DISEASES OF THE EXTERNAL GENITALS.
Vulvitis.—Vulvitis, or inflammation of the vulva, is not a common disease. The vulva is composed of several parts which are anatomically distinct, and, though all these parts are usually involved in an acute attack of inflammation of the vulva, yet the symptoms of the disease and the pathological appearance depend to a great extent upon the structures which are principally affected. The labia majora, the nymphæ, the vestibule with its mucous crypts or glands, the clitoris, the external urinary meatus, and the ducts of Bartholin’s glands may all be involved in the inflammation. The sebaceous glands of the labia may be especially involved, producing a form of sebaceous acne which has been called follicular vulvitis. Inguinal adenitis may accompany vulvitis.
The appearance of the parts is that characteristic of inflammation of the skin and mucous membrane in any other part of the body. The mucous membrane becomes red and swollen; the labia may become edematous; an abundant purulent discharge covers the parts, and unless cleanliness is practised the irritation from the discharge spreads to the inner aspects of the thighs, the perineum, and the anal region.
The patient suffers with local pain, which is increased by walking and by the passage or contact of urine.
The usual cause of vulvitis is gonorrhea. The condition is sometimes secondary to other diseases. It may be caused by the irritation from the discharges of a vesico-vaginal or recto-vaginal fistula, from a cancer of the cervix or in some forms of endometritis. Girls and women who are unclean may be attacked by vulvitis as a result of irritation from decomposed smegma, sweat, urine, etc. The oxyuris, or thread-worm, may enter the vulva from the rectum and cause, in unclean children, sufficient irritation to produce inflammation. Vulvitis from uncleanliness is most likely to occur in hot weather after prolonged exercise. It not infrequently attacks children, especially those of a strumous diathesis, whose hygienic surroundings are poor. In such cases the suspicions of the parents may demand a medico-legal examination; and it is of importance to remember that vulvitis of this kind is not rare, and is not due to violation or contagion. Vulvitis in little girls may be also due to gonorrhea, independently of violation. This is the cause of epidemics of vulvitis and vaginitis in girls crowded in houses, hospitals, or asylums. The disease is spread by contamination from towels or bed-clothing.
The essential points of treatment to observe in the acute stage of vulvitis are rest in the recumbent posture and perfect cleanliness. The labia should be separated and the parts frequently bathed and cleaned with warm water. Various local washes or applications are of use. A warm solution of boracic acid (ʒj to a pint of water), the dilute solution of the subacetate of lead, or a solution of bichloride of mercury (1:5000) may be used.
If the disease is of gonorrheal origin, the parts should be painted once or twice a day with a 2 per cent. solution of nitrate of silver, applied after the discharges have been gently washed away.
As the disease subsides the inflammation may be found to persist in the crypts of the vestibule, the urinary meatus, and the ducts of Bartholin’s glands. It is very important that all remains of the inflammation, especially if it be of septic or gonorrheal origin, should be eradicated before the woman is discharged from treatment. The presence of any focus of inflammation, even though latent, is a constant source of danger to the woman; for septic organisms or material may be carried from the external genitals to the higher parts of the genital tract, as the uterus and Fallopian tubes, with the most disastrous results.
Sometimes a small drop of pus will be observed escaping from one of the small glands or crypts of the vestibule, about the urinary meatus, after the inflammation has disappeared in other parts of the vulva. In this case the gland should be punctured with a fine cautery-point or a fine wooden probe or point saturated with pure carbolic acid or other caustic.
If the disease persists in the external meatus or urethra, it must be treated by the local applications appropriate for urethritis.
Fig. 16.—Appearance of the external genitals in a woman with gonorrhea: G. m., gonorrheal macula situated at the base of a vaginal caruncle.
Inflammation of the Vulvo-vaginal Glands.—The vulvo-vaginal glands are two in number. They are about the size of a bean, and are situated deeply on the inner aspect of the labia majora, where they may be felt in thin women. The duct of the gland is about one inch in length, and opens immediately in front of the hymen, about the middle of the side of the ostium vaginæ. In cases of vulvitis the duct of the gland usually becomes inflamed, and the inflammation may extend to the gland, producing abscess of the vulvo-vaginal gland.
Inflammation of the duct and the gland may also occur independently of vulvitis, from direct septic or gonorrheal infection.
