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Symptoms and Signs – Differential Diagnosis of Vulvar Lesions
Vulvar lesions are cutaneous masses, nodules, papules, vesicles, or ulcers arising from benign or malignant tumors, dystrophies, dermatoses, or infections. They may emerge anywhere on the vulva and could remain unnoticed until a gynecological examination. Typically, the patient observes lesions due to accompanying symptoms, like pruritus, dysuria, or dyspareunia.
Medical History and Physical Assessment
Inquire when the patient first observed a vulvar lesion and ascertain any accompanying characteristics, including swelling, pain, tenderness, itching, or discharge. Does she exhibit lesions in other areas of her body? Inquire about the signs and symptoms of systemic illness, including malaise, fever, or rash in other regions of the body. Is the patient engaged in sexual activity? Could she have been exposed to a sexually transmitted infection? Additionally, assess the lesion, conduct a pelvic examination, and get cultures.
Etiological Factors
Basal cell carcinoma
This nodular tumor, prevalent in postmenopausal women, features a central ulcer and a raised, poorly defined border. The tumor is usually asymptomatic but may sometimes induce itching, hemorrhage, discharge, and a burning feeling.
Nonmalignant cysts
Epidermal inclusion cysts, the predominant vulvar cysts, typically manifest on the labia majora and are generally spherical and asymptomatic. They occasionally exhibit erythema and tenderness. Bartholin's duct cysts are often unilateral, tense, nontender, and palpable; they manifest on the posterior labia minora and may induce minor discomfort during intercourse or, when sizable, impede intercourse or even ambulation. Bartholin's abscess, an infection of a Bartholin's duct cyst, results in progressive pain and tenderness, along with potential vulvar enlargement, erythema, and deformity.
Sexually transmitted illnesses are the predominant cause of vulvar lesions in premenopausal women, while vulvar tumors and cysts are the primary lesions in women aged 50 to 70.
Benign tumors of the vulva
Benign vulvar tumors, whether cystic or solid, are typically asymptomatic.
Chancroid
Chancroid, an uncommon sexually transmitted infection, results in painful vulvar sores. Headache, malaise, and a temperature of 102.2°F (39°C) may manifest, accompanied by swollen, painful inguinal lymph nodes.
Genital warts
Genital warts, a sexually transmitted infection, manifest as painless lesions on the vulva, vagina, and cervix. Warts commence as little red or pink protuberances that develop into pedunculated formations. Numerous swellings exhibiting a cauliflower-like morphology are prevalent. Additional findings including pruritus, erythema, and a copious, mucopurulent vaginal discharge. Patients often report experiencing burning or paresthesia in the vaginal introitus.
Gonorrhea
Vulvar lesions, typically localized to Bartholin’s glands, may manifest with pruritus, a burning feeling, discomfort, and a green-yellow vaginal discharge; nevertheless, the majority of patients remain asymptomatic. Additional findings encompass dysuria and urine incontinence; vaginal erythema, edema, hemorrhage, and engorgement; as well as intense pelvic and lower abdominal pain.
Granuloma inguinale
Initially, a solitary painless macule or papule emerges on the vulva, progressing to an ulcerated, elevated, beefy-red lesion with a granular, friable margin. Additional painless and sometimes malodorous lesions may appear on the labia, vagina, or cervix. Infection and pain ensue, leading to the enlargement and potential tenderness of regional lymph nodes. Systemic consequences encompass fever, weight reduction, and malaise.
Genital herpes simplex
Herpes simplex manifests as fluid-filled vesicles on the cervix and perhaps on the vulva, labia, perianal area, vagina, or oral cavity. The vesicles, initially asymptomatic, may rupture and progress into widespread, superficial, painful ulcers, accompanied by erythema, significant edema, and tender inguinal lymphadenopathy. Additional results encompass pyrexia, malaise, and dysuria.
Lymphogranuloma venereum
Individuals with lymphogranuloma venereum, a bacterial infection, typically have a solitary, painless papule or ulcer on the posterior vulva that resolves within a few days. Unilateral, painful, and swollen lymph nodes typically manifest 2 to 6 weeks later. Additional findings including fever, chills, headache, anorexia, myalgias, arthralgias, weight loss, and perineal edema.
