Definition & Overview
The destruction of lesions in the vulva is performed to treat several types of vulvar diseases. This can be carried out using laser surgery, electrosurgery, cryosurgery, or chemosurgery.
The vulva is the external opening of the vagina, located between the mons pubis and the anus. It is composed of several parts, namely the labia minora and majora, clitoris, vestibule, vaginal orifice, urinary meatus, hymen, Skene ducts, and Bartholin glands. A number of nerves and blood vessels supply the different parts of the vulva. It provides protection to the vagina and the womb and has a role to play in pleasure sensation during sexual arousal.
There are different types of epithelial cells and glands found in the vulva. This part of the female anatomy is quite prone to diseases and disorders that cause significant discomfort and distress to patients. These conditions can be caused by infectious agents as well as abnormal tissue growths. There are several treatment techniques available to patients to help them achieve immediate and lasting relief from symptoms of vulvar lesions. Although some vulvar diseases resolve themselves over time, there are some that are treated using topical drugs or surgery.
Who Should Undergo and Expected Results
The destruction of lesions in the vulva can be recommended to older, postmenopausal women with recurring cysts in the Bartholin’s glands or Skene’s duct. The Bartholin’s glands are responsible for secreting mucus for vaginal lubrication while the Skene’s duct serves as a passageway of secretions attributed to female orgasm. When these are blocked, a cyst could develop that could eventually lead to lesions that need to be removed. Another type of condition, the epidermal inclusion cyst, also develops when a sebaceous gland is blocked or obstructed.
The procedure can also be recommended to patients with:
Seborrheic keratosis in the vulva - This is a common abnormal skin growth that is benign. The growths look like warts or moles that are typically brown in colour. Though most seborrheic keratoses are not painful, they could be itchy and quite uncomfortable if located in the genital area.
Vulvar fibromyoma - Though a fibromyoma typically occurs in the uterus, rare cases of vulvar fibromyoma or fibroids also occur. Its symptoms include pain, vaginal bleeding, and even back pain.
Dermatofibroma - Benign vulvar lesions could also be the result of dermatofibroma, which could be removed if it causes significant discomfort. Other benign vulvar lesions eligible for destruction include lipoma (an abnormal growth of fat cells) and leiomyoma (which is made up of muscle tissues).
Melanoma in the vulva - This is a type of skin cancer characterised by the abnormal growth of pigment cells or melanocytes. These growths are itchy and may bleed if the condition is in its advanced state.
Malignant lesions - These include basal cell carcinoma as well as squamous cell carcinoma in situ and its invasive counterpart. These types of skin cancers, which are quite rare in the vulva, require prompt diagnosis and treatment to increase the chances of complete treatment and survival.
Kaposi sarcoma and malignant lesions arising from angiosarcoma - These are abnormal growths associated with blood vessels that are often painful. Kaposi sarcoma is associated with HIV infection and could be quite aggressive.
Rare occurring vulvar lesions that would necessitate the procedure include dermatofibrosarcoma protuberans, liposarcoma, Merkel cell carcinoma, leiomyosarcoma, and rhabdomyosarcoma.
Benign vulvar lesions can be removed through laser surgery, electrosurgery, cryosurgery, or chemosurgery. Small lesions can be destroyed in an outpatient setting, with the patient experiencing immediate symptoms relief right after the procedure. Certain precautions to encourage wound healing are also advised. These include avoiding strenuous physical activities and abstaining from sexual intercourse for a few days. Irritants should also be avoided.
The destruction of malignant lesions in the vulva may take more time to perform and has a longer wound healing process. Patients may be placed under close supervision due to their reduced immune state and wellbeing. In some cases, patients with cancerous growth are required to undergo chemotherapy or radiation therapy after the procedure to lower the chances of recurrence.
How is the Procedure Performed?
Non-malignant and pre-cancerous lesions that have not spread to other parts of the vulva and reproductive tract can be removed using laser surgery. For this procedure, the patient is placed under local or general anaesthesia. A catheter is inserted into the bladder to drain urine. In most cases, the patient is also asked to wear compression stockings to prevent blood clots from developing. After properly positioning the patient, the lesion site is accessed. A pulse of high-energy laser is then directed into the lesion to vaporise the skin with abnormal cells. Once the physician has determined that all lesions have been removed, the surgical site is cleansed with saline solution and left open to heal.
Electrosurgery can be used to remove small-sized lesions in the vulva. This procedure is performed under local anaesthesia and involves retracting the labia minora to expose the lesion. The electrosurgical instrument is looped around the lesion and enough electric current is applied to cut the lesion away from the base of the skin. In some cases, a healthy margin of skin is also removed along with the lesion. Sutures are used to close the surgical wound.
Lesions in the vulva can also be destroyed using cryosurgery, which only requires topical anaesthesia. For this procedure, the lesions are destroyed using extreme cold temperature. This is achieved using a refrigerant, typically a liquid nitrous oxide. Once the lesions are exposed, the refrigerant is applied to the lesions at a certain pressure. Cell death or necrosis occurs when the cells are dehydrated and any water left is crystallised. The proteins in the cell membrane are denatured and destroyed, initiating thermal shock and vascular stasis. If there is a need, the process is repeated through thawing and re-application of the refrigerant.
Another technique that can be used is chemosurgery. This procedure is performed under local anaesthesia. The most common type of chemical used in gynaecologic chemosurgery is the compound known as 5-fluorouracil. It is a topical cream applied to the lesions to encourage controlled necrosis of benign, pre-cancerous, or malignant cells. The necrotic tissues are then removed using a scalpel and the surgical site is closed with sutures.
Possible Risks and Complications
The use of laser surgery carries the risk of bleeding as well as damaging adjacent parts like the anus, rectum, and the bladder. Also, a blood clot can develop and travel to the legs and even the lungs. This could lead to shortness of breath, swelling in the affected extremity, and pain.
The surgical site is also prone to infection that could result in fever and pain. Other common complaints include:
- Postoperative pain, which typically resolves after a few days
- Formation of scar tissue
- Tightness and discomfort in the genital area
Recurrence of vulvar lesions
Abdullgaffar B, Keloth TR, Raman LG, Mahmood S, Almulla A, Almarzouqi M, et al. Unusual benign polypoid and papular neoplasms and tumor-like lesions of the vulva. Ann Diagn Pathol. 2014 Apr. 18(2):63-70.
Gunthert AR, Faber M, Knappe G, Hellriegel S, Emons G. Early onset vulvar Lichen Sclerosus in premenopausal women and oral contraceptives. Eur J Obstet Gynecol Reprod Biol. 2008 Mar. 137(1):56-60.