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MoonDragon's Women's Health Procedures Information
VULVA LESIONS & EXTERNAL ANOMALIES
(Vulva Examination For Various Types of Common Lesions & External Anomalies
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  • Vulva Exam Description
  • External Congenital Anomalies of the Vagina
  • Vulvar Lesions, Cysts & Tumors




  • VULVA EXAM DESCRIPTION

    Examination of the vulva is an integral and important part of every gynecological examination. The appearance of the vulva and vagina varies normally in relation to age and hormone status and changes in the skin of the vulva and vagina must take into account the expected texture of the epithelium for any given age. Good lighting and, where indicated, a magnifying glass or a colposcope, are needed for a systematic examination.

    Both benign and malignant tumors of the vulva and vagina are relatively uncommon.







    Normal Vulva Anatomy


    The vulva is the part of the female anatomy that surrounds the vaginal and bladder openings and consists mainly of four skin folds. Two skin folds on either side of the openings. The four folds are joint in front of the bladder opening to surround the clitoris.

    The vulva is examined as part of the annual gynecological check up. If you discover any lumps or sores let it immediately be checked. Although relatively rare cancer does occur on the vulva.





    EXTERNAL CONGENITAL ANOMALIES OF THE VAGINA

    THE NORMAL HYMEN OVERVIEW

    The hymen is seen as a thin membrane found at the external opening of a female's vagina, most often surrounding or partially covering the opening. It forms part of the female's vulva or external genitalia. The size of the hymenal opening increases with age. When this membrane is complete and intact, many societies consider the female is a "virgin" (meaning - not having had penetration during an act of sexual intercourse, causing a tearing of the membrane in most instances). Although an often practiced method, it not possible to confirm with certainty that a girl or woman is a virgin by hymenal examination. In cases of suspected child sexual abuse or rape, a detailed examination of the hymen may be performed by medical examiners, but the condition of the hymen alone is often inconclusive. A torn hymen in younger children will typically heal very quickly. The hymenal opening in adolescents does extend from natural causes and variation in shape and appearance increases. The hymen will most often be shaped like a half moon or crescent, which allows menses (blood flow) during a female's monthly menstrual cycle. The hymen has been seen with many other shape variations besides the crescent, having various degrees of thickening and opening sizes. Some females will have very little hymenal membrane or none at all and others will have a membrane that will cover the opening completely. After a woman gives birth, vaginally, she may be left with remnants of the hymen, called carunculae myrtiformes, or the hymen may be completely absent. Hymen defects or anomalies are not easily discovered during childhood, although it may be possible. Most of the time, diagnosis occurs during puberty.

    normal hymen


    Normal Hymen - Overview
    Hymen is the gray shaded area
    normal hymen close-up


    Normal Hymen Close-Up
    Hymen is the gray shaded area


    HYMENAL DEVELOPMENT - IN UTERO TO NEWBORN

  • The genital tract develops during embryogenesis, from the third week of gestation to the second trimester, and the hymen is formed following the vagina.
  • At week seven, the urorectal septum forms and separates the rectum from the urogenital sinus.
  • At week nine, the müllerian ducts move downwards to reach the urogenital sinus, forming the uterovaginal canal and inserting into the urogenital sinus.
  • At week 12, the müllerian ducts fuse to create a primitive uterovaginal canal called unaleria.
  • At month 5, the vaginal canalization is complete and the fetal hymen is formed from the proliferation of the sinovaginal bulbs (where müllerian ducts meet the urogenital sinus), and becomes perforate before or shortly after birth.
  • In newborn babies, still under the influence of the mother's hormones, the hymen is thick, pale pink, and redundant (folds in on itself and may protrude). For the first two to four years of life, the infant produces hormones that continue this effect. Their hymenal opening tends to be annular (circumferential).


  • HYMENAL RESORPTION

    Infants' hymenal openings tend to be redundant (sleeve-like, folding in on itself), and may be ring-shaped. Some females are born without hymens.

    Past neonatal stage, the diameter of the hymenal opening (measured within the hymenal ring) has been proposed to be approximately 1 mm for each year of age. In children, to make this measurement, an examining health care provider may place a Foley catheter into the vagina and inflate the balloon behind the hymen to stretch the hymenal margin and allow for a better examination.

