Benign Gynaecological Conditio

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### Genital Prolapse Genital prolapse is the downward displacement of pelvic organs, commonly affecting elderly women. It results from damage to the muscular and ligamentous supports of the uterus, often associated with childbirth trauma and hormonal changes. #### Supports of the Uterus (DeLancey's Levels) 1. **Level I (Uterosacral & Cardinal Ligaments):** Supports uterus and vaginal vault. Damage causes uterine descent, enterocele, and vault descent. 2. **Level II (Pelvic Fascia & Paracolpos):** Connects vagina to lateral pelvic wall (pubocervical fascia anteriorly, rectovaginal fascia posteriorly). Damage causes cystocele, rectocele. 3. **Level III (Levator Ani Muscle):** Supports the lower one-third of the vagina. Damage causes urethrocele, gaping introitus, and deficient perineum. #### Aetiology of Prolapse * **Weakness/Injury to Supports:** * **Mismanaged childbirth:** Prolonged bearing down, forceps application before full dilation, large baby, poor puerperal rehabilitation, heavy lifting. * **Menopause:** Declining estrogen leads to loss of tone in muscular and ligamentous supports. * **Other Causes:** Congenital weakness, pelvic trauma/nerve damage, raised intraabdominal pressure (chronic constipation, chronic obstructive airway diseases). #### Classification of Prolapse (Uterovaginal Prolapse System) * **Anterior Vaginal Wall:** * Upper two-thirds: Cystocele, Cystourethrocele * Lower one-third: Urethrocele * **Posterior Vaginal Wall:** * Upper one-third: Enterocele (herniation of pouch of Douglas) * Lower two-thirds: Rectocele * **Uterine Descent:** * 1st Degree: Cervix descends into vagina. * 2nd Degree: Cervix descends to introitus. * 3rd Degree: Cervix protrudes outside introitus. * **Procidentia:** Entire uterus is outside the introitus. #### POP-Q System (Pelvic Organ Prolapse Quantification) * Objective, site-specific measurement system using six reference points relative to the hymen (0 = hymen). * Points above hymen are "minus", points below are "plus". * **Staging:** * **Stage 0:** No demonstrable prolapse. * **Stage 1:** All points 1 cm below hymen but not complete prolapse. * **Stage 4:** Complete prolapse with lowest point equal to TVL-2 (Total Vaginal Length - 2). #### Symptoms of Prolapse * **Main Complaint:** Something descending/protruding outside vagina, aggravated by straining/coughing/heavy work, reduces on lying down. * **Perineal Weakness:** Sense of weakness/lack of support around perineum. * **Pain:** Vague mid-sacral discomfort, backache (relieved by rest, due to strain on uterosacral ligaments). "Bearing-down" feeling above pubes. * **Vaginal Discharge:** From inflamed cervix, vaginal relaxation allowing bacterial invasion, or decubitus ulcers. * **Urinary Symptoms:** Incomplete bladder evacuation, frequency, stress incontinence (involuntary urine escape with raised intraabdominal pressure), difficulty in micturition (splinting). * **Rectal Symptoms:** Less remarkable, constipation (rare). * **Coital Difficulties:** Obvious with 3rd-degree prolapse/procidentia. #### Complications of Pelvic Organ Prolapse 1. **Renal Damage:** Kinking of ureter (procidentia), ureteric obstruction during surgery. 2. **Urinary Tract Infection (UTI):** Frequent UTIs due to residual urine in large cystocele. 3. **Cancer:** Rare development of vaginal cancer at site of decubitus ulcer or with long-term ring pessary use. 4. **Incarceration:** Prolapse becomes irreducible due to edema/congestion. #### Prevention of Prolapse * **Childbirth Management:** * Antenatal physiotherapy, relaxation exercises, weight/anemia management. * Proper supervision of 2nd stage of labor. * Indicated episiotomy (usefulness debated). * Forceps/ventouse if prolonged 2nd stage. * Meticulous repair of perineal tear. * **Postnatal Care:** Postnatal exercises/physiotherapy, early ambulation, adequate rest (6 weeks), home help for heavy duties. * **Family Planning:** Reasonable interval between pregnancies, limiting family size to avoid strain. #### Treatment of Prolapse * **Conservative (especially for young women post-childbirth):** * Abdominal/perineal exercises, massage. * Ring pessary: For young women desiring more children, early pregnancy prolapse, puerperium, temporary use while treating infection/ulcer, unfit for surgery, or declining surgery. * *Limitations:* Vaginitis, ulcerations, discomfort, expulsion, forgotten pessary (ulcers, rare carcinoma), ineffective for stress incontinence. * **Operative Treatment:** * **Aims:** Relieve symptoms, restore anatomy, restore sexual function, prevent recurrence. * **Preoperative Preparation:** Estrogen cream for vaginal mucosa, urinary antibiotics if infection, decubitus ulcer healing (vaginal packing). * **Types of Surgery:** * **Anterior Colporrhaphy:** Repairs cystocele/cystourethrocele. Tightens vesicovaginal fascia, excises excess vaginal wall. Kelly suture for stress incontinence. Mesh for recurrence. * **Posterior Colporrhaphy & Colpoperineorrhaphy:** Corrects rectocele, repairs deficient perineum. Excises lax vagina, repairs rectovaginal fascia, approximates levator ani muscles. Often combined with anterior colporrhaphy/vaginal hysterectomy. Mesh use debated due to complications. * **Fothergill's Repair (Manchester Operation):** Combines anterior colporrhaphy with cervical amputation. Preserves uterus for fertility/menstruation, but subsequent pregnancies may have complications (abortion, preterm, cervical stenosis). Suitable for women 40 who have completed families. Alleviates prolapse and menstrual problems. Kelly stitch for stress incontinence. * *Complications:* Hemorrhage, sepsis, UTI, anesthesia complications, vault prolapse, dyspareunia. * **Le Fort's Repair:** For very elderly menopausal women unfit for major surgery. Approximates anterior/posterior vaginal walls below cervix, creating adhesion to prevent prolapse. Limits marital function. * **Abdominal Sling Operations:** For young women with nulliparous or 2nd/3rd