Obstetrics and Gynaecology chapters
Vulval and vaginal disease and cancer
Benign vulval and vaginal problems (pruritus, lichen sclerosus, Bartholin cyst, atrophy, vaginal discharge) and the premalignant and malignant diseases of the vulva and vagina, with how each is diagnosed and treated.
- The commonest vulval complaint is itching; in older women think of lichen sclerosus (white, thin skin in a figure-of-8 around vulva and anus, treated with clobetasol) and atrophy (treated with topical oestrogen); in younger women think of candida (check for diabetes if recurrent).
- Vaginal discharge: BV (thin, grey, fishy, pH over 4.5, clue cells, metronidazole), candida (white curdy, itchy), trichomonas (frothy, sexually transmitted, treat partners).
- Vulval cancer is mostly squamous, in elderly women, often on a background of lichen sclerosus (or VIN in younger women); it spreads first to the inguinofemoral nodes and is treated by wide radical excision with groin node assessment.
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Overview
About one in five women has vulval symptoms (itch, soreness, pain or skin change) at some time. Most causes are benign: infections, dermatitis, atrophy and skin diseases such as lichen sclerosus. A minority are premalignant (VIN) or cancer. Vaginal disease is mostly infective or atrophic; primary vaginal cancer is rare.
Rule of thumb: treat the skin, but biopsy anything raised, ulcerated, pigmented, hard or not responding to treatment.
Anatomy in brief
- The vulva = labia majora and minora, clitoris, vestibule and fourchette.
- Labia: keratinised, pigmented squamous skin. Vestibule: non-keratinised squamous epithelium.
- Bartholin's glands (greater vestibular glands) lie deep in the posterior labia; their ducts open at about 5 and 7 o'clock just above the fourchette.
- Lymph drainage: vulva and lower third of the vagina to the inguinal (groin) nodes; upper two-thirds of the vagina to the iliac nodes. Lesions near the midline drain to both groins.
Vulval itching (pruritus vulvae)
| Cause | Clues |
|---|---|
| Candidiasis | Itch, curdy white discharge, red swollen vulva; young women, pregnancy, diabetes, antibiotics |
| Lichen sclerosus | Older woman, white parchment skin, figure-of-8 |
| Vulvovaginal atrophy | Postmenopausal, breastfeeding, progestogen-only contraception |
| Contact or irritant dermatitis | Soaps, scented products, pads, incontinence |
| Lichen planus, eczema, psoriasis | Skin and mouth elsewhere |
| VIN, Paget disease, cancer | Raised, red, white or pigmented areas; biopsy |
| Other | Trichomonas, threadworms, low ferritin (about 5%) |
General measures: avoid soaps and scented products (wash with water, use an emollient), cotton underwear, treat incontinence.
Do not keep prescribing antifungals without examining. Candida is uncommon before puberty and after the menopause; in these women look for another cause.
Benign vulval skin conditions
Lichen sclerosus
- Chronic autoimmune inflammatory skin disease, mostly of the anogenital skin; about 1 in 300 women; associated with thyroid disease, pernicious anaemia and other autoimmune conditions.
- Itching and soreness, splitting, painful sex.
- White, thin, crinkly "parchment" skin in a figure-of-8 around vulva and anus, with loss of normal anatomy (labia minora flatten, clitoris buried), fissures and introital narrowing.
- Diagnosis is clinical; biopsy if atypical or not responding.
- Treatment: potent topical steroid (clobetasol propionate ointment), tapering over 3 months, then as needed; emollients.
- Small risk of squamous cancer (about 3-5%): teach self-examination; review any lump or ulcer.
Lichen planus
- Autoimmune; skin, mouth (lacy white streaks), nails and vulvovaginal mucosa; can cause erosive disease and vaginal stenosis. Treated with potent topical steroids.
Lichen simplex chronicus
- Thick, leathery skin from chronic itch-scratch cycle; no cancer risk. Break the cycle with emollients and topical steroids.
Vulvovaginal atrophy
- Low oestrogen (menopause, breastfeeding, progestogen-only methods): dryness, itching, superficial dyspareunia, urinary urgency and frequency; thin pale vagina with loss of rugae.
- Treatment: topical vaginal oestrogen (very little systemic absorption; does not raise endometrial cancer risk) plus lubricants and moisturisers.
Itching from atrophic vulvitis responds best to topical oestrogen, not antihistamines or hydrocortisone.
Vulval cysts and Bartholin's gland
- Bartholin's cyst: blockage of the duct; a painless swelling in the posterior labium majus.
- Bartholin's abscess: infected cyst; acutely painful, hot, tender swelling; she cannot sit or walk comfortably.
- Treatment: incision and drainage, or marsupialisation (the cyst lining is sutured to the skin to leave a permanent opening so it does not refill), or a small catheter left in the opening for some weeks.
