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 lesions because of associated symptoms, such as pruritus, dysuria, or dyspareunia.
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 rash on other body areas. Is the patient sexually active? Could she have been exposed to sexually transmitted disease?
Also, examine the lesion, do a pelvic examination, and obtain cultures. (See Recognizing common vulvar lesions.)
Most common in postmenopausal women, this nodular tumor has a central ulcer and a raised, poorly rolled border. Typically asymptomatic, the tumor may occasionally cause pruritus, bleeding, discharge, and a burning sensation.
Epidermal inclusion cysts, the most common vulvar cysts, appear primarily on the labia majora and are usually round and asymptomatic. 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, infection of a Bartholin’s duct cyst, causes gradual pain and tenderness and possibly vulvar swelling, redness, and deformity.
Cystic or solid benign vulvar tumors are usually asymptomatic.
Chancroid, a rare, sexually transmitted disease, causes painful vulvar lesions. Headache, malaise, and fever to 102.2° F (39° C) may occur, with enlarged, tender inguinal lymph nodes.
Genital warts, a sexually transmitted disease, produces painless warts on the vulva, vagina, and cervix. Warts start as tiny red or pink swellings that grow and become pedunculated. Multiple swellings with a cauliflower appearance are common. Other findings include pruritus, erythema, and a profuse, mucopurulent vaginal discharge. Patients frequently complain of burning or paresthesia in the vaginal introitus.
Vulvar lesions, which usually are confined to Bartholin’s glands, may develop along with pruritus, a burning sensation, pain, and a green-yellow vaginal discharge, but most patients are asymptomatic. Other findings include dysuria and urinary incontinence; vaginal redness, swelling, bleeding, and engorgement; and severe pelvic and lower abdominal pain.
Initially, a single painless macule or papule appears on the vulva, ulcerating into a raised, beefy-red lesion with a granulated, friable border. Other painless and possibly foul-smelling lesions may occur on the labia, vagina, or cervix. These become infected and painful, and regional lymph nodes enlarge and may become tender. Systemic effects include fever, weight loss, and malaise.
With herpes simplex, 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.
Patients with lymphogranuloma venereum, a bacterial infection commonly present with 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, myalgias, arthralgias, weight loss, and perineal edema.
Invasive carcinoma occurs primarily in postmenopausal women and may produce vulvar pruritus, pain, and a vulvar lump. 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, producing a vulvar lesion that may be white or red, raised, well defined, moist, crusted, and isolated.
Formerly known as hyperplastic dystrophy, these vulvar lesions may be well delineated or poorly defined; localized or extensive; and red, brown, white, or both red and white. However, intense pruritus, possibly with vulvar pain, intense burning, and dyspareunia, is the cardinal symptom. With 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.
Chancres, the primary vulvar lesions of syphilis, may appear on the vulva, vagina, or cervix 10 to 90 days after initial contact. Usually painless, they start as papules that then erode, with indurated, raised edges and clear bases. Condylomata lata, 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; vomiting; generalized lymphadenopathy; and a sore throat.
Varicella, measles, and other systemic viral diseases may produce vulvar lesions.
Expect to administer systemic an antibiotic, antiviral, topical corticosteroid, topical testosterone, or an antipruritic.
Vulvar lesions in children may result from congenital syphilis or gonorrhea. Evaluate for sexual abuse.
Vulvar dystrophies and neoplasia increase in frequency with advancing age. All vulvar lesions must be suspected of being malignant until proven otherwise. Also, many women remain sexually active well into their older years and may come from a time when sexually transmitted diseases were not openly discussed. These patients should be questioned about sexual activities and educated about safer sex practices.
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
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Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1 
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