Genital Lesions in Women

Photo Essay

Condylomata Acuminata

Extensive genital warts were noted on the vulva of a 57-year-old woman. She reported that the warts had been present since her first pregnancy 25 years earlier.

Genital warts, or condylomata acuminata, are caused by human papillomaviruses (HPV) 6 and 11.¹ These warts occur in about 1% to 2% of sexually active adults.²

Risk factors include number of sex partners, frequency of vaginal intercourse, and presence of warts in the sex partner. Condylomata acuminata vary considerably in number and size and may occur on the vulva and perianal areas as well as in the vagina and rectum, urethra, and urinary bladder.

Most genital warts in infants and children are related to child abuse³ and must be reported to the appropriate state agency. Finger and hand warts can be transmitted to the genital and perianal areas of children by their caregivers as well as by other children.

The diagnosis is usually made on the basis of the gross appearance of the warts. If there is any doubt, biopsy should be performed.

Treatment of the wart does not eradicate the virus in the surrounding tissue, although in many cases recurrence may be delayed indefinitely. Thus, there is no curative treatment. The HPV vaccine Gardasil prevents about 90% of cases of genital warts.

Therapeutic modalities include topical imiquimod, podophyllin, trichloroacetic acid, 5-fluorouracil and isotretinoin, surgical excision, electrocautery, cryotherapy, carbon dioxide laser therapy and, as a last resort, intralesional administration of interferon alfa-2b, recombinant.⁴ This patient is currently considering the various treatment options.

Treatment is indicated during pregnancy, when genital warts tend to proliferate. Topical application of trichloroacetic acid is commonly used, because podophyllin is contraindicated during pregnancy.

Laryngeal papillomatosis in infants is caused by HPV 6 and 11. The route of transmission from the mother is unknown, and papillomatosis has developed in infants after cesarean section. If a pregnant woman has condylomata acuminata, cesarean section is indicated only if the warts obstruct the pelvic outlet or if excess bleeding from birth trauma is anticipated.⁴ In the vast majority of patients with genital warts, vaginal delivery is appropriate. ■

REFERENCES:

1.Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia, PA: Mosby; 2004:369.

2.Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia, PA: Mosby; 2004:336.

3.American Academy of Dermatology Task Force on Pediatric Dermatology. Genital warts and sexual abuse in children. J Am Acad Dermatol. 1984;11(3):529-530.

4.Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia, PA: Mosby; 2004:340-342.

Squamous Cell Hyperplasia

Sharply demarcated areas of erythema had been present on a 59-year-old woman’s vulva and perineal and perianal regions for 2 years. She reported that the areas were intensely pruritic, especially when touched with anything, such as a washcloth during bathing. The itching was more severe than that associated with any episode of candidal vaginitis she had ever experienced. At times the areas would become white and scaly. She had tried antifungal creams, over-the-counter corticosteroid creams, and various herbal remedies with no response.

An elliptical incisional biopsy was done through the edge of the lesion on the right vulva. Histopathologic examination revealed squamous cell hyperplasia with mild hyperkeratosis, minimal chronic inflammation, and reactive squamous atypia; there was no evidence of dysplasia or malignancy.

At this point, a telephone consultation was obtained with a gynecologic oncologist at a tertiary center, who advised surgical excision of the entire lesion because of the atypia. The patient was referred to another gynecologic oncologist, who recommended topical treatment after an examination showed no concerning findings.

After 4 days of application of topical clobetasol propionate ointment 0.05% nightly and fluocinolone acetonide ointment 0.025% twice daily, the patient reported that the dermatitis had completely cleared. She was advised to continue application of the two ointments for 2 to 4 weeks until the condition was controlled; this regimen was to be followed by the use of fluocinolone acetonide cream 0.01% twice a week indefinitely as maintenance therapy.

Squamous cell hyperplasia is often chronic and may wax and wane. Recurrences can be re-treated with high-potency corticosteroids; however, long-term use of these agents should be avoided because they can cause skin atrophy and exacerbation of the condition.

Vulvar squamous cell hyperplasia is most common after menopause, but it may occur in premenopausal women.¹ Pruritus is the hallmark symptom. Lesions may be discrete and appear thickened and/or excoriated because of the intense itching and resultant scratching.

Biopsy—and rebiopsy of new lesions—is necessary to make the diagnosis and to exclude malignancy. Potential irritants should be avoided. Laser therapy or surgical excision may be necessary in cases that do not respond to medical therapy. ■

REFERENCE:

1.Berek JS. Novak’s Gynecology. 13th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:410.

Endocervical Polyp

This blood-colored polyp was found protruding through the cervical os in a 47-year-old woman who had presented for a Papanicolaou test. The polyp was removed at its base in the office using an endometrial polyp forceps. The patient tolerated the procedure well, and there were no complications, such as excess bleeding. The pathologic diagnosis was benign endocervical polyp with chronic inflammation. The polyp had been asymptomatic.

Endocervical polyps are the most common benign neoplasms of the cervix; they occur most frequently in multiparous women in their 40s and 50s.¹ The polyps appear red or purple and are fragile and bleed readily with slight trauma. They range from a few millimeters to several centimeters in length and have a narrow stalk of variable length within the endocervix. Ectocervical polyps are grayish white and usually have a short broad base on the cervix; these polyps occur most often in postmenopausal women.

Endocervical polyps classically present with intermenstrual bleeding, especially after contact, such as after coitus or examination. Many are asymptomatic.

Most endocervical polyps can be treated in the office by avulsion with a clamp at the base. Excess bleeding may be managed with chemical cautery with Monsel’s solution or silver nitrate, or with electrocautery. The polyp should be sent for histopathologic examination, although the vast majority are benign.

In a patient who presents with abnormal bleeding, it should not be simply assumed that the endocervical polyp is the cause. Endometrial imaging, hysteroscopy, and/or biopsy are required in this setting. ■

REFERENCE:

1.Berek JS. Novak’s Gynecology. 13th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:464.