BENIGN GYNECOLOGIC LESIONS

VULVA
BENIGN SOLID TUMORS Urethral Caruncle Urethral Prolapse Vulvar Compound Nevus Vulvar Fibroma Vulvar Lipoma Hidradenoma Vulvar Pain Syndrome Vulvar vestibulitis

BEINGN EPITHELIAL DISORDERS Contact Dermatitis Lichen Simplex Chronicus Vulvar Psoriasis Lichen Planus Hidradenitis Suppurtiva

BENIGN CYSTS Epidermal Inclusion Cysts Sebaceous Cysts Apocrine sweat gland cysts Skenes gland cysts Bartholins Duct Cyst and Abcess Gartners Duct Cyst

BENIGN SOLID TUMORS

Urethral Caruncle Urethral Prolapse Vulvar Compound Nevus Vulvar Fibroma Vulvar Lipoma Hidradenoma Vulvar Pain Syndrome Vulvar vestibulitis

Urethral Caruncle

Small, fleshy outgrowth of the distal edge of the urethra. The tissue of the caruncle is soft, smooth, friable, and bright red and initially appears as an eversion of the urethra. They occur most frequently in postmenopausal women and must be differentiated from urethral carcinomas. Dx: Biopsy under local anesthesia. Treatment: 1) Oral or topical estrogen and avoidance of irritation 2) Cryosurgery, laser therapy, fulguration, or operative excision

Urethral Prolapse

Usually in prepubertal patients. Can present acutely with a tender mass that may be friable or bleed slightly. Classic presentation is a mass symmetrically surrounding the Urethra Treatment: Hot sitz baths and antibiotics Topical estrogen cream In rare cases it may be necessary to excise the redundant mucosa.

Vulvar Compound Nevus

Potential for malignancy Generally asymptomatic Treatment: Excision biopsy The characteristic clinical features of an early malignant melanoma: ABCD Asymmetry, Border irregularity Color variegation Diameter usually greater than 6 mm.

Vulvar Fibroma

Most are attached to the labia majora Differential diagnoses: Bartholin cyst, Lipoma Most common benign solid tumors of the vulva. More frequent than lipomas Have a low-grade potential for becoming malignant. Treatment: Operative removal if symptomatic or continue to grow.

Vulvar Lipoma

Second most frequent benign vulvar mesenchymal tumor. Benign, slow-growing, circumscribed tumors of fat cells arising from the subcutaneous tissue of the vulva Not malignant no matter how big Excision biopsy is not needed because when you cut the specimen it is full of fat -> Lipoma.

Hidradenoma

Originated from the sweat glands If it is painful, excise Rare, small, benign vulvar tumor that originates from apocrine sweat glands of the inner surface of the labia majora and nearby perineum. Usually sessile, pinkish-gray nodules not larger than 2 cm in diameter. In most cases the surface epithelium is white, but occasionally necrosis of a central indented area occurs, with a protrusion of reddish-brown granulation tissue. Treatment: Excisional biopsy

Vulvar Pain Syndrome

BENIGN EPITHELIAL DISORDERS

Contact Dermatitis Lichen Simplex Chronicus Vulvar Psoriasis Lichen Planus Hidradenitis Suppurtiva Vulvar vestibulitis

Contact Dermatitis

Contact Dermatitis
Usually due to scented napkins or other substances applied on the area The vulvar skin, especially the intertriginous areas, is a frequent site of contact dermatitis. Contact dermatitis may be one of two basic pathophysiologic processes: Primary irritant (nonimmunologic) - immediate symptoms such as a stinging and burning sensation when applied to the vulvar skin; disappear within 12 hours of discontinuing the offending substance. Definite allergic (immunologic) origin - requires 36 to 48 hours to manifest its symptoms and signs;often the signs of allergic contact dermatitis persist for several days despite removal of the allergen Results in a red, edematous, inflamed skin. The skin may become weeping and eczematoid. Common symptoms include: superficial vulvar tenderness, burning, and pruritus.

Contact Dermatitis
Treatment: Remove cause of allergy, keep area aerated by removing panties at night, use steroids Use of a lubricating agent such as petroleum jelly or Eucerin cream will reduce the pruritus by rehydrating the skin. Cotton undergarments Nonmedicated cornstarch baby powder for relief of dryness Hydrocortisone (0.5% to 1%) and fluorinated corticosteroids (Valisone, 0.1%, or Synalar, 0.01%) as lotions or creams may be rubbed into the skin two to three times a day for a few days to control symptoms. Synthetic systemic corticosteroids (prednisone, starting with 50 mg/day for 7 to 10 days in a decreasing dose) are sometimes necessary for treatment of poison ivy and poison oak.

Lichen Simplex Chronicus

Leathery Chronic disease Evolved from a chronic untreated contact dermatitis Syndrome of lichenification, with the skin developing a leathery appearance and texture

Psoriasis

Psoriasis
No cure; unknown origin Develops during teenage years Chronic and relapsing, with an extremely variable and unpredictable course marked by spontaneous remissions and exacerbations. Common areas of involvement are the scalp and fingernails. Similar to candidiasis, psoriasis may be the first clinical manifestation of HIV infection. Vulvar psoriasis usually affects intertriginous areas and is manifested by red to red-yellow papules. These papules tend to enlarge, becoming well-circumscribed, dull-red plaques. Does not involve the vagina.