Squamous cell carcinoma
Invasive carcinoma predominantly affects postmenopausal women and may manifest as vulvar pruritus, discomfort, and a vulvar mass. As the tumor expands, it may invade the vagina, anus, and urethra, resulting in hemorrhage, discharge, or dysuria. Carcinoma in situ predominantly occurs in premenopausal women, manifesting as a vulvar lesion that may seem white or red, elevated, well-defined, wet, crusty, and solitary.
Hyperplasia of squamous cells
Previously referred to as hyperplastic dystrophy, these vulvar lesions may be distinctly outlined or indistinct; localized or widespread; and exhibit red, brown, white, or a combination of red and white hues. Intense pruritus, maybe accompanied by vulvar pain, severe burning, and dyspareunia, is the primary symptom.
Lichen sclerosus, a kind of vulvar dystrophy, results in vulvar skin exhibiting a parchment-like texture. Fissures may arise between the clitoris and urethra or other vulvar regions.
Syphilis
Chancres, the principal vulvar lesions of syphilis, may manifest on the vulva, vagina, or cervix 10 to 90 days following initial exposure. Typically painless, they commence as papules that subsequently dissolve, exhibiting indurated, elevated margins and transparent bases. Condylomata lata, extremely infectious secondary vulvar lesions, are elevated, gray, flat-topped, and frequently ulcerated. Additional findings encompass a maculopapular, pustular, or nodular rash; cephalalgia; malaise; anorexia; weight reduction; pyrexia; nausea; emesis; widespread lymphadenopathy; and pharyngitis. Systemic viral infection. Varicella, measles, and other systemic viral infections may result in vulvar lesions.
Anticipate the administration of a systemic antibiotic, antiviral, topical corticosteroid, topical testosterone, or an antipruritic.
Sitz baths may enhance the patient's comfort. Deliver guidance about safer sex behaviors.Vulvar lesions in children may arise from congenital syphilis or gonorrhea. Assess for sexual abuse. Vulvar dystrophies and neoplasms have an increased prevalence with advancing age. All vulvar lesions should be presumed malignant until demonstrated otherwise. Additionally, numerous women maintain sexual activity into their later years and may originate from an era when sexually transmitted infections were not openly addressed. These patients should be interrogated regarding sexual activity and instructed on safer sex practices.
Vulvar lesions are cutaneous masses, nodules, papules, vesicles, or ulcers arising from benign or malignant tumors, dystrophies, dermatoses, or infections. They may emerge anywhere on the vulva and could remain unnoticed until a gynecological examination. Typically, the patient observes lesions due to accompanying symptoms, like pruritus, dysuria, or dyspareunia.
Medical History and Physical Assessment
Inquire when the patient first observed a vulvar lesion and ascertain any accompanying characteristics, including swelling, pain, tenderness, itching, or discharge. Does she exhibit lesions in other areas of her body? Inquire about the signs and symptoms of systemic illness, including malaise, fever, or rash in other regions of the body. Is the patient engaged in sexual activity? Could she have been exposed to a sexually transmitted infection? Additionally, assess the lesion, conduct a pelvic examination, and get cultures.
Etiological Factors
Basal cell carcinoma
This nodular tumor, prevalent in postmenopausal women, features a central ulcer and a raised, poorly defined border. The tumor is usually asymptomatic but may sometimes induce itching, hemorrhage, discharge, and a burning feeling.
Nonmalignant cysts
Epidermal inclusion cysts, the predominant vulvar cysts, typically manifest on the labia majora and are generally spherical and asymptomatic. They occasionally exhibit erythema and tenderness. Bartholin's duct cysts are often unilateral, tense, nontender, and palpable; they manifest on the posterior labia minora and may induce minor discomfort during intercourse or, when sizable, impede intercourse or even ambulation. Bartholin's abscess, an infection of a Bartholin's duct cyst, results in progressive pain and tenderness, along with potential vulvar enlargement, erythema, and deformity.
Sexually transmitted illnesses are the predominant cause of vulvar lesions in premenopausal women, while vulvar tumors and cysts are the primary lesions in women aged 50 to 70.
Benign tumors of the vulva
Benign vulvar tumors, whether cystic or solid, are typically asymptomatic.
Chancroid
Chancroid, an uncommon sexually transmitted infection, results in painful vulvar sores. Headache, malaise, and a temperature of 102.2°F (39°C) may manifest, accompanied by swollen, painful inguinal lymph nodes.
