Vulva

Introduction

The vulva is the external female genitalia, encompassing several anatomical structures that play vital roles in protection, sexual function, and reproduction. It is a complex region that includes skin, mucosa, glands, and supporting connective tissues. Understanding its anatomy and physiology is essential for diagnosing and managing a wide range of clinical conditions.

Anatomy of the Vulva

External Structures

The vulva consists of multiple external components that form the visible genital region.

• Mons pubis: A rounded fatty eminence over the pubic symphysis providing cushioning.
• Labia majora: Outer folds of skin and adipose tissue protecting internal structures.
• Labia minora: Inner folds of hairless skin that enclose the vestibule.
• Clitoris and prepuce: Erectile organ with sensory nerve endings; the prepuce covers the glans clitoris.
• Vestibule: Area between the labia minora containing the openings of the urethra and vagina.
• Vestibular glands: Bartholin glands (posterolateral to vaginal opening) and Skene glands (near urethral meatus) that provide lubrication.
• Perineum: Area between the vulva and the anus providing support and structural integrity.

Skin and Fascia

The vulvar region contains specialized skin and connective tissue layers.

• Keratinized skin covering the labia majora and mons pubis, providing protection against friction and infection.
• Mucosal regions, including the labia minora and vestibule, which are sensitive and richly vascularized.
• Superficial fascia and connective tissue layers support the vulvar structures and contribute to elasticity.

Vascular Supply

The vulva receives a rich blood supply essential for function and healing.

• Arterial supply: Internal pudendal artery and branches, providing oxygenated blood to all vulvar structures.
• Venous drainage: Superficial and deep pudendal veins draining into the internal iliac venous system.

Nerve Supply

The vulva is highly innervated, supporting sensory, autonomic, and reflex functions.

• Pudendal nerve: Major sensory and motor innervation for the vulva and perineum.
• Ilioinguinal nerve: Provides sensory input to the mons pubis and anterior labia majora.
• Other small sensory nerves contribute to fine touch and pain perception.

Lymphatic Drainage

Lymphatic vessels in the vulva play a key role in immune defense and metastatic pathways.

• Superficial inguinal lymph nodes drain the external structures.
• Deep pelvic lymph nodes receive drainage from deeper vulvar tissues.

Embryology of the Vulva

The vulva develops from the genital tubercle, urogenital folds, and labioscrotal swellings during embryogenesis. Proper differentiation is critical for normal female genital anatomy.

• Genital tubercle: Forms the clitoris and glans clitoris.
• Urogenital folds: Develop into the labia minora and urethral vestibule.
• Labioscrotal swellings: Form the labia majora.
• Clinical relevance: Abnormal development can lead to congenital malformations such as labial fusion, clitoral hypertrophy, or intersex variations.

Physiology and Function

The vulva serves multiple physiological roles including protection, sexual function, and facilitation of reproductive processes.

• Protective barrier: The labia and mons pubis shield internal genital structures from mechanical injury and infection.
• Lubrication: Bartholin and Skene glands secrete fluids that maintain moisture and reduce friction during sexual activity.
• Sexual function: Richly innervated clitoris and labia provide sexual arousal and orgasmic response.
• Role in urination and childbirth: Vestibule and perineum assist in directing urine flow and supporting the birth canal.

Common Clinical Conditions

Inflammatory and Infectious Conditions

The vulva is susceptible to various infections and inflammatory processes that can cause discomfort and functional impairment.

• Vulvitis: Inflammation of the vulvar skin due to infection, irritants, or allergies.
• Bartholin gland cysts and abscesses: Obstruction or infection of the gland leading to swelling and pain.
• Yeast infections: Candida species causing itching, erythema, and discharge.
• Bacterial infections: Bacterial vaginosis or secondary infections affecting the vulvar region.

Neoplastic Conditions

Neoplastic disorders of the vulva range from premalignant lesions to invasive cancers.

• Vulvar intraepithelial neoplasia (VIN): Premalignant changes affecting the vulvar epithelium.
• Vulvar carcinoma: Malignant tumors, most commonly squamous cell carcinoma, requiring early detection and treatment.

Dermatologic Conditions

Chronic skin conditions frequently affect the vulvar region and can impact quality of life.

• Lichen sclerosus and lichen planus causing atrophy, scarring, or discomfort.
• Psoriasis and eczema leading to erythema, scaling, and pruritus.

Trauma and Structural Abnormalities

The vulva may be affected by congenital or acquired trauma and structural changes.

• Episiotomy and perineal tears occurring during childbirth.
• Congenital malformations such as labial agenesis or fusion.
• Sexual trauma and injuries causing lacerations or hematomas.

Diagnostic Evaluation

Physical Examination

Inspection and palpation are essential for assessing the vulva for structural, inflammatory, or neoplastic abnormalities.

• Visual inspection for color, symmetry, lesions, or swelling.
• Palpation to detect masses, cysts, or tenderness.

Laboratory and Microbiological Tests

Laboratory testing helps identify infectious or inflammatory causes of vulvar symptoms.

• Swabs for bacterial, fungal, or viral cultures.
• Pap smear and HPV testing for neoplastic screening.

Imaging Studies

Imaging may be indicated for deeper lesions or complex cysts.

• Ultrasound for Bartholin cysts or abscesses.
• MRI for suspected neoplastic invasion or congenital abnormalities.

Biopsy

Histological examination is necessary for diagnosing premalignant or malignant vulvar lesions.

• Punch or excisional biopsy depending on lesion size and location.
• Histopathology to guide further management.

Management

Medical Management

Medical therapies for vulvar conditions aim to treat infections, reduce inflammation, and alleviate symptoms.

• Topical antifungals or antibiotics for infectious causes
• Topical corticosteroids for inflammatory dermatoses such as lichen sclerosus
• Systemic medications for severe infections or dermatologic conditions
• Pain relief with analgesics or local anesthetic creams as needed

Surgical Management

Surgical interventions are indicated for structural abnormalities, cysts, abscesses, or neoplastic lesions.

• Excision of Bartholin cysts or abscesses
• Wide local excision for premalignant or malignant vulvar lesions
• Reconstructive or cosmetic surgery for congenital anomalies or post-traumatic repair
• Laser therapy for certain dermatologic conditions affecting the vulva

Preventive Care

Preventive measures help maintain vulvar health and reduce the risk of infections or neoplasia.

• Good hygiene practices and avoidance of irritants
• Regular gynecological examinations and vulvar self-exams
• HPV vaccination to prevent virus-related neoplasia
• Management of chronic skin conditions to prevent progression or complications

References

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