Suppuration of the duct may be demonstrated by pressing over the course of the duct, when a drop of pus will escape from the opening. In such cases the orifice of the duct is usually surrounded by a red areola, resembling a flea-bite, which has been called the gonorrheal macula ([Fig. 16]). This macula persists long after all other traces of inflammation about the vulva and vagina have disappeared, and after all frank suppuration in the duct has subsided. Its presence indicates at least the probability of previous gonorrheal infection.
When the duct of the gland alone is the seat of inflammation, it should be laid open with fine scissors or knife, and the tract thoroughly cauterized with the nitrate-of-silver stick, pure carbolic acid, or a solution of chloride of zinc (2 per cent.).
Suppuration of the vulvo-vaginal gland is accompanied by marked swelling and peripheral edema. The swelling may extend to the anus, and is of characteristic shape ([Fig. 17]). The pain is always severe. Fluctuation is first apparent on the inner surface of the labium majus. If the condition is not treated, one or more fistulous openings appear below the orifice of the duct, and the pus is discharged. The condition then becomes chronic. The fistulous openings persist. Acute inflammation disappears from the gland, leaving it in a condition of hypertrophic induration. A thin, milky or greenish, purulent fluid may be pressed out of the duct or the fistulous openings. Infection from this discharge may be communicated to man, or may ascend the genital tract, producing inflammation of the endometrium or of the Fallopian tubes.
Fig. 17.—Abscess of right vulvo-vaginal gland.
In abscess of the vulvo-vaginal gland a free incision should immediately be made into the labium at the junction of the skin and the mucous membrane. The interior should be wiped out with pure carbolic acid and the cavity packed with gauze. If the disease is first seen in the chronic stage, after the abscess has evacuated itself, the only method of cure is to excise, with curved scissors, the whole of the indurated gland, the duct, and the fistulous tracts. The wound may be left open and packed, or it may be closed immediately with buried catgut sutures.
Cysts of the Vulvo-vaginal Glands.—Cysts may occur in the duct of the vulvo-vaginal gland or in the gland itself. Cysts of the duct are small—about the size of a chestnut. They are situated superficially, lying immediately under the mucous membrane of the vagina at the base of the labium minus.
Fig. 18.—Cyst of the right vulvo-vaginal gland (Hirst).
Cysts of the gland may be unilocular if formed at the expense of a single lobule of the gland, or multilocular if several lobules enter into their formation. These cysts may attain the size of the fetal head ([Fig. 18]).
Cysts of the gland or of the duct are formed by retention of the cyst-contents. The retention is due to occlusion of the duct, usually the result of inflammation. In some cases the duct remains pervious, and the retention is due to the altered character of the secretion of the gland, which becomes too viscous to pass, except under unusual pressure, along the duct.
These cysts contain clear yellow or chocolate-colored fluid. The diagnosis of cyst of the vulvo-vaginal gland is usually not difficult. If we are in doubt in regard to the fluid character of the tumor, this may be determined with the exploring-needle.
Inguinal hernia, hydrocele of the canal of Nuck, cysts of the round ligament, and sacculated cysts of old hernial sacs may be mistaken for cysts of the vulvo-vaginal glands. In such cases, however, the tumor lies more in the upper and outer part of the labium majus, and extends to, and may be connected with, the external inguinal ring.
Cysts of the vulvo-vaginal glands should be treated by free incision and packing, or by extirpation. If the sac is emptied by the aspirator or by a small incision, it will refill. The best method is to extirpate the cyst. In case there has been no inflammatory action binding the cyst to surrounding structures, extirpation without rupture is easy. If rupture occurs, the cyst-wall may be dissected off with the knife or removed with the curved scissors. The wound may be immediately closed with deep and superficial sutures.
Pruritus Vulvæ.—Pruritus vulvæ, or itching of the vulva, may be due to a great variety of causes. Eruptions of the vulva, such as eczema, cause itching. Irritation from the discharge of vaginitis, metritis, cancer of the cervix or body of the uterus, the presence in children of the thread-worm, the irritation from diabetic urine, or trophic lesions of the nerves due to diabetes, may result in pruritus. Some of the pathological conditions of the uterus, tubes, and ovaries may produce reflex irritation of the nerves of the vulva, and cause itching, in a manner similar to that in which vesical calculus causes itching of the glans penis.
The congestion of the external genitals that accompanies pregnancy may also produce pruritus.
There are some cases of pruritus vulvæ, however, in which no physical cause for the intolerable itching can be discovered, and in which minute examination of the affected portions of skin or mucous membrane demonstrates no pathological change. Such cases are called idiopathic.
