Ridley's The Vulva

Figure 5.1 The multidisciplinary specialities that are required for patients with vulval disease.

Another vital facet of multidisciplinary working relates to clinicopathological correlation, and working closely with the pathologist is essential. It is important that the clinical and histological diagnosis concur, and if there is doubt, biopsies may need to be repeated. Agreement and understanding of changing classifications and terminology must also occur between clinicians and pathologists to avoid confusion. It has been shown that cooperation between gynaecology and dermatology pathologists improves the accuracy of reporting of vulval biopsies [16].

The importance of an accurate and thorough history cannot be overemphasised. Many find it convenient to have a formal proforma as a basis for history taking, and to then enlarge upon particular aspects in the light of the individual patient’s problem. A structured form ensures that essential information is collected. It is also useful to have similar baseline data for each patient to be used for future comparative clinical research. Some clinicians advocate the use of pre‐clinic questionnaires where the patient can provide basic information which can then act as the basis for more detailed face‐to‐face questioning [17]. However, it is possible to be misled and easy to miss non‐verbal cues from the patient with this approach. It can be helpful to use validated questionnaires to give a quantifiable assessment of how the vulval problem affects quality of life. It is common for even mild vulval disease to have a severe impact on the patient [18], which can be overlooked in history taking. Several tools are available, but these are usually generic and not specific to the vulva [19]. A Vulval Disease Quality of Life Index in lichen sclerosus has recently been published [20]. The Dermatology Quality of Life Index (DLQI) [21], Female Sexual Function Index (FSFI) [22], Female Sexual Distress Scale (FSDS) [23], and Hospital Anxiety and Depression Scale (HADS) [24] are frequently used in practice. In patients with pain, the McGill Pain Questionnaire [25] is most often used but several outcome measures are used in studies, which make results difficult to compare [26].

It is important that the initial interview should take place in a relaxed and sympathetic atmosphere, as this is the first encounter with the patient. Building a good rapport at this stage will help them gain confidence in the consultation. If there are language difficulties which will impede good history taking, an interpreter is needed, but this can unfortunately limit the information that the patient is willing to give. A professional interpreter should always be used in order to ensure that you are receiving the correct information, which may not be given accurately by a family member. In the setting of a teaching clinic, it is essential to ensure that the patient is content to have a student or observer present before starting to take the history.

There are several areas to be covered in the consultation, which are listed in Table 5.1. It is often best to start with an open‐ended question so that the patient can express the main problem. Details of the presenting complaint should include duration and initiating, provoking, and alleviating factors. Previous treatments used and their effects should be noted, either prescribed or bought ‘over the counter’. A general medical history, including medication taken and a previous dermatological and gynaecological history, is essential as the vulval problem may be part of more widespread disease. A sexual history [27] and some basic questions about psychosexual issues are important and will need referral to the appropriate specialist if indicated. If a sexually transmitted infection is possible from the history, a full travel history and assessment by a genitourinary physician are needed. Features of the social history, such as smoking, are highly relevant in conditions such as high‐grade squamous intraepithelial lesion (HSIL) and hidradenitis suppurativa.

Table 5.1 History taking in patients with vulval symptoms.

*Vaginal bleeding is rarely due to vulval disease, and any abnormal bleeding should be referred for full gynaecological assessment.

If a patient presents with vulval pain, the mnemonic SOCRATES is helpful for remembering to ask about Site, Onset, Character, Radiation, Associated factors, Timing, Exacerbating and relieving factors, and Severity.

Physical examination of the anogenital area should be conducted in a calm and sympathetic manner, with respect for the patient’s privacy. There should be a curtained area providing a space for undressing and dressing afterwards. Consent for examination should be sought, and this can be verbal but also implied by the patient cooperating with instructions. Clear explanation and reassurance should minimise any distress. Even if it is explained that there will be a female chaperone, some patients especially in certain religious cultures, will insist on a female doctor. This request should always be respected. If the patient has agreed to a student being present for history taking, it should not be assumed that the patient is willing to be examined in the presence of an observer, so a further request needs to be made before proceeding. The vast majority of patients readily agree to this if the importance of learning is explained.