24.1 Benign Lower Genital Tract Disorders & Pelvic Floor: Vulvar Dermatoses, Bartholin Cysts, Vaginal and Cervical Lesions, Premalignant Lesions, Pelvic Organ Prolapse, Urinary Incontinence and Fistula

Why this area matters

TOS areas L and P ask you to:

• classify disorders and tumors of the vulva, vagina and cervix and their premalignant potential;
• relate symptoms to risk factors;
• plan treatment with appropriate anesthesia and perioperative care;
• screen for and monitor these lesions;
• distinguish pelvic floor problems and their effect on the urinary tract;
• choose between surgical and conservative treatment;
• prevent these disorders.

Vulvar itching, discharge, "something coming down" and urine leakage are common reasons Filipino women consult. Many delay care from embarrassment. Cervical precancer remains common because screening coverage is low. Obstetric fistula still follows prolonged obstructed labor where emergency care is far away.

Vulvar disorders

• Bartholin duct cyst and abscess:
  • the glands lie at 4 and 8 o'clock at the vestibule;
  • a blocked duct forms a painless cyst, and infection, polymicrobial and sometimes gonococcal, forms a tender abscess;
  • treat an abscess with incision and drainage plus a Word catheter, or marsupialization for recurrence;
  • biopsy a new or solid Bartholin mass in a woman over 40 to exclude carcinoma.
• Other vulvar lesions: sebaceous and epidermal inclusion cysts, condylomata and molluscum (see STIs), hidradenitis suppurativa and vulvar varicosities.

Vaginal and cervical lesions

• Vagina:
  • Gartner duct cysts (from mesonephric remnants) on the anterolateral wall;
  • inclusion cysts after episiotomy;
  • vaginal adenosis after in utero DES exposure;
  • VaIN (vaginal intraepithelial neoplasia, HPV-related).
• Cervix:
  • ectropion, columnar epithelium on the ectocervix, which is common in pregnancy and with pills and may cause contact bleeding;
  • nabothian cysts, harmless retention cysts;
  • endocervical polyps, which cause intermenstrual or postcoital bleeding and are removed and examined;
  • cervicitis.
• The transformation zone: squamous metaplasia replaces columnar epithelium here, and HPV-driven precancer arises here.
• Cervical intraepithelial neoplasia:
  • CIN 1 (LSIL) usually regresses and is observed;
  • CIN 2 and 3 (HSIL) are true precursors, treated by excision: loop electrosurgical excision procedure (LEEP) or cold-knife cone, or by ablation where eligible.
• Screening:
  • Pap smear, visual inspection with acetic acid (VIA) or HPV DNA testing;
  • WHO 2021 recommends HPV DNA testing as the primary screening test from age 30, every 5 to 10 years;
  • women living with HIV start at 25 and are screened every 3 to 5 years;
  • in the Philippines, VIA with immediate cryotherapy or thermal ablation ("screen-and-treat") is used where cytology is not available.
• Excision and pregnancy: large or repeated excisions raise the risk of cervical insufficiency and preterm birth in later pregnancies.

Pelvic organ prolapse

• Cause: prolapse results from weakening of the levator ani and the endopelvic fascia. It is described by the compartment involved:
  • cystocele (anterior wall, bladder): incomplete emptying and recurrent UTI;
  • urethrocele;
  • uterine or vault prolapse (apical);
  • enterocele: small bowel in the pouch of Douglas;
  • rectocele (posterior wall): constipation, with the need to splint the vagina to defecate.
• Risk factors:
  • vaginal birth, especially many or traumatic births;
  • aging and menopause;
  • obesity;
  • chronic cough and constipation, heavy lifting;
  • connective tissue disorders.
• Grading: the POP-Q system measures points relative to the hymen, from stage 0 to stage IV (complete eversion, called procidentia).
• Symptoms: a bulge or "something coming down" that is worse at the end of the day, pressure, urinary and bowel symptoms, and ulceration of exposed cervix or vagina.
• Treatment:
  • asymptomatic prolapse needs no treatment;
  • conservative: pelvic floor muscle training (Kegel exercises), weight loss, treatment of cough and constipation, and a vaginal pessary (ring or Gellhorn), which is useful in older or medically unfit women;
  • surgical: vaginal hysterectomy with anterior and posterior colporrhaphy, sacrospinous fixation, abdominal or laparoscopic sacrocolpopexy for vault prolapse, and colpocleisis for frail women who are no longer sexually active.
• Prevention: good intrapartum care, avoiding prolonged second stages and unnecessary instrumental deliveries, repairing tears properly, postpartum pelvic floor exercises and weight control.

Urinary incontinence and fistula

• Assessment:
  • urinalysis to exclude infection;
  • a bladder diary;
  • post-void residual;
  • a cough stress test;
  • urodynamics before surgery in complex cases.
• Treatment cautions: antimuscarinics cause dry mouth, constipation and confusion in older people.