The itching may be so severe that the woman cannot refrain from scratching and rubbing the parts on all occasions. She becomes debarred from the society of her friends, and seeks relief in anodynes and hypnotics. The continual scratching increases the irritation of the vulva, and an eczematous eruption may result, which produces an irritating discharge that spreads the irritation to other parts of the body with which it may come in contact.
The itching of pruritus may extend into the vagina, to the skin of the abdomen, to the inner aspect of the thighs, and to the anus.
In the treatment of pruritus it is first of importance to discover, if possible, the cause of the itching. Any vaginal or uterine discharge should be investigated. Discharge from the uterus can be eliminated as a cause by placing against the external os a pledget of cotton, frequently renewed, to absorb the discharge before it reaches the vulva, or the parts may be kept clean by frequent douches. In children the stools should be examined for the thread-worm. The urine should always be examined. Diabetes is a frequent cause of pruritus vulvæ in old women. Any pathological condition of the uterus, Fallopian tubes, and ovaries should be treated before we can eliminate this as a possible cause of pruritus.
In the cases of so-called idiopathic pruritus in which no local lesion can be discovered attention should be directed to the general nutrition of the patient. As in pruritus ani, the gouty diathesis may cause the disease. Alcoholic drinks, rich food, fish and shell-fish, may assist in its production.
Treatment.—A great variety of local applications have been used for the relief of pruritus. In case of diabetes the urine should, as much as possible, be kept from contact with the parts, which should be thoroughly dried after urinating, and dusted with a powder consisting of equal parts of subnitrate of bismuth and prepared chalk.
The following local applications are useful in pruritus:
| Bichloride of mercury, | gr. ½; | ||
| Emulsion of bitter almonds, | ℥j, | ||
| applied twice a day. | |||
A powder of 1 grain of morphine to 2 grains of prepared chalk, applied twice a day.
| ℞. | Tinct. opii, | ||
| Tinct. iodi, | |||
| Tinct. aconit., | āā. | ʒv; | |
| Acid, carbolic., | ʒj, | ||
| applied once or twice in the twenty-four hours. | |||
An ethereal solution of iodoform sprayed into the folds of the vulva with an atomizer.
Cauterization with pure carbolic acid.
In pruritus of gouty origin an ointment, composed of 15 grains of calomel to 1 dram of cerate, will often relieve or cure the local condition. A small quantity should be rubbed over the itching area at bed-time. Often one or two applications give immediate relief. If the condition does not quickly improve it is useless to continue this treatment. The danger of salivation from its prolonged use should be remembered.
In cases which have resisted all local applications the affected areas of mucous membrane have been excised. Even this method, however, does not promise certain cure. It should be tried, however, when the pruritus is localized and has resisted the milder forms of treatment.
Kraurosis Vulvæ.—Kraurosis vulvæ is a very rare disease, of chronic inflammatory nature, affecting the vulva. The disease is characterized by cutaneous atrophy, with very marked shrinking and contraction of the vaginal orifice. The lesions may be unilateral or circumscribed, but usually the tissues of the labia majora, the nymphæ, and the area surrounding the clitoris and urinary meatus are more or less involved. The cause of the disease has not as yet been determined. It has been observed at every age after puberty, in the nulliparæ as well as the multiparæ, and in the parturient woman. It must be differentiated from pruritus and the atrophic changes which take place after the physiological and induced menopause.
The first symptoms noticed by the patient are usually those of pruritus—an intense itching and burning about the vulva. In some cases the affected tissue early becomes excessively hyperplastic. The mucous membrane and the skin of the vulva are often discolored, small red spots appearing, which are sensitive to touch. Later a peculiar shrinking of the superficial tissue takes place, and the diseased surfaces become dry and whitened. The nymphæ gradually disappear, fusing with the labia majora; and the mucous membrane and skin become shiny and drawn smoothly over the shrunken clitoris. Cracks or fissures appear on the dry surfaces. A sensation of drawing and shrinking of the vulva is now usually experienced. The vaginal orifice gradually narrows and contracts, until frequently the little finger can scarcely be introduced. When this last condition of atrophy is reached, the pathological process is arrested, the subjective sensations of shrinking pass away, and the symptoms resembling pruritus are no longer experienced. The shrunken and contracted vaginal orifice, however, persists and is never spontaneously restored.
