ANATOMY OF THE EXTERNAL GENITALIA

The female external genitalia is made up of both urinary tract and reproductive structures.

 collectively fall under the term vulva (covering or wrapping-from the exterior
observation of the female external genitalia, it does appear to be covered or wrapped
by skin folds)
 The components of the ENTIRE VULVA are the mons pubis, labia majora, labia minora,
clitoris, urethra, vulva vestibule, vestibular bulbs, Bartholin's glands, Skene's glands, and
vaginal opening. 
o Mons Pubis
 A prominent tissue mound made up of fat located directly anterior to
the pubic bones
  is usually covered in pubic hair in pubertal females
 Serves as a source of cushioning during sexual intercourse
 Also contains sebaceous glands that secrete pheromones to induce
sexual attraction.
o Labia majora
 defined as the larger lips
 pair of cutaneous skin folds that will form the lateral longitudinal
borders of the vulva
 forms the folds that cover the labia minora, clitoris, and other parts of
the vestibule
 Engorges with blood and appears edematous during sexual arousal
o Labia minora
 defined as the smaller lips
  a pair of small cutaneous folds that begins at the clitoris and extends
downward
 Its anterior folds encircle the clitoris forming the clitoral hood and the
frenulum of the clitoris. It descends obliquely and downward forming
the borders of the vestibule. Eventually, the posterior ends of the labia
minora terminate as they become linked together by a skin fold called
the frenulum of the labia minora. 
o Clitoris
 is homologous to the glans penis in males
 is a sex organ in females that functions as a sensory organ
 The glans clitoris is highly innervated by nerves and perfused by many
blood vessels
 Since the glans clitoris is so highly innervated, it becomes erected and
engorged with blood during sexual arousal and stimulation.
o Vestibule
 area between the labia minora
  contains the opening to the urethra and the vaginal opening
o Bartholin's Glands
 also known as the greater vestibular glands (homologous to the
bulbourethral glands in males)
 two pea-sized glands located slightly lateral and posterior to the vagina
opening
 function to secrete a mucus-like substance into the vagina and within
the borders of the labia minora. This mucus functions as a lubricant to
decrease friction during intercourse and a moisturizer for the vulva.
o Skene's Glands
 are also known as the lesser vestibular glands (homologous to the
prostate glands in males)
 located on either side of the urethra
 are believed to secrete a substance to lubricate the urethra opening
 also believed to act as an antimicrobial to prevent UTI
o Urethra
 an extension of a tube from the bladder to the outside of the body
  for the excretion of urine
 The urethra in females opens within the vulva vestibule located inferior
to the clitoris, but superior to the vagina opening
o Vagina
 an elastic, muscular tube connected to the cervix proximally and
extends to the external surface through the vulva vestibule
 The distal opening of the vagina is usually partially covered by a
membrane called the hymen
 The vaginal opening is located posterior to the urethra opening
  Acts as a reservoir for semen to collect before the sperm ascends.
 also acts as an outflow tract for menses.
 BLOOD SUPPLY AND LYMPHATICS
o Arterial
  Internal pudendal artery
 perfuses the majority of the external female genitalia
 a branch of the internal iliac artery
 Superficial external pudendal artery
 is a tributary of the femoral artery
 also supplies a part of labia majora
o Venous
 external and internal pudendal veins
 venous drainage of the external female genitalia 
o Lymphatic 
 superficial inguinal lymph nodes
  lymphatic drainage of the external female genitalia drains
except for the clitoris
 deep inguinal lymph nodes
 where the lymph from the clitoris drains
o Nerves
 pudendal nerve
 motor, sensory, and sympathetic nerve innervation of the
external female genitalia 
 is made up of the second, third, and fourth sacral spinal roots
 Will branch into three main branches: the dorsal nerve for the
clitoris, the perineal nerve for the external genitalia, and the
inferior rectal nerve.

CONDITIONS RESULTING TO GENITAL LESIONS

Episiotomy

 Is where the vaginal opening is enlarged by an incision that is done either midline or laterally
during delivery of a child that risks tearing and damaging the vaginal opening
 The reason for performing episiotomies is that an incision in episiotomy can be easily repaired
and decrease healing time, in contrast with a torn vaginal opening that could potentially involve
the perineum muscles and the rectum