 Treatment: - Oral retinoids for refractory psoriasis 1% hydrocortisone cream - Initial treatment for mild disease. -4-week course of a fluorinated corticosteroid cream If the patient has pain secondary to chronic fissures, more moderate disease. If this treatment is not successful, a dermatologist should be consulted.

Lichen Planus

Lichen Planus
Unique, chronic eruption of shiny, violaceous papules. These tiny flat papules appear on flexor surfaces, mucous membranes, and vulvar skin in women older than 30 years of age. Painful discharge which is foul-smelling Treatment: Give estrogen hormone and antibiotic Most lesions are located on the inner aspects of the vulva, especially the labia minora and vestibule. Papules often develop in linear scratch marks. Correct diagnosis is confirmed by a small punch biopsy of the vagina or vulva. Histologic findings include degeneration of the basal layers, a lymphocytic infiltrate of the dermis, as well as epidermal acanthosis Treatment: Potent topical steroid cream such as clobetasol - for local lesions Oral steroids

Hiradenitis Suppurativa

Hiradenitis Suppurativa
Chronic, unrelenting, refractory infection of the skin and subcutaneous tissue, primarily the apocrine glands. Lesions involve the mons pubis, the genitocrural folds, and the buttocks. It may also involve the axilla. The early phase of the disease is infection of the follicular epithelium. In the advanced stages, hidradenitis suppurativa progresses to multiple draining abscesses and sinuses. Dx: confirmed by biopsy. Treatment: -Wide operative excision of the infected skin for refractory cases -Antiandrogens, isotretinoin, and cyclosporine are used if treatment is unsuccessful with long-term antibiotic therapy and topical steroids.

Vulvar vestibulitis

Seen in post-menopausal elderly due to lack of estrogen Misnomer, since it is not inflammation. It involves the symptom of allodynia, which is hyperesthesia, a pain that is related to nonpainful stimuli. The diagnostic maneuver to establish the allodynia is to lightly touch the vulvar vestibule with a cotton-tipped applicator. If this produces pain, it is consistent with allodynia. There is intolerance to pressure in the vulvar region. Some authors have suggested that symptoms be present for at least 6 months prior to establishing the diagnosis.

Vulvar vestibulitis

Treatment: Tricyclic antidepressants Gabapentin Biofeedback 5% lidocaine ointment nightly for a period of 6 to 8 weeks For refractory vulvar vestibulitis: surgical removal of the vulvar vestibule, and reapproximation of tissue.

BENIGN CYSTS

Epidermal Inclusion Cysts Urethral Diverticulum Sebaceous Cysts Apocrine sweat gland cysts Skenes gland cysts Bartholins Duct Cyst and Abscess Gartners Duct Cyst

Epidermal Inclusion Cysts

most common cystic structures of the vagina lined by stratified squamous epithelium contain a thick, pale yellow substance that is oily and formed by degenerating epithelial cells Result from occlusion of a pilosebaceous duct or a blocked hair follicle. Either a small tag of vaginal epithelium buried beneath the surface following a gynecologic or obstetric procedure or a misplaced island of embryonic remnant that was destined to form epithelium. Usually asymptomatic. If superinfected then treatment is incision and drainage.

Urethral Diverticulum
permanent, epithelialized, saclike projection that arises from the posterior urethra symptoms are nonspecific similar to lower urinary tract infection: urgency, frequency, dysuria

Sebaceous Cysts

The normally secreted sebum accumulates when a sebaceous gland is blocked. Often multiple and asymptomatic If severely infected then treatment is incision and drainage.

Apocrine sweat gland cysts

Occluded sweat glands in the mons pubis and labia majora form cysts. Fox Fordyce disease is a pruritic microcystic disease of occluded sweat glands. Hidradenitis suppurativa forms in the axillary region when multiple cysts become infected and form abcesses. Tx: -Incision or excision and drainage. -Antibiotics if cellulitis is present.

Skenes gland cysts

Chronic inflammation of the skenes glands (paraurethral glands) located next to the urethral meatus causes obstruction of the ducts and results in cystic dilation.

Bartholins Duct Cyst and Abscess

Located bilaterally at the approximately 4 oclock and 8 oclock on the posterior lateral aspect of the vaginal orifice. Mucous secreting glands with ducts that open just external to the hymenal ring. Obstruction leads to cystic dilation of the Bartholins duct. Small cysts often resolve on their own or with sitz baths. Biopsy should be performed on women over 40 to rule out Bartholins gland carcinoma.

