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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.
CONGENITAL ABNORMALITIES OF THE VAGINA
The simplest vaginal abnormality which is easily treated by incision is the imperforate hymen.
Hymen: a thin membrane that surrounds the opening to a young woman's vagina. Hymens can come in different shapes. The most common hymen is shaped like a half moon. This shape allows menstrual blood to flow out of a girl's vagina.
Normal Hymen - Overview
Hymen is the gray shaded area
Normal Hymen Close-Up
Hymen is the gray shaded area
TYPES OF HYMENS:
IMPERFORATE HYMEN:
An imperforate hymen can be diagnosed at birth but sometimes the diagnosis is not made until the teen years. An imperforate hymen is a thin membrane that completely covers the opening to a young girl's or young woman's vagina. Menstrual blood cannot flow out of the vagina. This usually causes the blood to back up into the vagina and the abdomen (belly) resulting in abdominal and/or back pain. Some teens may also have pain with bowel movements and difficulty passing urine.
The treatment for an imperforate hymen is minor surgery to remove the extra hymenal tissue and create a normal sized vaginal opening so that menstrual blood can flow out of the vagina.
MICROPERFORATE HYMEN:
A microperforate hymen is a thin membrane that almost completely covers the opening to a young women's vagina. Some menstrual blood may be able to flow out of the vagina but the opening is very small. A teen with a microperforate hymen usually will not be able to get a tampon into her vagina and may not realize that she has a very tiny opening. If she is able to put a tampon into her vagina she may not be able to remove it when it becomes filled with blood.
The treatment is minor surgery to remove the extra hymenal tissue making a normal sized opening for menstrual blood to flow out.
SEPTATE HYMEN:
A septate hymen is when the thin hymenal membrane has a band of extra tissue in the middle that causes two small vaginal openings instead of one. Teens with a septate hymen may have trouble getting a tampon in or trouble getting a tampon out. The treatment for a septate hymen is minor surgery to remove the extra band of tissue and create a normal sized vaginal opening.
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.
VULVAR LESIONS, CYSTS, TUMORS
This page 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)
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 glades situated on either side of the vaginal openings. The are responsible for secreting lubricating fluid during sexual arousal. When one of these glans 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: 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.
Causes: 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.
Treatment: 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
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 limit 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.
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.
(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
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.
SYPHILIS OF THE VULVA
Genital herpes infection is caused by herpes simplex virus. It can be spread through sexual contact.
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.
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