Diseases of the vulva and vagina

1. Vulva — Vulvitis

Definition

• Inflammation of external female genitalia (labia, clitoris, vestibule).

A) Contact dermatitis

• Reactive inflammation to exogenous source.
• Contact irritant: soaps, detergents, antiseptics.
• Contact allergic: creams, perfumes.
• Most common cause of vulvar pruritus.

B) Bacterial infections

• Gonorrhea (N. gonorrhoeae) — affects entire gynecologic tract except vagina (only children get vaginitis); causes infertility.
• Syphilis (T. pallidum) — primary chancre, secondary condyloma lata.

C) Viral infections

• Herpes (HSV-2 in young women) — STD; labial papules → vesicles → ulcers.
• Condyloma acuminatum (HPV 6/11).

D) Fungal

• Candidiasis (Candida albicans) — vulvovaginitis; white patches + leukorrhea (thick whitish/yellow discharge) + itching.

2. Non-Neoplastic Epithelial Disorders

• Vulvar mucosa: atrophic thinning or hyperplastic thickening.
• Macroscopically: white de-pigmented lesions → leukoplakia.

A) Lichen sclerosus

• Consequence of chronic irritation (scratching).
• Thinning of epidermis + dermal fibrosis + dermal inflammation.
• Smooth white plaques/papules that merge over time.
• Postmenopausal women; autoimmune origin.
• ↑ Risk of squamous cell carcinoma in non-HPV setting.

B) Lichen simplex chronicus

• End-stage of inflammatory dermatoses.
• Epidermal thickening + hyperkeratosis + expansion of stratum granulosum.
• Clinically: leukoplakia.
• Most common premenarchal + postmenopausal.
• Atrophy + stiffening → constricted vaginal orifice.
• Squamous cell carcinoma can arise.

3. Vulvar Tumors

A) Bartholin’s cyst

• Bartholin’s glands secrete mucus to lubricate vagina.
• Duct obstruction (often after gonorrhea or acute inflammation) → fluid-filled cyst → abscess.
• Painful; often women ≥ 40 yr.
• Excision in older women due to risk of adenoid cystic carcinoma.

B) Condylomas

• Anogenital warts; in moist vulva environment → large.
• Cause: low-risk HPV (HPV 6/11).
• Two forms:
  • Condyloma lata — secondary syphilis; flat minimally elevated.
  • Condyloma acuminatum — STD; papillary; histology: koilocytes + hyperkeratosis + fibrovascular cores.
• Not pre-cancerous (low-risk HPV) but may coexist with VIN1 / cervical lesions.

C) Squamous cell carcinoma of vulva (90 % of vulvar carcinomas)

• Mean age 60–74.
• Two pathways:

Feature	HPV-related SCC	Non-HPV-related SCC
Age	Younger; smokers	Older women
Precursor	VIN II/III, high-risk HPV (HPV-16)	Lichen sclerosus (years)
VIN changes	+	Often absent
Progression	Slow; few progress	Frequent progression
Prognosis	Better	Poor

D) Extramammary Paget disease

• Intraepithelial form of carcinoma (analogous to breast Paget).
• Primary: cutaneous origin, may have invasive component.
• Secondary: from underlying anal/rectal/bladder carcinoma.
• Intraepidermal proliferation of mucinous (glandular) cells.
• Clinical: red, scaly, crusted plaque.
• Indistinct borders → frequent recurrences.

4. Vagina

• Rarely site of primary disease; usually secondarily involved by adjacent cancers/infections.

Vaginitis (infectious causes)

• Produces leukorrhea (whitish/yellowish discharge).
• Often part of normal flora becoming pathogenic in immunocompromise, antibiotics, HIV.

Organism	Features
Candida albicans	Yeast; vulvovaginitis; white “cottage cheese” discharge • itching
Trichomonas vaginalis	Large flagellated protozoan; gray-green frothy purulent discharge; “strawberry cervix”; mucosal-only inflammation
Gardnerella vaginalis	Bacterial vaginosis; gray fishy-odor discharge; clue cells

Vaginal Tumors

A) Vaginal intraepithelial neoplasia (VAIN) + SCC

• Extremely uncommon; usually > 60 yr.
• VAIN is HPV-associated precursor.
• Invasive SCC of vagina = HPV-associated in > 50 %.

B) Vaginal clear cell adenocarcinoma

• Young women, late teens to early 20s.
• Classic association: maternal diethylstilbestrol (DES) exposure during pregnancy.
• Sometimes presents in 3rd–4th decade.
• ~1/3 arise in cervix.
• Arises from precursor vaginal adenosis — small glandular/microcystic inclusions, red granular foci on vaginal mucosa.

💡 High-yield: Vulvitis: contact dermatitis (#1 pruritus), gonorrhea, HSV-2 ulcers, candidiasis (vulvovaginitis + leukorrhea). Non-neoplastic epithelial disorders: lichen sclerosus (thin epidermis + autoimmune + postmenopausal → ↑ SCC risk) vs lichen simplex chronicus (thick epidermis + hyperkeratosis). Bartholin cyst = duct obstruction post-gonorrhea. Condyloma acuminatum = HPV 6/11 + koilocytes. Vulvar SCC: HPV-related (younger, HPV-16, VIN, better prognosis) vs non-HPV (older, lichen sclerosus, poor). Vaginal clear cell adenocarcinoma = DES exposure in utero; precursor = vaginal adenosis. Trichomonas = strawberry cervix + gray-green discharge.