Sexually Transmitted Infections

1. Herpes Simplex Virus

 due to the infection from Herpes simplex virus 1&2
  HSV2 being the most common in the genital region while HSV 1 is more
  A chronic viral condition where the virus can develop lifelong latency residing in the
dorsal root gangliion. The latency and reactivation is controlled by the immune
mechanism of the body
 manifest as episodes of painful burning vesicular lesions which can be located in the
external genitalia which may also appears in the vagina, cervix, anus, and rectum.
 The virus infects the viable epidermal cells which manifest as erythema and papule
formation. Later on, the lesion becomes a blister which when disrupts, becomes a
painful ulcer.
 Signs of viremia are also seen: low-grade fever, headache, malaise, and myalgia
 Urinary frequency and dysuria occurs when urine is in contact with the ulcer
2. Syphilis
 result from Treponema pallidum
 manifests as a painless chancre (hallmark lesion)in the primary stage.
 i. The nontender ulcer has raised rounded borders and an uninfected base. This
may spontaneously heal up in 6 weeks but can also progress to secondary
syphilis
 With secondary syphilis, baccteremia develops 6 weeks to 6 months after a chancre
appears. Its hallmark is a maculopapular rash that may involve the entire body and also
includes the palms and soles and in mucuous membranes. It may also manifests as
fever, widespread lymphadenopathy (epitrochlear node is pathognomic), and genital
lesions similar to genital warts.
 If there is still no treatment during the secondary stage, the infection will progress into
the tertiary stage wherein there are necrotic lesions called Gummas, neurological
symptoms such as tabes dorsalis, Argyll Robertson pupils, and general paresis, cardiac
symptoms such as aortitis.
 Risk factors include low-socioeconomic status, adolescents, early sexual contact,
multiple partners
3. Chancroid
 may manifest as a painful ulcerative lesions described as having irregular, jagged
borders with exudative drainage
 caused by Haemophilus ducreyi (chancroid) – a nonmotile, non-spore-forming,
facultative, gram-negative bacilli
 It requires a break in the skin or mucous membrane for the bacteria to infect
 resents with inguinal adenopathy
4. Granuloma inguinale
 Caused by Klebsiella granulomatis (an intracellular, gram-negative bacteria)
 causes lesions similar to Haemophilus ducreyi. But the main difference is that these
lesions appear as a painless, beefy red ulcer that bleeds with touching, and it lacks
inguinal adenopathy. 
 Ulcer heals by fibrosis and resembles like keloids
 Bacteria appear ass closed safety pin in stained tissue biopsy or cytology specimens
5. Lymphogranuloma venereum
6. Genital wart
 Caused by human papillomavirus comes which comes in many viral strains, and among
the strains, HPV6 and HPV11 strains are the ones causing genital warts.
  a condition that manifests as cauliflower-like lesions in the genital region called
condylomata acuminate

 The defining feature of genital warts is koilocytes on histology.

Cells of the basal layer of the epidermis are invaded by human papillomavirus (HPV). These penetrate
through skin and cause mucosal microabrasions. A latent viral phase begins with no signs or symptoms
and can last from a month to several years. Following latency, production of viral DNA, capsids, and
particles begins. Host cells become infected and develop the morphologic atypical koilocytosis of
condyloma acuminatum.
The most commonly affected areas are the penis, vulva, vagina, cervix, perineum, and perianal area.
Uncommon mucosal lesions in the oropharynx, larynx, and trachea have been reported. HPV-6 even has
been reported in other uncommon areas (eg, extremities).

Epidemiolgy:

HPV is the most common sexually transmitted infection worldwide, with 9 to 13 percent of the
global population infected.[3] Coexist in most of HIV infected person.

Patients who are between 20 and 39 years of age are most commonly affected.[5] 

There are several known risk factors for acquiring HPV. Prevalence of infection increases with
an increased number of lifetime sexual partners, a history of chlamydia and gonorrhea infections,
smoking, and human immunodeficiency virus (HIV)infection.[3][6] 

 Smoking, multiple sexual partners, and early coital age are risk factors
for acquiring condyloma acuminatum. Generally, two thirds of individuals
who have sexual contact with a partner with condyloma acuminatum
develop lesions within 3 months

ondyloma acuminata are often diagnosed clinically following definitive history and thorough
visual examination of the lesions. Additional testing can be done to aid in the diagnosis.

A colposcope can be used to magnify the lesion for improved visualization.

Confirmatory testing and gene typing are possible via DNA detection assays such as polymerase
chain reaction (PCR).

Additionally, the acetic acid test can be used to evaluate the lesion further. In this test, five
percent acetic acid gets applied to the lesion. Following the application, white areas of the lesion
raise concern for dysplasia. The acetic acid test is not valid for screening as it has high false-
positive rates. If the clinician is concerned about dysplasia, a biopsy of the lesion is the
appropriate followup.

7.