Vulval Lumps and Ulcers

The vulva is affected by lack of oestrogen after the menopause. Vulvar pruritis and irritation are common symptoms in a post-menopausal woman. Examination of the vulva should exclude finding ulceration or a mass that may accompany these as they may also be indicative of infection, inflammation, or malignancy.

Ulcers

When a patient present with a vulval ulcer the following need to be excluded with culture and/or biopsy with colposcopy:¹

Sexually transmitted infection:

• Herpes simplex^2,3
• Chancroid
• Granuloma inguinale
• Lymphogranuloma venereum
• Syphilis

NB: This should not be forgotten. The number of cases in the UK is increasing.⁴
Malignancy:

• Invasive disease of the vulva
• Vulval intraepithelial neoplasia
• Paget's disease

• Behcet's disease
• Disseminated lupus erythematosus

Lumps

Causes of these include:

• Invasive disease of the vulva
• Vascular/lymphatic:
  • Varicosities
  • Haemangioma
  • Haematoma
  • Granuloma pyogenicum
  • Lymphangioma

• Molluscum contagiosum
• Condylomata acuminata
• Bartholin's abscess⁵

• Acrochordon
• Leiomyoma
• Fibroma/lipoma
• Schwannoma

Vulval Intraepithelial Neoplasia (VIN)

• Nature: this is considered a premalignant state. It can occur by means of cell transformation in already-existing vulvar disorders such as lichen sclerosus and squamous cell hyperplasia or it can occur independently.⁶
• Presentation: most patients have pruritis, but some are asymptomatic. The lesions may be white, grey, red or raised.
• Management: biopsy is performed before laser therapy, to make sure that a lesion does not contain invasive cancer. Conventional treatment is wide local excision or laser ablation. Because of the close association of VIN with human papillomavirus infection, lifelong follow-up is required to watch for recurrence.
• Prognosis: spontaneous regression of the disease at all stages has been reported.⁷

Paget's disease

• A patient with Paget's disease of the vulva (adenocarcinoma in situ) may present with pruritis and weeping or bleeding of the lesion.
• The lesion appears to have an eczematous or velvet-like surface.
• Wide local excision is recommended, because the margins of Paget's disease often extend beyond what is seen on gross examination.
• This explains the high incidence of recurrence.
• Because of the 20% incidence of underlying adenocarcinoma, the dermis should be removed for accurate diagnosis.^8,9
• Thorough evaluation of the cervix, colon, bladder, gallbladder and breasts is necessary when Paget's disease of the vulva is found; there is a 30% incidence of concomitant primary carcinoma in these locations.

Vulval cancer

Vulval cancer is a very rare disease and on average, a general practitioner will only see a new case once every 7 years.¹⁰ There should be a high index of suspicion for abnormal lesions on vulva, including ‘warts’ in the postmenopausal woman.

• Vulval cancer accounts for approximately 5% of all female genital malignancies.
• It occurs in about 1.5 per 100,000 women-years in developed countries but is 2-3 times more frequent in underdeveloped countries.¹¹
• With the exception of the rare sarcomas, this cancer appears most frequently in women aged 65-75 years.
• 85% are squamous, less than 5% are melanoma,¹¹ the second most common type.
• Squamous carcinomas can arise on a background of atrophic changes such as lichen sclerosis, or in hypertrophic epithelium.
• Squamous vulval cancer can have many different growth characteristics.
• It can occur in an area of epithelial neoplasia that develops into a small nodule, which may break down and ulcerate.
• Small, warty or cauliflower-like growths may be seen and confused with condylomata acuminata.
• 75% of all growths are primarily on the labia.
• Long-term pruritis, lumps or masses on the vulva are present in most patients with invasive vulval cancer.
• Staging recommendations are from FIGO.¹²
• Most are treated with radical vulvectomy, but in advanced stage primary vulval cancer, treatment is tailored to individual patient needs. Combined treatments have been developed, using chemotherapy, radiotherapy and surgery.¹³

Melanoma

• Melanoma should be considered if there are pigmented lesions on the vulva.
• They are suspicious if they are blue-black in color, have a jagged or fuzzy border, are raised or ulcerated, or are larger than approximately 1 cm.
• Melanomas may be misdiagnosed as undifferentiated squamous carcinoma, particularly if they are amelanotic.
• Most melanomas are located on the labia minora or clitoris and prognosis is related to the size of the lesion and the depth of invasion.

• Psoriasis is a multifocal disease that may affect vulvar tissue as well as skin of the joints, knees and scalp.
• Seborrheic dermatitis, another multifocal disease of the sebaceous glands commonly affecting the scalp, may affect the labia majora only.
• Tinea cruris begins as raised, sharply demarcated, red lesions on the thighs and can spread to the labia.
• These lesions are best diagnosed by punch biopsy with local anaesthetic.

• When a woman presents with vulval symptoms, a vulval examination should be offered.
• If an unexplained vulval lump is found, an urgent referral should be made.¹⁴
• Vulval cancer can also present with vulval bleeding due to ulceration. A patient with these features should be referred urgently.
• A patient who presents with pruritis or pain may reasonably managed with a period of 'treat, watch and wait'.
• This should include active follow-up until symptoms resolve or a diagnosis is confirmed.
• If symptoms persist, the referral may be urgent or non-urgent, depending on the symptoms and the degree of concern about cancer.
• Other paths of referral may include genito-urinary medicine clinic, gynaecology or dermatology, based on appearance and suspicions of the examining GP.