrome
 Blistering diseases

1. Familial benign chronic

pemphigus (Hailey-Hailey

disease)

2. Bullous pemphigoid

3. Cicatricial pemphigoid
4. Pemphigus vulgaris

5. Erythema multiforme

6. Epidermolysis bullosa
 Pigmentary changes

1. Acanthosis nigricans

2. Lentigo

3. Melanocytic nevus

4. Postinflammatory hyperpigmentation

5. Postinflammatory hypopigmentation

6. Vitiligo
 Benign tumors, hamartomas, and
cysts

1. Bartholin cysts 8. Hidradenoma

2. Epidermal inclusion cyst (Dermoid cyst) 9. Lipoma

3. Endometriosis 10. Chronic Inflammatory swellings

4. Hydrocele of the canal of Nuck 11. Hemangioma

5. Skene duct cyst 12. Lymphangioma

6. Seborrheic keratosis 13. Angiokeratoma

7. Acrochordon (fibroepithelial polyp) 14. Pyogenic granuloma

8. Fibroma, fibromyoma, and dermatofibroma 15. Sebaceous gland hyperplasia

16. Papillomatosis
 BENIGN LESIONS OF THE VULVA

BARTHOLINs CYST

ATROPHIC LICHEN (LICHEN SCLEROSUS ET ATROPHICUS)

SQUAMOUS HYPERPLASIA

LICHEN SIMPLEX CHRONICUS

HIDRADENOMA PAPILLIFERUM
 Bartholins Cyst/Abscess

Medial to labia minor

Blockage of duct following infection

N. gonorrhea

Staphylococci

Anaerobes
 Thomas Bartholin
Danish professor
In 1652 he gave the first full
description of the human
lymphatic system.
Marsupalization
lichen
 What is lichen?

A fungus, usually of the class Ascomycetes,

that grows symbiotically with algae, resulting
in a composite organism that
characteristically forms a crustlike or
branching growth on rocks or tree trunks.
In pathology.

Any of various skin diseases characterized by

patchy eruptions of small, firm papules.
 Lichen Sclerosus et Atrophicus

Most patients are post-menopausal women

Stenosis of the introitus develops

 Lichen Sclerosus et Atrophicus

Note the white, parchment-like or plaque-like lesion

 Lichen Sclerosus et Atrophicus

During early stages the patient may not have symptoms.

Some patients develop intractable pruritus

Burning and pain are less likely manifestations.

Figure-of-8 or keyhole configuration.

In late stages normal architecture may be lost

atrophy of the labia minora, constriction of the vaginal orifice
(kraurosis), synechiae, ecchymoses, fissures.

Squamous cell carcinoma develops in 3-6% cases

 Lichen Sclerosus et Atrophicus

Thinning of the surface epithelium with some

hyperkeratosis.
 Lichen Sclerosus et Atrophicus

Etiology
Unknown. A higher prevalence of the disease in
postmenopausal women suggests hormonal factors,
but this has not been confirmed.
Studies identifying an infection are inconclusive
Weakly linked to autoimmune diseases and genetic
factors
Local factors (eg, trauma, friction, chronic infection
and irritation)
Recurrence near vulvectomy scars has been
observed.
 Lichen Sclerosus et Atrophicus

Treatment
Potent topical corticosteroids

Testosterone propionate is ineffective and has

many adverse effects

Close follow-up -----epithelial cancer.

 Squamous Hyperplasia
Associated with a response to hormonal

influences or exposure to exogenous irritants

Precursor of squamous cell CA if cells are

atypical
 Squamous Hyperplasia

This lesion produces hyperplastic thickening of the

superficial squamous epithelium.
This lesion is a precursor of squamous cell carcinoma
of the vulva
 Squamous Hyperplasia

Note the keratin horn cysts and the infiltrate of

inflammatory cells at the base of the lesion.
 Squamous Hyperplasia

ITCHING is a common symptom.

If hyperkeratosis is not prominent, lesions may appear

as reddish plaques.

The clitoris, labia minora, and inner aspects of the labia

majora are more commonly affected.

Extensive lesions may result in stenosis of the vaginal

introitus.
 Squamous Hyperplasia

Etiology

Repetitive scratching or rubbing from irritants

Treatment is aimed at halting the

itch-scratch-itch cycle.
 Squamous Hyperplasia

Treatment
The same as lichen sclerosus
General attention to proper hygiene.
If the skin is moist or macerated, aluminum acetate
5% solution applied 3-4 times daily for 30-60 minutes
is beneficial.
Systemic antihistamines or tricyclic antidepressants
Refractory lesions, intralesional injections of
triamcinolone acetonide may be an alternative.
 lichen simplex chronicus

Hyperkeratotic, usually ill-defined,

grayish, thickened, and sometimes
excoriated lesion.

Usually located over the labia

majora.

Hyperpigmentation.

