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Pathology of the vulva

Pathology of the vulva is characterized by a variety of clinical and pathomorphological manifestations due to its dystrophic changes. The main causes of pathology of the external genitalia are metabolic and neuroendocrine disorders associated with age-related changes, as well as herpesviral infection. According to objective and subjective clinical manifestations, kraurosis, leukoplakia and vulvar itching are distinguished.

Vulvar kraurosis is a chronic sclerotic process with progressive atrophic changes, usually associated with involution of the genital organs. It is accompanied by itching in the clitoris, perineum, worse at night. Next, the symptoms of neuroendocrine and psychoemotional disorders join.

With kraurosis, atrophy of the stratified squamous epithelium develops, starting with the clitoris and labia minora and gradually capturing the entire area of ​​the vulva and even the pubis. The disease is accompanied by swelling of the papillary layer with the development of coarse connective tissue in this area. The death of elastic fibers, the hyalinization of connective tissue, atrophy of the sebaceous and sweat glands occur.

In the process of disease progression, three stages are distinguished. The first is characterized by edema, hyperemia of the external genital organs. The skin at first bright red becomes shiny and tense, pale pink with a bluish tint. With the further development of atrophic processes (second stage), small and then large labia are leveled, the clitoris atrophies. The skin loses elasticity, it becomes dry, whitish in color. Narrows the entrance to the vagina. At the third stage, atrophy progresses and sclerosis of the external genitalia develops, the labia minora and labia almost disappear, and the clitoris decreases sharply. The skin and mucous membranes become thinner, the hair follicles are lost and the hair (on the external genitalia and pubis) disappears. Due to the loss of elasticity and sclerosis, the skin wrinkles and looks like a crumpled parchment sheet with a dull sheen. Narrowing the entrance to the vagina, anus and urethra. Sexual intercourse is difficult, urination and defecation can be painful. If cracks occur, the infection easily joins. Kraurosis can spread to the perineum, thighs and inguinal areas.

Diagnosis of the disease is not difficult. It is only necessary to take into account the degree of metabolic-endocrine and neuropsychiatric disorders. To exclude possible malignancy, cytological and histological studies are performed.

Treatment includes local effects and general pathogenetic therapy.

Locally prescribed oil solutions for the treatment of tissues (olive, peach oil), ointments containing glucocorticoids. You can apply estrogen-containing ointments (for 30-50 g of ointment 10,000 units of folliculin are added) in courses of 5-7 days. The use of ointments with androgens is also effective. When an infection is attached, antibacterial ointments are recommended. It is important to conduct timely treatment of concomitant diseases.

The use of estrogenic compounds is considered pathogenetically substantiated. The most indicated of these is estriol, which contributes to the proliferative processes of the lower parts of the genital system. Estriol preparations (ovestin, orgametrile) are prescribed at 1.0 mg / day in two doses according to the contraceptive regimen for 2-3 months, if necessary, courses may be repeated after a break.

It is advisable to prescribe funds for the correction of metabolic and neuropsychiatric disorders, taking into account their severity: sedatives, antihistamines, antihypertensive drugs. Diet therapy with the restriction of spices, fats and carbohydrates is important.

In recent years, the effectiveness of laser therapy has been shown to improve metabolic processes in the affected area. 10-15 sessions of laser irradiation are carried out with the repetition of courses of treatment in the dynamics of observation. A preliminary examination is mandatory to exclude malignancy. Surgical treatment using a laser scalpel and cryosurgical effects is also indicated.

Leukoplakia is a hyperplastic change in the epithelium with leukocyte infiltration and subsequent atrophic and sclerotic phenomena. In the integumentary epithelium, the phenomena of parakeratosis, hyperkeratosis, acanthosis, alternating with sclerosis, are detected. According to the severity of hyperkeratosis, flat, hypertrophic and warty forms of leukoplakia are distinguished. The last two forms of the disease more often occur with limited processes. A flat form is usually observed with developed generalized distribution of the process through the external genitalia.

Clinically, leukoplakia initially does not show anything and can be asymptomatic. Then itching, paresthesia join. Scratches, abrasions and cracks appear. Against the background of the latter, inflammatory processes develop with infection. The disease is also accompanied by neuropsychiatric symptoms.

