The Vulva Terminology Normal Anatomy Normal Anatomy Symptoms

The Vulva

Terminology

Normal Anatomy

Normal Anatomy

Symptoms your patients will tell you about • • Pruritus (itch). General or just one spot Soreness: stinging / burning / pain Difficulty with sex Lumps

Causes of pruritus vulvae and/or pain • • • Candida albicans infection Irritant contact dermatitis Seborrhoeic dermatitis Psoriasis The three lichens: -Lichen simplex -Lichen sclerosus -Lichen planus

Candida albicans – vulvovaginal

Candida albicans – vaginal

Irritant contact dermatitis • Erythema • Oedema • Fissuring Soap, water, rubbing

Irritant contact dermatitis • • Burn-like Glazed erythema Superficial erosions Oedema Faecal and urinary incontinence

Seborrhoeic dermatitis • • Usually patient has it at other sites also Mons pubis and flexures May or may not be scaly Mild or absent symptoms

Seborrhoeic dermatitis

Causes of pruritus vulvae • • • Candida albicans infection Irritant contact dermatitis Seborrhoeic dermatitis Psoriasis The three lichens:

Vulval psoriasis

Vulval psoriasis

Causes of pruritus vulvae and /or pain • • Candida albicans infection Irritant contact dermatitis Seborrhoeic dermatitis Psoriasis The three lichens: lichens Lichen simplex Lichen sclerosus Lichen planus

Lichens • All three cause similar skin change • The skin becomes thickened, pale, with increased skin markings [grooves]and fissures

Lichen Simplex • Chronic irritation causes the skin change • Remove the irritant and the skin recovers

Lichen simplex • • • Perineum - ? Candida Skin thickening Fissuring Skin coloured Dyspigmentation common

Lichen simplex • Unilateral, labium major • Due to rubbing because of intense itch • Well-demarcated • Skin thickening • Increased skin markings • Skin coloured • Dyspigmentation common

Lichen sclerosus • • • Probably an immune system disease Itch: nil to very severe Soreness: nil to very severe Altered anatomy from tissue destruction Dyspareunia / apareunia because of symptoms or changed anatomy

The Itch of lichen sclerosus • Mainly the labia minora, clitoral hood and/or perineum • Perianal in 50% • Extragenital in 15%

Who gets Lichen Sclerosus • Most are 50 years or older but children and teenagers may be affected • May have other associated autoimmune conditions – 25% thyroid antibodies; – 10% psoriasis

LS and VIN • Lichen Sclerosus is associated with pre malignant change • VIN, Vulval Intraepithelial neoplasia • VIN untreated may become SCC

Lichen sclerosus • Distribution: figure of 8 with wings – Usually bilateral • Colour – white, crinkly (‘cigarette-paper’) • Sclerosis – firm

Lichen sclerosus • White, like vitiligo • Anatomic change – Loss of labia minora

Lichen sclerosus • Distorted clitoral hood and labia minora • Postinflammatory white areas • Postinflammatory brown pigmentation

Lichen sclerosus • Resorption of labia minora • Fissures in the labial sulcus and onthe perineum

Lichen sclerosus • Flattening of clitoral hood • Resorption of labia minora • Haemorrhages

Lichen sclerosus • Flattening of clitoral hood • Resorption of labia minora

Lichen sclerosus • Severe introital narrowing • Splitting of posterior forchette

Lichen sclerosus • Bridging / fusion / agglutination of left and right labia • Ulceration

Lichen sclerosus • Distortion of labia minora • Ulceration • Haemorrhage

Lichen sclerosus • Ulcer right labium minor

Lichen sclerosus • Hyperkeratosis – Consider biopsy

LS in a teenager

Psoriasis + lichen sclerosus • Psoriasis less symptomatic but more impressive • Psoriasis ‘outside’ • Lichen sclerosus ‘inside’ • Psoriasis does not alter anatomic features