- Other cysts: Skene's gland cysts, inclusion cysts.
"Bartholin at 5 and 7": the duct openings, like the hands of a clock, just above the fourchette.
Vulvodynia and vaginismus
- Vulvodynia: burning vulval pain without visible disease, like a neuropathic pain; provoked (by touch or sex) or unprovoked. Exclude dermatitis and infection; treat with skin care, pelvic floor physiotherapy, perineal massage, amitriptyline at night, psychosexual support.
- Vaginismus: involuntary spasm of the pelvic floor on attempted penetration; may prevent intercourse (non-consummation). Often coexists with vulvodynia.
Vaginal discharge (infective)
| Feature | Bacterial vaginosis | Candidiasis | Trichomoniasis |
|---|---|---|---|
| Organism | Loss of lactobacilli, overgrowth of anaerobes incl. Gardnerella vaginalis | Candida albicans (yeast) | Trichomonas vaginalis (flagellate protozoan) |
| Discharge | Thin, grey-white, homogeneous, fishy odour (worse after sex) | Thick, white, curdy (cottage cheese) | Variable; often frothy, yellow-green, offensive |
| Itch / soreness | Little or none; no vaginitis | Intense itch, red swollen vulva, fissures | Soreness, itch; may have dysuria |
| Vaginal pH | Over 4.5 | Normal (about 4.5 or less) | Raised |
| Tests | Clue cells; fishy smell with 10% KOH (whiff test); Gram stain (Hay-Ison or Nugent) | Microscopy shows spores and pseudohyphae; culture | NAAT (gold standard); wet mount shows motile flagellates |
| Sexually transmitted? | No (but linked to sexual activity) | No | Yes |
| Treatment | Metronidazole or clindamycin (oral or vaginal) | Clotrimazole pessary or cream; oral fluconazole second line | Metronidazole; treat partners |
| Partners | Not treated | Not treated (unless symptoms) | Treated at the same time |
| Pregnancy link | Preterm birth, PROM, miscarriage | Commoner in pregnancy | Preterm birth, low birth weight |
- Amsel criteria for BV (3 of 4): homogeneous discharge, pH over 4.5, clue cells, fishy smell with KOH.
- Recurrent candidiasis: check for diabetes, immunosuppression, steroids, antibiotics.
"BV = Bad smell, Very little itch; Candida = Curds and itch; Trich = Treat the partner".
Normal vaginal pH is acidic (about 4.5) because lactobacilli make lactic acid. A raised pH points to BV or trichomonas, not candida.
Premalignant vulval disease
| Condition | Cause | Features | Treatment | Cancer risk |
|---|---|---|---|---|
| Vulval intraepithelial neoplasia (VIN) | High-risk HPV (16, 18); immunosuppression (HIV, transplant) | Younger women; multifocal raised white, red or pigmented patches; itch | Excision, imiquimod cream, laser | About 10% (higher if immunosuppressed) |
| Lichen sclerosus (differentiated pathway) | Unknown (autoimmune) | Older women; figure-of-8 white skin | Potent steroid | Low (3-5% to about 10% quoted) |
| Extramammary Paget disease | Unknown | Well-defined red, eczema-like plaque ("cake icing"), itchy | Wide excision (recurs) | May hide invasive cancer; linked with other internal cancers |
Vulval cancer
Epidemiology and pathology
- Uncommon; traditionally a disease of elderly women (often over 70), now rising in younger women.
- Squamous cell carcinoma: almost 90%. Others: melanoma, basal cell carcinoma, Bartholin gland adenocarcinoma.
- Two pathways:
1. HPV-related (16, 18): younger women, from VIN. 2. HPV-independent: older women, from long-standing lichen sclerosus.
Clinical features
- Lump or ulcer on the vulva, with itching (often long-standing), bleeding, discharge or pain.
- Women often present late through embarrassment.
- Hard, raised, craggy or ulcerated lesion that bleeds on touch.
- Examine both groins: hard, fixed nodes suggest spread.
A new vulval lump or ulcer in an elderly woman is cancer until a biopsy proves otherwise.
Spread
- Local to urethra, vagina, anus.
- Lymphatic: first to the inguinofemoral (groin) nodes, then the pelvic nodes. Midline lesions drain to both groins.
- Blood-borne spread (lungs, liver) is late.
Diagnosis and staging
- Biopsy (punch biopsy including the edge of the lesion); photograph small lesions first.
- Chest X-ray; CT for large tumours or obvious node disease.
- FIGO staging (surgical):
| Stage | Extent | 5-year survival |
|---|---|---|
| I | Confined to the vulva (IA: 2 cm or less with invasion 1 mm or less; IB: larger or deeper) | 80% |
| II | Lower third of the urethra, vagina or anus | 50% |
| III | Inguinofemoral node metastases | 30% |
| IV | Upper urethra or vagina, bladder or rectal mucosa, pelvic bone, fixed or ulcerated groin nodes, distant spread | 0-15% |
Treatment
- Radical wide local excision with a clear margin of at least 10 mm (margins under 2 mm recur more often); large defects need skin flaps.
