Diseases of the

Vagina

Azza AlYamani

Prof.
Obstet. & Gynecol.
Anatomy of the vagina

* it is a flattened muscular tube extending from
the hymenal ring at the introitus up to the
fornices . It is about 8 cm in length.

* the posterior fornix (Douglus pouch) allows
easy access to the peritoneal cavity from the
the vagina by culdocentesis or colpotomy.

* its epithelium is non-keratinized squamous in
type normally devoid of mucous glands and
hair follicles.




Benign Conditions
Structural and Benign Neoplastic
Conditions :

(1)Urethral diverticula
* small sac-like projections in the anterior vaginal
wall along the posterior urethra, it may or may not
communicate with the urethra.
it can cause :
= recurrent urinary tract infections.
=dyspareunia.

* treatment :
*urethral dilatation or
*surgical excision of the diverticulum.



(2) Bartholins cyst
* it is the most common vulvo vaginal mass. It
presents as swelling postrolateral in the introitus
usually unilateral , 3cm in diameter. It is not
infected but can be symptomatic.

* after 40 y. it is necessary to palpate the base of
the cyst to rule out carcinoma.

* teatment :
by marsupialization.
Bartholin s cyst




* Bartholin abscess

* infection of the gland may result from blockage
and accumulation of purulent material and a
large painful inflammatory mass can develop.

* The treatment
by incision of the abscess and left drain in place
for 2-4 weeks.


(3) Inclusion cysts
* result from infolding of the vaginal epithelium,
located in the posterior or lateral wall of the
lower 1/3 of the vagina.

* They are most frequently associated with
lacerations from delivery or surgery. They are
treated by surgical excision.

(4) Endometriotic cysts
* are endometriotic implants located in the upper
1/3 of the vagina.
* presents as black cysts which may bleeds at the
time of menstruation.
* they are most common in an episiotomy wound.


(5) vaginal adenosis
* multiple mucus containing vaginal cysts
rarely give symptoms.

* common in daughters of women who took
di ethyl stilboesterol ( DES) during
pregnancy.

(6) Prolapse
as ; cystocele , rectocele and enterocele.















cystocele

(7) Fistula
as ; vesico vaginal , recto vaginal and
uretero vaginal fistulas. They may result from
obstetric or surgical trauma , invasive cancer and
radiation therapy.

(8) Erosive lichen planus
erythematous papules involve vagina as well
as vulval vestibule . Condyloma acuminata ,flat
warts ( HPV) and herpes simplex infections can
be found in the vaginal vault.


Erosive lichen planus
(9) Gartners duct cyst
* are generally thick-walled , soft cysts resulting
from embryonic remnants. Gartners cyst
arise from the remnant of the Wolffian duct .


* they vary in size from 1 5cm , found on the
antero lateral walls in the upper of the
vagina and more laterally in the lower vagina.

* most of them are asymptomatic.
* require no intervention.
if ttt is required , marsupialization is
effective and safer than excision.




















































Garteners cyst


In summary

Benign Conditions:
1. urethral diverticula.
2. Bartholins cysts & abscess.
3. inclusion cysts.
4. endomeriotic cysts.
5. vaginal adenosis.
6. prolapse.
7. fistula.
8. erosive lichen planus.
9. Gartners duct cyst.
Vaginal intraepithelial
neoplasia
(VAIN)
Vaginal Intraepithelial Neoplasia (VAIN)

VAIN or carcinoma in situ :

* much less common than CIN and VIN.
* occurs in the upper 1/3 of the vagina.
* caused by HPV infection or after irradiation
for cervical cancer .
* women with past history of in situ or
invasive ca.cx or ca. vulva are at increased
risk.



* Diagnosis by:
= Pap smear is abnormal.
= colposcopy.
findings are similar to cervical lesions.
abnormal epithelial proliferation and
maturation above the basement membrane.
VAIN I : inner 1/3 .
VAIN II: inner 2/3 .
VAIN III: full thickness involvement.
= vaginal biopsy
directed by colposcopy & Lugols iodine.

* management
= vaginal vault lesion
surgical excision to exclude invasive cancer.

= multifocal lesions
laser therapy or topical 5 fluorouracil.

= extensive disease
total vaginectomy and neovagina using a
split thickness skin graft.

In summary

VAIN
diagnosis:
1. Pap smear.
2. colposcopy.
3. vaginal biopsy.

management :
1.vaginal vault lesion.
2. multifocal lesions.
3. extensive disease.
Vaginal Cancer
Squamous Cell Carcinoma
Clear Cell Adenocarcinoma





rare cancer


Squameous Cell Carcinoma
of the Vagina

* uncommon tumor.
* mean age 60 70 years.
* 30% have a history of in situ or invasive
cervical cancer that was treated at least 5ys
earlier.
* 50% of lesions are in the upper 1/3 of
vagina on the posterior wall.
* Symptoms:
= vaginal bleeding.
= vaginal discharge.
= urinary symptoms.

* examination:
ulcerative , exophytic and infiltrative
growth patterns.




Squamous cell carcinoma of vagina

* pattern of spread:
= direct invasion to bladder ,urethra or rectum
or progressive lateral extension to the
pelvic side wall.

= lymphatic to the obturator ,internal iliac
and external iliac nodes.
lesions in the lower vagina drains to the
inguino femoral nodes.

= hematogenous
is uncommon until the disease is advanced.

Staging

is made clinically by:
* chest X-ray.
* pelvic & abdominal CT.
* MRI for metastatic spread & bulky pelvic
and para aortic lymph nodes.
* PET (position emission tomography)
to look for metastatic disease.
FIGO staging of Vaginal Cancer

Carcinoma limited to the vaginal wall.

Carcinoma has involved the subvaginal tissue
but not extended into the pelvic side wall .

Carcinoma has extended to the pelvic side wall.

Carcinoma has extended beyond the true
pelvis or has involved the mucosa of the
bladder or rectum.
Spread to bladder or rectum.
Spread to distant organs.






Stage I

Stage II


Stage III

Stage IV


IVa
IVb
Management

1. Radiotherapy or chemo radiotherapy
are the main methods of treatment for 1ry
vaginal cancer.

2. Radical surgery has a limited role :
* Radical hysterectomy + radical
vaginectomy + pelvic lymphadenectomy,
for stage 1 in the posterior fornix.

* Pelvic exenteration with creation of a
neovagina ,if LN. are free.


Clear Cell Adenocarcinoma

*An association between in utero exposure
to di ethyl stilbesterol (DES) and the latter
development of clear cell carcinoma in the
vagina was reported in 1971.

*Vaginal adenosis (columnar epithelium) is
the most common anomaly ,present in 30%
of exposed females.

* this tissue behaves similarly to the columnar
epithelium of the cervix & is replaced initially by
immature metaplastic squamous epithelium.

* the risk for developing a clear cell
adenocarcinoma following DES exposure in utero
is only 1/1000 .

* the mean age is 19 years, rare before 14y.
few cases reported in women in their 40s & 50s.

*Treatment :
for early tumor , radical hysterectomy and
vaginectomy ( cereation of neovagina) or
radiation therapy is effective.

*The 5-year survival rate is 80%, which is
better than that for squameous cell carcinoma
of the vagina.
Thank you