Lichen sclerosus: treatment • Ultrapotent topical steroid, usually clobetasol ointment • Once daily until clear (one to three months) • Then alternate days for the same duration • Then once or twice per week long-term or PRN • Explain to patient precisely where to apply the ointment

Lichen planus Less common More painful Just as destructive More likely to be seen on other parts of the patient • Two types: cutaneous and mucosal • •

Lichen planus: cutaneous type • • Violaceous plaques Wickham’s striae Labia majora Irregular distribution

Lichen planus: mucosal type • • May be very itchy More often very painful Very tender to touch Destructive – loss of clitoral hood, labia minora May cause introital narrowing More likely to involve vagina (unlike lichen sclerosus) May also affect oral mucosa – Buccal mucosa, inner lips, tongue – Desquamative gingivitis

Erosive lichen planus • Red glistening painful mucosal patch • Loss of labia minora

Erosive Lichen Planus

Erosive lichen planus

Erosive lichen planus • Mucosal disease may result in postinflammatory pigmentation

Erosive lichen planus • Destruction of tissue • Introital narrowing • Eaten-away appearance

Erosive lichen planus: treatment • Topical clobetasol daily – May be required daily long-term • Topical calcineurin inhibitors, e. g. , pimecrolimus cream • Oral prednisone • Methotrexate • Often symptoms respond better than signs

Plasma cell Vulvitis • Much less common • Much less destructive • Often asymptomatic

Plasma cell vulvitis • Deeper red than LP – Haemorrhagic • More internal • More patchy

Plasma cell vulvitis • May extend periurethrally • Contact bleeding

Plasma cell vulvitis: treatment • Topical antibiotic – Clindamycin cream – Metronidazole cream • Hydrocortisone cream

Symptoms your patients will tell you about • • Pruritus (itch). General or just one spot Soreness : stinging / burning / pain Difficulty with sex Lumps

Lumps that might not cause symptoms • Frightening things • Not so frightening things

Pre malignant and Malignant lesions • Vulval intraepithelial neoplasia, VIN • Invasive squamous cell carcinoma • Melanoma

Vulval intraepithelial neoplasia • • This is a pre malignant lesion Mild or no symptoms but does have signs Two types: Usual and Differentiated Usual VIN = HPV related Differentiated VIN = Lichen sclerosus or lichen planus related – more likely to become an aggressive SCC

HPV • Human Papilloma Virus • Low risk and High risk, but Hr. HPV types are associated with cancers in many parts of the body: cervix, vagina, vulva, anal canal, mouth. • Sexually transmitted • Vaccine • ENT surgeons now very interested

VIN

VIN

VIN

VIN + Lichen sclerosus

Invasive squamous cell carcinoma • • Arises within VIN [HPV or lichen sclerosus] Irregular, hard nodule, often ulcerated May be multifocal Often aggressive

Invasive squamous cell carcinoma

Invasive squamous cell carcinoma

Melanoma • Rare • Not related to fair skin or sun exposure • Mild or no symptoms

Vulval melanoma

Melanoma

Less frightening things • You will often notice lumps or bumps • Ask about them • The patient may be waiting to see if you think its abnormal.

Sebaceous Cyst

Vaginal Wall prolapse

Prolapse

Varicosities

Genital Warts

Others • Urethral caruncle • Bartholin’s cyst • Asymmetrical labia

Bartholins cyst

Urethral caruncle

It’s a very private area • • Our perception of our vulva is effected by: Culture Religion Age Education Marital status Sexual experiences Facebook

Vulval Disease • • • Most women present late, and very distressed They often feel guilt or ashamed They always feel embarrassed They worry it’s an STI If there is a lump they think it’s a wart Results of surveys of the impact of vulva disease are alarming

Vulval disease • Any one of the conditions I have discussed today, even the most innocuous will disrupt their sex lives no matter their age. • Patients can become very socially isolated and their relationships severely altered. • There is usually something we can do to help

Vulva Sign