CHAPTER XXI THE DIAGNOSIS OF DISEASES OF THE VULVA (Part 1)

CHAPTER XXI THE DIAGNOSIS OF DISEASES OF THE VULVA Anatomy, p. 388 : Age changes, p. 391. Congenital Anomalies, p. 391: Malformations of the vulva as a whole, p. 391. Development of the external genital organs, p. 392. Anomalies, p. 393. Malformations of the clitoris, p. 393. Malformations of the labia majora, p. 394. Malformations of the labia minora, p. 394. Mal- formations of the hymen, p. 396. Imperforate hymen, p. 396. Hermaph- roditism, p. 399. Injuries of the vulva, p. 400. Inflammation of the vulva, p. 402: Simple or catarrhal vulvitis, p. 402. Gonorrheal vulvitis, p. 402. Diabetic vulvitis, p. 403. Thrush, p. 403. Elephantiasis, p. 404. Pruritus vulvae, p. 404. Kraurosis vulvae, p. 404. Edema and gangrene, p. 405. Varix, p. 405. Venereal lesions of the vulva, p. 406; Chancroids, p. 406. Chancre, p. 406. Mucous patches, p. 407. Condylomata, p. 407. Gumma, p. 408. Tuberculosis of the vulva, p. 408. Cysts of Bartholin's gland, p. 408; Abscess of Bartholin's gland, p. 409; Differential diagnosis of cyst and abscess, p. 412. Labial Hernia, p. 412. Benign tumors of the vulva, p. 413. Malignant tumors of the vulva, p. 414: Cancer, p. 414; Differential diagnosis of cancer, p. 415. Sarcoma, p. 416. ANATOMY The term vulva is applied collectively to the structures often called the external genital organs, and includes: the mons veneris, the labia majora and minora, the clitoris, the vestibule, and the hymen. The Mons Veneris. — The mons veneris is the eminence in front of the symphysis pubis. It is formed by a collection of subcutaneous fat and is covered with coarse hair, generally of the same color as the hair of the head. The upper limit of the hair is a horizontal line, differing from the male pubic hair, which is continued up- ward along the linea alba in a V shape. Below, the hair is con- tinuous with the hair on the outer surfaces of the labia majora. The Labia Majora.— These are two thick, parallel folds of skin 388 ANATOMY 389 extending from the mons veneris nearly to the anus. They are wider above and grow thinner as they approach the perineum where they are lost. Each fold is called a labium ma jus and the opening where the two meet in the middle line is called the pu- dendal slit (rima puclendi). The posterior limit of the slit is a transverse cutaneous fold called the fourchette, the depression between this and the base of the hymen being the fossa navicularis. f Fig. 156. — Diagram of the Vulva. (Dickinson.) The labia majora are pigmented more than the surrounding skin and the outer surfaces contain sebaceous glands and are covered with more or less hair, the hair becoming scanty and short to- ward the posterior parts. The inner surfaces of the labia majora are smooth, and the thin skin covering them resembles mucous membrane in the virgin, but is harder in the parous woman. The outer ends of the round ligaments become lost in the upper por- 390 DISEASES OF THE VULVA tions of the labia majora, which are made up of fat and connec- tive tissue. The Labia Minora, or Nymphae. — These are two thin, pink, deli- cate folds of skin extending from the frenum of the clitoris above, downward to be lost on the inner surfaces of the labia majora at about the level of the opening of the vagina. They are developed from the margins of the genital cleft. They have no hairs but abundant sebaceous glands. Each fold is a labium minus, and the two labia may be asymmetrical. In the virgin the lesser labia are entirely covered by the greater labia, but under abnormal conditions the nymphae may project beyond the labia majora, and in this case they are pigmented. The Clitoris. — This is a rudimentary penis developed from the genital eminence, but it is without a urethra traversing it (see Fig. 157). It is situated between the labia majora and is concealed by the upper portions of these structures, it is about an inch and a quarter long, and arises from the pubic arch by two crura, which unite to form the body of the clitoris. At its tip is a glans, which is covered partially or wholly by a prepuce, that, coming from above and partially encircling the glans, is prolonged downward into the labia minora. The clitoris is made up of erectile tissue and the glans is covered by a very sensitive epithelium. At the base of the glans are sebaceous glands which secrete smegma. The Vestibule. — The space between the clitoris above, the en- trance of the vagina below, and the nymphae on the sides is the vestibule. It is developed from the urogenital sinus, is, roughly, triangular in shape, and is pierced in its centre by the external orifice of the urethra, (meatus urinarius) which presents a longi- tudinal slit closed by two little lips (labia urethras) which form a slight elevation above the surface of the vestibule. The Hymen. — This is a thin, circular, white or light pink, per- forated membrane which separates the vulva from the vagina. It is made up of connective tissue and elastic fibers and is covered on both sides with stratified epithelium. Its shape, thickness, and even its situation vary in different cases. The opening into the vagina (introitus vaginae) is generally in the anterior part; it may be ring-shaped (annular), admitting the tip of the forefinger; this is the commonest condition, or it may be cribriform, fimbriate, horseshoe-shaped, septate or linear. The tissues of the hymen CONGENITAL ANOMALIES 391 may be tough and resistant, though generally friable and torn with the first coitus or even by vaginal examination, always by parturi- tion. The remains of the torn hymen are called carunculae myrti- formes. In the infant and embryo the hymen projects forward into the cleft between the labia in the form of two apposed longi- tudinal lips. (See