Benign Gynecologic

Lesions
By Dr Hossam El Sokkary
Lecturer of
obst&gynaecology

Benign Lesions
of the Genital
Tract

lesions of the vulva, vagina, cervix, uterine corpus,

ovaries and fallopian tubes

Benign Characteristics:
1.
2.
3.
4.

slow-growing
well-circumscribed
not associated with hemorrhage, necrosis or evidence of
widespread dissemination (metastasis)
no constitutional signs and symptoms of weight loss and
anorexia

a tissue biopsy is needed to make a specific diagnosis.

Topic Objectives
1. To describe and discuss the more
common lesions and conditions of the
female genital tract
2. To discuss their pathophysiology, as well
as their corresponding treatment

Benign
Lesions of the
Vulva

Urethral Caruncle

fleshy outgrowth of the distal edge of the urethra

frequently in postmenopausal women
must be differentiated from urethral carcinomas
generally small, single and sessile but may be
pedunculated and grow to be 1 to 2 cm in
diameter
tissue is soft, smooth, friable and bright red and
initially appears as an eversion of the urethra

Urethral Caruncle
believed to arise from an ectropion of the
posterior urethral wall associated with
retraction and atrophy of the
postmenopausal vagina
histologically composed of transitional and
stratified squamous epithelium with loose
connective tissue

Urethral Caruncle
Growth is secondary to chronic irritation
Symptoms may be variable
mostly asymptomatic
dysuria frequency, and urgency

Urethral Caruncle

differential diagnosis

primary carcinoma of the urethra

prolapse of the urethral mucosa

not a precursor for urethral carcinoma

diagnosis is established by biopsy under
local anesthesia

Urethral Caruncle
Treatment
Initially
1. oral or topical estrogen
2. avoidance of irritation

cryosurgery, laser therapy, fulguration, or operative

excision
following operative destruction - a foley catheter
should be left in place for 48 to 72 hours
follow-up is necessary to ensure that the patient
does not develop urethral stenosis

Urethral Prolapse
predominantly in premenarchal
females
Grossly
does not have the bright-red color of
a caruncle
is not as circumscribed in gross
configuration
it may be ulcerated with necrosis or
grossly edematous

Majority are asymptomatic but

some may have dysuria

Urethral Prolapse
Therapy
1. hot sitz baths
2. antibiotics
3. topical estrogen cream
4. excision of the redundant mucosa
rarely done but may be necessary

Vulvar Cysts
Bartholins duct cyst is the
most common of the large
vulvar cysts
treatment is not necessary
in women younger than 40
unless the cyst becomes
infected or enlarges enough
to produce symptoms

Vulvar Cysts
the most common small vulvar cysts are
epidermal inclusion cysts or sebaceous
cysts

Sebaceous Cysts
located immediately beneath the epidermis
mostly discovered on the anterior half of the
labia majora
multiple, freely movable, round, slow growing,
and nontender with firm consistency
grossly appear white or yellow with caseous
contents on cut section
local scarring of the adjacent skin sometimes
occurs when rupture of the contents of the cyst
produces inflammatory reaction in the
subcutaneous tissue.

Inclusion Cysts
develops when an infolding of squamous
epithelium has occurred beneath the
epidermis in the site of an episiotomy or
obstetric laceration
When found in the vagina most likely
related to previous trauma

Inclusion Cysts
alternative theories of histogenesis
include embryonic remnants
Treatment
excision.

Hemangioma

are rare malformations of

blood vessels rather than
true neoplasms.
frequently discovered
initially during childhood
approximately 60% of
vulvar hemangiomas
spontaneously regress in
size by the time the child
goes to school

Hemangioma

appear histologically as predominantly

thin-walled capillaries arranged randomly
and separated by thin connective tissue
septa.
most are asymptomatic
may occasionally become ulcerated and
bleed

Fibroma

most common benign solid tumor of the vulva

commonly found in the labia majora
occur in all age groups
have smooth surface and distinct contour
with low grade potential for becoming malignant
smaller fibromas are asymptomatic
large tumors may produce chronic pressure
symptoms or acute pain
treatment - operative removal if the fibromas
are symptomatic and/or continue to grow

Lipoma
benign, slow growing, circumscribed
tumors of fat cells arising from the
subcutaneous tissue of the vulva.
second most frequent benign vulvar
mesenchymal tumor
most lipomas are discovered in the labia
majora and are superficial in location
malignant potential is extremely low

