Vulvar lesions
Vulvar lesions: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Vulvar lesions are cutaneous lumps, nodules, papules, vesicles, or ulcers that result from benign or malignant tumors, dystrophies, dermatoses, or infection. They can appear anywhere on the vulva and may go undetected until a gynecologic examination. Usually, however, the patient notices the lesions because of associated symptoms, such as pruritus, dysuria, or dyspareunia.
History and physical examination
Ask the patient when she first noticed a vulvar lesion, and find out about associated features, such as swelling, pain, tenderness, itching, or discharge. Does she have lesions elsewhere on her body? Ask about signs and symptoms of systemic illness, such as malaise, fever, or a rash on other body areas. Is the patient sexually active? Could she have been exposed to a sexually transmitted disease?
Also, examine the lesion, do a pelvic examination, and obtain cultures. (See Recognizing common vulvar lesions, page 814.)
Medical causes
Basal cell carcinoma
Most common in postmenopausal women, this nodular tumor has a central ulcer and a raised, poorly rolled border. Although it typically produces no symptoms, basal cell carcinoma occasionally causes pruritus, bleeding, discharge, and a burning sensation.
Benign cysts
Epidermal inclusion cysts, the most common vulvar cysts, appear primarily on the labia majora. They’re usually round and cause no symptoms; occasionally, they become erythematous and tender.
Bartholin’s duct cysts are usually unilateral, tense, nontender, and palpable; they appear on the posterior labia minora and may cause minor discomfort during intercourse or, when large, difficulty with intercourse or even walking. Bartholin’s abscess, an infected Bartholin’s duct cyst, causes gradual pain and tenderness and possibly vulvar swelling, redness, and deformity.
Benign vulvar tumors
Cystic or solid benign vulvar tumors usually produce no symptoms.
Chancroid
This rare sexually transmitted disease causes painful vulvar lesions. Other findings may include headache, malaise, fever up to 102.2° F (39° C), and enlarged, tender inguinal lymph nodes.
Dermatoses (systemic)
Psoriasis, seborrheic dermatitis, and other skin conditions may produce vulvar lesions that resemble the causative lesions found in other body areas.
Genital warts
This sexually transmitted condition is characterized by painless warts on the vulva, vagina, and cervix. The warts start as tiny red or pink swellings that grow and become pedunculated. Multiple swellings with a cauliflower-like appearance are common. Other findings include pruritus, erythema, burning or paresthesia in the vaginal introitus, and a profuse mucopurulent vaginal discharge.
Gonorrhea
Although most women with gonorrhea are asymptomatic, some develop vulvar lesions, which are usually confined to Bartholin’s glands and may be accompanied by pruritus, a burning sensation, pain, and a green-yellow vaginal discharge. Other findings include dysuria and urinary incontinence; vaginal redness, swelling, bleeding, and engorgement; and severe pelvic and lower abdominal pain.
Granuloma inguinale
This rare, chronic venereal infection begins with a single painless macule or papule on the vulva that ulcerates into a raised, beefy-red lesion with a granulated, friable border. Later, other painless and possibly foul-smelling lesions may erupt on the labia, vagina, or cervix. Eventually, they become infected and painful and may be accompanied by enlarged and tender regional lymph nodes, fever, weight loss, and malaise.
Herpes simplex (genital)
In this disorder, fluid-filled vesicles appear on the cervix and, possibly, on the vulva, labia, perianal skin, vagina, or mouth. The vesicles, initially painless, may rupture and develop into extensive shallow, painful ulcers, with redness, marked edema, and tender inguinal lymph nodes. Other findings include fever, malaise, and dysuria.
Herpes zoster
This viral infection may produce vulvar lesions, although other areas are more commonly affected. Small, red nodular lesions erupt on painful erythematous areas. The lesions quickly evolve into vesicles or pustules, which dry and form scabs about 10 days later. Other findings include fever, malaise, paresthesia or hyperesthesia, and pain.
Lymphogranuloma venereum
Most patients with this bacterial infection initially exhibit a single painless papule or ulcer on the posterior vulva that heals in a few days. Painful, swollen lymph nodes, usually unilateral, develop 2 to 6 weeks later. Other findings include fever, chills, headache, anorexia, myalgia, arthralgia, weight loss, and perineal edema.
Malignant melanoma
This type of skin cancer may cause irregular, pigmented vulvar or clitoral lesions that enlarge rapidly and may ulcerate and bleed.
Molluscum contagiosum
This viral infection produces raised, umbilicated, pearly or flesh-colored vulvar papules that are 1 to 2 mm in diameter and have a white core. Pruritic lesions may also appear on the face, eyelids, breasts, and inner thighs.
Pediculosis pubis
This parasitic infection produces erythematous vulvar papules with pruritus and skin irritation. Adult pubic lice and nits are visible on pubic hair with magnification.
Squamous cell carcinoma
Invasive carcinoma occurs primarily in postmenopausal women and may produce a painful, pruritic vulvar tumor. As the tumor enlarges, it may encroach on the vagina, anus, and urethra, causing bleeding, discharge, or dysuria. Carcinoma in situ is most common in premenopausal women and produces a vulvar lesion that may be white or red, raised, well defined, moist, crusted, and isolated.
Squamous cell hyperplasia
Formerly known as hyperplastic dystrophy, this disorder produces vulvar lesions that may be well delineated or poorly defined; localized or extensive; and red, brown, white, or red and white. However, its cardinal symptom is intense pruritus, possibly with vulvar pain, intense burning, and dyspareunia. In lichen sclerosis, a type of vulvar dystrophy, vulvar skin has a parchmentlike appearance. Fissures may develop between the clitoris and urethra or other vulvar areas.
Syphilis
In this sexually transmitted disease, chancres may appear on the vulva, vagina, or cervix 10 to 90 days after initial contact. They usually start as painless papules and then erode to form indurated ulcers with raised edges and clear bases. Condylomata lata develop after these ulcers clear up. These highly contagious secondary vulvar lesions are raised, gray, flat topped, and commonly ulcerated. Other findings include a maculopapular, pustular, or nodular rash; headache; malaise; anorexia; weight loss; fever; nausea and vomiting; generalized lymphadenopathy; and sore throat.
Viral diseases (systemic)
Varicella, measles, and other systemic viral diseases may produce vulvar lesions.
Special considerations
Expect to administer a systemic antibiotic, an antiviral, a topical corticosteroid, topical testosterone, or an antipruritic.
Pediatric pointers
Vulvar lesions in children may result from congenital syphilis or gonorrhea. Evaluate for sexual abuse.
Geriatric pointers
Vulvar dystrophies and neoplasia become more common with advancing age. All vulvar lesions should be considered malignant until proven otherwise. Many women remain sexually active well into their older years, so be sure to question them about sexual activities and teach them safer sex practices.
Patient counseling
Show the patient how to give herself a sitz bath to promote healing and comfort. If she has a sexually transmitted disease, encourage her to inform her sexual partners and persuade them to be treated. Advise her to avoid sexual contact until the lesions are no longer contagious. Provide information about safer sex practices.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
More About Vaginitis
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Medical Books Excerpts
- Metrorrhagia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Vaginal Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Vaginal bleeding, postmenopausal (Professional Guide to Signs & Symptoms (Fifth Edition))
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