    The hymen is most apparent in young girls: At this time, their hymen is thin and less likely to be redundant, that is to protrude or fold over on itself. In instances of suspected child abuse, health care providers use the clock face system to describe the hymenal opening. The 12 o'clock position is below the urethra, and 6 o'clock is towards the anus, with the patient lying on her back.

    By the time a girl reaches school age, this hormonal influence has ceased, and the hymen becomes thin, smooth, delicate, and nearly translucent. It is also very sensitive to touch; a physician who must swab the area should avoid the hymen and swab the outer vulval vestibule instead.

    Prepubescent girls' hymenal openings come in many shapes, depending on hormonal and activity level, the most common being crescentic (posterior rim): no tissue at the 12 o'clock position; crescent-shaped band of tissue from 1 to 2 o'clock to 10 to 11 o'clock, at its widest around 6 o'clock. From puberty onwards, depending on estrogen and activity levels, the hymenal tissue may be thicker, and the opening is often fimbriated or erratically shaped.

    In the normal course of life, the hymenal opening can also be enlarged by tampon or menstrual cup use, pelvic examinations with a speculum, regular physical activity or sexual intercourse. Once a girl reaches puberty, the hymen tends to become so elastic that it is not possible to determine whether a woman uses tampons or not by examining her hymen. Hymens can be stretched or torn during the first experience of sexual penetration, or with tampon use or other non sexual activity. It can also be stretched with fingers. In one survey, only 43 percent of women reported bleeding the first time they had intercourse, indicating that the hymens of a majority of women are sufficiently opened. On torn or stretched, the hymen becomes an irregular ring of tissue around the vaginal opening.

    After giving birth, the vaginal opening usually has nothing left but hymenal tags (carunculae myrtiformes) and is called "parous introitus".

    TYPES OF HYMENAL ANATOMIC ANOMALIES

    Anomalies of the female reproductive tract can result from agenesis or hypolasia, canalization defects, lateral fusion and failure of resorption, resulting in various complications.

    The simplest external vaginal anomalies, which are easily treated by medical incision, is the imperforate hymen, microperforate (cribriform) hymen and septate hymen. Sometimes, the hymenal tissue is thicker than usual, creating a stronger membrane barrier which cannot be penetrated during normal sexual intercourse resulting in painful intercourse attempts and frustrated lovers. This, too, is easily remedied by an incisional procedure that opens the vagina and removes the extra hymenal tissue, thus allowing normal sexual penetration during intercourse.

    IMPERFORATE HYMEN

    When the thin hymenal membrane of a female completely covers the vaginal opening, it is called an imperforate hymen. This is usually not a problem with a female child until she begins her menstrual cycle during the onset of puberty. The imperforate hymen will cause the menstrual blood to back up behind it, not allowing it to flow out of the body during her menstrual period. This will result in blood collecting in the vagina, uterus and even into the abdomen causing abdominal pain. The blockage may also create back pain, pain during bowel movements and urination difficulties. Diagnosis of imperforate hymen may be done at the time of birth or later during puberty when symptoms develop.

    Treatment for imperforate hymen involves opening the vagina by surgically removing hymenal tissue, thus creating a vaginal opening of normal size if it has not corrected itself by puberty to allow menstrual fluids to escape. This is considered minor surgical procedure and is a relatively easy procedure to do. Once the vagina is opened, the menstrual blood will be able to flow out of the vagina normally during a female's menses.


    imperforate hymen


    CRIBRIFORM OR MICROPERFORATE HYMEN

    When the thin hymenal membrane tissue obstructs the vaginal opening almost completely with only a very small opening, it is called a microperforate hymen. Hymen cribriformis has several very small openings. The cribriform or microperforate hymen is sometimes confused for imperforate since the hymenal opening appears to be nonexistent, but has under close examination, small openings. These small opening(s) will allow some menstrual blood to flow from the vagina. Since there is blood flow during her menses, a female may not realize that she has a very small vaginal opening. Because the microperforate hymen opening is so small, a female may not be able to use tampons during her menses. The tampons may be too large for her vaginal opening and she may have difficulty inserting them into the vagina. If she does manage to insert a tampon into her vagina, she may experience great difficulty, or find it impossible, in removing it from her vagina as the tampon will expand in size when it becomes saturated with menstrual blood. Again, treatment involves a minor surgical procedure to open the vagina by removing extra hymenal membrane tissue, thus opening the vagina to a normal size for menses.