Bartholins Duct Cyst and Abscess

Large unresolved infected cysts become Bartholins gland abscess Tx: Incision and drainage however recurrence is common Two methods: Word Catheter placement: -5mm incision to drain and irrigate the abscess. Then a Word catheter balloon tip is inflated inside the remaining cyst and is inflated to fill the space. The balloon is left in place to 4-6 weeks and is serially reduced in side as epithelialization of the cyst and tract occurs. Marsupialization: -For recurrent Bartholin duct cysts. The entire abscess or cyst is incsised and the cyst wall is sutured to the vaginal mucosa to prevent reformation of the abscess.

Gartners Duct Cyst

Gartners Duct Cyst are remnants of the mesonephric ducts found most commonly in the anterior lateral aspects of the upper part of the vagina. Most are asymptomatic Vaginal and Cervical cancers should be ruled out

CERVIX

Endocervical and Cervical Polyps Nabothian Cyst Mesonephric cyst Cervical Myoma

Endocervical and Cervical Polyps

Endocervical and Cervical Polyps

most common benign neoplastic growths of the cervix. endocervical polyps are most common in multiparous women in their 40s and 50s usually present as a single polyp, but multiple polyps do occur occasionally. Either pedunculated or broad-based. secondary to inflammation or abnormal focal responsiveness to hormonal stimulation S/Sx: intermenstrual bleeding

Nabothian Cyst
Retention cysts of endocervical columnar cells occurring where a tunnel or cleft has been covered by squamous metaplasia. Caused by intermittent blockage of an endocervical gland usually expanding to no more than 1cm. Comonly found in menstruating women and are usually asymptomatic. No treatment required.

Mesonephric cyst

Remnants of the mesonephric (wolffian) ducts that become cystic. Differ from Nabothian cysts in that they tend to lie deeper in the cervical stroma and on the externalsurface of the cervix

Cervical Myoma

Common benign tumors of the uterine corpus arising from the cervical canal or prolapse in to the endometrial canal. Sx: Intermenstrual bleeding, dyspareunia and bladder or rectal pressure. Cervical cancer must first be ruled out

UTERUS
Endometrial Polyps Leiomyoma

Endometrial Polyps
Localized overgrowths of endometrial glands and stroma that project beyond the surface of the endometrium May be single or multiple Most arise from the fundus of the uterus Gross: Succulent and velvety with a large central vascular core Histologically has 3 components: endometrial glands, endometrial stroma, and central vascular channels. Management: Hysteroscopy with D/C

Leiomyoma
Benign tumors of muscle cell origin Most frequent pelvic tumors and the most common tumor in women Highest prevalent in 5th decade Risk factors:
Increasing age Early menarche Low parity Tamoxifen use Obesity High fat diet

Leiomyoma
3 most common types:
Intramural Subserous Submucous

OVARY

Corpus Luteum Cyst Theca Lutein Cyst Benign Cystic Teratoma (Dermoid Cyst) Endometrioma Fibroma

Corpus Luteum Cyst

Develop from mature graafian follicle and are a minimum of 3cm in diameter Gross: smooth surface, purplish red to brown in color Has clinical features similar to an unruptured ectopic pregnancy Diagnosis:
Serum or urinary assay for HCG Culdocentesis Ultrasound

Mgt: Cystectomy

Theca Lutein Cyst

Arise from either prolonged or excessive stimulation of the ovaries by endogenous or exogenous gonadotropins or increased ovarian sensitivity to gonadotropins Almost always bilateral Honeycomb appearance Diagnosis: Ultrasound Mgt: Conservative

Benign Cystic Teratoma

Most common ovarian neoplasm Slow-growing tumor that occurs from infancy to postmenopausal years Symptoms: Diagnosis:
Pain Sensation of pelvic pressure

Palpation of semisolid mass anterior to the broad ligament Pelvic calcifications on radiographic examination Ultrasound: echoic dense cyst

Benign Cystic Teratoma

Complications:
Torsion Rupture Infection Hemorrhage Malignant degeneration

Associated Disease

Mgt: Cystectomy

Thyrotoxicosis Carcinoid syndrome Autoimmune hemolytic anemia

Endometrioma
Areas of ovarian endometriosis that become cystic Symptoms:
Pelvic pain Dypareunia Infertility

Diagnosis: Mgt:

Pelvic exam Ultrasound

Medical Surgical

Fibroma
Most common benign, solid neoplasm of the ovary Arises from the undifferentiated fibrous stroma of the ovary Meigs syndrome: Association of ovarian fibroma, ascited, and hydrothorax Mgt:
Excision of the tumor In postmenopausal: Bilateral salpingo-oophorectomy and total abdominal hysterectomy

FALLOPIAN TUBE / OVIDUCT

Adenomatoid Tumor / Angiomyoma Paratubal Cyst

Adenomatoid Tumor / Angiomyoma

Most prevalent benign tumor of the oviduct Usually unilateral Do not produce pelvic s/sx Microscopically composed of small tubules lined by low cuboidal or flat epithelium

Paratubal Cyst
Frequently incidental discoveries during gynecologic operations Majority are asymptomatic Slow-growing Discovered during 3rd or 4th decade May be mesonephric, mesothelial, or paramesonephric in origin Mgt: Simple excision