Ridley's The Vulva

2 32 Habeshian, K., Fowler, K., Gomez‐Lobo, V. and Marathe, K. Guidelines for pediatric anogenital examination: Insights from our vulvar dermatology clinic. Pediatr Dermatol. 2018 Sep; 35(5): 693–695.

Fiona M. Lewis

Symptoms in vulval disease Vulval ulceration Vulval oedema Acute vulval oedema Chronic vulval oedema

Signs in vulval disease

References

Symptoms relating to vulval disorders tend to fall into a few clear categories. Itch, soreness, and pain are the common descriptions that women will give. It is always important to clarify exactly what the patient experiences when they report symptoms, as misunderstanding is easy. If a patient describes irritation, this does not always correlate with itch, and so asking them if they have the desire to scratch (which does define pruritus) is helpful. The same is true for signs. Patients may report ‘blisters’, but these are rarely, if ever, true bullae, which can then lead to unnecessary investigations.

As different specialties are involved in treating women with vulval disease, it is important to have a clear and common terminology for describing lesions. This should ensure that the same language is spoken when discussing cases with colleagues and in research.

There are classifications of disease according to clinical [ 1] and histological patterns [ 2]. These may be helpful initially, but they can be simplistic as some disorders can fit into more than one category and there can be atypical presentations of common disease.

Some common causes of vulval symptoms are shown in Table 6.1.

There are two specific situations where there is a more extensive differential diagnosis: vulval ulceration and vulval oedema. An approach to patients presenting with these symptoms is considered here, with more details on the specific conditions in the appropriate chapter.

Patients presenting with one or more vulval ulcers can pose a diagnostic challenge [ 3]. Some clinical patterns of disease such as herpes simplex infection are easy to recognise. However, some chronic ulcers will require extensive further investigation in order to make a diagnosis.

There are four main causes of vulval ulcers:

Infection

Inflammation

Malignancy

Trauma

A full history must be taken, as outlined in Chapter 5. When examining the patient, the site, number, and characteristics of any ulcer should be noted. A differential diagnosis can then be formulated ( Figure 6.1).

In a similar way, there is a wide differential diagnosis in patients who present with vulval swelling as the predominant symptom. The potential causes are shown in Figure 6.2.

Table 6.1 Common causes for vulval symptoms.

Figure 6.1 Causes of vulval ulceration.

No classification for the types of oedema exists, but a useful way of thinking about the differential diagnosis is to consider acute and chronic causes.

A degree of oedema is often seen in patients with acute inflammatory conditions such as candidiasis or eczema. This settles with treatment of the primary problem. Urticaria or angio‐oedema, including hereditary angio‐oedema, may affect the vulva. Acute swelling will occur in type I allergic reactions (see Chapter 22). Vulval oedema has been reported in the ovarian hyperstimulation syndrome, a rare complication following ovulation in cases of infertility [4]. The mechanism was thought to be fluid retention, decreased oncotic, and increased hydrostatic pressure. Gross vulval oedema has been described in pre‐eclampsia [5] and vulval oedema occurring in pregnancy [6] and after delivery have been rarely reported [7].

Figure 6.2 Causes of vulval oedema.

Rarely, a direct passive transfer effect can also result in vulval oedema in patients undergoing peritoneal dialysis, in which the channel can be a small hernia or a defect of the peritoneal fascia [8]. Acute, but self‐limiting unilateral vulval oedema has also been described after instillation of adhesion barrier solution at laparoscopy [9].

This topic is dealt with in Chapter 33.

Figure 6.3 Diagrammatic section of normal skin.

The keratinised epithelium has four layers which overlies the dermis containing adnexal structures and the vascular network ( Figure 6.3). Changes will occur with disease processes which will manifest in different ways. It is important to be able to describe these lesions accurately. These are detailed in Table 6.2and shown diagrammatically in Figure 6.4.

Figure 6.4 Features of cutaneous lesions.

Table 6.2 Types of cutaneous lesions.