Preinvasive Disease of the Vagina and Vulva Fred Ueland, MD Division of Gynecologic Oncology University of Kentucky Juneau, Alaska Examining… the External Genitalia Dorsal lithotomy position  Clitoris and frenulum  Urethra and anus  Labia majora and minor  Introitus  Perineum Vulva Conditions… the Labia and Perineum  Infection – HPV, HSV – Chancroid, LGV, syphilis – Molluscum contagiosum  Dermatologic – Lichen sclerosus, hyperplasia Vulvar HPV Non-neoplastic Conditions Syphilis Non-neoplastic Conditions Condyloma lata Non-neoplastic Conditions Molluscum Contagiosum Non-neoplastic Conditions  Squamous hyperplasia  Lichen sclerosus  Other dermatoses – Psoriasis – Lichen simplex chronicus – Lichen planus – Tinea Trichomonas VAIN Benedet, J Reprod Med, 1992  Normal epithelium – Epithelial thickness = 0.28 mm – Menopausal patients 33% thinner  VAIN – Epithelial thickness = 0.46 mm – No difference for menopause  Recommend treatment to 1.5 mm VAIN Appearance  Subtle, often multifocal  Punctate, possibly raised  Peau d’orange  May show acetowhite changes but rarely the mosaicism of CIN VAIN Colposcopy  Largest speculum  Start at apex and move to introitus  Aceitic acid or Lugol’s  Alligator biopsy forceps  AgNO3, Monsel’s solution Treatment Options VIN and VAIN  Excision – Not LEEP  CO2 laser vaporization  Electrical vaporization (fulguration)  Topical therapy – 5-FU – Aldara Surgical Excision Laser Ablation VAIN CO2 Laser Vaporization  Colposcopy-assisted  15-20 watts, continuous  General anesthesia  Destruction depth – 1.0 to 1.5 mm  Post-treatment narcotics Medical Treatment VAIN 5-Fluorouracil  “Not for intra-vaginal use” – Actinic keratosis, superficial basal cell  Daly et al Obstet Gynecol, 1980 – Post-radiated VIN treated with 5-FU – bid for 10-14 days – NED for 2-5 years  8% non-healing ulcers at months  Pregnancy Category X Medical Treatment VAIN Daily 5-Fluorouracil Efudex 5% cream Disp: 25 gram tube Sig: Use ½ applicator (2-2.5 gm) in vagina qHS for nights Insert tampon and coat vulva with Desitin In morning, remove tampon and allow medicine to drain into commode Gently cleanse vulva Medical Treatment VAIN Weekly 5-Fluorouracil Efudex 5% cream Disp: 25 gram tube Sig: Use 1/3 applicator (1.5 gm) in vagina at night weekly for up to 10 weeks Insert tampon and coat vulva with Desitin In morning, remove tampon and allow medicine to drain into commode Gently cleanse vulva Medical Treatment Aldara  Immune modifier – Induces cytokines, interferon-α, lymphocytes, macrophages      Actinic keratosis, superficial basal cell, external condylomata Age 12 and older 72% CR for condylomata 90% with vulvar discomfort, 15% with flu-like symptoms, 20% don’t finish therapy Pregnancy Category C Medical Treatment Aldara Aldara 5% cream Disp: 250 mg single use packets Sig: Use packet times weekly qHS Leave on for 6-10 hours and remove with mild soap and water Use no longer than 16 weeks Surveillance  Colposcopy or vulvoscopy  Cytologic screening – Cervicovaginal – Anal  to months  Smoking cessation  Vaccination? Parting Thoughts… “Paratus simper disceri “ …Always prepared to learn From a doorway arch in the Vatican library ... Genitalia Dorsal lithotomy position  Clitoris and frenulum  Urethra and anus  Labia majora and minor  Introitus  Perineum Vulva Conditions… the Labia and Perineum  Infection – HPV, HSV – Chancroid,... multifocal Vulvar Intraepithelial Neoplasia VIN VIN VIN Vulvar Intraepithelial Neoplasia Vulvar Intraepithelial Neoplasia Vulvar Intraepithelial Neoplasia VIN Pigmented Lesion Location of Multifocal... urethral)  Progression in untreated 1.1-7.3 years (mean = 3.9 years) Paget’s Disease  Disease of the apocrine glands – Arm pits, genital, anal regions – Fat containing sweat, odor after bacterial