DISORDERS AND

DISEASES IN
FEMALE GENITALIA
Dr. Winawati E.P, SpKK

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S
 VULVOVAGINAL DISEASE
Common problems:
-infections
-inflammatory dermatoses
-Bullous and erosive diseases
-ulcers
-Vulvodynia

challenging
- normal vulvar anatomy not well understood
- Morphologic&histologic features often nonspecific
- Causes often multiple&complex
-Patient anxiety and depression often severe and
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can worsen 2
 -

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 Physical examination

-multifactorial etiology (yeast, estrogen, bacterial)

- cutaneus, vaginal, both
-irritating/infected vaginal secretionvestibular symptom
speculum!!
Laboratory test

- microscopic evaluation
- culture
-patch test
-skin biopsy, direct IF
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 Inflammatory Bullous and Ulcers Abscesses
dermatoses erosive
diseases
LiczZhen Lichen planus Apthous ulcers Bartholin gland
simplex EM major Chrons disease abscess
chronicus TEN Syphilis Hidradenitis
Irritant contact Cicatrial Chancroid suppurativa
dermatitis pemphigoid Others
Allergic contact Pemphigus
dermatitis vulgaris
Psoriasis FDE
Lichen Herpes simplex
sclerosus Vulvar CA
Vulvar fissure Extramamary
Paget disease

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 Lichen simplex chronicus
S Vulvar LSK - >>> atopic px
w/sensitive skin
S Morphology : vary min
hyperpigmentation & dullness
of texture lichenification &
edema, excoriation, fissure.
S Hydrated white, mimick
lichen slerosus or leukoplakia
S Therapy : superpotent GC,
nighttime sedation, proper
hydration

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 Contact dermatitis
S Irritant >> allergic contact dermatitis
S Irritant:
- acute burning, erosion in mucous membrane
- chronic poorly demarcated erythema /
hyperpigmentation difficult because vulva
normally pink or dusky
- Lichenification and scale-make dx easier
- Pruritus can be intense

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S Allergic contact dermatitis:
- Acute vesicle erode as
quickly as they form painful
exudative erosion and plaque
- Chronic more often, mild
erythema and subtle edema,
lichenification-
Diphenhydramine
Neomycin, polymyxin,
sulfonamide, benzocaine,
antifungal cr, GC, antiseptic,
fragrance
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S Therapy: -avoidance irritants and allergens
-mild-moderate eruption: Class II-IV topical
-GC oint
-severe/extensive eruption: systemic
GC-> avoid topical except bland emollient
(petrolatum)

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 Psoriasis
S Vulvar psoriasis too often missed
S Vulvar-common site of koebnerization
S Usually affect only full keratinized skin-sparing mucous
membrane in labia majora and minor
S Dusky red, well demarcated plaque, glazed, shiny surface
texture
S Respond well to topical tx (mid-high potency GC)
S Extensiveoral tx (MTX, retinoid, cyclosporine, biologic agent)

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 Lichen sclerosus
S Any age
S Most symptomatic in childhood & postmenopausal
S Pruritus (mild-severe)->scratcherosion
S Classic presentation: hypopigmented demarcated plaque
w/shiny, crinkled cellophane-like surface
S >>>complaint of late sign lichen sclerosus: remarkable textural
changes and scarring w/loss of normal vulvar architecture
S Other site: upper trunk and arms, usually asymptomatic
S Associated w/hypothyroidism

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S Differential diagnosis
S Lichen simplex chronicus
S Lichen planus
S Vitiligo
S Complication
S Sexual dysfunction
S SCC
S Treatment
S Superpotent topical GC 1-2x/day 3-5 mo
S Intralesional triamcinolone-resistant area
S Antihistamin or tricyclic antidepressant
S Tacrolimus, pimecrolimus, surgery (cryotx, vulvectomy, CO2 laser)

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 Vulvar fissures
S Small, linear fissure causes itching, stinging and dyspareunia
S Fissures at post fourchette most well recognized, stinging
and pain when tearing and touch w/semen
S Reccurent fissure w/in skin folds (interlabia)stinging and
irritationpapercut sensation
S Intercourse and tight clothing: precipitating events
S Result from inflammatory dermatosis (psoriasis, lichen
sclerosus, LSK)
S Treatment underlying causeno underlying: topical GC
oint+oral AB and anticandidal

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 Lichen planus
S Wide variety clinical manifest
S Erosive vulvovaginal LP >>>:
-glazed erythema and variable red, painful erosion
either nonspecific or surounded by typical white often
scalloped, epithelial changes
-often accompanied by erosive buccal and ginggival
oral disease,
-Burning, itching, dyspareunia, scarring
S <<<: Solid, uniformly hypopigmented, flat, white plaques mimic
LS an abstinence crinkled cellophane paper-like texture

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S Diagnosis made by biopsy (nonspecific) or identification classic
lacy lesions
S DD:Lichen sclerosus, immunobullous disease, SSJ
S Complication: Sexual dysfunction, depression, vulvar SCC
S Treatment:
-Pruritic noneroded: potent topical GC oint
-1st line: Superpotent GC oint
-Severe: systemic steroid or triamcinolone im 1 mg/kg
up to 80 mg/dose repeat monthly for 3 mo
-Antifungal to prevent candidiasis

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 EM MAYOR, SSJ and TEN
S All lead to erosive vulvar disease
S Can experience permanent scarring
S Complication: sexual dysfunction

S Multiple mucosal erosions

S Indistinguishable from LP and LS
S Can result in vaginal scarring
S Therapy: local and systemic GC, vaginal tx = vaginal LP,
secondary infection control