degree prolapse desiring fertility. Reinforces weak supports with synthetic mesh/tapes. Examples: Abdominal wall cervicopexy, Shirodkar's abdominal sling, Khanna's abdominal sling. * **Enterocele Repair:** Essential during prolapse surgery to prevent vault prolapse. Can be done vaginally (excision of redundant peritoneum, ligation of neck, approximation of uterosacral/levator ani) or abdominally (Moschcowitz repair). * **Vault Prolapse Treatment:** (Delayed complication of hysterectomy) * **Right Transvaginal Sacrospinous Colpopexy:** Fixes vaginal vault to sacrospinous ligament. Preferred for elderly. * **Abdominal Sacrocolpopexy:** Fixes vault to sacral promontory with mesh. Better for younger women to avoid dyspareunia. Can be laparoscopic. * **Colpocleisis:** For very old women unfit for major surgery, precludes sexual activity. Obliterates vagina. * **Le Fort's Operation:** Partial colpocleisis. * **Ring Pessary:** For women unfit for surgery. * **Posterior Intravaginal Slingoplasty:** Supports uterosacral ligaments with tape. Less morbidity, but recurrence and injury risks. #### Recurrent Prolapse and Prosthetics * High recurrence rate (30%) due to poor collagen strength. * Synthetic and biological prosthetics (meshes, tapes) used to reduce recurrence in high-risk cases. * **Synthetic:** Macroporous nonabsorbable (Marlex, Prolene) - risk of erosion, infection, dyspareunia. Absorbable (polyglactin/Vicryl) - fewer complications, but long-term data needed. * **Biological:** Autologous (rectus fascia, fascia lata) - longer surgery, recurrence risk. Xenografts (porcine). * Newer systems: Polypropylene tape in posterior intravaginal slingplasty, Apogee/Perigee slings. ### Displacements of the Uterus The uterus is normally anteverted and anteflexed, but its position can vary. Displacement can be sideways, backwards (retroversion), or downwards (prolapse). #### Introduction * **Supports:** Pubocervical, uterosacral, cardinal (Mackenrodt's/transverse cervical) ligaments, pelvic floor muscles, connective tissue. * **Aetiology:** Pelvic inflammatory disease (PID), endometriosis (adhesions causing fixed retroversion/lateral tilting), uterine tumors, faulty development of supports. * **Types:** * **Retroversion:** Uterus tips backward, possibly sags downward. * **Prolapse:** Uterus settles downward, cervix may protrude (discussed in Genital Prolapse section). * **Symptoms:** Most displacements are asymptomatic. Symptomatic cases may include retention of urine in early pregnancy (retroverted gravid uterus), backache, dyspareunia, dysmenorrhea, infertility, menstrual irregularities, leukorrhea, constipation. #### Retroversion * **Normal Position:** Anteversion (cervical canal direction) and anteflexion (uterine body inclination). * **Retroversion:** Uterine body flexed backward. * **Aetiology:** Often difficult to explain. Round ligaments play a role. Usually seen after childbirth. * **Mobile Retroversion:** Uterus is retroverted in 20-50% of patients with no symptoms. Can be caused by prolapse or tumors. Often corrects spontaneously post-childbirth. * **Fixed Retroversion:** Uterus bound by adhesions (PID, salpingo-oophoritis, chocolate cysts, pelvic endometriosis) or tumors. * **Symptoms (Historically attributed, now linked to underlying causes):** * **Dysmenorrhea:** May be present with fixed retroversion. * **Menorrhagia:** Due to myohyperplasia/AUB (mobile) or pelvic congestion (fixed). * **Pressure:** Normal-sized uterus doesn't cause pressure. * **Backache:** More likely orthopedic. * **Dyspareunia:** Genuine symptom, especially if uterus is tender or ovary prolapsed into pouch of Douglas. * **Infertility:** Rare, only if cervical canal is inaccessible to sperm (confirmed by Sims-Huhner test). Fixed retroversion with tubal blockage causes infertility. * **Abortion:** Greatly exaggerated. * **Retroverted Gravid Uterus with Retention of Urine:** Around 12-14 weeks of pregnancy, due to failure of uterus to rise out of pelvis, causing urethral kinking. * **Diagnosis:** Bimanual vaginal examination. Differentiate from ovarian tumor/fibroid by movement with cervix. * **Treatment:** * **Mobile, Asymptomatic:** No treatment. * **Pessary Treatment:** For dyspareunia/backache. Uterus manually replaced, Hodge pessary inserted for 3 months. "Pessary test" to confirm retroversion as cause. * **Surgery (Indications):** 1. Fixed retroversion (treat primary lesion, then ventrosuspension). 2. Pessary test confirms symptoms/infertility due to retroversion. 3. After tuboplasty/myomectomy to prevent adhesions. * **Ventrosuspension:** Elevates uterus by attaching round ligaments to anterior abdominal wall (e.g., modified Gilliam's operation). * **Plication of Round Ligaments:** Shortening with non-absorbable suture. * **Baldy-Webster Operation:** Round ligaments passed through broad ligament and sutured to posterior uterus. #### Inversion of the Uterus * **Definition:** Uterus turned inside out, fundus pushed into cavity. * **Classification:** Complete or Partial based on degree. * **Acute Inversion:** * **Aetiology:** Mismanagement of 3rd stage of labor (pulling umbilical cord before placental separation, Crede's maneuver, traction on morbidly adherent placenta, squeezing relaxed uterus). May be spontaneous. * **Symptoms:** Severe shock (neurogenic/hemorrhagic), profuse bleeding. * **Prevention:** Proper 3rd stage management. * **Treatment:** Immediate replacement (manual reposition, O'Sullivan's hydrostatic method). Treat shock. If severe, laparotomy with incision of cervical ring. * **Chronic Inversion:** * **Aetiology:** Missed acute inversion, extrusion of submucous fundal fibroid (myoma). * **Symptoms:** Intermittent lower abdominal pain, irregular vaginal bleeding, offensive blood-stained discharge (if infected myoma). * **Diagnosis:** Cup-shaped depression in fundus, non-palpable cervix (complete), short uterine sound insertion (partial). Differentiate from myomatous polyp (cervix moves up with inverted uterus, down with polyp). Ulcerated fundus may resemble