Vulva
General
Infection

Author: Monika Roychowdhury, M.D. (see Authors page)

Revised: 4 October 2017, last major update February 2013

Copyright: (c) 2002-2017, PathologyOutlines.com, Inc.

PubMed Search: Vulva infections [title]

Cite this page: Roychowdhury, M. Infection. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/vulvainfections.html. Accessed November 20th, 2017.
Candida
Definition / general
  • Causes vulvovaginitis; most frequent mycoses of women; 10% of women are carriers
  • Risk factors: diabetes, oral contraceptives, pregnancy
  • Transmission: male genitalia are not a relevant reservoir for recurrent vulvovaginal candidosis, thus decreasing the possibility of sexual heterosexual transmission (J Eur Acad Dermatol Venereol 2011;25:145)
  • Recurrent vulvovaginal candidosis: mostly caused by identical Candida strains suggesting C. albicans persistence in female anogenital area, particularly in external vulva (Mycoses 2011;54:e807)


Etiology
  • Acute vulvovaginitis: most commonly C. albicans, followed by C. glabrata
  • Chronic recurrent vulvovaginitis: C. albicans and C. glabrata are often equally distributed (Med Monatsschr Pharm 2010;33:324)


Clinical features
  • Small white surface patches with leukorrhea and itching


Diagnosis
  • Fungal hyphae on wet mount


Treatment
  • Local and systemic antimycotic agents based on the severity of disease and etiological agent
Gardnerella vaginalis (bacterial vaginosis)
Definition / general
  • Small gram negative rods, implicated in vaginitis when other causes can't be found
  • Presence of 3 of 4 criteria indicate BV (bacterial vaginosis, Medscape Womens Health 1997;2:2):
    • Homogenous noninflammatory discharge (not many WBCs)
    • pH > 4.5
    • Clue cells (bacteria attached to border of epithelial cells, > 20% of epithelial cells)
    • Positive "whiff" test
Granuloma inguinale
Definition / general
  • Caused by Calymmatobacterium granulomatis, an encapsulated, nonmotile gram negative rod
  • Soft granulomatous area enlarges by peripheral extension and ulcerates


Clinical features
  • Genital ulceration, genital tract bleeding


Microscopic (histologic) description
  • Donovan bodies (small round encapsulated bodies within histiocytes), seen best with silver or Giemsa stains
  • Also pseudoepitheliomatous hyperplasia, plasma cells, histiocytes, small abscesses


Differential diagnosis
Herpes simplex virus
Definition / general
  • Sexually transmitted disease characterized by labial ulcers with punched out centers
  • Usually HSV2 in young women
  • 1/3 are symptomatic (lesions 3 - 7 days after sex); lesions heal in 1 - 3 weeks but virus is latent in regional nerve ganglia
  • 2/3 suffer recurrences (less painful)
  • High risk of transmission to neonate during vaginal birth, especially if active primary infection


Clinical features
  • Extremely painful ("heartbreak of herpes"), papules in vulva, progress to vesicles, later coalescent ulcers
  • Also affects vagina and cervix


Case reports

Clinical images

Images hosted on other servers:

Ulcerative form



Microscopic (histologic) description
  • Multinucleated giant cells with molding, ground glass nuclei


Microscopic (histologic) images

Images hosted on other servers:

Edge of ulceration

Immuno-histochemistry

Human papillomavirus (HPV)
Definition / general
  • HPV subtypes 6, 8,11,13 associated with papillary lesions
  • HPV subtypes 16, 18, 31, 33 associated with flat lesions
  • HPV 16 produces E6 protein that binds to p53 and E7 protein that binds to Rb protein
  • Koilocytotic atypia is a viral cytopathic effect, often NOT present in vulvar condylomas
  • Verrucopapillary lesions, even in children / young adults, are likely to be HPV associated (Am J Surg Pathol 1994;18:728)

  • HPV and vulvar neoplasia:
    • HPV leads to pathogenetic pathways for vulvar squamous cell carcinoma and vulvar intraepithelial neoplasia (VSCC and VIN)
  • HPV associated vulvar squamous cell carcinoma: basaloid or warty type; arise from VIN of usual type
  • HPV independent vulvar squamous cell carcinoma: keratinizing, associated with differentiated VIN and lichen sclerosus; frequently have p53 mutation
  • Most studies show no survival differences between HPV associated and HPV independent tumors (Histopathology 2013;62:161)


