be noted. A differential diagnosis can then be formulated (Figure 6.1).
Vulval oedema
In a similar way, there is a wide differential diagnosis in patients who present with vulval swelling as the predominant symptom. The potential causes are shown in Figure 6.2.
Table 6.1 Common causes for vulval symptoms.
| Pruritus | Soreness/discomfort | Pain | Dyspareunia | |
|---|---|---|---|---|
| Infection – sexually transmitted | Scabies Trichomonas vaginalis | Any vaginal discharge can cause vulval soreness | Herpes simplex | Herpes simplex |
| Infection – non‐sexually transmitted | Candidiasis Tinea cruris | Candidiasis | Herpes zoster | Candidiasis |
| Inflammatory | Eczema/lichen simplex Psoriasis Lichen sclerosus Lichen planus – classic or hypertrophic types | Erosive lichen planus Immune‐bullous disease Irritant dermatitis | Crohn’s disease Hidradenitis suppurativa | Erosive lichen planus Lichen sclerosus Psoriasis Immuno‐bullous disease Graft versus host disease |
| Malignancy | High grade squamous intraepithelial lesion (HSIL) | HSIL | Any malignant tumour | Extra‐mammary Paget’s disease Any malignant tumour |
| Neuropathic | Dysaesthesia for itch | Extra‐mammary Paget’s disease | Vulvodynia | Localised provoked vulvodynia |
| Others | Urticaria Syringomas | SJS/TEN Graft versus host disease | Acute reactive genital ulcers (Lipschutz) SJS/TEN Neuroma | Mechanical fissuring of fourchette or hymenal ring |
Figure 6.1 Causes of vulval ulceration.
No classification for the types of oedema exists, but a useful way of thinking about the differential diagnosis is to consider acute and chronic causes.
Acute vulval oedema
A degree of oedema is often seen in patients with acute inflammatory conditions such as candidiasis or eczema. This settles with treatment of the primary problem. Urticaria or angio‐oedema, including hereditary angio‐oedema, may affect the vulva. Acute swelling will occur in type I allergic reactions (see Chapter 22). Vulval oedema has been reported in the ovarian hyperstimulation syndrome, a rare complication following ovulation in cases of infertility [4]. The mechanism was thought to be fluid retention, decreased oncotic, and increased hydrostatic pressure. Gross vulval oedema has been described in pre‐eclampsia [5] and vulval oedema occurring in pregnancy [6] and after delivery have been rarely reported [7].
Figure 6.2 Causes of vulval oedema.
Rarely, a direct passive transfer effect can also result in vulval oedema in patients undergoing peritoneal dialysis, in which the channel can be a small hernia or a defect of the peritoneal fascia [8]. Acute, but self‐limiting unilateral vulval oedema has also been described after instillation of adhesion barrier solution at laparoscopy [9].
Chronic vulval oedema
This topic is dealt with in Chapter 33.
Figure 6.3 Diagrammatic section of normal skin.
Signs in vulval disease
The keratinised epithelium has four layers which overlies the dermis containing adnexal structures and the vascular network (Figure 6.3). Changes will occur with disease processes which will manifest in different ways. It is important to be able to describe these lesions accurately. These are detailed in Table 6.2 and shown diagrammatically in Figure 6.4.
Figure 6.4 Features of cutaneous lesions.
Table 6.2 Types of cutaneous lesions.
| Lesion | Description | Example |
|---|---|---|
| Papule | Small palpable lesion up to 5 mm in diameter | Syringoma |
| Macule | Visible lesion up to 5 mm in diameter but not palpable | Pityriasis versicolor |
| Nodule | Palpable lesion >5 mm in diameter | Malignancy |
| Plaque | Flat palpable lesion >5 mm in diameter | Psoriasis, HSIL, lichen sclerosus |
| Ulcer | Break in epithelium that reaches into dermis |
Crohn’s
|