Itching and many of the described changes in the vulva can be observed in diabetes mellitus, liver damage, various skin diseases (lichen, vitiligo). Therefore, differential diagnostics should be carried out to determine the primary and secondary changes. An important diagnostic method is colposcopy. With leukoplakia, the following colposcopic picture is noted: a low-transparency keratinous surface, whitish, yellowish or brick color, tuberosity, lack of vascular pattern or its lack of expression. The appearance of a vascular pattern without branching of blood vessels and without anastamoses with varicose veins and necrotic areas already characterizes the process of malignancy. During colposcopy, it is precisely the suspicious areas of the leukoplastic lesion area that are taken for further investigation (targeted biopsy).

The treatment of leukoplakia, like kraurosis, is characterized by a duration, often an individual selection of drugs and methods, taking into account age and other disorders of the reproductive system. Although pathogenetically, leukoplakia is also considered as a disease caused by involutive changes in the genitals with various disorders, it should be noted that it often occurs in women of a younger age. Therapy of the disease should begin with the creation of an appropriate regimen of the day and the consideration of hygiene. Conducting exercise therapy, walking in the fresh air, dieting are the necessary attributes of the treatment of such patients. A milk and vegetable diet is shown with the exception of spicy dishes, smoked meats, strong tea and coffee. When performing personal hygiene, it is not recommended to use soap, potassium permanganate for douching, and use infusions of flowers (calendula, chamomile).

Hormone therapy is prescribed in the form of ointments, creams, vaginal balls, emulsions. They add estrogenic compounds, can be combined with androgens. Estrogen-progestogen preparations, unconjugated estrogens (premarin, presomen), estriol derivatives (ovestin, estriol) are also used. Conjugated estrogens are administered at 0.625-1.25 mg / day, estriol 0.5-1 mg / day, estradiol valerate at 1.0-2.0 mg / day. Estrogenic compounds are prescribed cyclically or in contraceptive mode, courses of 2-3 months. Within 1 year, if necessary, a repetition of such courses is possible. During hormone therapy, careful colposcopic and cytological monitoring is indicated.

In the treatment of leukoplakia, ultrasound is used (10-20 sessions per course), which has a resolving and anti-inflammatory effect, stimulates ovarian function and blocks pathological impulses.

Encouraging results were obtained after laser irradiation and cryosurgical exposure by spraying with refrigerants or by contact in the form of probes or spades on the affected area.

In the absence of the proper effect of conservative methods of treatment, surgical treatment is used - removal of the affected areas with a scalpel, laser scalpel and cryodestruction.

Itching of the vulva can be caused by a variety of reasons and is actually not a disease, but only a symptom.
However, in the absence of somatic pathology and diseases of the reproductive system in women, itching appears as a special form of the disease - idiopathic or essential vulvar itching. Often, occurring in the external genitalia, itching acquires a generalized spread to the perineum, anus and inner thighs. It can become protracted, accompanied by a burning sensation, scratching, abrasions and soreness, the addition of secondary inflammatory changes. The etiological factors of pruritus are: genital contamination due to improper implementation or violation of personal hygiene rules, as well as various kinds of industrial dust; thermal factors and mechanical stimuli (cooling, friction, masturbation); infectious pathogens; helminthic invasion and pediculosis; chemical irritants; diaper rash, especially in obese women.

Clinically, itching of the vulva can be characterized by constancy or be paroxysmal in nature, often intensifying at night. It should be considered pruritus vulva as a background condition for the development of cancer, as it precedes and accompanies kraurosis, leukoplakia and vulvar cancer.

The treatment of vulvar pruritus is based on the treatment of the underlying disease, eliminating causative factors wherever possible. With idiopathic forms of vulvar itching, sedatives, hormone-containing ointments (with estrogens, glucocorticosteroids) are indicated. Correct psychotherapy and suggestive effects are justified. Effective needle, laser, electroreflexotherapy, irradiation with a helium-neon laser. A temporary effect can be obtained by introducing a 0.25-0.5% solution of novocaine into the ischiorectal space with the aim of blocking the reproductive nerves (50-60 ml from the perineum in the direction of the medial sciatic tubercles to a depth of 5-6 cm). Personal hygiene and ultraviolet irradiation are always shown - during infection.

Genital warts of the vulva have a viral or gonorrheal etiology. They are found, as a rule, at a young age and increase progressively during pregnancy. They are warty protrusions, single and merging with each other (Fig. 31).

Fig 31.

Genital warts vulva



Combined genital warts treatment - anti-inflammatory with surgical removal (laser cryodestruction or scalpel).

