Vaginal disease

Published on 09/03/2015 by admin

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Chapter 23 Vaginal disease

Amy Tang

Benign conditions

Vaginal epithelium changes in different phases of life:

• In the newborn, it is thick with much glycogen due to the maternal oestrogen effect; then, with the withdrawal of oestrogen, the vaginal epithelium atrophies and the basal layer is covered by a thin, cornified epithelium.
• At menarche, the epithelium regenerates.
• At climacteric, the epithelium reverts to its prepubertal state.

Vaginal discharge

Physiological vaginal discharge is a product of vaginal mucosal transudate, cervical mucus and secretions from Bartholin’s and Skene’s glands. Excess physiological discharge occurs during pregnancy, sexual arousal, at mid-cycle/ovulation, with use of a high-oestrogen oral contraceptive or an intrauterine contraceptive device, and with large cervical ectropion.

Abnormal vaginal discharge may originate from diseases of the vagina, cervix, uterus or fallopian tubes. Causes of abnormal vaginal discharge include infections, foreign body, atrophic vaginitis and neoplasia of the upper and lower genital tract.

History

• colour, consistency, odour and duration of discharge
• blood-stained discharge
• pruritus, pain
• associations with menstrual cycle, coitus
• medical history (e.g. diabetes)
• medications, contraception
• cervical cytology

Examination

• general examination
• genital/pelvic: vulval examination
• speculum: examining vagina and cervix, checking discharge (colour, odour), cervical ectropion, malignancy, cervical cytology, microbiological swabs
• pelvic examination for cervical excitation and palpable masses

Vaginal infections

During the reproductive life, the vaginal pH is <4.5, and this offers some protection against infections.

Trichomonas

• It is a flagellate, about 20 microns in size.
• It presents with vaginal discharge and pruritus.
• Examination reveals a yellow/green frothy discharge, punctate injection of vagina with pH >5.0.
• Treat with metronidazole 400 mg orally three times a day for 7 days or a 2 g dose statim, and treat the partner.

Candida

• It presents with vaginal discharge and vulval pruritus, and curd-like patches which are adherent to the epithelium.
• Predisposing factors include pregnancy, premenstrual period of cycle, glucose intolerance, and the use of the oral contraceptive pill, antibiotics and corticosteroids.
• It may be distinguished as uncomplicated (isolated episodes, albicans species and normal host), and complicated (severe, recurrent, non-albicans Candida species, abnormal host).
• Treatment: miconazole, econazole or clotrimazole inserted into the vagina for the short term, or single-dose oral fluconazole. Complicated Candida requires longer duration therapy.

Gardnerella vaginalis

• It is also called bacterial vaginosis.
• It is a highly prevalent polymicrobial syndrome.
• The vaginal epithelium is coated with the small bacteria; on microscopy, clue cells are present.
• It is present in up to 40% of women.
• It presents with grey, frothy, offensive discharge and pruritus.
• Treat with metronidazole 400 mg orally three times a day for 7 days or 2 g dose statim, or vaginal clindamycin cream.

Postmenopausal woman

• Atrophy secondary to oestrogen deficiency predisposes to bleeding and secondary infection.
• Perform microbiological swabs and cervical cytology.
• Treat with oestrogen if atrophic.

Other vaginal conditions

Cysts

• Endometriosis: involves pain, dyspareunia, postcoital bleeding.
• Gartner’s duct runs lateral and anterolateral, at any level from the cervix to urethra. If it is small, no treatment is required; marsupialise if large.

Fistula

• It occurs between the vagina and gastrointestinal or genitourinary system.
• It may be congenital or acquired.

Vaginal intraepithelial neoplasia (VAIN)

VAIN coexists with cervical intraepithelial neoplasia in 1%–3% of cases. The mean age at diagnosis is 52 years. The cause is unknown, but it may be associated with the human papillomavirus (HPV).

Classification

• VAIN1: low-grade squamous intraepithelial lesion
• VAIN2 and VAIN3: high-grade squamous intraepithelial lesion

There is no adequate study to prove the progression of VAIN to cancer. If the lesion is small, treatment options include an excisional biopsy, topical chemotherapy with imiquimod (Aldara) or 5-fluorouracil (5-FU), laser or cryotherapy.

Vaginal carcinoma

It may be primary or secondary. It usually occurs by direct spread or metastasis from the cervix, uterus, vulva, bladder, rectum or sigmoid colon. It accounts for 1% of female genital tract cancer. Squamous cell cancer presents in the sixth to seventh decade of life.

Histopathology

• Primary disease is usually squamous cell (80%–90%) or adenocarcinoma.
• Clear-cell adenocarcinoma is related to maternal diethylstilboestrol ingestion.
• Rarer tumours include melanoma, sarcoma botryoides, verrucous squamous cell carcinoma and endodermal sinus tumour.

Presentation, site and spread

• It involves postmenopausal bleeding, vaginal discharge, pain and urinary symptoms.
• Diagnosis can be missed if the lesion is small. A Pap smear may detect malignant cells in 20% of cases.
• About 50% occur in the upper vagina, 30% in the lower vagina and 20% in the mid-vagina.
• Posterior-wall tumour is the most common, followed by anterior-wall and lateral-wall; therefore, the most common site is in the posterior upper third, and then anterior lower third of the vagina.
• Spread is by direct extension and via the lymphatic system.

Investigations

• examination under anaesthesia and biopsy
• cystoscopy, sigmoidoscopy
• chest X-ray, ultrasound scan, computed tomography (CT) scan, intravenous pyelogram

FIGO staging for primary cancer of the vagina

This is a clinical (not surgical) staging (same as for cervical cancer).

• stage 1: limited to the vaginal wall
• stage 2: involvement of subvaginal tissue, but not extending to the pelvic wall

• 2A: subvaginal infiltration, but not to the parametrium
• 2B: parametrial involvement, but not to the pelvic wall

• stage 3: tumour extending to the pelvic wall
• stage 4: involves mucosa bladder/rectum; extends beyond the true pelvis

• 4A: spread to adjacent organs and/or direct extension beyond the true pelvis
• 4B: spread to distant organs

Five-year survival rates

• stage 1: 70%–80%
• stage 2: 30%–45%
• stage 3: 25%
• stage 4: 0%–30%

Management of vaginal cancer

• Therapy is individualised depending on the stage and site of vaginal disease.
• Generally, radiotherapy and/or surgical excision are performed.
• Stage 1 upper vaginal <2 cm lesions can be treated with either surgery (radical hysterectomy, upper vaginectomy, bilateral pelvic lymphadenectomy) or intracavitary radiotherapy.
• Less radical surgery may be appropriate as the primary treatment in some forms of vaginal cancer (e.g. basal cell carcinoma).
• Chemoradiation therapy is currently being assessed.

Further reading

Berek S., Hacker N., editors. Practical gynecologic oncology, 4th edn, Philadelphia: Lippincott Williams & Wilkins, 2005.

Joura E.A. Epidemiology, diagnosis and treatment of vulvar intraepithelial neoplasia. Current Opinion in Obstetrics and Gynecology. 2002;14:39-43.

Shafi M., Luesley D., Jordan J., editors. Handbook of gynaecological oncology. London: Churchill Livingstone, 2001.

Stewart E.G. Developments in vulvovaginal care. Current Opinion in Obstetrics and Gynecology. 2002;14:483-488.

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