infected polyp/malignancy. Ultrasound/laparoscopy confirm. * **Degrees of Inversion:** * **1st Degree:** Fundus inverts into uterine cavity. * **2nd Degree:** Fundus protrudes through cervix into vagina. * **3rd Degree:** Whole uterus inverted and protrudes through introitus. * **Treatment:** * Pre-op: Antibiotics, local antiseptics. * **Uterus Conservation (Young Patients):** Vaginal (Spinelli's, Kustner's) or abdominal (Haultain's) approach. Division of constricting cervical ring, reposition, repair. * **No Uterus Conservation (Multiparous):** Vaginal or abdominal hysterectomy. * **With Sarcomatous Changes:** Radical hysterectomy + radiotherapy. * **Myomectomy:** Vaginal myomectomy under laparoscopy guidance. ### Diseases of the Broad Ligament, Fallopian Tubes and Parametrium These are mostly benign, often associated with ovarian or uterine conditions, including cysts, tumors, or infections. #### Broad Ligament Cysts * **Origin:** Vestigial remnants of Wolffian duct (mesonephric duct/Gartner's duct) or its tubules (epoophoron/parovarium/Kobelt's tubules). * **Characteristics:** Usually small, pedunculated or intraligamentary. Mesonephric duct cysts are non-ciliated; tubule cysts may be ciliated. Lie separate from ovary. * **Paraovarian Cysts:** Extraperitoneal, in broad ligament adjacent to ovary, below fallopian tube. Can grow large (15-30 cm), unilocular with clear fluid. Wall may contain smooth muscle. Can undergo torsion. * **Treatment:** Surgical removal if large, often via laparoscopy. Care to identify ureter. Ovary usually saved. #### Tumors of the Fallopian Tubes * Extremely rare, often malignant. #### Conditions Affecting the Broad Ligament and Parametrium 1. **Haematoma:** * **Causes:** Ectopic gestation rupture into broad ligament, uterine rupture, cervical laceration during childbirth, dilatation of cervix (if uterine vessels torn), concealed accidental hemorrhage, slipping vascular pedicle after hysterectomy, prophylactic anticoagulants. * **Spread:** Extraperitoneal, can extend to Poupart's ligament or perinephric region. * **Symptoms:** Pain, tachycardia, hemorrhagic shock, painful lower abdominal lump. * **Treatment:** Small resolve conservatively. Large require laparotomy, drainage, ligation. 2. **Parametritis:** * **Definition:** Cellulitis of soft tissues of parametrium. * **Aetiology:** Post-childbirth/abortion (infection from lacerations), acute uterine/fallopian tube infections, advanced cervical carcinoma. * **Symptoms:** Pain (hypogastrium/back), fever (~102°F), raised pulse. Large indurated pelvic swelling, uterus pushed to opposite side, fixed. * **Spread:** Backwards along uterosacral ligaments, upwards above Poupart's ligament, rarely to ischiorectal fossa/buttock. * **Complications:** Suppuration (rare), chronic pelvic pain (scarring, drawing uterus to affected side), ureteric kinking (hydronephrosis), pelvic thrombophlebitis (risk of pyaemia, pulmonary infarction, 'white leg'). * **Treatment:** Bed rest, local heat, appropriate antibiotics. 3. **Tumours of the Broad Ligament and Parametrium:** * **Myoma:** Most common. * **Primary (true):** Arises from uterosacral/round ligament or broad ligament tissues. Uterine vessels medial to fibroid. * **Secondary (false):** Arises from lateral uterus/cervix, grows into broad ligament. Retains attachment to uterus, pushes vessels/ureter laterally. * **Sarcoma:** Very rare, presents like myoma. Early surgery, advanced radiation. * **Lipoma:** Rare, easily enucleated with care to avoid ureter/vessels. 4. **Retroperitoneal Tumours:** Often mistaken for ovarian/broad ligament tumors. * **Congenital:** Ectopic pelvic kidney. * **Dermoid Cyst:** Rarely retroperitoneal. * **Neurogenic Origin:** Neurofibromas, spinal meninges tumors. * **Solid Bony Pelvis Tumours:** Osteoma, chondroma, sarcoma. * **Diagnosis:** IVP, barium enema, CT, MRI, diagnostic laparoscopy, biopsy. Ultrasound for location. * **Dangers of Removal:** Ureter injury, major pelvic vessel injury. * **Treatment:** Inoperable fixed growth: radiotherapy. ### Benign Diseases of the Ovary Ovaries can be sites of various diseases: functional cysts, ovarian endometriosis, polycystic ovaries, and neoplastic diseases. #### Nonneoplastic Enlargements of the Ovary * **Causes:** Pelvic congestion (PID), ovarian endometriosis (chocolate cyst), persistence/enlargement of physiological structures (Graafian follicle, corpus luteum). * **Functional Cysts:** Size 3-7 cm. * **Follicular Cysts:** Single/multiple, bilateral, 7 cm or persists >3 months. * **Follicular Haematomas:** Follicular cysts with hemorrhage. Can rupture, mimicking ectopic pregnancy. * **Lutein Cysts:** * **Corpus Luteum (Granulosa Lutein) Cysts:** Functional, nonneoplastic. Cause local pain, tenderness, delayed menstruation. Most resolve, observe. Sonography and $\beta$-hCG to differentiate from ectopic pregnancy. * **Theca Lutein Cysts:** Bilateral, straw-colored fluid. Associated with trophoblastic disease (hydatidiform mole, choriocarcinoma) or gonadotropin therapy. Regress spontaneously after mole evacuation/treatment. Avoid hCG if hyperstimulation. * **Multiple Functional Cysts:** * **FSH-Secreting Pituitary Adenoma:** Cysts >1 cm, raised FSH/estrogen, low LH. Amenorrhea, oligomenorrhea, infertility. Treat adenoma, ovarian cysts resolve. * **Ovarian Hyperstimulation Syndrome (OHSS):** Caused by hCG injection during controlled ovarian stimulation. Follicular size >3 cm. #### Polycystic Ovarian Syndrome (PCOS)/Disease (PCOD) * **Definition:** Heterogeneous, multisystem endocrinopathy in reproductive-aged women, with ovarian expression of metabolic disturbances. Formerly Stein-Leventhal Syndrome. Requires exclusion of adrenal/androgen-producing ovarian tumors. * **Incidence:** 5-15%, increasing. Common problem in adolescents post-puberty. 