Figs. 163 to 170.) The Glands of Bartholin. — These glands furnish a clear, glairy, lu- bricating mucus for coitus and for the delivery of the child during labor. They are two in number, each is about the size of a large pea and is situated at the side of the posterior part of the vaginal canal in the sphincter vaginae muscle. The opening of the canal of the gland is a minute pin-point hole to be found in the posterior portion of the inner surface of the labium majus. In women who have borne children it is just outside the last and uppermost car- uncula myrtiformis. Age Changes Infancy. — In infancy there is no visible hair on the mons, and the labia majora are rounded and firm, the labia minora projecting between them as slightly elevated, pink folds. (See Fig. 203.) Puberty. — At puberty hair grows on the mons and the outer surfaces of the labia majora, the latter becoming pigmented and increasing in size so that they conceal the nymphse. The nymphse may grow larger after puberty, and if they do, the exposed parts become pigmented and of coarser texture. Enlargement of the nymphse has been ascribed to masturbation, and it is likely that such is sometimes the case, though this is not the only cause. Old Age. — The hair on the mons and labia majora becomes gray and is shed soon after the hair of the head. After the meno- pause the mons loses its fat gradually and the labia shrink so that in old age the orifice of the vulva gapes. The hymen if unbroken shrinks, and the introitus vaginae is narrowed in any event. CONGENITAL ANOMALIES Malforations of the Vulva as a Whole. — True congenital anom- alies of the vulva, such as complete atresia of the vulva, arc very rare and occur for the most part in non-viable fetuses. There are 392 DISEASES OF THE VULVA on record, however, one case of double vulva in an adult, and many cases of infantile vulva where the labia majora and minora were small and flat, the introitus narrow, and the mons veneris not prominent and poorly provided with hair. Such a condition is usually associated with poorly developed general physique. Pre- cocious development of the vulva is found sometimes in conjunction with precocious menstruation in very young children. In these cases the breasts also show abnormal development. In the chapter on diseases of the vagina, page 356, I have referred to the not in- frequent occurrence of a normal vulva and normal body form Ghns cVttonciis*.^ llrogpmtal Sinus. Anus Fig. 157. — The External Genital Organs at the Beginning of the Third Month of Fetal Life. (After Keibel.) associated with a rudimentary uterus and vagina. An apprecia- tion of the steps in the development of the several parts of the urogenital system is a necessity for the proper understanding of the different congenital malformations of the external genitals. Development of the External Genital Organs. — At the end of the first month of intra-uterine existence there is developed in the outer surface of the caudal region of the embryo a depression in the skin (Fig. 158), which grows deeper until it reaches the allantois and rectum to form the cloaca (Fig. 159). About this time ap- pears the genital eminence above the cloaca, flanked on each side by a fold of skin. The genital eminence in the female becomes later the clitoris, and the folds of skin the labia majora, the nymphse being developed on their inner surfaces. (See Fig. 157.) Figure COXGEXITAL ANOMALIES 393 160 shows the differentiation of the bladder and rectum from the allantois and hind gut respectively, and the beginning of the formation of the perineum by the downward extension of the perineal septum between the rectum and the urogenital sinus, which has been formed by a union of the ducts of Miiller and the cloaca. The proctodeum, the posterior portion of the invagination of the skin that is to form the anus, is now differentiated. In Fig. 161 the urethra has been formed and a septum divides the urinary from the genital tract. Figure 162 (at about the end of the fourth month) shows the vagina, although not yet with a canal, developed from the ducts of Miiller and separated by the hymen from the vulva. The perineum has its mature shape and the anus now opens backward. The vestibule, the clitoris, and both sets of labia are already formed, although they do not assume their final shape until the fifth or sixth month. The external genital organs are at birth much more completely developed than the internal organs, which remain in a more or less rudimentary condition until the child is eight or ten years old. Anomalies. — Persistence of the Urogenital Sinus. — This is most often met with as an opening of the anus into the vagina, "anus vaginalis" so called, in which there is incontinence of feces because of the absence of the sphincter ani muscle. There is met with rarely a hypospadias, or a connection of the urethra with the vagina high up, the vestibular canal being long. Another form of hypospadias, also rare, is the condition where there is no urethra and the bladder opens directly into the vestibular canal. In these cases there is of necessity incontinence of urine and the bladder opening can be seen in the anterior wall of the vagina. Occasionally a case of persistent cloaca is met with, the perineal septum and the sphincter ani not being developed. Incontinence of feces exists in such cases. Malformations of the Clitoris. — The clitoris may be absent, it may be small, it may be hypertrophied, it may be cleft, as in epispadias, or the prepuce may be adherent. Absence of the clitoris is an extremely rare occurrence, and so is cleavage of the clitoris, but the organ is found very small not infrequently, and large quite com- monly. Sometimes the clitoris attains the size of a small puerile penis. Such a condition has no clinical significance and requires no treatment unless it interferes with coitus, — an unusual happening. 