- Groin nodes:
- Invasion 1 mm or less (stage IA): node spread is very unlikely (under 5%), so no groin surgery.
- Deeper tumours: sentinel lymph node biopsy (radioactive tracer + blue dye) for small tumours (under 4 cm); full inguinofemoral lymphadenectomy if the sentinel node is positive or sentinel biopsy is not suitable. Lateral lesions: same-side groin; lesions within 10 mm of the midline: both groins.
- Groin dissection complications: wound breakdown, infection, lymphocyst, chronic leg lymphoedema, VTE.
- Adjuvant radiotherapy (often with chemotherapy) if margins are close, two or more positive nodes, or extracapsular spread.
- Neoadjuvant chemoradiotherapy to shrink tumours near the urethra or anus; radical radiotherapy if unfit for surgery.
Untreated groin node disease is almost always fatal, so groin assessment is part of treatment for any vulval cancer invading more than 1 mm.
Vaginal disease
- Vaginal cancer is rare (1-2% of gynaecological cancers). Most vaginal tumours are secondary (from the cervix or endometrium).
- Primary vaginal cancer: mostly squamous, age 60-70; over 60% HPV-related; risk factors: previous CIN or cervical cancer, VAIN (about 10% progress), pelvic radiotherapy.
- Presents with bleeding or blood-stained discharge; mass or ulcer usually in the upper vagina.
- Treatment: mainly radiotherapy; surgery for small early tumours.
- Clear cell adenocarcinoma: rare; linked with in utero exposure to diethylstilboestrol (DES) through vaginal adenosis.
- Sarcoma botryoides (embryonal rhabdomyosarcoma): young girls (peak around 8 years in Ten Teachers; usually under 5 in pathology texts); grape-like mass protruding from the vagina with bleeding or watery discharge.
- Other: urethral caruncle (small red fleshy lesion at the posterior urethral meatus in postmenopausal women; benign).
Female genital mutilation (brief)
All procedures that injure the female genitalia for non-medical reasons. Type 1 removes the clitoral hood with or without the clitoris; type 2 also removes the labia minora; type 3 (infibulation) narrows the opening by cutting and sealing the labia; type 4 covers all other harmful procedures. Complications: pain, infection, scarring, dyspareunia, urinary problems, obstructed labour; deinfibulation may be needed before or during delivery.
Expect: lichen sclerosus (figure-of-8, parchment skin, clobetasol, small cancer risk) versus lichen simplex (thick skin, no risk); topical oestrogen for atrophic vulvitis; checking for diabetes in recurrent thrush; BV with fishy odour, clue cells, pH over 4.5 and metronidazole; trichomonas needing partner treatment; Bartholin abscess drainage or marsupialisation; VIN from HPV; squamous vulval cancer in the elderly, spread to inguinofemoral nodes, radical excision with groin node assessment and the 1 mm rule; vaginal cancer being mostly secondary; DES and clear cell adenocarcinoma; sarcoma botryoides as a grape-like vaginal mass in a child.
Quick revision
- Vulval itch: candida (young), lichen sclerosus and atrophy (old), dermatitis (any age).
- Lichen sclerosus: autoimmune, figure-of-8, clobetasol, 3-5% cancer risk.
- Atrophic vulvitis: topical oestrogen.
- BV: fishy, thin, pH over 4.5, clue cells, metronidazole; partner not treated.
- Candida: curdy, itchy; clotrimazole then fluconazole; screen for diabetes if recurrent.
- Trichomonas: frothy, NAAT, metronidazole, treat partner.
- Bartholin abscess: drain or marsupialise.
- Vulval cancer: squamous ~90%, elderly, groin nodes first; excise with 10 mm margin; no groin surgery if invasion 1 mm or less.
- Vaginal cancer: rare, mostly secondary; DES = clear cell; sarcoma botryoides in girls.
Written by The House Job from standard references (Gynaecology by Ten Teachers).
FAQ
Should every woman with vulval itching be given an antifungal?
No. She should be examined first; candida is uncommon before puberty and after the menopause, when atrophy, dermatitis or lichen sclerosus are more likely.
Does lichen sclerosus always turn into cancer?
No. The risk is small, but because squamous cancer can develop, any new lump, ulcer or area not responding to steroids should be biopsied.
Why are both groins operated on for some vulval cancers?
Lymph from tumours lying close to the midline can drain to either side, so tumours within 10 mm of the midline need both groins assessed.
Why is the partner treated for trichomonas but not for bacterial vaginosis?
Trichomonas is a sexually transmitted infection, so untreated partners re-infect the woman; bacterial vaginosis is a change in vaginal flora, and treating partners has not been shown to help.