    SEPTATE HYMEN:

    When the thin hymenal membrane has one or more bands of extra tissue extending across the opening of the vagina, instead of the usual - one opening, it is called a septate hymen. As with the microperforate hymen, there may be problems using tampons, putting them inside the vagina and removing them, during menses. Minor surgery is performed to open and remove the extra hymenal tissue to creat a normal opening to the vagina.


    septate hymen


    Some of this information was obtained from Wikipedia.org:Hymen. To review the complete article with references and citations, visit their webpage.




    VULVAR LESIONS, CYSTS, & TUMORS

    This article will discuss a few of the lumps and growths that frequently effect the vulva. I will not discuss the treatment in detail. For more information about various types of vulvar lesions, see the medical links provided below. It is very important that treatment should be decided in consultation with the health care practitioner. It depends on many factors and the final decision should be made after a discussion between health care provider and patient.

    EMedicine.com: Benign Vulvar Lesions (With Pictures)
    EMedicine.com: Malignant Vulvar Lesions (Without Pictures)



    SEBACEOUS CYSTS

    They occur anywhere on the vulva. Small lumps of variable size and are benign. They developed in blocked sebaceous glands (skin oil glands). The tend to be small round cystic nodules in the labia. They are sometimes yellowish in color. Look for the dark punctum marking the blocked opening of the gland.


    Sebaceous Cyst




    BARTHOLIN CYSTS

    A lump or swelling occurring at either side of the entrance to the vagina is most probably a Bartholin cyst. One of the most common lumps occurring on the vulva is a Bartholin cyst. It is a swelling that is caused by a blocked gland. The Bartholin glands are two large glands situated on either side of the vaginal openings. The are responsible for secreting lubricating fluid during sexual arousal. When one of these glands are block a lump develops at the entrance of vagina. If the contents became infected a Bartholin abscess can occur. This is very painful condition. Bartholin cysts and abscesses keep on recurring if not properly treated.

    Inflammation of Bartholin's Glands may be acute or chronic. It is commonly but not necessarily caused by gonococcal infection. Acutely, it presents as a tense, hot, very tender abscess. Look for pus coming out of the duct or erythemia around the duct opening. Chronically, a non-tender cyst occupies the posterior labium. It may be large or small.

    The treatment is surgical drainage . The best results are achieved through a drainage procedure known as marsupialization. Under certain conditions total removal of the effected gland might be necessary.



    Inflamed Bartholin's Gland


    Bartholin's Glands Anatomy




    URETHRAL CARUNCLE

    A urethral caruncle is a bright red, polypoid growth that protrudes from the urethral meatus. Most cause no symptoms. A caruncle may be confused with simple pouting of the posterior aspect of the urethral mucosa, which is often visible in post-menopausal women. Urethral caruncles are rare in peri-menopausal women.



    Urethral Caruncle




    Symptoms of Urethral Caruncle may be present with urethral bleeding, urinary urgency or frequency, or dysuria. Unlike a neoplasm, which generally is firm and non-tender. A urethral caruncle may cause no signs or symptoms. But some women may have:
    • Difficult or painful urination.
    • Blood in the urine.
    • Tenderness or irritation around the opening of the urethra.
    • Soaking in a warm bath.
    • Hormone creams applied directly to the caruncle.
    • Surgical removal of the caruncle.
    • Painful micturition or dyspareunia.
    • Bloody spotting with mild trauma.
    • Sassile or pedunculated red mass that is tender to touch.

    Urethral caruncle is caused by redundancy of the mucosa combined with laxity of the peri-urethral fascia, and it may be aggravated by an increase in intra-abdominal pressure and a relative lack of estrogen, the causes include urethral caruncles, which often originate from the posterior lip of the urethra, may be described as fleshy outgrowths of distal urethral mucosa. Urethral caruncles are common in elderly women but are rare in peri-menopausal women. A urethral caruncle looks like a bed of granulation tissue covered by either squamous or transitional epithelium. Many present as bleeding or blood on the undergarments. Some caruncular lesions may look like urethral carcinoma.

