Vaginal Pelvic Relaxation

Background - importance and magnitude of problem
Diagnostic goals - for overall category

• uterine prolapse
• vaginal vault prolapse
• cystocele
• urethrocele (urethrovesical neck descensus)
• rectocele
• paravaginal defect
• enterocele

Background

Relaxation of the supporting structures of the vagina and uterus occur commonly, but mostly in the postmenopausal female. It is postulated that there is a disruption (rather than stretching) of the ligaments at childbirth. Relaxation is infrequent, but not absent, in women who have never had a vaginal delivery. Caucasian women are most susceptible to this. The presenting complaint may be protrusion of "something" from the vagina rather than any pain or pressure feelings. Other symptoms may include low back pain, difficulty initiating stool or urination, stress urinary incontinence, and pelvic pain or pressure.

Goals

Most of the problems in this category can be diagnosed by pelvic exam alone. The examiner should determine what anatomy of the pelvis has become detached from its normally strong support to the remainder of the pelvic structures. The precise anatomical defect description is needed to determine therapy.

Vulvar pain / burning / painful intercourse (superficial)

vulvodynia/dyspareunia

• congenital abnormalities of the hymen
• post traumatic scarring of the entrance
• episiotomy scarring or delivery lacerations
• post laser treatment of condyloma
• vulvar hypersensitivity or allergic reactions
• periorificial (irritant) dermatitis
• cyclic/recurrent yeast vulvovaginitis
• cyclic/recurrent bacterial vulvovaginitis
• vulvar vestibulitis
• dysesthetic vulvodynia
• vulvar dermatoses

lack of estrogen
• breast feeding
• menopausal estrogen deficiency
• use of DepoProvera (R)
• use of progestin only birth control or
• ovarian suppression
• vaginal foreign body
  vaginismus (involuntary pelvic muscle contraction)
  • fear of vulvar/vaginal pain with penetration
  • previous history of rape or sexual abuse
  • phobias
  • stress reactions
  • interpersonal issues

Background

Painful intercouse may be from vulvar or vaginal pain. Vulvar pain starts at the opening of the vagina (vulva, introitus) and hurts at just touching the vulva or at initial penetration through the hymen into the vagina. It would hurt just with touching the area with your fingers or a pad rubbing against it. When it occurs, it is a very serious problem because it effects not only sexual relations but also sitting and walking. A problem with chronic vulvar pain can seriously disrupt a woman's normal daily activities.

Vaginal pain is a little harder to identify. The pain would be present mostly upon the partner entering the vagina and with the movement back and forth without deep penetration. Usually the pain only occurs with sex and goes away in between. Vaginal pain can also be secondary rather than primary. This is because the vaginal muscles may involuntarily contract (vaginismus) due to the of fear of being hurt and the contraction causes pain.

Goals

Therapy in this category is almost always directed at relief of the original cause of the pain rather than concern about a vulvar cancer. Most cancers do not present with pain. The diagnostic goals are to determine some type of etiology and rule out others so that therapy can be specifically directed toward pain relief. If any lesions are present on the vulva and pain mapping shows only that area to produce pain, then surgical removal of the lesion is the overall therapeutic goal and may not need to be further diagnosed. Pain that occurs without visible lesions is a much more difficult diagnostic problem. Low estrogen states of the vaginal lining are treated with lubricants if the hormonal levels cannot be changed. If the vaginal pain is thought to be caused by underlying involuntary muscle contraction, then biofeedback and relaxation therapy are needed to overcome the involuntary muscle spasm.

Vulvar lesions - white

• vitiligo
• condyloma accuminata
• lichen planus
• psoriasis
• diabetic vulvitis
• lichen sclerosis
• squamous cell carcinoma insitu
• Paget's disease of vulva

Background

Vulvar lesions most commonly occur in postmenopausal women, especially those who are more than a decade passed menopause. Many of the white lesions are produced by chronic irritation such as scratching or a chronic infectious process or chronic vulvar soiling with urine or feces. In general, whiteness of a lesion just connotes that there is a very thin epithelium overlying the disease process.

Goals

Treatment may initially be directed at clearing up any inflammatory process, however, the main reason for doing this is just to indicate what areas will provide the best biopsy to show characteristic changes for whatever the lesion is. Vulvar carcinoma in situ can be present and also underlying malignancies, so biopsy should be performed very early.

Vulvar lesions - red

• candidiasis
• vaginal intraepithelial neoplasia
• squamous cell hyperplasia
• Paget's disease
• invasive carcinoma
• seborrheic dermatitis
• psoriasis
• lichen planus
• tinea cruris
• erythrasma
• contact irritant vulvitis

Background

A red or a fleshy color lesion is much less likely to represent only atrophic epithelium. It often results from an underlying inflammatory process and thus there is a slightly higher chance of malignancy in this group of lesions.

Goals

Initial treatment may be directed toward candidiasis or an irritant vulvitis with steroids but if there is not quick resolution, further studies will need to be performed usually including a vulvar biopsy. This looks for other dermatological inflammatory lesions.