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 Pemphigus vulgaris
S Often present w/mucosal eroison on vulva
S Can lead to scarring, w/ vaginal adhesion and obliteration
vulvar architecture

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 Fixed drug eruption
S Erosion sometimes on vulvairregular, slightly shaggy border,
hyperpigmentation is absent
S Acetaminophen, HCT, NSAID, Oral contraceptive, sulfa drugs,
penicillin, tetracycline, allopurinol, barbiturate and furosemide
S >>> vestibule or modified mucous membrane labia minora or
medial labia majora

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 Apthae
S >> girls 9-19 yo
S Sudden onset painful, punched out, well demarcated vulvar ulcers, <
1 cm, found on vulvar trigone, labia and lower vagina
S Prodrome syndrome+ (flu-like symptoms, mild fever, headache,
malaise), past history of oral apthae+
S Pathogenesis: genetic and infection-microbial Ag (EBV, HIV, CMV, M.
pneumonia) w/molecular mimicry induce a reactive process directed
at host Ag
S Recurent oral+genital ulcers most seen inn IBD, Chrons disease,
ulcerative colitis, celiac disease (<<)can also seen w/medication,
myeloproliferative disease, netropenia, lymphopenia, FAPA syndrome
(Fever, Apthae, Pharyngitis, Adenitis)

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S DD: HS, other STI, pyoderma
gangrenosum
S Tx: short course of
prednisone
recurent: colchicine,
dapsone, colchicine
+dapsone, cyclosporine

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 Crohn disease
S Noninfectious granulomatous inflammatory disorders, primarily
involves bowel
S Vulvar and perianal can be affected
S >>34 y.o
S Metastatic spread: >>common presentation
S Swelling and pain also induration in labia majora w/ or w.o
ulcers that extend to groin
S Dx: biopsy and identification of bowel disease (25% vulvar
crohn have no GI symptom)
S DD: hydradenitis suppurativa, sarcoidosis, TB, LGV, atypical
pyogenic infection
S Tx: systemic therapy for underlying intestinal crohn
disease
topical and IL GC and local care

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 Bartholins cyst and abscesses
S Bartholins gland-largest of vulvar vestibular glands, secrete
mucus-like material for lubrication
S Cyst- occlusion of opening ducts on lower labia minora at 5
and 7 oclock just lateral to hymenal ring
- 1-3 cm in size
- often asymptomatic
- dx: typical nodule lying in post vestibule w/labium
minus classically transecting the cyst
- No tx unless patient is >40 and suspect Ca

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S Bartholin duct abscesses:
-infected obstruction
bartholins duct
-E.coli, Staphylococcus,
Streptococcus
-STI
-Severe pain and swelling,
inability to walk and sit
-Warm, swollen and tender
cyst, edema and erythema
-Tx: incision and drainage
antibiotic

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 Hydradenitis suppurativa
S Chronic, inflammatory, recurrent, debilitating, follicular disorder
S >>women (20 y.o, remission after menopause)
S Intertriginous area (axillary, inguinal, inframammary and anogenital)
S Diagnosis criteria (based on The 2nd international hidradenitis
suppurativa research symposium):
1. Typical lesion: deep seated painful nodules; abscesses;
draining sinuses; scars and tombstone open comedones
in secondary lesion
2. Typical topography: axillary, groin, perineal and perianal
lesion, buttocks, infra and intermammary fold
3. Chronicity and recurrence

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S Tx: depends on severity using Hurley classification
S Stage I (abscess formation w/o sinus tract)
S Reduce flares
S topical clindamycin lotion; AB tetracycline, doxycycline, clindamycine;
oral zinc gluconate; IL triamcinolone; short course prednisone)
S Stage II (recurrent abscesses w/sinus tract and scarring, single or multiple
widely separated lesion)
S Same w/ stage I +surgical tx (reduce activity to stage I, prepare for wide
unroofing of sinuses and persistent cysts)
S AB: tetracycline or clindamycine and rifampicin used in combination for 3
mo
S Stage III (Diffuse or extensive involvement, or multiple interconnecting tracts
and abscesses across the entire area)
S Surgical disease (unroof sinuses, to include a thorough exploration and
exposure any secondary sinuses and cyst, eradicate to inflammatory
masses)

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 Vulvodynia
S Vulvar pain in the absence of relevant, visible physical findings
or a specific clinically identifiable neurological disorder
S Ages 20-50
S Classification vulvar pain:
S Secondary (related to specific disorder)
1. Infectious (candidiasis)
2. inflammatory (erosive LP)
3. neoplastic (SCC)
4. Neurologic (PHN)
S Primary
1. Localized (formerly vulvar vestibulitis)
2. Generalized (formerly dysesthetic or essential
vulvodynia)

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S Therapy:
-education and support
-Avoid laundry detergents, cleanser, pads, ill-fitting clothing
- Avoid bike riding, sexual intercourse
- Topical lidocaine 5% oint, gabapentine 6% cream,
estradiol cream
-Tricyclic antidepressant
- Localized vulvodynia: surgical vestibulectomy
- Generalized vulvodynia w/neuralgia:pain
management

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 Pruritus vulvae
S Affect 10% women
S Acute/chronic, minor, debilitating
S Common cause: candidiasisDKI
S Therapy :
1. Eliminate all irritants and control infection
2. Sedationstop scratching, systemic and topical
GC, calcineurin inhibitors-steroid sparing
3. Neurotropic agents (for women who difficult to
pinpoint a cause for itching)

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