Figure 5.2 Diagnostic clues to be found at other sites.
Investigation of the vagina in children requires the expert help of a paediatric gynaecologist. The un‐oestrogenised vaginal mucosa can be easily damaged even with cotton‐tipped swabs [33]. An alternative is a small 5 mm endoscope with the capacity for irrigation or very small catheters to obtain secretions.
Documentation
Recording findings can be done with the aid of diagrams, but clinical photography is very helpful for monitoring changes in vulval pathology over time and also response to treatment. However, this must be done in a secure manner, with appropriate consent and the images stored with the patient record. This is especially important in the era of smartphone technology [34]. Several digital platforms and secure apps are available, and many hospitals have secure systems. An attempt to standardise views for genital photography has been made, but this is targeted towards use in cosmetic procedures [35].
Management
The diagnosis and further management should be discussed in detail with the patient after she has dressed. In some cases, specific areas in the history may need to be checked or explored in more detail and may be volunteered by patients once they are more relaxed. However, there are some instances when it may be appropriate to demonstrate certain things with the aid of a mirror while the patient is still undressed. This can be particularly helpful to explain the correct method and sites of treatment, or to provide reassurance about normal anatomical variants.
For many of the conditions, it will be appropriate to reinforce the verbal explanation and advice given at the time with information leaflets or helpful websites.
Helpful websites for patient information
These are useful websites that give patient information about several different dermatoses and infections. Other resources are given in the relevant chapters.
Dermatoses
British Association of Dermatologists
DermNet
International Society for the Study of Vulvo‐vaginal Disease
www.issvd.org/patient‐education
Sexually transmitted infections
British Association of Sexual Health and HIV
International Union against Sexually Transmitted Infection
www.iusti.org/patient‐information/
Examples of forms that can be used to take the history and document a diagram of the vulva can be found in the supplementary information in the online edition.
Last accessed September 2021.
References
1 14 Standards of care for women with vulval conditions. https://www.bad.org.uk/shared/get‐file.ashx?itemtype=document&id=6475 Last accessed March 2021.
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.
6 Symptoms and Signs in Vulval Disease
Fiona M. Lewis
CHAPTER MENU
Symptoms in vulval disease Vulval ulceration Vulval oedema Acute vulval oedema Chronic vulval oedema
Symptoms in vulval disease
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.
Vulval ulceration
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