Page 737 - Textbook of Pathology, 6th Edition

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Chapter 24 The Female Genital Tract
Chapter 24

VULVA duct to a flattened lining because of increased intracystic
pressure. The cyst wall may show chronic inflammatory
NORMAL STRUCTURE infiltrate and a few mucus-secreting acini.

The vulva consists of structures of ectodermal origin—labia
majora, labia minora, mons pubis, clitoris, vestibule, hymen, NON-NEOPLASTIC EPITHELIAL DISORDERS
Bartholin’s glands and minor vestibular glands. The mons The older nomenclature vulvar dystrophy has been replaced
pubis and labia majora are covered externally by skin with by more descriptive and clinically relevant term, non-
hair follicles, sebaceous glands and sweat glands including neoplastic epithelial disorders of vulval skin and mucosa of
apocrine glands. The inner surface of labia majora, labia vulva. The term is applied to chronic lesions of the vulva
minora and vestibule are covered by stratified squamous characterised clinically by white, plaque-like, pruritic
epithelium. The clitoris is made up of vascular erectile tissue. mucosal thickenings and pathologically by disorders of
Bartholin’s or vulvovaginal glands are located one on each epithelial growth. Clinicians often use the term ‘leukoplakia’
side of the mass of tissue forming labia majora. The glands for such white lesions. But white lesions may represent other
are racemose type and their secretions are released during depigmented conditions as well such as vitiligo, inflam-
sexual excitement. matory dermatoses, carcinoma in situ, Paget’s disease, or
Since vulva is of ectodermal origin, the common inflam- even invasive carcinoma, and thus use of the term CHAPTER 24
matory conditions affecting it are similar to those found on leukoplakia by pathologists is not recommneded.
the skin generally. A few specific conditions such as Currently, non-neoplastic epithelial disorders of the skin
Bartholin’s cyst and abscess, vulvar dystrophy and certain of vulva includes following 2 lesions:
tumours are described below. 1. Lichen sclerosus (older term: atrophic dystrophy).
2. Squamous hyperplasia (older term: hyperplastic
BARTHOLIN’S CYST AND ABSCESS dystrophy).
The two types of lesions may coexist in the same patient.
Inflammation of Bartholin’s vulvovaginal glands (Bartholin’s
adenitis) may occur due to bacterial infection, notably Lichen Sclerosus
gonorrhoeal infection. Infection may be acute or chronic. The Female Genital Tract
Acute Bartholin’s adenitis occurs from obstruction and Lichen sclerosus may occur anywhere in the skin (Chapter
dilatation of the duct by infection resulting in formation of a 26) but is more common and more extensive in the vulva in
Bartholin’s abscess. The condition presents with intense pain, post-menopausal women. The lesions appear as multiple,
swelling and fluctuant mass which can be incised and small, coalescent, yellowish-blue macules or papules which
drained. produce thin and shiny parchment-like skin. The lesions may
extend from vulva onto the perianal and perineal area.
Microscopic examination shows the usual appearance of Clinically, the patient, usually a post-menopausal woman,
acute suppurative inflammation with neutrophilic infil- complains of intense pruritus which may produce excoriation
tration, hyperaemia, oedema and epithelial degeneration. of the affected skin. Eventually, there is progressive shrinkage
and atrophy resulting in narrowing of the introitus, clinically
Chronic Bartholin’s adenitis results from a less virulent referred to as kraurosis vulvae.
infection so that the process is slow and prolonged. Alter-
natively, the chronic process evolves from repeated attacks MORPHOLOGIC FEATURES. Microscopically, the
of less severe acute inflammation which may be short of following characteristics are seen (Fig. 24.1,A):
abscess formation and resolves incompletely. In either case, 1. Hyperkeratosis of the surface layer.
the chronic inflammatory process terminates into fluid-filled 2. Thinning of the epidermis with disappearance of rete
Bartholin’s cyst. The resulting cyst may be quite large, ridges.
3-5 cm in diameter and readily palpable in the perineum, 3. Amorphous homogeneous degenerative change in the
but may remain asymptomatic for years. dermal collagen.
4. Chronic inflammatory infiltrate in the mid-dermis.
Histologic examination shows variable lining of the cyst
varying from the transitional epithelium of the normal Lichen sclerosus is not a premalignant lesion and responds
favourably to topical treatment with androgens.