The lower reproductive tract, comprised of the vulva, vagina, and cervix, harbors a wide spectrum of benign and neoplastic diseases. Disorder characteristics often overlap, thus differentiating normal variants, benign diseases, and potentially serious lesions can be challenging. Benign lesions of the lower reproductive tract are common and mastery of their identification and treatment is essential. This chapter highlights the most common conditions encountered.
Vulvar skin is more permeable than surrounding tissues because of differences in structure, hydration, occlusion, and susceptibility to friction (Farage, 2004). As a result, pathology involving the vulva is common, although estimates are difficult because of patient underreporting and clinician misdiagnosis. Lesions may result from infection, trauma, neoplasia, or immune responses. As a result, symptoms may be acute or chronic and may 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.
General Approach to Vulvar Complaints
The initial encounter should include reassurance that the patient's complaints will be investigated thoroughly. Women often minimize and may be uncomfortable with describing their symptoms. Those with chronic conditions may relate protracted histories of assorted diagnoses and treatments by a number of providers and may voice frustration and doubt that relief is possible. These patients should not be promised a cure but rather that every effort will be made to alleviate their symptoms. This may require multiple visits and treatment attempts, and potentially a multidisciplinary approach. A patient-provider partnership in developing a management strategy enhances compliance and satisfaction with care.
Counseling should include discussion of the suspected diagnosis, current treatment plan, and necessary vulvar skin care. 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 specific national web sites and support groups is usually welcome.
Scheduling adequate time for the initial evaluation is a wise investment, as detailed information is essential. Symptom characterization should include descriptions of duration, location, abnormal sensations, and associated vaginal pruritus or discharge. A thorough medical history should encompass 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.
This is a frequent vulvar symptom of many dermatoses, and the underlying cause is often discoverable during the initial interview. Patients may have been previously diagnosed with psoriasis, eczema, or dermatitis at other body sites. Isolated vulvar pruritus may be associated with initiation of a new medication. Patients may identify foods that provoke or intensify symptoms, and in such cases, a food diary may be helpful. Most often, vulvar pruritus is due to a contact ...