Endometriosis

Rare in the vulva

firm, small nodule or nodules
varies from a few millimeters to several centimeters in
diameter
found at the site of an old, healed obstetric laceration,
episiotomy site, an area of operative removal of a
Bartholins cyst, or along the canal of Nuck
Pathophysiology
secondary to metaplasia
retrograde lymphatic spread,

Endometriosis
commonly present with introital pain and
dyspareunia
classic history - cyclic discomfort and
enlargement of the mass during menses
Treatment
wide excision or laser vaporization depending
on the size of the mass

Recurrence after treatment are common

Hematoma

usually secondary to
blunt trauma - (straddle
injury)
spontaneous hematomas
are rare and usually
occur from rupture of a
varicose vein during
pregnancy or the
postpartum period

Hematoma
Management
usually conservative unless the hematoma is
greater than 10 cm in diameter or is rapidly
expanding
direct pressure may be applied to control the
bleeding
compression and application of an ice pack to
the area
Identification and ligation of bleeders if the
hematoma continues to expand

Dermatologic Lesions
skin of the vulva is susceptible to any
generalized skin disease or involvement
by systemic disease.
most common skin diseases include

contact dermatitis
Psoriasis
seborrheic dermatitis
Tinea cruris
lichen planus

Dermatologic Lesions

majority are scalelike rashes and usually

presents with pruritus
diagnosis and treatment are often
obscured or modified by the environment
of the vulva

Vulvar Edema
may be a symptom of either local or
generalized disease
Most common causes:
secondary reaction to inflammation
lymphatic blockage

Benign
Lesions of the
Vagina

Urethral Diverticulum

a saclike projection arising from the posterior urethra

often present as a mass of the anterior vaginal wall
symptoms are identical to lower urinary tract infection

Diagnosis:
ascending cystourethrography
cystourethroscopy.
Treatment:
Excisional surgery in acute infection

Inclusion Cyst
most common cystic structures of the vagina
usually discovered in the posterior or lateral
walls of the lower third of the vagina
common in parous women
often results from birth trauma or gynecologic
surgery
majority are asymptomatic
if symptomatic, excisional biopsy is indicated

Tampon Problems
risks with its usage:
vaginal ulcers
toxic shock syndrome from toxins produced by
Staphylococcus aureus

associated with microscopic epithelial changes

the classic forgotten tampon presents with a
foul vaginal discharge and occasional spotting
Treatment: broad spectrum antibiotic

Local Trauma
Coitus is the most frequent etiology
most common injury is a transverse tear
of the posterior fornix
Manifests with profuse or prolonged
vaginal bleeding
Management:
prompt suturing under adequate anesthesia

Benign
Lesions of the
Cervix

Endocervical and
Cervical Polyp
most common benign
neoplastic growth of the
cervix
Seen in multiparous
women in their 40s and 50s
usually secondary to
inflammation

Endocervical and
Cervical Polyp
Symptoms
classic symptom is intermenstrual bleeding
many are asymptomatic
recognized for the first time during a routine
speculum examination

Endocervical and
Cervical Polyp
Management
Polypectomy may be an office procedure
most can be managed by grasping the base of the
polyp with an appropriately sized clamp.
The polyp is avulsed with a twisting motion and sent
to the pathology for microscopic evaluation.
if bleeding ensues, the base may be treated with
chemical cautery, electrocautery, or cryocautery

Nabothian Cysts
so common that they are
considered a normal
feature of the adult cervix
retention cysts of
endocervical glands
occurring due to
obstruction of the gland
duct
asymptomatic

Cervical Lacerations

frequently occur with both normal and abnormal deliveries

vary from minor superficial lacerations to extensive fullthickness lacerations

Management
Acutely bleeding cervical lacerations should be sutured
Complications
extensive cervical lacerations especially those involving the
endocervical stroma may lead to incompetence of the cervix
during a subsequent pregnancy

Cervical Myomas
smooth, firm masses similar to myomas of the
uterus
may become pedunculated and protrude
through the external os of the cervix
diagnosis is by inspection and palpation
management
observation/ expectant management
medical therapy with GnRH agonists
myomectomy or hysterectomy

Cervical Stenosis
most often occurs in the region of the
internal os
may be divided into congenital or acquired
causes of acquired cervical stenosis:
Operative (i.e. cone biopsy, cautery)
Radiation
Infection
Neoplasia

Cervical Stenosis
Symptoms
in premenopausal women: dysmenorhea,
pelvic pain, amenorrhea and infertility
postmenopausal women are usually
asymptomatic
diagnosis is established by inability to
introduce a 1 to 2 mm dilator into the uterine
cavity

Benign
Lesions of the
Uterus

Endometrial Polyp

localized overgrowths of
endometrial glands and stroma
that project beyond the surface of
the endometrium
most arise from the fundus of the
uterus
may vary from a few millimeters to
several centimeters in diameter
may have a broad base or be
attached by a slender pedicle.