15-20% of infertility cases. Linked to later life CV disease, hypertension, endometrial cancer, type 2 diabetes. * **Aetiology & Pathogenesis:** Unknown exact cause. Theories: * **Lifestyle:** Diet, stress, sedentary life. * **Genetic/Familial/Environmental:** Autosomal dominant inheritance, CYP1 gene mutation. Environmental factors (in utero, early adolescence). * **Enhanced Serine Phosphorylation:** In ovary (hyperandrogen) and reduced insulin receptor activity (insulin resistance). * **Obesity (50-70% of PCOS patients):** Adipose tissue secretes leptin, adiponectin, cytokines, interfering with insulin signaling, leading to insulin resistance and hyperinsulinemia. Increased birth weight in obese/PCOS mothers can cause PCOS in daughters. * **Hyperandrogenism & Anovulation:** Insulin resistance with hyperinsulinemia initiates PCOS (50-70% cases) via hypothalamic-pituitary-ovarian axis. Adrenal glands also play a role. * **Ovarian Steroidogenesis in PCOS:** Insulin induces LH, causing theca-cell hyperplasia, secreting androgens (testosterone, epi-androstenedione). These convert to estrogen in granulosa cells. Epi-androstenedione converts to estrone in peripheral fat. Leads to increased LH surge, increased estrone/estradiol ratio. Hyperandrogenism lowers SHBG, increasing free testosterone (hirsutism). Androgens suppress dominant follicle growth and prevent apoptosis of smaller follicles. * **Endocrinological Changes:** 1. Estrone/E2 level rises. 2. LH level >10 IU/mL, FSH normal, FSH/LH ratio falls. 3. SHBG levels fall. 4. Testosterone and epi-androstenedione levels rise. 5. Fasting blood glucose/insulin 150 mg/dL, HDL 2 ng/mL, free T >2.2 pg/mL. Normal androstenedione. Raised DHEA-S. 8. Prolactin mildly raised (15%). 9. Fasting insulin levels raised (>10 mIU/L in 50-70%). 10. Thyroid function tests abnormal (hypothyroidism). 11. Urinary cortisol 10 cm³). * **Clinical Features:** (Often manifest in reproductive age, initiated in utero/early adolescence) * Early adrenarche/menarche in some. * **Menstrual Irregularities:** Oligomenorrhea (87%), short amenorrhea followed by prolonged/heavy periods. Dysmenorrhea absent. * **Infertility:** Due to anovulatory cycles. Pregnancy loss (20-30%) if conceived. * **Metabolic:** Carbohydrate intolerance, diabetes, hypertension if woman conceives. * **Hyperandrogenism:** Acne (30%), hirsutism (facial hair, breasts, thighs), baldness (no virilism). * **Obesity:** Central obesity (waist line >88 cm), BMI >30 kg/m². Acanthosis nigricans (5%) in obese PCOS women (75% have hyperinsulinemia). * **Pelvic Findings:** Usually normal, enlarged ovaries not easily palpable. * **Diagnostic Criteria (Rotterdam 2003):** At least two of three criteria: * Oligo/amenorrhea, anovulation, infertility. * Hirsutism/acne. * Ultrasound findings (polycystic ovaries). * **Differential Diagnosis:** Adrenal hyperplasia, Cushing's disease, ovarian masculinizing tumors (especially with extreme obesity/virilism). Hypothalamic-pituitary-ovarian dysfunction, thyroid disorders. * **Investigations:** * **Ultrasound:** Diagnostic. Enlarged ovaries, increased stroma, >10 cm³ volume. 12+ small follicles (2-9 mm) peripherally. Rules out ovarian tumor, shows endometrial hyperplasia. Increased blood flow on Doppler. Perform in early follicular phase. * **Hormonal Studies:** Not routine, specific tests as needed. * **Laparoscopy:** Reserved for therapeutic purposes; diagnosis usually by ultrasound. * **Treatment:** Tailored to patient needs. * **Aims:** Cure menstrual disorders, treat hirsutism, treat infertility, prevent long-term effects (X syndrome). * **Weight Loss:** >5% weight loss improves hormonal milieu, increases SHBG, reduces insulin/testosterone. * **Lifestyle Changes:** Stop smoking, diet, exercise. * **Hormones to Regulate Menstruation:** * Oral Combined Pills (OCs): Suppress androgens, raise SHBG, suppress LH. Low-dose OCs with anti-androgenic progestogen (e.g., drospirenone) are best for PCOS (Yasmin, Yaz, Tarana). * Progestogen: To induce menstruation in amenorrheic women before cyclical therapy. * Cyproterone-containing OCPs: For hirsutism. * Spironolactone, Ketoconazole: Reduce testosterone. * **Hirsutism:** Eflornithine cream. Anti-androgens (see Hormone Therapy chapter). * **Acne:** Clindamycin lotion, erythromycin gel. Isotretinoin for severe cases (teratogenic). * **Dexamethasone (0.5 mg at bedtime):** Reduces androgen production if DHEA-S raised. * **Infertility:** * **Clomiphene:** First-line. Induces ovulation in 80%, conception in 40-50%. High abortion rate (25-40%). Risk of OHSS. Clomiphene + dexamethasone improves fertility. * **Tamoxifen/Letrozole:** For resistant cases. * **FSH, LH, GnRH analogues:** If above fail. * **Metformin:** Treats root cause, rectifies endocrine/metabolic functions, improves fertility. Reduces insulin, delays glucose absorption, improves glucose utilization. Improves SHBG, reduces testosterone. Ovulation in 70-80%, pregnancy in 30-40%. Contraindicated in hepatic/renal disease. * **N-acetyl-cysteine (NAC):** With micronutrients (Vit D, minerals, inositol, folic acid) for raised homocysteine. * **Surgery:** Reserved for medical therapy failure, hyperstimulation, infertility, previous pregnancy losses. * **Laparoscopic Drilling/Puncture:** Of not more than four cysts per ovary (laser or unipolar electrocautery). Restores endocrine milieu, improves fertility for 6-12 months. * **Advantages:** Simultaneous tubal testing/endometriosis check, one-time treatment, cost-effective, reduces androgen/LH, avoids hyperstimulation/multiple pregnancy with subsequent drug use. * **Disadvantages:** Anesthesia/laparoscopy risks, postoperative adhesions, premature ovarian failure (if cautery damages tissue). Not preferred due to ovarian reserve decrease. * **Prevention:** Early treatment of PCOS, avoiding/correcting obesity in adolescents, lifestyle changes to prevent long-term adverse effects (diabetes, hypertension, CV disease, hyperlipidemia, endometrial cancer). ### Benign Diseases of the Vulva The vulva is susceptible to various developmental, trophic, inflammatory, allergic, and neoplastic diseases. Diagnosis often delayed due to patient modesty. #### Introduction * **Affected Structures:** Epidermis/dermis (dermatological