vaginal diseases

BENIGN AND MALIGNANT DISEASE OF THE VAGINA
The vagina is a fibromuscular canal lined with stratified squamous epithelium that leads from the uterus to the vulva
Many of the disorders that affect the vagina are discussed in your lectures like congenital abnormalities; infections; atrophic changes of menopause; and also the prolapse.
In this lecture we will discuss benign and malignant conditions of the vagina.
Vaginal atrophy
This is seen following the menopause, prior to puberty and during lactation. Examination shows loss of rugal folds and prominent subepithelial vessels, sometimes with adjacent ecchymoses. The patient may present wit h vaginal bleeding, vaginal discharge, or vaginal dryness and dyspareunia. Superficial infection, may be associated. Treatment requires oestrogen to restore the vaginal epithelium and pH.

Fistula
A fistula may be due to trauma, carcinoma or Crohn’s disease

Benign tumours
Tumours in the vagina are uncommon but occur within the vaginal wall and include myoma, fibromyoma, neurofibroma, papilloma, myxoma and adenomyoma. Cystic lesions may be found within the vagina, like Gartner’s or Wolffian duct origin.

1. Condylomata acuminata are by far the commonest seen. The frond like surface is usually characteristic, but it is wise to await the result of a biopsy before instituting treatment, especially if the lesion is close to the cervix.
2. Occasionally deposits of endometriosis can be found beneath the vaginal epithelium, following surgery or episiotomy. They may cause abnormal vaginal bleeding or pain. Treatment can be by laser vaporization or excision, or by drug therapy as for endometriosis elsewhere.
3. Simple mesonephric (Gartner s) or ,paramesonephric cysts may be seen, especially higher near the fornices. if asymptomatic, they are best not treated. If treatment is required, marsupialization is effective and safer than excision.
4. Adenosis - multiple mucus-containing vaginal cysts - is a rare condition. A variety of abnormalities are reported in the daughters of women who took diethylstilboestrol during their pregnancy. Most of these are of no significance.

Vaginal intraepithelial neoplasia
The terminology and pathology of VAIN are analogous to those of CIN (VAIN I-III). The main difference is that vaginal epithelium does not normally have crypts, so the epithelial abnormality remains superficial until invasion occurs.
Vaginal intraepithelial neoplasia (VAIN) is seen coexisting with cervical intraepithelial neoplasia (CIN) in 1–6% of such patents. It is almost always in the upper vagina, and confluent with the cervical lesion.
It is uncommon to find VAIN in the presence of a normal cervix.

AETIOLOGY:
The aetiology of VAIN is probably similar to that of CIN. Extension of the transformation zone into the fornices would seem responsible.
A higher incidence of VAIN has been noted in patients on chemotherapy, immunosuppressive therapy, or radiotherapy for carcinoma of the cervix.

GRADES:
As for cervical lesions VAIN I is equivalent to mild dysplasia, VAIN II moderate dysplasia and VAIN III severe dysplasia or carcinoma in situ.

DIAGNOSIS:
The disease is normally recognized as a result of
A) Abnormal cytology seen in a vaginal vault smear specimen. It is recommended that vault smears should be performed annually for women after hysterectomy performed for CIN, and 3-yearly if the hysterectomy was for benign disease.
B) Colposcopic assessment of patients with abnormal vault smears will delineate areas of
1- Aceto-white epithelium.
2- Punctuation.
C) Vaginal biopsies from the vault can usually be taken without anesthesia but occasionally difficult access into vaginal angles after hysterectomy may require the use of general anaesthesia and appropriate vaginal retractors.

Treatment:
There have been a wide variety of treatments used to treat VAIN. These include:
1- excision biopsy for smaller lesions
2- 5-fluorouracil cream or
3- laser vaporization (Use of the carbon dioxide laser )for more extensive lesions. healing may take several months. Treatment failure is common.

4- partial vaginectomy of the vault after hysterectomy, Occasionally more extensive disease will require total vaginectomy.
5- The other option is to use radiotherapy by the intravaginal approach.

Vaginal cancer
Vaginal cancer is rare and accounts for only 1–2% of all gynaecological malignancies. They arise as primary squamous cancers or are the result of extension from the cervix or vulva.
the peak incidence in the 6th decade of life and a mean age of approximately 60–65 years.
Aetiology
The cause is unknown although several predisposing and associated factors have been noted. These include:
• Prior lower genital tract intraepithelial neoplasia (mainly CIN and/or cervical carcinoma)
• HPV infection (Oncogenic subtypes).
• Previous gynaecological malignancy.
There is a concern that women below the age of 40 treated with radiotherapy for cervical cancer may be at a high risk of subsequently developing vaginal cancer 10-40 years later. The prevalence of clear cell adenocarcinoma is increased by intrauterine exposure to diethylstilboestrol (DES).
There would appear to be no relationship with race or parity, longterm
use of a vaginal pessary and chronic uterovaginal prolapse as causative factors.