The presented forms of vulvar pathology are collective clinical concepts and may be more acceptable in clinical practice. However, from the standpoint of evaluating precancerous and baseline conditions, it is generally recognized that the vulva diseases are divided according to morphological criteria.



Classification of diseases of the vulva (J.V. Bohman, 1989)

Background processes.

1. Hyperplastic dystrophy: a) without atypia; b) with atypia.

2. Sclerotic lichen.

3. Mixed dystrophy (a combination of hyperplastic dystrophy with sclerotic lichen): a) without atypia; b) with atypia.

4. Condylomas, nevus.

Dysplasia.

1. Weak.

2. Moderate.

3. Severe: a) without dystrophy; b) with dystrophy.

Preinvasive cancer.

Microinvasive cancer (invasion up to 5 mm).

Paget's disease of the vulva (preinvasive and invasive form).

Invasive cancer (squamous keratinized, non-keratinized, adenocarcinoma, basal cell, low-grade).

Non-epithelial malignant tumors: malignant melanoma, sarcoma.

According to the presented classification, the true “precancer” of the vulva is dysplasia. Kraurosis and leukoplakia persist as clinical terms in which dystrophy is more often detected, and dysplasia may or may not be present. A final diagnosis is possible only after analysis of the histological examination.

Dystrophic changes of the vulva are polyetiological and are a collective and conditional concept. The outer cover of the vulva serves as the boundary zone between the stratified squamous epithelium of the skin and the vaginal epithelium. They differ embryologically (by origin from the ecto- and endoderm of the urogenital sinus), anatomically and functionally (by the degree of sensitivity of the receptors to steroid sex and glucocorticoid hormones).

Depending on the histological picture, the dystrophic processes of the vulva are divided into hyperplastic dystrophy, sclerosing lichen and mixed dystrophies.

Hyperplastic dystrophy is a benign disease characterized by changes in the type of acanthosis epithelium with a thickening of the keratin layer and inflammatory infiltrates in the underlying tissues.

Sclerosing lichen is characterized by changes in the skin epithelium, thinning and hyperkeratosis. It can be observed in any areas of the body, but in women in the postmenopausal period is more often manifested on the genitals. Whitish spots appear at the lesion site, the skin becomes shiny, with a grayish or yellowish tint. Initially, hypertrophic processes (pseudo-edema) develop in the labia or clitoris, which are then replaced by atrophic ones. Tissue elasticity is lost, deep lymphocytic infiltrates occur. The arrangement of basal cells is disrupted, their swelling occurs. Then, a decrease in the clitoris, labia and narrowing of the vagina due to atrophic changes can occur. Clinically, the disease can be manifested by itching, burning, discomfort during sexual intercourse.

Mixed vulvar dystrophy is a combination of epithelial hyperplasia and sclerosing lichen.

Diagnosis of dystrophic processes of the vulva is carried out in conjunction with a dermatovenerologist.

The determining factor for the diagnosis is histological examination. The detection of vulvar dystrophy without atypia allows us to consider it a background process. The detection of atypia in dystrophic processes should be alarming and relate this disease to precancer.

Vulvar dysplasia can develop against the background of all the stated dystrophic processes, less often without them. Dysplasia, like pre-invasive vulvar cancer, can regress, remain stable, or progress to invasive cancer. Dysplasia progresses to the development of cancer in 20-30%, and preinvasive cancer in invasive cancer in 50%.

Dysplasia develops against the background of metaplasia of the stratified squamous epithelium and is characterized by proliferation and structural rearrangement of basal and parabasal cells of the stratified squamous epithelium.

Depending on the presence of atypia, the intensity of proliferation and the localization of the process, mild, moderate and severe dysplasia is distinguished in depth.

Background and precancerous diseases of the vulva include benign tumors of the external genital organs. Of these, various condylomas are more common, as well as fibromyomas, leiomyomas, paraadenomas, dermatofibromas, angiokeratomas, etc. Their diagnosis is not difficult.

Surgical treatment - removal of tumor formations with a surgical or laser scalpel, and, if indicated, cryodestruction.

Treatment of hyperplastic and dystrophic processes of the vulva is carried out taking into account the form of background and precancerous conditions and the age of the patients. The choice of radical methods of therapy is determined by histological data.

Conservative (medical, hormonal, physiotherapeutic) and operative (surgical, laser and cryodestruction) methods of treatment are used.
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Pathology of the vulva

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