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INTRODUCTION

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The lower reproductive tract, comprising the vulva, vagina, and cervix, exhibits a wide spectrum of benign and neoplastic diseases. Disorder characteristics often overlap, and thus differentiating normal variants, benign disease, and potentially serious lesions can be challenging. Lower reproductive tract infection is a frequent cause and discussed in Chapter 3, whereas congenital anomalies and preinvasive neoplasia are infrequent and described in Chapters 18 and 29. The benign lesions highlighted in this chapter are common, and mastery of their identification and treatment is essential.

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VULVAR ASSESSMENT

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Vulvar skin is more permeable than surrounding tissues because of differences in structure, hydration, occlusion, and friction susceptibility (Farage, 2004). Accordingly, pathology can develop in this area, although frequency estimates are difficult because of patient underreporting and clinician misdiagnosis. Lesions may result from allergen or irritant exposure, infection, trauma, or neoplasia. As a result, symptoms may be acute or chronic and include pain, pruritus, dyspareunia, bleeding, and discharge. Effective therapies are available for most disorders, yet embarrassment and fear may prove significant roadblocks to care for many women.

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General Approach to Vulvar Complaints

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The initial encounter includes reassurance that the patient’s complaints will be investigated thoroughly. Women often minimize and may be uncomfortable with describing their symptoms. They may relate protracted histories of assorted diagnoses and treatments by numerous providers and may voice frustration and doubt that relief is possible. Patients are not promised a cure but rather that every effort will be made to alleviate their symptoms. This can require multiple visits, tissue sampling, treatment attempts, and even a multidisciplinary plan. A patient-provider partnership approach to management enhances compliance and care satisfaction.

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During counseling, the suspected diagnosis, current treatment plan, and recommended vulvar skin care are outlined. Printed materials that explain common conditions, medication use, and skin care are helpful. Patients are often relieved to learn that their complaints and conditions are not unique. Thus, referral to national websites and support groups is usually welcomed.

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Diagnosis

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History
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Scheduling adequate time for the initial evaluation is a wise investment, as detailed information is essential. Symptom characterization includes descriptions of abnormal sensations, duration, precise location, and associated vaginal pruritus or discharge. Patients often refer to vulvar pruritus as vaginal, and symptom location should be clarified. A thorough medical history addresses systemic illnesses, medications, and known allergies. Obstetric, sexual, and psychosocial histories and any potentially provocative events around the time of symptom onset often suggest etiologies. Hygiene and sexual practices should be investigated in detail.

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Of symptoms, vulvar pruritus is frequent with many dermatoses. Patients may have been previously diagnosed with psoriasis, eczema, or dermatitis at other body sites. Isolated vulvar pruritus may be associated with a new medication. Patients may identify foods that provoke or intensify symptoms, and in such cases, a food ...

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