394 DISEASES OF THE VULVA An adherent prepuce, on the other hand, may be the source of sexual irritation and conduce to masturbation, and in children may be the cause of enuresis, some writers even attributing the existence of symptoms of grave derangement of the general ner- vous system to this as a cause. All women who apply for gyne- cological treatment should be examined with reference to the adhesions of the prepuce. The prepuce should be pushed upward with two fingers until the glans can be distinguished. By the use of gentle pressure, aided if necessary by the flat end of a surgical probe, the prepuce may be separated from the glans. Hard, white specks of retained smegma not larger than a pin's point are gen- erally found under the adherent prepuce. Some authors maintain that adhesion is a condition normal to the prepuce in both sexes. The number that are found to be adherent in girls and women, if every case coming under observation is examined for this con- dition, has been surprisingly large in my experience, and my own view is that adhesion of the prepuce in the girl and woman plays a much less important role in the causation of symptoms than in the boy and man. Malformations of the Labia Majora. — The following malformations have been described, although all must be regarded as extremely rare. Absence of the labia, rudimentary labia, multiple labia, hypertrophy of the labia, and adhesions of the labia. The only ones that require comment are multiple and adherent labia. The former consists of longitudinal division of the labia into several folds of skin instead of one, and the latter is a part of apparent vulvar atresia. If the closure is complete the child is non-viable. Generally there is a small opening anteriorly through which mic- turition takes place. Malformations of the Labia Minora. — The same malformations as in the case of the labia majora have been met with. The two that need description are hypertrophy of the labia and adherent labia. Hypertrophy of the nymphce is by no means rare. It reaches a stage of extreme development in the " Hottentot apron," so- called, in which the labia extend downward some seven or eight inches between the thighs. This condition is unknown among the women of civilized races. A moderate degree of hypertrophy is not uncommon and is of no importance unless it interferes with coitus. Adherent labia represent inflammatory affections during Depresstoq m shin Fig. 158. — The Allantois, the Hind gut, M filler's Duct and the Depression in the Skin. Cloaca. Fig. 159. — The Depression in the Skin Has United with the Al- lantois and Hindgut to Form the Cloaca. 'UroaeniTal -* Smu$ Fig. 160.— The Bladder Is Formed, also the Beginning of the Urethra and the Vagina, Both Opening into the Urogenital Sinus. The Rectum opens Separately into the Proctodeum. Anus Fig. 161. — The Urethra is further Developed, the Opening of the Vagina Reaches nearer the Vulva, and the Perineum Is Formed. Vestibule: Perineum Fig. 162. — Complete Development. The Urogenital Sinus Has Be- come the Vestibule. The Hymen nearly Closes the Opening of the Vagina, which Has Become Enlarged. The Rectum is more Capacious and the Anus Opens Backward Posterior to the fully Developed Perineum. Figs. 158-162. — Five Diagrams of Longitudinal Median Sections op Embryos, Illustrating the Stages of Development of the Genital Organs. (After Schroeder.) 395 396 DISEASES OF THE VULVA fetal or infantile life. The union is generally incomplete and there is an opening through which urine can escape. Imme- diate division of the two labia is demanded if there is no open- ing when a child with this deformity is born, otherwise it is non-viable. Malformations of the Hymen. — Authorities are divided as to the structures from which the hymen is developed. Pozzi's view of its development ("Traite de Gynecologie," quat. edit'n, p. 1383) seems as near the facts as any. It is that the hymen is developed in the fifth month from both the vagina above, after fusion of the Mullerian ducts, and from the vestibular canal, — a vestige of the urogenital sinus, — below. Gellhorn (Amer. Jour. Obstet., Aug., 1904, p. 145), who has studied this question most carefully, thinks that the indications point to the hymen being derived from the Mullerian ducts exclusively. The hymen has never been found absent by competent observers. As has been stated in describing the anatomy, the form of the hy- men varies much in different individuals, also its thickness. Of the different forms in which the hymen is found, the fimbriate or, denticulate, the septate, the cribriform, the annular, the linear and the crescent, the annular and crescent-shaped hymens are the most common. The hymen may be so tough and resistant that it is not ruptured by attempts at sexual intercourse, on the other hand it may be so dilatable that it stretches to accommodate the penis with- out tearing. The rule is that it is generally torn by intercourse, and always by parturition. Cysts and solid tumors of the hymen have been described, but they are excessively rare. Imperforate Hymen. — The opening in the hymen may be ex- tremely minute and yet pregnancy may ensue. A case has been recorded by H. L. Horton (Boston Med. and Surg. Jour., vol. 82, p. 33) of a patient who was in labor with a hymeneal opening measuring only one-sixteenth of an inch in diameter. From the most recent researches the view has gained ground that imper- forate hymen is a misnomer, the condition being one really of atresia of the vagina, for in many of the cases recorded after the liberation of retained menses a hymen has been found outside the obstructing membrane. In other words, the lower end of the va-