Genital warts
Genital warts, a sexually transmitted infection, manifest as painless lesions on the vulva, vagina, and cervix. Warts commence as little red or pink protuberances that develop into pedunculated formations. Numerous swellings exhibiting a cauliflower-like morphology are prevalent. Additional findings including pruritus, erythema, and a copious, mucopurulent vaginal discharge. Patients often report experiencing burning or paresthesia in the vaginal introitus.
Gonorrhea
Vulvar lesions, typically localized to Bartholin’s glands, may manifest with pruritus, a burning feeling, discomfort, and a green-yellow vaginal discharge; nevertheless, the majority of patients remain asymptomatic. Additional findings encompass dysuria and urine incontinence; vaginal erythema, edema, hemorrhage, and engorgement; as well as intense pelvic and lower abdominal pain.
Granuloma inguinale
Initially, a solitary painless macule or papule emerges on the vulva, progressing to an ulcerated, elevated, beefy-red lesion with a granular, friable margin. Additional painless and sometimes malodorous lesions may appear on the labia, vagina, or cervix. Infection and pain ensue, leading to the enlargement and potential tenderness of regional lymph nodes. Systemic consequences encompass fever, weight reduction, and malaise.
Genital herpes simplex
Herpes simplex manifests as fluid-filled vesicles on the cervix and perhaps on the vulva, labia, perianal area, vagina, or oral cavity. The vesicles, initially asymptomatic, may rupture and progress into widespread, superficial, painful ulcers, accompanied by erythema, significant edema, and tender inguinal lymphadenopathy. Additional results encompass pyrexia, malaise, and dysuria.
Lymphogranuloma venereum
Individuals with lymphogranuloma venereum, a bacterial infection, typically have a solitary, painless papule or ulcer on the posterior vulva that resolves within a few days. Unilateral, painful, and swollen lymph nodes typically manifest 2 to 6 weeks later. Additional findings including fever, chills, headache, anorexia, myalgias, arthralgias, weight loss, and perineal edema.
Squamous cell carcinoma
Invasive carcinoma predominantly affects postmenopausal women and may manifest as vulvar pruritus, discomfort, and a vulvar mass. As the tumor expands, it may invade the vagina, anus, and urethra, resulting in hemorrhage, discharge, or dysuria. Carcinoma in situ predominantly occurs in premenopausal women, manifesting as a vulvar lesion that may seem white or red, elevated, well-defined, wet, crusty, and solitary.
Hyperplasia of squamous cells
Previously referred to as hyperplastic dystrophy, these vulvar lesions may be distinctly outlined or indistinct; localized or widespread; and exhibit red, brown, white, or a combination of red and white hues. Intense pruritus, maybe accompanied by vulvar pain, severe burning, and dyspareunia, is the primary symptom.
Lichen sclerosus, a kind of vulvar dystrophy, results in vulvar skin exhibiting a parchment-like texture. Fissures may arise between the clitoris and urethra or other vulvar regions.
Syphilis
Chancres, the principal vulvar lesions of syphilis, may manifest on the vulva, vagina, or cervix 10 to 90 days following initial exposure. Typically painless, they commence as papules that subsequently dissolve, exhibiting indurated, elevated margins and transparent bases. Condylomata lata, extremely infectious secondary vulvar lesions, are elevated, gray, flat-topped, and frequently ulcerated. Additional findings encompass a maculopapular, pustular, or nodular rash; cephalalgia; malaise; anorexia; weight reduction; pyrexia; nausea; emesis; widespread lymphadenopathy; and pharyngitis. Systemic viral infection. Varicella, measles, and other systemic viral infections may result in vulvar lesions.
Anticipate the administration of a systemic antibiotic, antiviral, topical corticosteroid, topical testosterone, or an antipruritic.
Sitz baths may enhance the patient's comfort. Deliver guidance about safer sex behaviors.Vulvar lesions in children may arise from congenital syphilis or gonorrhea. Assess for sexual abuse. Vulvar dystrophies and neoplasms have an increased prevalence with advancing age. All vulvar lesions should be presumed malignant until demonstrated otherwise. Additionally, numerous women maintain sexual activity into their later years and may originate from an era when sexually transmitted infections were not openly addressed. These patients should be interrogated regarding sexual activity and instructed on safer sex practices.
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