Treatment.—Palliative treatment by local applications may be tried, or a cure may be attempted by operation. The palliative treatment is simply directed toward the relief of the subjective symptoms, which at times are exceedingly painful. Pure carbolic acid or a solution of cocaine applied locally, or pure nitrate of silver applications frequently repeated, afford temporary relief. Cloths wrung out of hot water and placed over the vulva also lessen the suffering. A solution of the neutral acetate of lead in glycerin, on cotton placed between the labia, is recommended. Forced dilatation of the vaginal orifice under ether has been practised with good result. The most satisfactory treatment is complete excision of the diseased tissue. Unless all affected tissue is removed, the disease may return.
Varicose Tumors of the Vulva.—Varicose tumors of the vulva are usually the result of pregnancy. They may, however, accompany any form of pelvic or abdominal tumor, the pressure of which interferes with the venous circulation of the pelvis. The varicose condition usually affects the labia majora. It varies from a mere increase in size of the veins of the vulva to a varicose tumor the size of the fetal head. The condition, being secondary, usually disappears with the removal of the exciting cause. The labia may be supported with a compress and a bandage.
Hematoma of the Vulva.—Hematoma of the vulva is due to the subcutaneous rupture of a vein. Blows, kicks, or falls cause this condition. It is usually produced by rupture of a varicose vein during pregnancy or labor.
The affected labium is purple in color and may reach the size of a fetal head. When the hematoma is small the vagina should be kept as clean and aseptic as possible, and a light compress should be applied. Absorption usually takes place. If the collection of blood is large or if it has become infected, a free incision should be made into the labium, the clots should be turned out, and the cavity thoroughly washed and packed with gauze.
Papilloma.—Papillomata or warts of the vulva are not uncommon. They may occur singly, scattered over the vulva and the neighboring skin, and extending up the vagina as far as the cervix uteri, or they may occur in large cauliflower-like masses. They are pink or purplish in color. They often exude a bloody, offensive discharge, which is capable of exciting a similar condition by contact. Papilloma is usually the result of gonorrhea or syphilis. It may, however, be caused by irritation from filth or by the leucorrhea of pregnancy.
The treatment of papilloma is by excision. The small warts should be picked up with forceps and clipped off with curved scissors. Every one should be removed or the condition may recur. In the case of large papillomatous tumors the wound of excision should be closed with continuous sutures. Pregnancy is no contraindication to excision of papillomata.
The vulva may be the seat of epithelioma, lupus, sarcoma, fibroma, fibromyoma, myxoma, lipoma, or enchondroma. These tumors present the same characteristics and demand the same surgical treatment as in other parts of the body.
Small cysts have been found in the labia majora and minora, the vestibule, the hymen, and the clitoris.
Elephantiasis.—True elephantiasis of the vulva (elephantiasis Arabum), due to the presence of the Filaria sanguinis hominis, is a rare disease in this climate. The disease occurs especially in Barbadoes. It may affect the labia and the clitoris. The hypertrophied labia may attain the size of the adult head.
The treatment of this condition is excision of the affected structures.
There is a syphilitic form of hypertrophy or elephantiasis of the vulva which is not uncommon in this country. The labia minora and majora may be transformed into enormous flap-like folds. Though at first free from ulceration, this may subsequently result from chafing. Warty growths may cover the hypertrophied labia, the perineum, and the buttocks. The disease usually affects both labia, though it may be confined to one.
This manifestation of syphilis does not yield readily to constitutional or local medicinal treatment. Many cases prove to be incurable by medicine. Antisyphilitic treatment should always be tried at first, and if this fails, the hypertrophied structures should be excised with the knife.
If, in such cases, there is any doubt in regard to diagnosis between syphilis and cancer, a small portion of tissue should be excised and submitted to microscopic examination.
Adhesions of the Clitoris.—Adhesions between the glans of the clitoris and the prepuce or hood which covers it are exceedingly common. Usually no trouble whatever is caused by these adhesions, unless an accumulation of smegma takes place, or irritation is produced by the presence of a concretion.
In case of any irritation about the genitals, the prepuce and clitoris should always be carefully examined. In fact, a careful examination of the clitoris should form a routine part of all examinations of the external genitals.
When trouble arises from the presence of adhesions, the prepuce should be drawn back and the adhesions freed with a blunt probe. A 20 per cent. solution of cocaine should be applied to the clitoris for ten minutes previous to the operation. The whole corona and the sulcus back of the corona should be exposed. The raw surface should be covered with vaseline, and the patient should abstain from walking as long as pain is caused by it. The prepuce should be drawn back and vaseline applied every day for two weeks, to prevent the formation of adhesions.