    A list of some of the Treatment of Urethral Caruncle:
    • Warm sitz baths.
    • Topical estrogen cream and topical anti-inflammatory drugs.
    • Surgical excision.
    • First, perform a cystourethroscopy to rule out bladder and urethral abnormalities. Many urologists perform a cystoscopy in the office, upon initial patient presentation, to rule out other pathologies.
    • Place a Foley catheter.
    • Use stay-sutures in the epithelium to prevent mucosal retraction and meatal stenosis.
    • Excise the lesion.
    • Oversew the edges with 3-0 or 4-0 chromic sutures.



    CYSTOCELE

    A cystocele is present when the anterior wall of the vagina, together with the bladder above it, bulges into the vagina and sometimes out the introitus. Look for the bulging vaginal wall as the patient/client strains down.



    Cystocele






    RECTOCELE

    A rectocele is formed by the anterior and downward bulging of the posterior vaginal wall together with the rectum behind it. To identify it, spread the patient's / client's labia and ask her to strain down.



    Rectocele




    RELATED LINIKS

    MoonDragon's ObGyn Womens Health Information: Uterine Prolapse (Including Cystocele, Rectocele)



    GENITAL WARTS

    Genital Warts - The scientific name for this condition is Condyloma accuminata. It is a benign growth caused by a virus (Human Papilloma virus) It is a contagious condition and can be sexually transmitted. They begin as small lesions and if not treated in the early stages they will multiply and enlarge. In advance cases the whole vulva may consists of warts disturbing the anatomy of the vulva and causing sexual dysfunction. They basically consist of skin folds that are formed by fast growing cells (see graphics below).



    The drawing illustrates changes occurring in skin cells following papilloma virus contamination. The virus combines with the DNA in the cell and the nucleus changes.


    This drawing illustrates how the abnormal cells starts dividing at an increased rate and change the structure of the skin.


    This drawing shows how the fast growing cells causes skin folds to develop. Due to limited space the fast growing cells are pushed to the surface and skin folds develop. The cells do not infiltrate or invade the surrounding tissue and the resultant wart is a benign growth.


    This drawing gives an illustration of an established wart with many skin folds.


    The diagnosis is confirmed via biopsies and histology (microscopic examination of the tissue obtained during the biopsy).

    Treatment Options: Different treatment options are available. The latest is applying an antiviral ointment. Surgical removal, laser treatment, application of chemicals to destroy the wart tissue and application of antiviral ointments. The antiviral drug in the ointment infiltrate the wart tissue and immobilizes the papilloma viruses causing the warts.

    The treatment option to be implemented should be decided in consultation with the treating health care provider. Repeated treatments might be necessary for optimum results.



    Vulvar Warts - Warty lesions on the labia and within the vestibule suggest condylomata acuminata. Like warts elsewhere, they are reactions to a viral infection.




    Genital warts on vulva.


    Genital warts on penis.


    MoonDragon's Womens Health STD Information: Genital Warts



    MALIGNANT GROWTHS OF THE VULVA (CANCER)

    Vulvar cancer is not very common but early detection is very important. Early cancer can appear in different forms. It may appear as small hard swellings, sores (ulcers), depigmentated areas (white skin patches) or hyperpigmentated (dark patches). It can occur in the |Bartholin's glands although very rarely.

    Vulval inspection is part of the annual check up, but do not rely completely on that. Regular inspection (self-exam using a mirror) for white or dark patches and feeling for lumps is important. Anything that is alarming should be further investigated. Fortunately most of the lesions will turn out to be benign.

    The drawing below shows the danger of cancer and why early detection is important. If it is compared with a wart, the cancer cells invades the surrounding tissues and destroys the basement membrane to invade the deeper tissues and even the blood and lymph vessels. The ideal treatment will be removal or destruction of the cancer before the basement membrane is penetrated.



    This drawing illustrates how the abnormal cells starts dividing at an increased rate and change the structure of the skin. The fast growing cells are pushed to the surface and skin changes become apparent.