Itching is always present and may

be intense.
 lichen simplex chronicus
Lichen simplex chronicus of the vulva is the end stage of
the itch-scratch-itch cycle.
The initial stimulus to itch may be:
Underlying seborrheic dermatitis.
Intertrigo
Tinea.
Psoriasis.
In most cases, the underlying cause is not evident and may have
been transient vulvitis or vaginal discharge.
Any itching disease of the vulva may become secondarily
lichenified.
 lichen simplex chronicus
Epidermal and epithelial hyperplasia,
Hyperkeratosis.
Fibrotic vertical streaks of collagen between the
hyperplastic rete are present.
 lichen simplex chronicus
Treatment
Includes removal of irritants and/or allergens
Topical application of mild-to-highpotency corticosteroids.
Avoid soaps and cleansing agents other than aqueous cream.
Discourage excessive cleaning of the genital area; use of hot
water; overheating; and wearing of synthetic, rough, and/or
tight clothing.

Lichen simplex chronicus may be associated with

underlying diseases (eg, Paget disease, Bowen disease)
 Lichen planus

Three types:

Papulosquamous
Erosive
Hypertrophic

Malignancy is possible in long-standing and ulcerative

lichen planus.
 Lichen planus
The papulosquamous form:
Occurring as part of a generalized
disease
Is the most common and is
characterized by:
Flat-topped
Polyhedral,
Violaceous, shiny, and itchy papules
located on keratinized skin of the
labia and mons pubis. Delicate and
whitish reticulated papules may be
present on the mucosa, but no
atrophy or scarring is observed.
 Lichen planus
The erosive form:
Involves the mucous membranes of the mouth and vulvovaginal
area and may be locally destructive, leading to atrophy and
scarring.
Synonyms include erosive vaginal lichen planus, desquamative
inflammatory vaginitis, vulvovaginal-gingival syndrome, and
ulcerative lichen planus.

Itching is rare, but pain, burning,

and irritation occur and may be
responsible for dyspareunia and
dysuria.
 Lichen planus
The rare hypertrophic form:
Resembling lichen sclerosus, manifests
with extensive white scarring of the
periclitoral area with variable degrees of
hyperkeratosis.
It may be very itchy.
Extensive vaginal involvement may result
in a malodorous discharge.
Large denuded areas may become
adherent, causing stenosis of the vaginal
introitus and dyspareunia.
Marked atrophy may develop with time.
ID/CC A 75 year old woman visits her gynecologist
for a routine checkup and is found to have
white spots on her genitalia
HPI She complains of slight outer
vaginal itching but denies any
postmenopausal bleeding, vaginal
discharge, or drug intake
PE Hypochromic macules on labia
majora extending to perineum and
inner thighs in patchy distribution
with scale formation; skin is
thickened
 Pruritus vulva

Causes:
General
Local
Psychosomatic
Idiopathic
General Examination
Local examination:
Smears
Culture and sensitivity
BIOPSY: KEYEs Dermatological knife
 BENIGN LESIONS OF THE Vagina

CYSTIC SWELLINGS

SOLID TUMORS

ATROPHIC VAGINITIS

VAGINAL ADENOSIS
 Cystic swellings

Gartners Cyst
Dilatation of the Gartners (Wollfian) duct
Anterior and lateral vaginal walls

Epithelial inclusion cysts

Endometrioma
Uretheral diverticulum
 Solid Tumors

Fibromyoma

Condyloma accuminata

Bilharzial polyps
 Atrophic vaginitis
Thinning and atrophy of vaginal
epithelium

Most common in postmenopausal

women with low estrogen levels

Dyspareunia and vaginal spotting

(differential includes uterine cancer)
 Vaginal Adenosis
Persistent Mullerian columnar
epithelium in the anterior wall
and upper 1/3 of vagina

Manifestation of maternal DES

exposure

Red, granular patches

Precursor of clear cell

adenocarcinoma
 Vaginal Adenosis

Note the red granular patches on the vaginal mucosa on

the left. The slide on the right shows glandular
development.
Most patients are 7-35 years of age
 BENIGN LESIONS OF THE cervix

CERVICITIS
EROSION
POLYPS
Inflammatory Lesions of the Cervix

Cervicitis (acute)

Symptoms: backache, bearing-down feeling in the

pelvis, dull pain in the lower part of the

abdomen, urinary tract symptoms

 Erosion of the Cervix

Characterized by columnar epithelium replacing squamous

epithelium, grossly resulting in an erythematous area

Causes:

Physiological:

Cervicitis: Acute or Chronic

Hormonal therapy
 Erosion of the Cervix

Erosion of the cervix following delivery. A normal cervix

is on the left
 Erosion of the Cervix

SMEAR

If infection---- Treat cause

IF CIN ------ Manage according to stage

 Chronic Cervicitis

Chronic inflammation, sometimes ulceration with repair,

atypia or dysplasia, nabothian cysts from endocervical

glands

Backache is a common symptom

 Chronic Cervicitis
Nabothian Cysts

Endocervical glands blocked by inflammation or

scarring.
 Chronic Cervicitis

Chronic inflammation underlies an area of cervical

dysplasia
 Endocervical Polyps

Postcoital bleeding and

irregular vaginal spotting

Inflammatory

proliferations of cervical

mucosa; not true

neoplasms

Soft; may protrude

through the cervical os