Diseases of the Vulva and Vagina

Vulva

Anatomy: vulva includes all visible structures of female external genitalia from pubis to perineal body

includes mons pubis, labia majora, labia minora, clitoris, vestibule of vagina (fourchette), posterior fourchette (fossa navicularis), urethral meatus, hymen, three glands that open onto vestibule (periurethral (Skenes) glands, major vestibular (Bartholin) glands, minor vestibular glands)
tissue types include skin, subcutaneous fat, fibrous connective tissue, glands

Function: sexual skin; fat pad/hair protects vaginal opening; glands involved in secretion (clinically insignificant)

Pathology

(1) In Skin – vaginitis is most common cause of vulvitis

skin conditions occurring elsewhere can also occur in the vulva; e.g., contact dermatitis
infection: mostly STDs; e.g. herpes, HPV
some conditions are specific to vulva: vulvar dystrophies are non-neoplastic epithelial disorders of the vulva
(a) Lichen Sclerosis – leads to atrophy, fibrosis, and scarring

pathogenesis unknown but genetic predisposition, autoimmuity, hormonal factors have been implicated
occurs in all age groups, but more common after menopause

(b) Squamous Cell Hyperplasia – hyperplasia of the vulvar squamous epithelium usually with hyperkeratosis

Neoplasia: intraepithelial or invasive; Carcinoma in situ (CIS) of the vulva, invasive vulvar carcinoma

(2) In Subcutaneous Tissue – inclusion cysts, fibromas, lipoma, hernia, female hydrocele, ectopic breast tissue

(3) In Gland – vestibulitis: inflammation of minor vestibular glands

Skenes gland abscess – associated with bacterial urithritis; rare

Bartholin gland cysts or abscesses – always bisected by labia minora

Vagina

Anatomy: fibromuscular tube with non-keritonized squamous epithelium; hormone responsive epithelium

contains rugae (folds), microbial ecosystem

Function: functions best in presence of estrogen during reproductive years

sexual – vaginal transudate provides lubrication for intercourse
reproductive – allows sperm to reach cervix; conduit for childbirth

Vaginal Ecosystem – upper genital tract is sterile, lower has commensal bacteria

lactobacilli – the most common bacteria of the vagina; necessary to fight off other organisms and maintain environment

thrive in the acidic environment of the vagina and are also involved in maintaining its acidity

produce lactic acid, H₂0₂, and bacteriocins

in absense of estrogen: less protectiveÞ thin epithelium, Þ ß glycogen, neutral pH, mixed bacteria

conditions that upset vaginal equilibrium:

(1) pH change – douching, sex, menses, infections
(2) nutrient availability changes – diabetics, changes in estrogen levels
(3) bacteria infections – only if environment is altered; antibiotic use

Pathology

(1) Masses – Garner duct cyst, vaginal polyp

(2) Vaginitis – disturbance of normal vaginal flora (ecosystem)

(a) Bacterial Vaginosis (synergistic infection) – most common vaginitis

ecology imbalance with Ý anaerobes, ß lactobacilli; little inflammation

related to STDs, but probably not the result of a specific infection

vaginal pH > 4.5; amine odor Þ trimethalamine is odorous at alkaline pH; Whiff Test to diagnose

Clue Cells – epithelial cells with bacteria adherent to the periphery

Repercussions: Pelvic Inflammatory Disease (PID), post-hysterectomy infection, septic abortion +infection, premature delivery, chorioamnionitis and endometritis

(b) Candida vaginitis (fungus) – usually affects women during reproductive years; rare after menopause

Candida prefer acidic pH and estrogenic environment; dermatitis may predispose
vaginal yeast present in 20-30% of healthy women without causing infection; culture positive for Candida
symptomatic infection depends on host factors and organism virulence

Wet Prep – potassium hydroxide (KOH) used to lyse squamous cells; allows ID of yeast (60% sensitivity)

(c) Trichomonas – most common parasitic STD

infects vaginal and cervical epithelium; inflammatory response; often asymptomatic Þ especially in men

Wet Prep – "shimmy" one slide

(d) Atrophic Vaginitis – due to hormone deprivation

thin, inflamed epithelium, parabasal cells prominent due to lack of estrogen; Ý risk of infections; Treatment Þ estrogen

Evaluation of Vaginitis:

History – estrogen status, douch, sex, diabetes, IUD use
Physical Exam – check for vulva inflammation and discharge, KOH, pH, Whiff Test