Vulvar lesions - ulcerated

• herpes genitalis
• Behcet's disease
• Crohn's disease
• syphilis
• granuloma inguinale
• granular cell myoblastoma
• hidradenoma
• invasive carcinoma
• basal cell carcinoma
• traumatic ulcer
• anal fistula
• pemphigus vulgaris
• tuberculosis

Background

Ulcerated lesions do not occur commonly. In the younger woman less than 40, inflammatory or infectious porcesses are more common. Over 40, malignancy is a stronger concern.

Goals

Ulcerated lesions often represent either malignancy or a necrosing inflammatory process commonly associated with sexually transmitted diseases. Acute ulcerative lesions usually fall into the category of sexually transmitted diseases while chronic ulcerated lesions almost always require biopsy. In addition to biopsy special pathological stains should sometimes be requested to look for some of the more unusual sexually transmitted diseases.

Vulvar lesions - pigmented

• nevus
• melanosis
• melanoma
• squamous cell carcinoma in situ
• lentigo
• seborrheic keratosis
• Bowenoid papulosis - atypical condylomata

Background

Pigmented lesions appearing bluish/brown or black raise a high index of suspicion for malignant melanoma of the vulvar skin. While not a frequently occurring cancer (1% of all vulvar cancers) any newly occurring pigmented lesion should be biopsied. Lesions which have been present for most of the patients reproductive life are unlikely to represent malignancies.

Goals

Biopsy is almost standard for this group of lesions with the exception of vulvar melanosis which is usually just a discolored area in the skin like a large freckle. If it is newly occurring it must be biopsied. If it is just newly discovered in a patient who had not been previously examined and the area is less than a centimeter and there is no elevated component to the lesion (it is entirely intradermal) then it may be observed over a short period of time without biopsy to make sure that it does not enlarge.

Vulvar lesions - cystic tumors

• epidermal inclusion cyst
• pilonidal cyst
• sebaceous cyst
• hidradenoma
• Fox-Fordyce disease
• syringoma
• mesonephric (Gartner's duct) cyst
• paramesonephric (mullerian duct) cyst
• urogenital sinus (mucus) cyst
• cysts of canal of Nuck
• cysts of supernumerary mammary glands
• adenosis
• dermoid cysts
• bartholin duct cyst
• bartholin duct abscess
• endometriosis
• cystic lymphangioma
• liquified hematoma
• vulvar varicosity
• anterior perineal hernia
• vaginitis emphysematosis

Background

Vulvar cysts are not common. They are usually noticed by women but are often painless. Presenting complaints may just be the finding of a "lump". Cystic lesions present from birth or uncommon, but normal, anatomy may not need any investigation. Cystic tumors in the area of the vulva are almost always benign lesions.

Goals

Some characteristic lesions such as a vulvar varicosity do not need to be biopsied but when there is any doubt as to what the cystic lesion is, excision and pathological examination should be performed.

Vulvar lesions - solid tumors

• condyloma accuminatum
• molluscum contagiosum
• acrochordon
• fibroepithelial polyp
• accessory nipple
• seborrheic keratosis
• nevus
• hidradenoma
• sebaceous adenoma
• basal cell carcinoma
• fibroma
• lipoma
• neurofibroma
• leiomyoma
• granular cell myoblastoma
• hemangioma
• pyogenic granuloma
• lymphangioma
• adenofibroma

Background

Solid lesions of the vulva frequently occur. When they do occur, they may represent almost any dermatologic process that can produce skin nodules elsewhere.

Goals

Most solid lesions of the vulva need to be biopsied except for characteristic lesions of condyloma acuminata. Once it is determined what is the dermatologic process taking place, some of the benign lesions may not need to have further biopsies when they are newly occurrent lesions such as acrochordons or keratoses.

Rectoanal discomfort/bleeding

• anal fissure
• hemorrhoids
• condyloma accuminata
• pruritus ani
• cryptitis
• anorectal abscess
• fistula in ano
• hidradenitis suppurativa
• pilonidal sinus
• rectal prolapse
• ulcerative proctitis
• granulomatous proctitis
• infectious proctitis
• radiation proctitis
• proctalgia fugax
• fecal impaction
• coccygodynia
• anal stenosis
• foreign bodies

Background

Hemorrhoids are varicose veins of the rectum. They are quite frequent in occurrence and predominate this category. The other causes in this category occur less frequently but because of their location, they may pose significant problems for a woman, causing pain with each bowel movement.

Goals

These problems are divided into inflammatory processes versus other problems. Malignancy is not frequent in this category but many of the entities are chronic infectious processes that are difficult to treat.

Rectal masses

• adenocarcinoma
• intraepidermal carcinoma
• Paget's disease
• cloacogenic carcinoma
• malignant melanoma
• squamous cell carcinoma

Background

Many rectal masses are asymptomatic and are found only at rectal exam during the time of a routine pelvic examination. Rectal carcinoma is an uncommon occurrence but a serious one.

Goals

All solid lesions of the rectum should be evaluated for possible malignancy since this has the most severe consequence.