Endometrial Polyp
peak incidence between ages 40 and 49
associated with endometrial hyperplasia
unopposed estrogen may be the cause
May be associated with chronic administration
of tamoxifen

majority are asymptomatic

those that are symptomatic are associated
with a wide range of abnormal bleeding
patterns.

Endometrial Polyp
Components
1. endometrial glands
2. endometrial stroma
3. central vascular
channels

Endometrial Polyp
malignant transformation
has been estimated to be as
high as 0.5%
Diagnosis:
Hydrosonography
hysteroscopy and/or
hysterosalpingography

management - removal by
curettage or via the
hysteroscope.

Leiomyoma
benign tumors of muscle cell
origin
often referred to as fibroids or
myomas
most frequent tumors of the
pelvis
highest prevalence occurring
during the fifth decade of a
womans life
majority are found in the
corpus of the uterus

Leiomyoma
classified into subgroups
by their relative anatomic
relationship and position to
the layers of the uterus.
3 most common types
a.intramural
b.subserous
c.submucous

Leiomyoma
submucosal tumors
associated with abnormal vaginal bleeding or
distortion of the uterine cavity that may produce
infertility or abortion

subserosal myomas give the uterus its knobby

contour during pelvic examination
parasitic myoma - myoma that outgrows its
blood supply and obtains a secondary blood
supply from another organ
broad ligament myoma results from lateral
growth of myoma

Leiomyoma
Etiology
each tumor results from an original single
muscle cell (monoclonal theory)
somatic mutation of normal myometrium
to leiomyomas influenced by estrogen.

Leiomyoma
never before menarche
most diminish in size following
menopause with the reduction of a
significant amount of circulating estrogen.
often enlarge during pregnancy and
occasionally enlarge secondary to oral
contraceptive therapy.

Leiomyoma
pathology
grossly, has a lighter color than the
normal myometrium
on cut surface it has a glistening, pearlwhite appearance, with the smooth
muscle arranged in a trabeculated or
whorled configuration
histologically there is a proliferation of
mature smooth muscle cells; the
nonstriated muscle fibers are arranged
interlacing bundles.

Leiomyoma
Types of Degeneration
1. Hyaline
2. Calcific
3. Cystic
4. Fatty
5. Red degeneration

occurs in pregnancy in 5% to 10% of

gravid women with myomas
medically treated during pregnancy,
otherwise, myomectomy is done

6. Necrosis
7. Malignant - 0.3% and 0.7%

Leiomyoma
symptoms
most common are pressure from an enlarging
pelvic mass, pain and abnormal uterine bleeding
severity of symptoms is usually related to the
number, location, and size of the myomas
majority are asymptomatic
rapid growth after menopause is a disturbing
symptom

Leiomyoma
diagnosis
1. pelvic examination
2. Ultrasound

management
if small, symptomatic, judicious observation is made
at first discovery, a pelvic examination at 6 month
intervals to determine the rate of growth should be done
women with abnormal bleeding and leiomyomas should
be investigated thoroughly for concurrent problems such
as endomterial hyperplasia
surgery when persistently symptomatic

Leiomyoma
Medical Management

Medical treatment involves reduction in the size of the myoma by

reducing the level of estrogen and progesterone

e.g.GnRh agonists
Advantages
1. Facilitate easier surgery
2. induction of amenorrhea
Disadvantages
1. degeneration of some leiomyomas, necessitating piece-meal
enucleation at myomectomy
2. hypoestrogenic side effects (e.g. trabecular bone loss, vasomotor
flushes)
3. cost

Leiomyoma
Surgical Management
Indications for Surgery
1. rapidly expanding pelvic mass
2. persistent abnormal bleeding
3. pain or pressure
4. enlargement of an asymptomatic
myoma to more than 8 cm in a
woman who has not yet
completed child bearing

Adenomyosis
growth of glands and
stroma into the uterine
myometrium to a depth
of at least 2.5 mm from
the basalis layer
sometimes known as
internal endometriosis
pathogenesis remains
unknown.

