Gynecology Topic 19. Benign lesions of the vulva and vagina

I. General Approach

Definition

• Benign vulvar/vaginal lesions: cystic, inflammatory, infectious, epithelial, dermatosis, wart-like, or pain disorders.
• Main complaints: swelling/mass, pain, pruritus, burning, dyspareunia, discharge, bleeding, ulceration.
• Important exclusions: vulvovaginitis/STI, VIN, vulvar SCC, melanoma, Bartholin gland carcinoma, trauma/sexual assault when relevant.

Examination and biopsy rules

• Inspect and palpate: distribution, color, border, ulcer/fissure, excoriation, scarring, tenderness, fluctuation, fixation, lymph nodes.
• Speculum examination if vaginal/cervical disease, discharge, ulceration or fistula is suspected.
• Swabs/pH/microscopy/NAAT: discharge, ulcer, inflammation, or STI risk.
• Biopsy: unclear or persistent lesion, ulcer, pigmented lesion, thick/white lesion, treatment failure, suspected VIN/cancer.
• New Bartholin mass after age 40 or postmenopause → biopsy/excision to exclude carcinoma, especially if solid/fixed/irregular.

II. Bartholin and Vaginal Cystic Lesions

Bartholin Cyst and Abscess

• Bartholin glands: posterior introitus, lower third of labia majora, classically 4 and 8 o'clock.
• Pathomechanism: obstruction of Bartholin duct due to inflammation/trauma → cyst; secondary infection → abscess.
• Pathogens: usually polymicrobial; gonococcal infection may occur.

Clinical Features

• Cyst:

• Soft unilateral swelling at posterior introitus/lower labia majora.
• Usually painless; may cause pressure or dyspareunia if large.

• Abscess:

• Acute severe vulvar pain, tender fluctuant swelling.
• Erythema, fever, cellulitis, discharge may occur.

Treatment

• Diagnosis: clinical; culture/test for STI if severe, recurrent, high risk, cervicitis, or purulent discharge.
• Asymptomatic small cyst: observation; mild symptoms: sitz baths + analgesia.
• Recurrent/symptomatic cyst: marsupialization → incision, drainage/washing, permanent opening.
• Abscess: incision and drainage, preferably with Word catheter or marsupialization; simple I&D alone has high recurrence.
• Antibiotics: cellulitis/systemic infection, recurrent abscess, pregnancy, immunosuppression/poorly controlled diabetes, MRSA risk, or proven STI.
• Recurrent disease or malignancy suspicion → consider gland excision.

Other Vulvar/Vaginal Cysts

• Epidermal inclusion cyst: common vulvar cyst; excise only if symptomatic or uncertain.
• Gartner duct cyst: Wolffian duct remnant on anterolateral upper vagina; observe unless symptomatic/large.
• Mullerian/vaginal epithelial cysts: benign vaginal wall cysts; treat if symptomatic or diagnosis uncertain.

III. Benign Vulvar Dermatoses

Lichen Simplex Chronicus

• Pathomechanism: chronic irritation/scratching → hyperplasia of vulvar squamous epithelium = squamous cell hyperplasia.
• Itch-scratch cycle: pruritus → scratching → thick plaques/excoriation → more pruritus.
• Clinical features: sharply bordered thickened lichenified plaques, excoriations, itching.
• Diagnosis: clinical + punch biopsy if unclear or to exclude psoriasis, lichen sclerosus, VIN.
• Treatment: remove irritants + topical corticosteroids; treat triggering infection/dermatitis.

Lichen Sclerosus

• Pathomechanism: chronic inflammatory dermatosis → epidermal atrophy + dermal fibrosis/sclerosis; possible autoimmune background.
• Clinical features: white atrophic plaques, thin fragile skin, fissures, itching, burning, dyspareunia.
• Chronic disease → scarring, introital narrowing, loss of vulvar architecture.
• Risk: increased risk of vulvar squamous cell carcinoma.
• Diagnosis: clinical + biopsy, especially if atypical or to exclude psoriasis/VIN/cancer.
• Treatment: high-potency topical corticosteroid, emollients, avoid irritants, long-term follow-up.
• Biopsy any persistent ulcer, hyperkeratosis, lump, or non-healing area.

Lichen Planus

• Pathomechanism: unknown, probably autoimmune inflammatory epithelial disease.
• Clinical features: pruritic, purple, polygonal, planar papules/plaques; erosive vulvovaginal disease may cause burning, dyspareunia, discharge.
• Wickham striae: white lacy streaks; vaginal involvement may cause adhesions/stenosis.
• Diagnosis: clinical + punch biopsy.
• Treatment: topical corticosteroids; severe vaginal disease may need specialist care and dilators.

Vulvovaginal Atrophy / GSM

• Hypoestrogenism after menopause/postpartum/lactation → dryness, burning, dyspareunia, recurrent UTI, pale fragile epithelium.
• Treatment: lubricants/moisturizers; local estrogen when indicated.

Other Benign Vulvar Findings

• Vitiligo or genital melanosis: pigment change; biopsy if melanoma concern.
• Vestibular papillomatosis and Fordyce spots: benign normal variants; avoid confusing with warts.
• Hidradenitis suppurativa: recurrent painful nodules/abscesses/sinus tracts in apocrine areas.
• Aphthous/Behcet/Crohn lesions: consider when recurrent ulcers, edema, fissures, fistulas or systemic symptoms are present.

IV. Warts, Vulvodynia and Vaginal Lesions

Genital Warts

• Cause: low-risk HPV 6 and 11.
• Clinical features: skin-colored papules or cauliflower-like lesions on vulva, vagina, cervix, perianal area.
• Diagnosis: clinical; biopsy if atypical, pigmented, ulcerated, fixed, bleeding, or treatment-resistant.
• Treatment: imiquimod/podophyllotoxin, cryotherapy, trichloroacetic acid, electrocautery, laser or surgical removal.
• Prevention: HPV vaccination; condoms reduce but do not eliminate transmission.

Vulvodynia

• Definition: persistent vulvar pain, usually burning, for >3 months without identifiable infection, skin disease, or neurologic lesion.
• Important rule: vulvodynia is a diagnosis of exclusion.

1. Localized/provoked vulvodynia

• Localized to vestibule; provoked by touch, intercourse, tampon, gynecologic exam, sitting.
• Allodynia: pain from normally non-painful stimulus.
• Typical in younger women.

2. Generalized/unprovoked vulvodynia

• Spontaneous diffuse vulvar pain.
• May continue after removal of mechanical trigger.
• More typical in postmenopausal women.

• Diagnosis: inspection + cotton swab test; exclude Candida, BV/trichomoniasis, HSV, dermatoses, atrophy, contact dermatitis, neuralgia.
• Treatment: education, avoid irritants, local anesthetic/lidocaine, pelvic floor physiotherapy, psychosexual therapy/CBT, neuropathic pain drugs such as TCA/SNRI/SSRI/gabapentin.
• Vestibulectomy: selected refractory localized vestibulodynia; not for generalized unprovoked pain.