disorders, allergies, infections, nevi, dystrophies, ulcers, new growths), skin appendages (folliculitis, sebaceous cysts, hidradenomas, Bartholin's cyst/abscess, Paget disease), adjacent structures (lipomas, fibromas, hemangiomas, varicosities, endometriosis), developmental issues, hormonal changes (atrophy). * **Symptoms:** Excoriation, swelling, ulceration, altered pigmentation, itching, pain, bleeding. * **Diagnosis:** Inspection, palpation, smear, culture, biopsy. #### Inflammatory Lesions 1. **Skin Infections:** * **Intertrigo & Folliculitis:** Common in obese women, tight garments, moisture. Chaffing leads to bacterial/fungal infection (Staphylococcus). * **Treatment:** Weight reduction, loose clothing, hygiene, bland soap, dusting powder. Antimicrobial ointments, oral antibiotics if severe. Hydrocortisone for itching. * **Tinea Cruris (Ringworm):** *Trichophyton rubrum*. Chronic, relapsing. Erythematous, circumscribed areas in skin flexures, fine papular rash. Intense itching. * **Treatment:** Meticulous hygiene, light underclothes, fungicidal powder/ointment, oral griseofulvin. * **Threadworms (*Enterobius vermicularis*):** Secondary vulval infection from anorectal area, especially in children. * **Treatment:** Anthelmintics (piperazine, mebendazole). * **Vulvovaginitis:** In children: nonspecific (foreign body), threadworm. Rare gonococcal/fungal (sexual abuse). * **Bartholinitis:** Mostly gonococcal, painful/tender swelling of labia majora. Recurrent. * **Treatment:** Antibiotics. * **Bartholin's Abscess:** Painful vulval swelling, purulent discharge. * **Treatment:** Drainage under anesthesia, culture, antibiotics. * **Psoriasis:** Scaly, well-defined erythematous plaques on vulval skin, easily scraped to reveal red surface. Also on elbows/knees. * **Treatment:** Local steroids. * **Filariasis:** *Wuchereria bancrofti*. Causes lymphatic edema, elephantiasis of legs/vulva. 2. **Contact Vulvitis:** Local reaction to synthetic materials, soaps, detergents, chemicals, medicaments. * **Symptoms:** Edema, reddening of vulvar skin/vestibule. * **Treatment:** Oral antihistamines, local steroids, cotton underwear, bland soaps, avoid irritants. 3. **Pruritus Vulvae (Itching Vulva):** Intense itching, leading to scratching/abrasions. * **Causes:** * **Vaginal Discharge:** *Trichomonas vaginalis*, fungal (monilial) infection (80% cases). * **General Disease:** Diabetes, jaundice, uremia, cirrhosis, hemochromatosis. * **Nutritional:** Iron deficiency anemia, vitamin A/B12 deficiency, achlorhydria. * **Dermatitis:** Psoriasis, eczema. * **Allergy:** Drugs, contact dermatitis, soaps, deodorants, synthetic garments. * **Cervical Conditions:** Cervicitis, erosion. * **Vulval Parasitic Infections:** Pediculosis, scabies. * **Vulval Tumors:** Condyloma acuminata, granulomas, Behcet syndrome, Paget disease, vulval cancer. * **Anal:** Threadworm. * **Urinary:** Bacilluria, acidic urine, incontinence, glycosuria, bladder fistula. * **Psychological:** Stress, sexual frustration, guilt. * **Chronic Vulval Dystrophies:** Leukoplakia, lichen sclerosis, kraurosis vulva. * **Radiation Vulvitis.** * **Symptoms:** Itching, soreness, inflammation, sleep loss, irritability. * **Treatment:** Systemic investigation for cause. Antihistamines, sedation. Local hydrocortisone/steroid ointment, Furacin ointment. Estrogen cream for kraurosis vulva. Antifungals for fungal infection. Metronidazole for *Trichomonas*. Zinc oxide cream for cracked skin. Absolute alcohol injection (breaks scratch habit, but risks). Ball's operation (nerve division, rarely performed). Interferon ointment/systemic interferon. #### Ulcers 1. **Traumatic Ulcers:** Recognizable appearance, history of injury. * **Treatment:** Local antibiotics, oral analgesics. 2. **Tuberculous Ulcers:** Thin serpiginous ulcers, undermined edges, yellowish discharge. Biopsy shows granulomas. 3. **Venereal Diseases:** Syphilis, chancroid, granuloma inguinale. 4. **Vulval Cancers:** Non-healing ulcers with raised/everted edges, or growths that ulcerate. 5. **Other Causes:** Fungal, streptococcal, herpes simplex, Behcet disease, amebiasis, lymphogranuloma venereum, Crohn's disease, drug allergy, lichen sclerosus/planus, VIN, Paget disease. * **Clinical Features:** Most painful except malignant. Pruritus suggests infection. Serology, culture, biopsy for diagnosis. * **Behcet Disease:** Associated with oral/ocular ulcers. Chronic inflammatory, multisystem. * **Treatment:** Nonspecific, corticosteroid cream. #### Atrophy * **Causes:** Normal consequence of decreased estrogen post-menopause. Radiation therapy, surgical castration. * **Changes:** Labia flatten, skin hangs loosely (loss of subcutaneous fat). Epithelium pale, smooth, thin. Introitus narrows. * **Prevention:** Timely estrogen (local creams/systemic). Changes irreversible once atrophy occurs. * **Vulval Pain Syndrome:** Chronic vulval discomfort (burning, stinging, irritation) without visible abnormality. * **Causes:** Urinary oxalate excretion, deficient immune system, HPV, fungal, herpes, autoimmune, iatrogenic (topical agents), irritants/allergens, tense levator ani muscles, psychological, low estrogen, oral contraceptives, pelvic floor muscle tension, vulval vestibulitis. * **Vestibulitis:** Pain on touch, local tenderness, erythema in vestibular region. Superficial dyspareunia. * **Dysesthetic Vulvodynia:** Non-localized, unprovoked constant neurological pain (burning ache) in vulva/perianal region. Usually perimenopausal/postmenopausal. Psychological distress. * **Management:** Eliminate underlying cause. Spontaneous remission (30%). Medical (topical lignocaine, steroids), interferon gel. Tricyclic antidepressants (amitriptyline) for neuralgic pain. Carbamazepine, gabapentin for severe cases. Vestibulectomy in severe cases. #### Vulval Dystrophies (Nonneoplastic Epithelial Disorders) * Spectrum of atrophic and hypertrophic lesions, "white lesions." Can have dysplasia to malignancy. Multiple biopsies needed; toluidine blue test helps identify areas for