Adenomyosis
Pathology
1. diffuse involvement of the anterior and
the posterior alls of the uterus, with
the posterior being more often
involved
2. there is a focal area of the lesion adenomyoma.
results in a asymmetric uterus
where there is usually a
pseudocapsule.
Criteria for diagnosis
a finding of active or proliferative
glands, (2.5 mm) from the basalis
layer of the endometrium.

Adenomyosis
Diagnosis
majority of women are asymptomatic
May present with secondary
dysmennorhea and menorrhagia. severity
of symptoms increases proportionally with
depth of invasion and penetration.
Usually presents with uterine enlargement
palpated through pelvic examination
Ultrasound is helpful in diagnosis.

Adenomyosis
Treatment
no satisfactory
proven medical
treatment for
adenomyosis.
Hysterectomy is the
definitive treatment

Benign
Lesions of the
Ovaries

Follicular Cysts
most frequent cystic structure
in normal ovaries
arises from temporary
variation of a normal
physiologic process
may result from either

the dominant mature follicles

failing to rupture (persistent
follicle) or
an immature follicles failing to
undergo the normal process of
atresia.

most commonly found in

young, menstruating women

Follicular Cysts

majority are asymptomatic

May be discovered during ultrasound imaging of the pelvis or a
routine pelvic examination
May also present with signs and symptoms of ovarian enlargement
and therefore must be differentiated from a true ovarian neoplasm

Management
Conservative observation
majority disappear spontaneously by either reabsorption of the cyst
fluid or silent rupture within 4 to 8 weeks on initial diagnosis
persistent ovarian mass necessitates operative intervention to
differentiate it from a true neoplasm of the ovary
cystectomy and oophorectomy

Corpus Luteum Cyst

less common than follicular cysts,

but clinically more important
minimum of 3 cm in diameter
may be associated with either
normal endocrine function or
prolonged secretion of
progesterone.
associated menstrual pattern may
be normal, delayed menstruation
or amenorrhea
vary from being asymptomatic to
those causing catastrophic and
massive intraperitoneal bleeding
with rupture.

Corpus Luteum Cyst

Differential Diagnosis
1. ectopic pregnancy
2. ruptured endometrioma
3. adnexal torsion

Management
Conservative if unruptured
With persistent bleeding - treatment is
cystectomy.

Theca Lutein Cysts

least common of the three types of physiologic
ovarian cysts
almost always bilateral and produce moderate to
massive enlargement of the ovaries
Seen in 50% of molar pregnancies and 10% of
choriocarcinoma
also discovered in the latter months of
pregnancies often with conditions that produce a
large placenta, such as twins, diabetes and Rh
sensitization

Theca Lutein Cysts

Luteoma of pregnancy
not a true neoplasm but rather a specific,
benign, hyperplastic reaction of ovarian theca
lutein cells

Theca Lutein Cysts

produce vague symptoms, such as

pressure in the pelvis
presence is established by palpation and
often confirmed by ultrasound examination
treatment is conservative

Dermoid Cyst
Benign cystic teratoma
most common ovarian neoplasm
in prepubertal females and in
teenagers
vary from a few millimeters to 25
cm in diameter, may be single or
multiple
usually discovered either in the
cul-de-sac or anterior to the
broad ligament

Dermoid Cyst

composed of mature
cells, usually, from all
three germ layers
most solid elements
arise are contained in a
protrusion or nipple
(mamila) in the cyst
wall termed the
prominence or tubercle
of Rokitansky

Dermoid Cyst
adult thyroid tissue is discovered
microscopically in approximately 12% of
benign teratomas
Struma ovarii
teratoma in which the thyroid tissue has
overgrown other elements and is the
predominant tissue

Dermoid Cyst

presenting symptoms include pain, sensation of pelvic pressure

50% to 60% are asymptomatic
Some are discovered during a routine pelvic examination,
coincidentally visualized by an abdominal x-ray or ultrasound
examination

management
cystectomy with preservation of as much normal ovarian tissue as
possible
Complications
1. Torsion
2. Rupture
3. Infection
4. Hemorrhage
5. malignant degeneration

Endometrioma
areas of ovarian
endometriosis that become
cystic
usually associated with
endometriosis in other areas
of the pelvic cavity
large chocolate cysts of the
ovary may reach 15 to 20 cm

Endometrioma
the most common symptoms
associated
1. pelvic pain
2. Dyspareunia
3. infertility

Tender and immobile ovaries

on pelvic examination
dense adhesions on surrounding
structures is a common finding

Endometrioma
management
medical therapy is rarely successful in
treating ovarian endometriosis
surgical therapy is complicated by
formation of de novo and recurrent
adhesions

