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| Labial swelling, clear discharge? Suspect genital lymphedema - After Pelvic, Gyn. Surgery |
by Kate Johnson
MONTREAL -- Unusual gynecologic complaints of labial swelling or clear labial/vaginal discharge could be symptoms of genital lymphedema, especially if the patient has had previous pelvic or gynecologic surgery or radiation affecting lymph nodes or vessels.
Awareness of this phenomenon is slowly growing among gynecologic oncologists, but until recently 'there was [little recognition] that gynecologic lymphedema could complicate their treatments,' Dr. Andrea Cheville, director of the University of Pennsylvania Cancer Center's Lymphedema Program, said at a meeting sponsored by the World Federation for Ultrasound in Medicine and Biology.
'I have found limited receptivity regarding lymphedema on the part of gynecologic oncologists. This reflects the general emphasis in cancer care on disease and worrying about recurrence. Historically, there hasn't been emphasis on addressing the non-life-threatening sequelae,' she said in an interview.
Lymphedema can occur after treatment of gynecologic malignancies such as ovarian, endometrial, or cervical cancer, because of the extensive use of pelvic lymph node dissection and radiation therapies. In addition, treatments for bladder, colon, and renal cancer also have potential to compromise the deep lymphatic structures, increasing the risk of gynecologic lymphedema, she said.
The incidence of genital lymphedema is not known, largely because it often goes undiagnosed, but it has been estimated to occur following 10%-20% of all gynecologic oncology surgery and radiation therapy. Like other forms of lymphedema, it most commonly occurs in the first 3-4 years after cancer treatment, but can occur up to 30 years later.
'For patients with this history, if they have any genital swelling; changes in the skin texture; changes in hair growth; thickening of the labia; the presence of papillomas or discreet warty growths; or lymphorrhea, which is leakage of serous fluid through compromised or intact skin, think lymphedema,' she said.
Lymphorrhea may be difficult to recognize, especially if it is occurring intravaginally, but physicians can distinguish it from normal vaginal discharge or vaginal infections in a number of ways. 'Many times vaginal discharge is whitish or curdish, thick, and opaque, but this is not. Lymphorrhea tends to be clear or a little bit yellow colored. If you culture it, it will be negative. But patients may sometimes complain that it is malodorous. Lymph has no odor, but it is very proteinaceous, which makes it a good culture medium for bacteria,' she said.
Genital lymphedema is a devastating condition, but unlike breast cancer, it is not a topic of polite conversation, Dr. Cheville said. She urged physicians to ask patients about these symptoms.
Treatment for the condition, as with general lymphedema, involves combined decongestive therapy consisting of compressive bandaging and manual lymph drainage, but this treatment approach can prove very problematic in gynecologic lymphedema.
'Bandaging is very difficult, because it's tricky to adequately compress the vulvar region,' she noted, adding that she uses a specially designed bandage with Velcro straps and odor control pads.
She recommended that unless physicians have training in lymphedema management, they should refer the patient, but she acknowledged the difficulty in finding well-trained therapists.
'There are very few therapists who have comfort and experience treating genital lymphedema. Predominantly these would be physical therapists, but some nurses and some occupational therapists do it as well.'
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