References
1 1 Lynch, P.J., Moyal‐Barracco, M., Scurry, J. and Stockdale, C.2011 ISSVD Terminology and classification of vulvar dermatological disorders: An approach to clinical diagnosis. J Low Genit Tract Dis. 2012 Oct; 16(4): 339–344.
2 2 Lynch, P.J., Moyal‐Barracco, M., Bogliatto, F. et al. 2006 ISSVD classification of vulvar dermatoses: Pathologic subsets and their clinical correlates. J Reprod Med. 2007 Jan; 52(1): 3–9.
3 3 Bohl, T.J. Vulvar ulcers and erosions: A clinical approach. Clin Obstet Gynecol. 2015; 58: 492–502.
7 Investigations in Vulval Disease
Fiona M. Lewis
CHAPTER MENU
Biopsy Reasons for taking a biopsy Site of biopsy Pre-biopsy Types of biopsy Punch biopsy Incisional biopsy Elliptical biopsy Excisional biopsy Shave biopsy Local anaesthesia Technique Post-biopsy instructions Samples Documentation What do you need to tell the pathologist?
Microbiological investigation Swabs Scrapings Serology Wet mount microscopy
With some clinical presentations, the diagnosis can be made on the basis of the history and examination alone. However, investigations may be necessary to confirm the clinical diagnosis and to gain further information in order to formulate an appropriate management plan. These investigations need to be tailored to the clinical features, as performing extensive investigations without a clinical differential diagnosis is never helpful.
With any investigation, there must be good communication with the laboratory and the appropriate specialist, particularly with the histopathologist as clinicopathological correlation is crucial. If infection is suspected, special tests are often required, which may need specific collection techniques and transport media. This will require discussion with microbiology specialists and the local laboratory before taking specimens.
Biopsy
Reasons for taking a biopsy
A vulval biopsy is performed to confirm the clinical diagnosis, to help when there are a number of clinical differential diagnoses, or where the clinical features are atypical. A biopsy must always be done in the context of clinical diagnosis, and if sent in isolation without this, it is very easy to draw the wrong conclusion. The majority of biopsies are done for diagnostic reasons, but excisional biopsies can also be therapeutic.
Site of biopsy
In order to get the most useful information from the biopsy, the site must be carefully chosen. In general, the edge of a lesion will give the most helpful histological information. The base of an ulcer or erosion is more likely to be non‐specific (Figure 7.1). If there is widespread change, with non‐uniform features, such as in extensive intra‐epithelial disease, multiple mapping biopsies may be required. These must be labelled correctly so that correlation with the original biopsy site is clear.
Most vulval biopsies are easily performed under local anaesthesia in the outpatient setting, but it is best to avoid biopsies of the clitoris, urethra, and anal margin. These patients should be referred to the relevant specialist – gynaecologist, urologist or colorectal surgeon – to consider biopsy under general anaesthetic.
Pre‐biopsy
A clear drug history specifically asking about anticoagulants must be taken before the biopsy. Some patients may take low‐dose aspirin that is not prescribed, so this needs to be checked. Genetic clotting problems and allergies, especially to local anaesthetic, must be detailed.
The procedure is