Pathology
The great majority ( 89%) of primary vaginal cancers are squamous. Clear cell adenocarcinomas, malignant melanomas, embryonal rhabdomyosarcomas and endodermal sinus tumours are the commonest of the small number of other tumours seen very rarely in the vagina.

Natural history
The upper vagina is the commonest site for invasive disease. Squamous vaginal cancer spreads by local invasion initially. Lymphatic spread occurs to the pelvic nodes from the upper vagina and to both pelvic and inguinal nodes from the lower vagina.

Clinical staging
The FIGO clinical staging is as the following:
0 Intraepithelial neoplasia grade 3 (carcinoma in situ)
I Invasive carcinoma confined to vaginal mucosa
II Subvaginal infiltration not extending to pelvic wall
III Extends to pelvic wall
IVa Involves mucosa of bladder or rectum
IVb Spread beyond the pelvis being less common



Diagnosis and assessment
Presentation
The symptoms at presentation will depend on the stage of tumour at presentation. The most common presenting features are:
• Vaginal bleeding. Accounts for more than 50% of presentations.
• Vaginal discharge
• Urinary symptoms
• Abdominal mass or pain
• Approximately 10% of tumours will be asymptomatic at the time of diagnosis.
Vaginal tumours may be overlooked during vaginal examination, particularly when a bivalve speculum is used.
Careful inspection of the vaginal walls while withdrawing the speculum is necessary.
SITE AND SIZE
Tumours can occur at any site in the vagina. The upper third of the vagina is the site most frequently involved, the size of tumour shows great variation at presentation but the majority of tumours are 2–4 cm in maximum diameter.
Examination:
A careful examination under anaesthesia combined with colposcopy.
Combined rectal and vaginal examination is helpful to determine if there is any extension of the tumour beyond the vagina.
• Cystoscopy and sigmoidoscopy are required to exclude or confirm the involvement of bladder or rectum.
• Chest X-ray.
• Intravenous urogram.
• rectal ultrasound scanning or MRI may be used.
Treatment and results
Radiotherapy:
Invasive vaginal cancer is usually treated with radiotherapy. Early cases, Stage I-IIa, may be treated with interstitial therapy, or external beam therapy. Cases with parametrial involvement receive teletherapy (external beam radiation) followed by interstitial therapy. The field may be extended to include the groins if the tumour involves the lower half of the vagina.
Acute complications of radiotherapy include
• Proctitis
• Radiation cystitis
• Vulvar excoriation or ulceration and even vaginal necrosis.
Significant long-term complications reported include:
• Vesico-vaginal or recto-vaginal fistulae
• Rectal stricture
• Vaginal stenosis.

Surgery:
1-A Stage I lesion in the upper vagina can be adequately treated by radical hysterectomy, radical vaginectomy and pelvic lymphadenectomy.
2- Patients with small mobile stage I tumours low down in the vagina, which if amenable to excision can be treated by vulvectomy with inguinal lymphadenectomy.
3 in Bulky lesions Surgery is problematic in this respect since, to achieve adequate margins around tumour, important structures (e.g. bladder or rectum) may be compromised.
Serious complications include urinary problems (stress and/or urge incontinence) and fistulae.
Prognosis:
The 5-year survival figures described for Stage I are generally good, but the results of therapy in more advanced disease are much less satisfactory
Lying between 39 – 66 %

Recurrence
Recurrence occurs locally or within the pelvis in most instances with about 20% relapsing with distant metastasis. The majority of relapses occur soon after primary therapy.

Rhabdomyosarcoma (sarcoma botryroides):
Rhabdomyosarcoma accounts for <2% of vaginal sarcomas.
It is the most common soft-tissue tumour in the genito-urinary tract during childhood. Presentation is classically with a vaginal mass composed of soft ‘grape-like’ vesicles, vaginal bleeding, discharge.
Treatment involves conservative surgery (aimed at preserving function of the female pelvic organs) but depends largely on combination chemotherapy, Adjuvant surgery or radiotherapy, over 90% of individuals have been reported to survive following treatment.