Microscopic (histologic) images

Images hosted on other servers:

HPV+ squamous cell carcinoma

HPV-

Lymphogranuloma venereum
Definition / general
  • Sexually transmitted disease caused by Chlamydia trachomatis, L1 - L3 serotypes, treated with tetracycline
  • Initially small ulcer at contact site, then inguinal adenopathy with stellate abscesses surrounded by epithelioid histiocytes, then scarring, fistulas and strictures of urethra, vagina, rectum (Prim Care 1990;17:153)
  • Squamous cell carcinoma or adenocarcinoma may be engrafted on lymphogranulomatous structures


Diagnosis
  • Frei test (intradermal skin test), complement fixation, immunofluorescence


Case reports

Clinical images

Images hosted on other servers:

Vulvoperineal lesions



Microscopic (histologic) images

Images hosted on other servers:

Immuno-peroxidase staining

Immuno-peroxidase and May-Gr├╝nwald-Giemsa staining

Direct immuno-fluorescence

Molluscum contagiosum
Definition / general
  • Sexually transmitted disease that affects vulva only


Microscopic (histologic) description
  • Molluscum bodies
Mycoplasma
Definition / general
  • Causes spontaneous abortions and chorioamnionitis
Neisseria gonorrhea
Definition / general
  • Affects entire gynecologic tract in adults except vagina; only children get vaginitis
  • Causes infertility
  • Begins in Bartholin glands or other vestibular or periurethral glands, then spreads to cervix, tubes, ovaries


Microscopic (histologic) description
  • Acute suppurative reaction, inflammation within mucosa and submucosa only
Pelvic inflammatory disease
Definition / general
  • Clinical syndrome due to various bacteria
  • Compared to N. gonorrhea, exudates are less with staphylococcal or streptococcal infections or coliforms but infection extends throughout wall to serosa and may cause bacteremia
  • Complications: bacteremia, infertility, intestinal obstruction due to adhesions, peritonitis


Additional references
Syphilis
Primary syphilis
  • First symptom is small, round, firm ulcer known as chancre, which is infectious
    • Occurs where bacteria first enters body - usually vulva in women ~3 weeks after infection
    • Usually disappears in 3 - 6 weeks even without treatment
  • Composed of plasma cells, lymphocytes, histiocytes, covered by zone of ulceration with neutrophils and necrosis; also endarteritis
  • Adjacent lymph nodes may be enlarged with plasma cells, endarteritis within or outside capsule, fibrosis (capsular, pericapsular), follicular hyperplasia


Secondary syphilis
  • Usually rash on palms and soles that doesn't itch, which appears 2 - 10 weeks after chancre
  • Other symptoms include headache, sore throat, swollen lymph glands, tiredness
  • Lesions contain bacteria and are infectious
  • This stage may disappear without treatment but will recur and progress if not treated appropriately


Latent syphilis
  • Begins when symptoms of secondary syphilis are over
  • Early latent syphilis is infectious
  • Late latent syphilis has low to no risk of infecting the partner
  • If not treated appropriately, latent syphilis may progress to tertiary syphilis


Tertiary syphilis
  • Affects very small number of syphilis patients even if never treated
  • Can affect heart, eyes, brain, joints, nervous system, bones


Additional references
Trichomonas vaginalis
Definition / general
  • Large, flagellated, ovoid protozoan, causes up to 25% of vaginitis cases
  • Diagnose with wet mount
  • 15% of women in sexually transmitted disease clinic are infected
  • Purulent discharge, local discomfort, "strawberry" cervix (fiery red with thin epidermis)
  • Infection limited to epithelium and lamina propria


Diagnosis
  • Foul frothy discharge, pH > 4.5 (in 70% of cases), punctuate cervical microhemorrhages (25% of cases) and motile trichomonads on wet mount (25 - 75% of cases, Medscape Womens Health 1997;2:2)


Treatment
  • Oral metronidazole; treatment failure is usually due to nontreatment of male partner