Ridley's The Vulva

It is known that most women find it helpful to have a chaperone for examination, but wide variation in policies and practice has been described previously [28,29]. It is now clearly recommended by many regulatory bodies that a chaperone must always be offered for all intimate examinations, which includes genital examination [30,31]. This is not only for the protection of the patient but also for the protection of the healthcare professional. From a practical perspective, an assistant is needed for examination anyway, and a good nurse can act as both chaperone and assistant. Another role for the chaperone is to ensure that there is continuing consent from the patient for examination. A family member should not act as a chaperone, as they are not impartial. In the rare instance where the patient refuses a chaperone, this must be clearly documented in the patient’s notes, and examination should not proceed without someone else being present if there are any concerns about the patient behaving in an inappropriate manner.

A parent may act as a chaperone when examining children, but it is still best practice to have an independent chaperone and many hospitals have a policy in relation to this. As with adults, a nurse can act as both chaperone and assistant.

Some practitioners use stirrups, but it is possible to examine the vulva adequately with the patient in the dorsal position with heels together and hips adducted, and then (for the perianal area) the left lateral position. It is vital to have good lighting, and ring lamps with central magnification are ideal. Other equipment is shown in Table 5.2. It is important to have all this readily available before examination is started.

The examination must be thorough and methodical, and include all areas of the vulva as well as the perineum and perianal area. A knowledge of the normal variations in appearance of the vulva is required in order to be able to note the abnormalities. Simple inspection will allow only the mons pubis, the labia majora, the margins of the labia minora, the perineal body, and the anus to be seen. Adequate exposure of the vulva requires the separation of the labia majora and minora. As several of the common vulval dermatoses alter the normal architecture, it is not only important to note abnormal additions such as inflammation or masses, but also to note important omissions, such as resorption of the labia minora or sealing of the clitoral hood. A specific order of examination helps, starting from the outside and working inwards that will include inguinal folds, mons pubis, labia majora, interlabial sulci, labia minora, vestibule, clitoris, hymen, posterior fourchette, perineum, perianal area, and gluteal cleft.

Table 5.2 Equipment needed for vulval examination.

Examination of the vagina and cervix should be routine for those presenting with features suggestive of mucocutaneous diseases, HSIL, and vaginal discharge. Plastic speculums are most helpful as they allow any changes in the wall of the vagina to be easily seen. In some situations, the inguinal lymph glands will need to be palpated. Additional information and helpful diagnostic clues will be obtained from examination of the mouth, eyes, scalp, nails and other flexural sites, including the umbilicus ( Figure 5.2).

The history for younger children will be given by the parents, but older children can often give a good account of their symptoms. Additional questions about toileting, bladder, and bowel function are important as these are frequent issues in children with vulval symptoms. As in adults, a specific proforma for taking the history in a paediatric patient is useful.

Most older children will permit examination of the vulva and perianal area in the same position as adults in a ‘frog‐leg’ position. Younger children and babies can be held by a parent and positioned in front of them [ 32]. As the labia majora are not fully formed, visualisation is usually easy, and even the vestibule and hymen are often readily visible without any need to separate the labia minora. Gentle downward traction on the lower buttocks will expose the area if needed. In specific situations, such as suspicion of a foreign body, examination under anaesthesia may be required.

Figure 5.2 Diagnostic clues to be found at other sites.

Investigation of the vagina in children requires the expert help of a paediatric gynaecologist. The un‐oestrogenised vaginal mucosa can be easily damaged even with cotton‐tipped swabs [33]. An alternative is a small 5 mm endoscope with the capacity for irrigation or very small catheters to obtain secretions.

Recording findings can be done with the aid of diagrams, but clinical photography is very helpful for monitoring changes in vulval pathology over time and also response to treatment. However, this must be done in a secure manner, with appropriate consent and the images stored with the patient record. This is especially important in the era of smartphone technology [34]. Several digital platforms and secure apps are available, and many hospitals have secure systems. An attempt to standardise views for genital photography has been made, but this is targeted towards use in cosmetic procedures [35].

The diagnosis and further management should be discussed in detail with the patient after she has dressed. In some cases, specific areas in the history may need to be checked or explored in more detail and may be volunteered by patients once they are more relaxed. However, there are some instances when it may be appropriate to demonstrate certain things with the aid of a mirror while the patient is still undressed. This can be particularly helpful to explain the correct method and sites of treatment, or to provide reassurance about normal anatomical variants.

For many of the conditions, it will be appropriate to reinforce the verbal explanation and advice given at the time with information leaflets or helpful websites.

These are useful websites that give patient information about several different dermatoses and infections. Other resources are given in the relevant chapters.

British Association of Dermatologists

www.bad.org.uk

www.skinhealthinfo.org.uk

DermNet

www.dermnetnz.org

International Society for the Study of Vulvo‐vaginal Disease

www.issvd.org/patient‐education

British Association of Sexual Health and HIV

www.bashh.org/pils

International Union against Sexually Transmitted Infection

www.iusti.org/patient‐information/

Examples of forms that can be used to take the history and document a diagram of the vulva can be found in the supplementary information in the online edition.

Last accessed September 2021.

1 14 Standards of care for women with vulval conditions. https://www.bad.org.uk/shared/get‐file.ashx?itemtype=document&id=6475Last accessed March 2021.