Fibroma

the most common benign,

solid neoplasm of the ovary
comprise approximately 5%
of benign ovarian neoplasms
and approximately 20% of all
solid tumors of the ovary
arises from undifferentiated
fibrous stroma of the ovary
commonly presents in
postmenopausal women
malignant potential is low,
less than 1%

Fibroma

Manifest with pressure symptoms and abdominal

enlargement
Meigs syndrome
the association of an ovarian fibroma, ascites and hydrothorax
both resolve after the removal of an ovarian tumor

management
Exploratory operation
in postmenopausal women, often a bilateral salpingooophorectomy and total abdominal hysterectomy are
performed

Cystadenoma

the epithelial element is

most commonly serous,
but histologically may be
mucinous and
endometrioid
are usually small tumors
that arise from the
surface of the ovary
bilateral in 20% to 25% of
women
usually occur in
postmenopausal women

Cystadenoma

smaller tumors are asymptomatic or pelvic operations.

large tumors may cause pressure symptoms, rarely
adnexal torsion.

Management
postmenopausal women: bilateral salpingooophorectomy and total abdominal hysterectomy
in younger women: simple excision of the tumor and
inspection of the contralateral ovary is appropriate

Torsion

a complication of benign ovarian tumors in the

postmenopausal woman
important cause of acute lower abdominal and pelvic
pain
commonly affects both fallopian tube and ovaries
pregnancy appears to predispose women to adnexal
torsion

Symptoms
Acute abdominal and pelvic pain

nausea and vomiting

fever

Torsion
management
conservative operation for young women
laparoscope or via laparotomy

with severe vascular compromise unilateral salpingo-oophorectomy

Endometriosis

a benign disease but a

progressive one
the presence or growth of the
glands and stroma of the lining
of the uterus in an aberrant or
heterotopic location
Aberrant endometrial tissue
grows under the cyclic
influence of ovarian hormones
mid 30s, nulliparous and
involuntarily infertile with
symptoms of secondary
dysmenorrhea and pelvic pain

Etiology of
Endometriosis
1. RETROGRADE MENSTRUATION
pelvic endometriosis is secondary to implantation of endometrial cells
shed during menstruation

2. METAPLASIA
arises from the metaplasia of coelomic epithelium or proliferation of
embryonic rests.

3. LYMPHATIC AND VASCULAR METASTASIS

endometrial tissue is transplanted via lymphatic pathways and the
vascular system.

4. IATROGENIC DISSEMINATION
5. IMMUNOLOGIC CHANGES
the altered function of the immune-related cells are directly involved on
the pathogenesis of endometriosis

6. GENETIC PREDISPOSITION

Endometriosis
PATHOLOGY
ovaries are the most common
site
grossly exhibit wide variation in
color, shape, size and
associated inflammatory and
fibrotic changes.

cardinal histological features

1. ectopic endometrial glands
2. ectopic endometrial stroma
3. hemorrhage into the adjacent
tissue.

Endometriosis
Signs and Symptoms
Classic symptoms include cyclic pelvic pain and
infertility.
Pelvic pain is often inversely proportional to the
amount of endometriosis.
cyclic pelvic pain is related to the sequential swelling
and the extravasations of blood and menstrual debris
in to the surrounding tissue and mediated by
prostaglandins and cytokines
Dyspareunia
GI and urinary symptoms
classic pelvic findings of a retroverted uterus with
scarring and tenderness posterior to the uterus

Endometriosis
Diagnosis
1. Ultrasound
2. Laparoscopy

Endometriosis
Goals of Management
1. relief of pain
2. promotion of fertility
Primary long term goal in management is
to prevent progression of the disease
process

Endometriosis
Medical Management
primary goal of hormonal treatment is
induction of amenorhea.
DOES NOT provide a long lasting cure of the
disease

Endometriosis
Medications for Endometriosis
1. Danazol
2. GnRH Agonists*
3. Oral contraceptives
4. Medroxyprogesterone acetate (DMPA)

Endometriosis
SURGICAL THERAPY

Often occurs concurrently during laparoscopy to establish diagnosis

only option after failed medical treatment
for women who have moderate to severe endometriosis
Conservative surgery has as its goal the removal of macroscopic
visible areas of endometriosis with preservation of fertility.

Types of Surgical Therapy Used

1. laparoscopy
2. laser
3. Total hysterectomy with ovarian preservation
4. total abdominal hysterectomy with bilateral salpingo
oophorectomy
.

Thank you!