biopsy. * **Causes:** Trauma (scratching), allergy, folic acid/B12 deficiency, chronic infection, metabolic (diabetes, thyroid), immunosuppression, autoimmune (SLE). * **Types:** 1. **Hyperplastic Dystrophy (Squamous Cell Hyperplasia/Leukoplakia):** Chronic irritation/infection leads to epithelial thickening, hyperkeratosis. Red/moist in acute phase, then raised white, rubbery lesions. Can involve vulva, perianal area, perineum, thighs ("splashed with white wash"). Pruritus, soreness, discharge, dyspareunia. Premenopausal. * **Microscopy:** Irregular rete pegs, active mitosis in basal layer, thickened prickle cell layer, heavy keratin, inflammatory cell infiltration. * **Malignant Change:** 10-30% cases. * **Treatment:** Estrogens (oral/local). Bland medicaments (calamine, zinc oxide). Steroid ointments (hydrocortisone, betamethasone, fluocinolone) with/without antimicrobials. Clobetasol 0.05% cream. Sedatives. * **Malignancy Suspicion:** Multiple biopsies from suspicious areas (guided by colposcopy, acetic acid, toluidine blue). Dysplasia needs observation; advanced lesions need surgical excision. 2. **Lichen Sclerosus (Atrophic Dystrophy):** With aging/estrogen decrease. Vulval skin/subdermal tissues atrophy. Vaginal introitus contracts, vaginal mucous membrane thin/traumatized. Linked to autoimmune diseases (diabetes, thyroid, SLE, pernicious anemia). Elderly women (>65 years). Genetic/familial. * **Appearance:** Dusky, involving vulva, perineum, perianal area in "hourglass" pattern. Skin papery thin, wrinkled. Labia minora blend into majora (narrow introitus). * **Malignant Change:** 1-5% of longstanding lesions. Predisposing factor for vulval carcinoma. * **Symptoms:** Intense pruritus, dysuria, dyspareunia, local discomfort. * **Microscopy:** Hyperkeratosis, thinning epidermis, flattened rete pegs, hyalinization of dermis. * **Treatment:** Bland creams. Local steroids (estrogen cream, testosterone propionate). Clobetasol 0.05% ointment for 8-12 weeks. Testosterone ointment (risks virilization). Vitamin A, retinoid analogues. Intralesional interferon. * **Surgery:** Rarely employed (recurrence risk). Skinning vulvectomy, cryoablation, laser ablation, vulvectomy. * **Follow-up:** Long-term due to recurrence and malignancy risk. 3. **Mixed Dystrophy:** Histological changes of both hypertrophied and atrophic dystrophy at different sites. Treatment based on predominant lesion. * **Denervation of Vulva:** "Me ring" procedure (circular incision around vulva). #### Cysts and Neoplasms 1. **Vulval Cysts:** * **Sebaceous Cyst:** Blockage of sebaceous gland duct. Cheesy material. Can get infected. * **Bartholin's Cyst:** Blocked duct (inflammation/inspissated secretion). Swelling on labium majus. Asymptomatic if small, large causes dyspareunia/discomfort, can get infected. * **Treatment:** Excision or marsupialization (preferred, preserves gland function). * **Cyst of the Canal of Nuck:** Remnant of processus vaginalis. * **Endometriotic Cyst:** Bluish bulge in posterior fornix. Grows painful during menstruation. * **Treatment:** Surgical excision. 2. **Vulval Neoplasms:** * **Fibroma & Lipoma:** Pedunculated benign swellings, easily excised. * **Hidradenoma:** Arises from apocrine glands, ### Benign Diseases of the Vagina The vagina is usually a site of benign conditions (infections, ulceration, age-related changes), but malignancy is rare. Normal defenses (acidic pH, thick squamous epithelium) protect against disease. #### Biology of the Vagina * **Vaginal Secretions:** White coagulated material (squamous cells, Döderlein's bacilli, coagulated secretion). * **Döderlein's Bacilli:** Large Gram-positive, sugar-fermenting bacteria. Convert glycogen to lactic acid, maintaining acidic pH (4-4.5) in healthy adult vagina. * **Origin:** Mostly from vaginal squamous cells (glycogen under estrogen stimulation, desquamation), some from endometrial/cervical secretion. * **Secretion Variation:** * **Age:** Varies with age. * **Pregnancy:** Increases. * **Puerperium/Abortion:** Maximal. * **Menstrual Cycle:** Increases at ovulation and pre-menstruation. * **Vascular State:** Estrogen-dependent. Congestive conditions (prolapse, retroversion, PID, chronic constipation) increase transudation. * **Components of Vaginal Secretion:** * Vulval sweat/sebaceous glands, Bartholin's glands (apocrine glands provide characteristic odor). * Transudate of vaginal epithelium and desquamated cornified cells (strongly acidic). * Mucous secretions of endocervical glands (alkaline). * Endometrial glandular secretion. * **Structure of Vaginal Epithelium:** Squamous cells in three layers: * **Deep Layer:** Basal cells (immature, small, basophilic, large nucleus), parabasal cells (slightly more mature). Predominate in low estrogen states (menopausal, lactating, postpartum). * **Intermediate Layer:** Ellipsoid/quadrilateral, light cytoplasm, smaller vesicular nucleus. * **Superficial Layer:** Precornified (hexagonal/octagonal, basophilic, small pyknotic nucleus) and cornified (fully mature, pink eosinophilic cytoplasm, largest, pyknotic nucleus). Max cornification at ovulation. * **Physiological Changes (Cytological Examination):** * **Menstruation:** Endometrial debris, blood, histiocytes, immature basophilic squames. * **Early Proliferative Phase:** Few polymorphs, discrete, more mature squames, rising cornification index. * **Late Proliferative Phase:** Uniform mature squames, small pyknotic nuclei, cells separate, highest cornification index. * **Early Secretory Phase:** Clumped, less mature squames, basophilic cytoplasm, larger vesicular nuclei, falling cornification index. * **Late Secretory Phase:** Intermediate precornified cells predominate, basophilic, crumpled/folded, large pale nuclei. Polymorphs increase, muddy background. * **Cytology of the Vagina:** * **Newborn:** High cornification (maternal estrogen), then thins until puberty. * **Pregnancy:** Low cornification index (progesterone effect). Rise >25% indicates abortion risk. Falls in late pregnancy. * **Post-menopause:** Atrophies (estrogen withdrawal). Thin, parchment-like epithelium, prone to senile vaginitis. Smear shows basal/parabasal cells, WBCs, few superficial cells. * **Vaginal Acidity:** pH 5.7 (newborn), 6-8 (children), 4 (puberty), 4.5 (childbearing), 7 (menopause). Döderlein's bacillus thrives at pH 4-4.5. Higher pH allows other pathogens. * **Natural Defence Mechanism:** Tough stratified squamous epithelium, no glands/crypts. Low pH. Estrogen-dependent thickness and pH. * **Raised pH:** Menstruation (alkaline discharge), post-abortion/childbirth (alkaline lochia), excessive cervical discharge (endocervicitis), antibiotics, barrier contraceptives. * Vagina is naturally self-sterilizing by Döderlein's bacilli. * **Flora of the Female Genital Tract:** * **Sterile:** Fallopian tubes, uterine cavity, upper 1/3 cervical canal. * **Microorganisms:** Lower 2/3 cervical canal, vagina. * **Lactobacilli (Döderlein's bacilli):** Produce hydrogen peroxide, protect against bacteria/candida. * **Facultative Organisms (low numbers):** Diphtheroids, coagulase-negative staphylococci, streptococci (B/D), *E. coli*, *Ureaplasma urealyticum*, *Mycoplasma hominis*. * **Anaerobic Organisms (poor concentration):** Peptostreptococci, Bacteroides, Fusobacterium species. * Döderlein's bacillus typically found in upper 2/3 vagina. In puerperium/climacteric/menopause, Döderlein's bacilli decrease, pH rises, allowing other organisms to grow. #### Leucorrhoea * **Definition:** Increased normal vaginal secretions without excess leukocytes (non-purulent). * **Physiological:** Puberty, pregnancy, ovulation, pre-menstrual phase. Increased vascularity of genital tract. * **Nonpathogenic Leucorrhoea:** * **Cervical (Excessive Cervical Secretions):** From endocervical glands (chronic cervicitis, cervical erosion, mucous polypi, ectropion). Mucoid discharge at vulva. * **Vaginal (Excessive Vaginal Secretions):** Transudation through vaginal walls. Increased blood flow to pelvic organs (pregnancy, acquired retroversion, prolapsed congested ovaries, chronic PID, chronic constipation). * **Diagnosis:** Differentiate from specific vaginitis (bacteriological exam). Speculum exam to identify source. #### Pathological Vaginal Infections * Gonococcal, Trichomonal (15-20%), Monilial (20-25%), Chlamydial, Bacterial Vaginosis (50%). * Most are sexually transmitted (except bacterial vaginosis). * **Vaginitis:** Significant inflammatory response, increased WBCs in vaginal fluid. Seen in trichomoniasis, candidiasis, herpes, STDs. * **General Features:** Pruritus, burning, malodorous discharge, dyspareunia. Congestion, microhemorrhages, abnormal discharge, increased vaginal pH. Tenderness on exam. * **Investigations:** * Hanging drop: Motile *Trichomonas*. * KOH prep: *Candida* hyphae/spores. * Whiff test: Fishy odor with KOH (bacterial vaginosis). * Gram's stain: Gonococci (intracellular/extracellular diplococci), clue cells (bacterial vaginosis). * Culture: Chocolate Agar (gonococci), Sabouraud's/Nickerson's (candida), special enriched medium (*Trichomonas*). 1. **Candidal Vaginitis (*Candida albicans*):** Not STI. Increased glycogen in vagina (pregnancy, diabetes, OCPs, immunocompromised), post-antibiotics. * **Symptoms:** Pruritus, burning, dysuria. Vulvar erythema, edema, scratch marks. Whitish, flaky, curd-like discharge. Vaginal pH 4.5. * **Diagnosis:** KOH wet mount (hyphae, spores). Culture (Sabouraud's, Nickerson's). * **Treatment:** * **Preventive:** Hygiene, discontinue offending meds, control diabetes. * **Antifungal:** Creams/pessaries (clotrimazole, miconazole, terconazole, butoconazole) for 7-14 days. Oral (fluconazole single dose 150 mg, itraconazole) for frequent recurrences. 2. **Trichomonas Vaginitis:** Protozoal infection. * **Clinical Findings:** Vulvar erythema/edema. Copious, frothy, yellowish-green, foul-smelling discharge. Punctate lesions on cervix ("strawberry cervix"). Vaginal pH >4.5. * **Diagnosis:** Hanging drop (motile flagellates). Culture (special media, not routine). * **Treatment:** Metronidazole (400 mg tid for 5 days or 2 gm single dose). Tinidazole/Secnidazole (2 gm single dose). Treat both partners. 3. **Vaginosis (Bacterial):** (Nonspecific vaginitis, *Gardnerella vaginalis*, anaerobic vaginitis). Minimal inflammatory response, few leukocytes. Alteration in normal vaginal flora. * **Pathogenesis:** Decrease in lactobacilli (reduce pH, release H₂O₂), 100-fold increase in other anaerobes (*Haemophilus vaginalis, G. vaginalis, Mobiluncus, M. hominis*). Polymicrobial. * **Transmission:** Not STI. Variable incubation. 50% asymptomatic. * **Characteristics (Amsel's criteria):** * White, milky, nonviscous discharge adherent to vaginal wall. * pH >4.5 (5-7). * Fishy odor with 10% KOH (whiff test, due to amino-metabolites). * Clue cells (epithelial cells with fuzzy border due to adhering bacteria). * Increased *G. vaginalis* and other microorganisms, reduced lactobacilli/leukocytes. * **Complications:** PID, chorioamnionitis, premature rupture of membranes (PROM), preterm labor. * **Diagnosis:** Wet smear (clean background, few inflammatory cells/lactobacilli, many clue cells). Gram stain (90% sensitive, 83% specific). DNA probe for *G. vaginalis*. * **Treatment:** * Metronidazole (400 mg bid for 7 days, or 2 gm single dose - less effective). Avoid in 1st trimester. * Ampicillin/cephalosporin (500 mg bid for 7 days). * Tetracycline/doxycycline/sulfafurazole (nonpregnant). * Clindamycin (2% cream locally or 300 mg daily orally for 7 days). * Ornidazole (500 mg vaginal tablet daily for 7 days). * Lacteal (protein-free acidifying lactate gel) 5 mL daily for 7 days. * **Probiotics (Ecoflora):** *Lactobacillus rhamnosus* GR-1 and *L. reuteri* Rc-14. Effective against Gram-negative pathogens, resist spermicides, anti-inflammatory. Produce H₂O₂, maintain pH. Contraindicated in pregnancy. #### Miscellaneous Causes of Excessive Vaginal Discharge * **Physiological:** Sexual excitement, cervical erosion, ovulation, psychological factors. * **Management:** Exclude pathology, counseling, electrocautery