Disorders of the Vulva

Urethral caruncle

A urethral caruncle is a polypoidal outgrowth from the edge of the urethra, which is most commonly seen after menopause. The tissue is soft, red, and smooth, appearing as an eversion of the urethral mucosa. Most women are asymptomatic, but others experience dysuria, frequency, urgency, and focal tenderness. If there are any suspicious features, an excision and biopsy may be required to exclude the rare diagnosis of a urethral carcinoma.

Bartholin gland cysts

The greater vestibular, or Bartholin, glands lie in the subcutaneous tissue below the lower third of the labium majus and open via ducts to the vestibule between the hymenal orifice and the labia minora. They secrete mucus, particularly at the time of intercourse. When the duct becomes blocked, a tense retention cyst forms. If there is super-added infection, a painful abscess develops. The abscess can be incised and drained, usually under general anaesthesia. To prevent the cyst reforming, the fistula is kept open by suturing its edges to the surrounding skin, a procedure known as marsupialization ( Fig. 16.1 ). Insertion of a balloon catheter (Word catheter) under local anaesthesia is an alternative to incision, drainage, or marsupialization. The aim of this procedure is to allow a sinus tract to develop after 3 to 4 weeks. Carcinoma of the Bartholin gland is very rare.

Small cysts

The most common small vulval cysts are usually either inclusion cysts or sebaceous cysts. Inclusion cysts form because epithelium is trapped in the epidermis, usually following perineal trauma at the time of childbirth. They are usually asymptomatic and need no treatment. Sebaceous cysts are usually multiple, mobile, non-tender, white or yellow, and filled with a ‘cottage cheese-like’ substance. Excision may be requested by the woman.

Naevi

Vulval naevi (moles) are usually asymptomatic but become more pigmented at puberty. Any other change in a vulval naevus is an indication for removal. Of malignant melanomas in women, 2% arise from the vulva.

Fibroma, lipoma, hidradenoma

Fibromas and lipomas are benign, mobile tumours of fibrous tissue and fat, respectively. Hidradenomas are rare tumours of sweat glands near the surface of the labia. All are benign, but the diagnosis is usually only made once they have been excised.

Haematoma

The most common cause of a vulval haematoma is vaginal delivery. It may also occur following surgery to the vulva, or by ‘falling astride’ accidents (particularly in children, where the possibility of sexual assault should be borne in mind). Vulval haematomas usually present with pain, and surgical evacuation under general anaesthesia is often required.

Simple atrophy

Older women develop vaginal, vulval, and clitoral atrophy as part of the normal ageing process of skin. In severe cases, the thin vulval skin, terminal urethra, and fourchette can cause dysuria and superficial dyspareunia, and the labia minora may fuse and ‘bury’ the clitoris. Introital stenoses can make coitus difficult and sometimes impossible. A simple moisturizer rubbed into the vulva is effective and topical estrogen is often appropriate. There may be a small amount of systemic absorption with topical estrogen therapy. If this route is chosen, treatment should be for no more than 2 or 3 months without either a break or a short course of progesterone to prevent endometrial stimulation.

Ulcers

These may be:

• Aphthous (yellow base)

• Herpetic (exquisitely painful multiple ulceration, pp. 202)

• Syphilitic (indurated and painless, pp. 204)

• Associated with Crohn disease

• A feature of Behçet syndrome (a rare, chronic, painful condition with aphthous genital, oral, and ocular ulceration)

• Malignant (see later discussion)

• Associated with lichen planus (see later discussion) or Stevens-Johnson syndrome

• Tropical (lymphogranuloma venereum, chancroid, granuloma inguinale).

Treatment depends on the cause. The management of Behçet syndrome is challenging and multidisciplinary, but the combined oral contraceptive and topical and oral steroids may be effective.