Benign Disorders of the Lower Genital Tract

• Congenital anomalies of the vulva and vagina

  • Labial fusion
  • Imperforate hymen
  • Transverse vaginal septum
  • Vaginal atresia
  • Vaginal agenesis
• Labial fusion


  Associated with excess androgens, often due to exogenous androgen exposure or enzymatic error leading to increased androgen production
• Congenital adrenal hyperplasia (21-hydroxylase deficiency)

  1. Elevated 17α-hydroxyprogesterone or urine 17-ketosteroid with decreased serum cortisol

  2. Treatment is exogenous cortisol to inhibit ACTH and androgen production

  3. May also require mineralocorticoid (fludrocortisone acetate) for salt wasting
• Imperforate hymen


  Failure of epithelial cells in the central portion of the hymenal membrane to degenerate, leaving the hymen intact
• Imperforate hymen occurs in 1 in 1,000 female births
• Transverse vaginal septum


  Failure of the central portion of the vaginal plate to degenerate, leaving a transverse septum
• Transverse vaginal septum occurs in approximately 1 in 30,000 to 1 in 80,000 women
• Vaginal atresia


  Failure of the urogenital sinus to contribute the lower portion of the vagina, resulting in fibrous tissue replacing the lower vagina
• Vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)

  Congenital absence of the vagina, often with absence or hypoplasia of the cervix, uterus, and fallopian tubes
• Vaginal agenesis occurs in 1 to 2.5 per 10,000 female births
• Treatment for vaginal agenesis

  1. Psychosocial support and counseling

  2. Nonsurgical vaginal dilation

  3. Surgical creation of a neovagina (e.g. McIndoe procedure)
• Benign epithelial disorders of the vulva and vagina

  • Lichen sclerosis
  • Lichen planus
  • Lichen simplex chronicus
  • Vulvar psoriasis
• Lichen sclerosis


  Inflammatory dermatosis associated with 3-4% risk of vulvar skin cancer
• Lichen planus


  Uncommon inflammatory skin condition that can affect the vulva and vagina, associated with 3-4% risk of vulvar skin cancer
• Lichen planus can be associated with vaginal adhesions and with erosive vaginitis
• Lichen planus generally occurs in women in their 50s or 60s and it is associated with a 3% to 4% risk of vulvar skin cancer
• McIndoe procedure


  To make a neovagina, the skin graft is sewn around a mold
• Pathological subsets and their clinical correlates

  • Lichenoid pattern (and dermal homogenization/sclerosis pattern)
  • Acanthotic pattern (formerly squamous cell hyperplasia)
  • Spongiotic pattern
  • Vesiculobullous pattern
  • Vasculopathic pattern
  • Acantholytic pattern
  • Granulomatous pattern
  • Intraepithelial neoplasia
• Vulvar psoriasis


  May be a feature of psoriasis, a very common skin rash that affects up to 2% of the population
• Lichen simplex chronicus


  Characterized by thickened skin with accentuated skin markings and excoriations due to chronic itching and scratching
• Lichen simplex chronicus


  The intense pruritis may be due to atopic dermatitis, psoriasism, neuropathic pain, or psychologic disorders
• Lichen simplex chronicus


  This skin disorder leads to a scratch-itch cycle
• Diagnosis of these disorders may be made clinically, often histologic confirmation is sought, and biopsy of vulvar lesions is appropriate
• Vulvar and vaginal lesions can be evaluated with a colposcope and this will aid directed biopsy
• Differential diagnosis of benign lesions of the vulva and vagina

  • Aphthous ulcers
  • Behçet syndrome
  • Crohn disease
  • Erythema multiforme
  • Bullous pemphigoid
  • Plasma cell vulvitis
  • Squamous cell carcinoma
  • Basal cell carcinoma
  • Melanoma
  • Sarcoma
  • Paget disease of the vulva
• Healthy vulvar and vaginal hygiene practices

  Avoid tight-fitting clothes, pantyhose, panty liners, scented soaps and detergents, bubble baths, washcloths, and feminine sprays, douches, and powders. Wear loose-fitting cotton underwear and loose-fitting clothing. Use unscented detergents and soaps.
• High-potency topical steroids


  Can be used to treat lichen sclerosus or lichen planus and severe lichen simplex chronicus
• Low- to medium-potency steroids


  Should be used for mild cases of dermatoses
• There is no role for topical estrogens or testosterone in the treatment of these disorders
• Low-dose vaginal estrogen is an effective treatment for concomitant postmenopausal vulvovaginal atrophy
• Surgical management is generally not indicated in treatment of these disorders
• Exceptions are cases of lichen planus, where postinflammatory sequelae can include vaginal adhesions and introital stenosis
• Surgical procedures to enlarge the introitus and open adhesions in lichen sclerosus may be necessary if attempts at intercourse have been unsuccessful following conservative measures
• Epidermal inclusion cysts


  The most common tumor found on the vulva, usually result from occlusion of a pilosebaceous duct or a blocked hair follicle
• Sebaceous cysts


  Form when the duct of a sebaceous gland becomes blocked, the normally secreted sebum accumulates in this cyst
• Apocrine sweat gland cysts

  Sweat glands can become occluded and form cysts, Fox-Fordyce disease is an infrequently occurring chronic pruritic papular eruption that localizes to areas where apocrine glands are found
• Skene's gland cysts


  Chronic inflammation of the Skene's glands can cause obstruction of the ducts and result in cystic dilation of the glands
• Bartholin's duct cyst and abscess

  Obstruction of the Bartholin's gland ducts leads to cystic dilation of the Bartholin's duct while the gland itself is unchanged
• Bartholin's abscess


  The result of polymicrobial infections, occasionally associated with sexually transmitted diseases
• Word catheter placement


  Make a small incision to drain and irrigate the abscess, then place a Word catheter with a balloon tip inside the remaining cyst and inflate it to fill the space, leave in place for 4-6 weeks