Diseases of the Vagina

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Chapter 9 Diseases of the Vagina

Benign vaginal disease

Vaginal diseases can manifest as benign, premalignant or malignant conditions

Benign

Vaginal cysts are not uncommon but are rarely large. They are found in the anterior or lateral walls of the lower third of the vagina and in the posterior wall of the upper third, are seldom larger than a walnut, are sometimes multiple, and may be mistaken for a cystocele. These cysts are occasionally a cause of dyspareunia but they usually cause no symptoms at all.

Treatment is by excision or marsupialisation.

Traumatic epithelial cysts

Traumatic epithelial cysts (inclusion cysts) are found usually in the lower vagina and are caused by an infolding of epithelium at repair operations. If they cause any symptoms, they should be excised or marsupialised.

Vaginal infections

See pages relating to infection.

Malignant and premalignant disease

Vaginal intraepithelial neoplasia (VAIN)

This can be a very difficult condition to treat. It is rare, can affect any point on the vaginal wall and may progress to an invasive malignant disease. Its aetiology is likely to be due to human papilloma virus infection. The mature epithelium and a lack of metaplastic change may explain its reduced incidence when compared to cervical intraepithelial neoplasia.

It is often asymptomatic but symptoms may include irregular vaginal bleeding or discharge. Diagnosis is usually by colposcopy with directed biopsy, but it may also be detected incidentally in histology after a hysterectomy.

Treatment will depend on the age of the patient, previous treatment (some may have had a hysterectomy or treatment for cervical cancer), general health and desire to retain normal sexual function. Surgical excision (partial or total vaginectomy) and laser ablation have been employed and some authors report the use of topical 5-fluorouracil (5-FU) chemotherapy. Due to the rarity of this condition, treatment should be undertaken by a clinician with specialist skills in this area.

Carcinoma of the vagina

Primary growths of the vagina are rare. The most common vaginal cancers are squamous cell carcinomas, however, adenocarcinomas, melanomas and sarcomas may also be seen. 30% of patients will have a history of CIN or of a carcinoma of the cervix.

Its aetiology is mixed, with oncogenic human papilloma virus being implicated in squamous carcinoma development. Although rare, VAIN is being diagnosed more frequently and it may proceed to cancer. Historically, intrauterine exposure to diethylstilboestrol (DES) has carried a risk of causing vaginal adenocarcinomas, but more commonly, vaginal adenosis. Metastatic deposits are also seen, especially as extensions from cervical cancer and endometrial carcinoma.

Clinical features

The patient is usually postmenopausal and asymptomatic. The most common symptoms are bleeding (60%), discharge (15%) and pelvic pain (10% or less). If the bladder is involved, patients may experience pain and dysuria.

The tumour is not at first painful, and unless it appears in a woman who is still sexually active, it is not likely to present until it has penetrated the vaginal wall and caused bleeding. An early tumour can easily be missed if it is obscured by the blade of a speculum. The whole vagina should always be inspected, and a biopsy be taken from any unusual lesion.

A thorough examination, including colposcopy, cystoscopy and proctosigmoidoscopy, may be indicated to detect its spread. In addition, magnetic resonance imaging (MRI) scans can provide information on local and regional disease.

Site and spread

The most common site of disease is the upper vagina. The disease can have a variety of appearances depending on its histology, such as a mass lesion, plaques of abnormal tissue or ulceration.

Upper third: approximately same drainage as the cervix.

Middle third: any pelvic lymphatic channel may be involved.

Lower third: approximately same drainage as the vulva.

Clinical staging		Five-year survival rates (%)
Stage I	Invasive. Confined to the vaginal mucosa.	75–90
Stage II	Invading paravaginal tissue, but not to the pelvic side wall.	45
Stage III	Extension to the pelvic side wall.	30–40
Stage IVa	Extension to mucosa of bladder or rectum.	20
Stage IVb	Extension beyond the pelvis.	20

Prognosis depends on the clinical stage of the disease.

Treatment

Treatment will be tailored to the patient; size and stage of the disease and psychosexual impact of the treatment will also be taken into consideration. If the disease is localised to the vagina in a fit patient, it may be treated by radical surgery (radical hysterectomy, vaginectomy, lymphadenectomy). More advanced disease and disease in the mid to lower third of the vagina may be treated with radiotherapy. Some authors are also exploring the use of chemotherapy (cisplatin and 5-FU) alongside radiotherapy.

The vaginal melanoma carries a poor prognosis, with radical excision and radiotherapy currently being employed in its treatment.

Sarcoma botryoides is a rare tumour of young children, presenting as grape-like masses with bleeding. Chemotherapy with vincristine, actinomycin D and cyclophosphamide gives good results.

Plastic surgery of the vagina

This is required when the patient is found to have a congenital absence of the vagina, is having the vagina removed as a part of radical cancer surgery, or distortion and contractures due to injury or genital mutilation. Such a situation is rare, but various operations have been devised. The small bowel has been used successfully in male to female sex change procedures.

The placement of a skin graft

1. A plastic mould is covered with skin from the thigh. (This is done by a plastic surgeon.)

2. The space between the urethra/bladder and the rectum is opened up. A finger in the anus helps the surgeon to avoid damaging the rectum.

3. The mould and the graft are inserted and kept in place by suturing the split ends of the labia minora. The moulds can now be fashioned from inflatable plastic and in varying sizes. The vaginal orifice may need enlarging later on by the plastic surgeon.

The mould must be kept for a prolonged time, and once it is removed, the patient should use vaginal trainers or have regular sexual intercourse to prevent closure of the neovagina.

Additional procedures

The techniques available to the plastic surgeon have allowed the evolution of a variety of procedures to create a neovagina. Some may raise myocutaneous flaps from the rectus abdominus muscle or the gracilis muscle.

Related

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