for erosion. * **Other Infections:** *Chlamydia trachomatis*, gonorrhea, herpes, foreign body, chemical irritation, senile vaginitis. * **Management:** Hygiene, avoid irritants, remove foreign body. Specific antibiotics for chlamydia (tetracycline/doxycycline/erythromycin), gonorrhea (penicillin/ceftriaxone/ciprofloxacin/cefixime), herpes (acyclovir). #### Inflammation of the Vagina * **Mixed Pathogens:** *Staphylococcus*, *Streptococcus*, *E. coli*. * **Aetiology:** Chemicals, drugs, douches, pessaries, tampons, trauma, foreign bodies. Altered pH towards alkalinity (puerperium). Coexisting trichomoniasis. * **Symptoms:** Red, swollen, tender vagina, irritation, burning, dysuria, frequency. Variable discharge. More common post-menstruation/intercourse. * **Diagnosis:** Smear, culture. * **Treatment:** * **General:** Improve patient's general health. * **Local:** Correct vaginal pH (water-dispersible buffered vaginal jelly). Bactericidal cream (triple sulpha), antibiotic pessaries (if organism/sensitivity known). Eliminate cervical infection (diathermy, conization). * **Convenient Therapy:** 1-day therapy kit (fluconazole 150 mg, azithromycin 1g, secnidazole). #### Estrogen Deficiency-Related Vaginitis * **Vulvovaginitis in Children:** First 5 years/prepubertal girls. * **Aetiology:** Pyogenic coccus, *E. coli*. *Trichomonas/Monilia* rare (sexual abuse). Threadworms. Foreign bodies. * **Symptoms:** Red, edematous vulva, profuse purulent discharge, soreness, irritation. Child fidgety, scratching. Labial adhesions. * **Diagnosis:** Examination under anesthesia (exclude foreign body, obtain smear). * **Treatment:** Local/systemic antibiotics. Ethinyloestradiol (0.01 mg) for epithelial resistance/acidity. Isolation. * **Senile Vaginitis (Postmenopausal Women):** * **Aetiology:** Estrogen deficiency. Thin/atrophic vaginal epithelium, low glycogen, low Döderlein's, high pH. * **Symptoms:** Dry vagina, dyspareunia, purulent/blood-tinged discharge. Inflamed/tender/excoriated mucosa. Urinary symptoms (frequency, dysuria). Pouting urethral meatus (urethritis). Patchy granular vaginitis (bleeds easily). Adhesions/obliteration of canal. Infection can spread to endometrium (senile endometritis, pyometra). * **Diagnosis:** Clinical features. Exclude cancer of endometrium/endocervix (postmenopausal bleeding requires examination under anesthesia, diagnostic curettage). * **Treatment:** Estrogen therapy (ethinyloestradiol 0.01 mg daily for 3 weeks). Local estrogen pessary/cream. #### Secondary Vaginitis * **Causes:** * **Foreign Body:** Retained pessary, contraceptives, tampons. * **Infected Cervix:** Chronic infection (endocervicitis), childbirth injuries (cervical tear). * **Fistulae:** Vesicovaginal, ureterovaginal, rectovaginal. * **Growth on Cervix:** Carcinoma, polyp. * **Vaginitis Medicamentosa:** Chemicals, douches, arsenic pessaries, contraceptives. #### Rare Forms of Vaginitis * **Emphysematous Vaginitis:** Rare. Vaginal walls distended with gas-containing vesicles. Subepithelial induration/edema. Profuse vaginal discharge. Aetiology unknown, often in pregnancy. Resolves spontaneously. * **Treatment (General):** Remove cause. Treat primary cause (prolapse, fistula). Specific antibiotics for identified organisms. * **Vaginal Irrigations:** Rarely used. Betadine, acriflavine. * **Vaginal Pessaries:** Estrogen, antibiotics, cortisone, bactericidal agents (Betadine), fungicidal (nystatin, imidazole), antiprotozoal. * **Bactericidal Creams:** Triple sulpha, Betadine. * **Swabs:** For culture from cervix, vagina, urethra. * **Toxic Shock Syndrome:** Septicemic shock (Todd, 1978). Follows tampon use (menstruation/puerperium). *Staphylococcus aureus* (rarely *Streptococcus*) endotoxin release. * **Symptoms:** Sudden pyrexia (>39.9°C), myalgia, diffuse skin rash, edematous erythema. Vomiting, diarrhea, hypotension. Leukocytosis, thrombocytopenia, raised bilirubin/liver enzymes. Blood culture sterile. * **Treatment:** Correct hypovolemia (IV fluids). Beta-lactamase-resistant penicillin, cephalosporin, gentamicin. High mortality if untreated. * **Prevention:** Tampons/contraceptive sponges not left for >24 hours. #### Ulcerations of the Vagina * Rare. * **Foreign Bodies:** Retained pessary (high posterior fornix), granulation tissue, offensive discharge. Long-standing irritation can lead to malignant transformation (biopsy needed). * **Treatment:** Remove pessary, local douche, oral antibiotics. * **Venereal Ulcers:** Common on vulva, occasionally vagina. * **Tuberculous Ulcers:** Rare, usually with concomitant lesions on cervix/vulva. * **Chemical Ulcers:** Potassium permanganate pessaries (abortion induction). Can cause widespread cicatrization/stenosis. * **Radiation Ulcers:** Post-radiotherapy (cervical cancer). Don't heal readily, cause adhesion/disunion of vaginal vault. * **Trophic Ulcers:** In procidentia. * **Vaginal Granulation Tissue:** In scars/vault post-hysterectomy. Offensive, blood-stained discharge. * **Treatment:** Cauterization. * **Scars, Stenosis, Atresia:** Childbirth injuries, extensive prolapse repair, radiotherapy, chemical burns, fulminant vulvovaginal infections. * **Amoebiasis of Vagina:** Fungating subcutaneous ulcer, foul-smelling discharge, postmenopausal bleeding. * **Diagnosis:** Biopsy. * **Treatment:** Oral metronidazole (400 mg bid for 7 days). #### Cysts and Neoplasms of the Vagina * **Vaginal Cysts:** Rare, most commonly anterior vaginal wall. Small, but can reach 7.5 cm. * **Gartner's Duct Cyst:** Remnants of mesonephric duct, anterolateral vaginal wall. Asymptomatic if small, large needs excision (if causing dyspareunia). * **Inclusion Cyst:** Lower end of vagina, posterior surface. Tags of mucosa embedded in scar. * **Bartholin Cyst:** Can extend into vagina, cause dyspareunia. * **Endometriotic Cyst:** Bluish bulge in posterior fornix. Painful during menstruation. * **Treatment:** Surgical excision. * **Vaginal Neoplasms:** Rare. * **Benign:** Fibromyoma. * **Malignant:** (Described in separate chapter).