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ULY CLINIC

20 Septemba 2025, 03:55:45

Vulvar lesions

Vulvar lesions are cutaneous lumps, nodules, papules, vesicles, or ulcers that arise from benign or malignant tumors, vulvar dystrophies, dermatoses, or infections. They may appear anywhere on the vulva and are sometimes unnoticed until a gynecologic examination. Patients usually present due to pruritus, dysuria, dyspareunia, bleeding, or discharge.

Pathophysiology

Benign cysts and tumors: Epidermal inclusion cysts, Bartholin’s duct cysts, and benign solid tumors result from obstructed ducts, cystic degeneration, or benign hyperplasia.
Malignant lesions: Squamous cell carcinoma or basal cell carcinoma involves uncontrolled proliferation of epithelial cells.
Inflammatory and infectious causes: Sexually transmitted infections (e.g., herpes simplex, syphilis, chancroid) trigger vesicular or ulcerative lesions via local tissue infection.
Vulvar dystrophies: Lichen sclerosis and squamous cell hyperplasia alter vulvar skin architecture, producing pruritus, fissures, and color changes.

History and Physical Examination

History

Onset: sudden or gradual.
Symptoms: pain, tenderness, itching, burning, swelling, discharge, dyspareunia, dysuria.
Systemic symptoms: fever, malaise, rashes elsewhere.
Sexual history: activity, exposure to STIs, history of similar lesions.
Past medical history: dermatologic, gynecologic, or systemic conditions; prior vulvar lesions or surgeries.

Physical Examination

Inspect the vulva for lesion type, size, location, color, surface, and borders.
Perform a pelvic examination, including speculum inspection if indicated.
Obtain cultures or biopsies as appropriate.
Check for inguinal lymphadenopathy.
Examine for lesions elsewhere on the body.

Medical causes

Cause	Onset	Key Features	Associated Findings	Pathophysiology	Management
Basal cell carcinoma	Gradual	Nodular lesion with central ulcer	Pruritus, bleeding, burning	Malignant epithelial proliferation	Surgical excision
Epidermal inclusion cysts	Gradual	Round, asymptomatic nodules	Occasionally erythema or tenderness	Cystic accumulation of keratin	Observation or excision if symptomatic
Bartholin’s duct cyst	Gradual	Unilateral, tense, nontender mass	Discomfort with intercourse, possible walking difficulty	Duct obstruction	Sitz baths, incision & drainage, marsupialization if infected
Bartholin’s abscess	Acute	Painful, swollen, erythematous vulvar mass	Fever, tenderness, localized deformity	Secondary infection of cyst	Incision & drainage, antibiotics
Chancroid	Acute	Painful ulcers on vulva	Fever, malaise, tender inguinal lymphadenopathy	Haemophilus ducreyi infection	Antibiotics (azithromycin, ceftriaxone)
Genital warts (HPV)	Gradual	Painless, pedunculated cauliflower-like warts	Pruritus, mucopurulent discharge, burning	Viral-induced epithelial proliferation	Topical therapy, cryotherapy, surgical removal
Gonorrhea	Acute	Vulvar lesions in Bartholin’s glands	Dysuria, pruritus, green-yellow discharge, pelvic pain	Bacterial infection of glands	Antibiotics (ceftriaxone, doxycycline)
Granuloma inguinale	Gradual	Beefy-red ulcer with granulated border	Regional lymphadenopathy, fever, malaise	Klebsiella granulomatis infection	Antibiotics (doxycycline)
Herpes simplex (genital)	Acute	Fluid-filled vesicles → shallow painful ulcers	Fever, malaise, inguinal lymphadenopathy	HSV infection	Antivirals (acyclovir, valacyclovir)
Lymphogranuloma venereum	Acute	Single painless papule → heals; later painful lymphadenopathy	Fever, chills, headache, anorexia, weight loss	Chlamydia trachomatis infection	Antibiotics (doxycycline)
Squamous cell carcinoma	Gradual	Vulvar lump, pruritus, pain	Bleeding, dysuria, encroachment on vagina/anus	Malignant epithelial proliferation	Surgical excision, chemo/radiotherapy
Squamous cell hyperplasia	Gradual	Red/brown/white plaques, pruritus, burning	Dyspareunia, fissures	Chronic epithelial hyperplasia	Topical corticosteroids, antipruritics
Syphilis	Gradual	Chancres (papules → ulcer)	Condylomata lata, systemic rash, malaise	Treponema pallidum infection	Antibiotics (penicillin G)
Viral systemic diseases	Acute	Vulvar vesicles/ulcers	Rash elsewhere, fever	Viremia affecting mucosa	Supportive care

Special considerations

Pharmacologic therapy: systemic antibiotics, antivirals, topical corticosteroids, topical testosterone, antipruritics as indicated.
Pain relief and hygiene: sitz baths can alleviate discomfort.
Safety: counsel on safer sexual practices and STI prevention.

Patient counseling

Educate on hygiene, sexual health, and lesion monitoring.
Discuss potential malignancy and importance of follow-up.
Advise avoidance of irritants and management of pruritus.
Reassure regarding benign lesions while emphasizing early evaluation of suspicious changes.

Pediatric pointers

Causes: congenital syphilis, gonorrhea, trauma, sexual abuse.
Evaluate for systemic infection and possible abuse.
Refer to pediatric gynecology if persistent or unusual lesions.

Geriatric pointers

Increased frequency of vulvar dystrophies and neoplasia with age.
All lesions should be suspected malignant until proven otherwise.
Older sexually active women may have STIs or late presentations; counseling on sexual health is essential.

References

Schuiling KD. Women’s Gynecologic Health. 3rd ed. Burlington (MA): Jones & Bartlett Learning; 2013.
Sommers MS, Brunner LS. Pocket Diseases. 3rd ed. Philadelphia (PA): F.A. Davis; 2012.
Disaia PJ, Creasman WT. Clinical Gynecologic Oncology. 9th ed. Philadelphia (PA): Elsevier; 2020.
Baggish MS, Karram MM. Atlas of Pelvic Surgery. 4th ed. Philadelphia (PA): Elsevier; 2017.
Heller DS. Vulvar disorders: Diagnosis and management. Obstet Gynecol Surv. 2011;66:233–245.
Workowski KA, Bolan GA. Sexually transmitted infections treatment guidelines, 2015. MMWR Recomm Rep. 2015;64:1–137.
Preti M, Micheletti L, Villa A. Vulvar intraepithelial neoplasia: Clinical aspects and treatment. Int J Gynecol Obstet. 2009;106:1–6.
Jones RW, Rowan DM. Benign vulvar lesions. BMJ. 2008;337:a864.
Kyrgiou M, Mitra A, Paraskevaidis E. Vulvar cancer: Epidemiology and risk factors. Best Pract Res Clin Obstet Gynaecol. 2013;27:125–136.
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Schwartz RA, Suskind RM. Vulvar dermatology: Lichen sclerosus and hyperplasia. J Am Acad Dermatol. 2011;65:197–210.
Edwards L, Heller DS. Pediatric vulvar lesions. Pediatr Rev. 2010;31:509–516.
Dwyer PC, Briggs JC. Vulvar infections in the elderly: Diagnosis and management. Maturitas. 2006;54:215–224.