    Vulvar intraepithelial neoplasia. Extensive involvement, mainly of non-hairy vulvar skin, in a 26-year-old heavy smoker. The lesion is multi-focal, papular, and partially pigmented, with a somewhat verrucous surface. Biopsy showed basal/verrucous carcinoma in situ.


    An ulcerated or raised, red vulvar lesion in an elderly woman may indicate vulvar carcinoma.


    Invasive squamous cell carcinoma of non-hairy vulvar skin in a 79-year-old woman. The lesion arises in an area of lichen sclerosus related to longstanding, untreated pruritus.


    American Family Physician: Vulvar Cancer
    (Photo 2 and 4 above, courtesy of AFP. For full article by AFP regarding vulvar cancer, click on the link above.)

    OTHER FEMALE REPRODUCTIVE CANCER LINKS FROM MOONDRAGON

    MoonDragon's Womens Health Information: Cervical Cancer
    MoonDragon's Womens Health Information: Ovary Cancer
    MoonDragon's Womens Health Information: Uterine Cancer
    MoonDragon's ObGyn Womens Health Information: Vaginal Cancer



    HERPES OF THE VULVA

    Genital herpes infection is caused by herpes simplex virus. It can be spread through sexual contact.



    Shallow, small painful ulcers on red bases suggest a herpes infection. Initial infection may be extensive, as illustrated here. Recurrent infections are usually confined to a small local patch.


    MoonDragon's ObGyn Womens Health Information: Genital Herpes



    SYPHILIS OF THE VULVA

    Syphilis is a highly contagious sexually-transmitted disease caused by a corkscrew or spiral-shaped spirochete bacterium called Treponema pallidum. Syphilis causes widespread tissue destruction. Syphilis is known by many names throughout history, including the "French disease" and the "Great Pox". It is also known as the "great mimic" or "the great imitator," because its symptoms resemble or are indistinguishable from those of many other diseases. It involves the genitals, skin, and central nervous system.

    Syphilis Bacterium
    Syphilis Bacterium


    Syphilis is passed from person to person through direct contact with a syphilis sore. Sores occur mainly on the external genitals, vagina, anus, or in the rectum. Sores can also occur on the lips and in the mouth. Transmission of the organism occurs during vaginal, anal or oral sex. Pregnant women with the disease can pass it to the babies they are carrying. Syphilis cannot be spread through contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing or eating utensils.



    SYPHILITIC CHANCRE: A firm painless ulcer suggests the chancre of primary syphilis. Since most chancres in women develop internally, they often go undetected.

    SECONDARY SYPHILIS (Condyloma Latum): Slightly raised, flat or oval papules, covered by a gray exudate, suggest condylomata lata. These constitute one manifestation of secondary syphilis and are contagious.



    MoonDragon's Womens Health STD Information: Syphilis




    RELATED MOONDRAGON LINKS

    MoonDragon's Womens Health Information: Bacterial Vaginitis
    MoonDragon's Womens Health Information: Candida
    MoonDragon's Womens Health Information: Cervical Dysplasia
    MoonDragon's Womens Health Information: Cervical Polyps
    MoonDragon's Womens Health Information: Cervicitis
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    MoonDragon's Womens Health Information: Cystitis
    MoonDragon's Womens Health Information: Gonorrhea
    MoonDragon's Womens Health STD Information: Granuloma Inguinale
    MoonDragon's Womens Health Information: Hemorrhoids
    MoonDragon's Womens Health Information: Lymphogranuloma Venereum (LGV) / Inguinale
    MoonDragon's Womens Health Information: Molluscum
    MoonDragon's Womens Health Information: Pruitus Vulvae
    MoonDragon's Womens Health STD Information: Trichomonal Vaginitis
    MoonDragon's Womens Health Information: Urethritis
    MoonDragon's Womens Health Information: Vaginal Hernias
    MoonDragon's Womens Health Information: Vaginitis, Post-Menopausal





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    MOONDRAGON'S REALM - WEBSITE DIRECTORY


    A website map to help you find what you are looking for on MoonDragon.org's Website. Available pages have been listed under appropriate directory headings.