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PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Vulval Lumps And Ulcers

The vulva is affected by lack of oestrogen after the menopause. Vulvar pruritus 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:

Malignancy:

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

Other ulcerative conditions:

Lumps

Causes of these include:

Infection:

  • Molluscum contagiosum
  • Condyloma acuminata

Benign tumours:

Malignant Disease of The Vulva

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.
  • Presentation: most patients have pruritus, 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.3

Paget's disease

  • A patient with Paget's disease of the vulva (adenocarcinoma in situ) may present with pruritus 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.4,5
  • 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.

Vulvar cancer

  • Vulvar 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.6
  • 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,6 the second most common type.
  • Squamous carcinomas can arise on a background of atrophic changes such as lichen sclerosis, or in hypertrophic epithelium.
  • Squamous vulvar 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 pruritus, lumps, or masses on the vulva are present in most patients with invasive vulvar cancer.
  • Staging recommendations are from FIGO.7

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.

Non-neoplastic skin conditions

  • 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
Referral
  • 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.8
  • 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 pruritus 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.


Document references
  1. DeCherney AH, Nathan L. Current Obstetric & Gynecologic Diagnosis & Treatment 9th edition. Eds. Lange Medical Books 2003.
  2. Young F; Syphilis: still with us, so watch out! J Fam Health Care. 2006;16(3):77-81. [abstract]
  3. Jones RW, Rowan DM, Stewart AW; Vulvar intraepithelial neoplasia: aspects of the natural history and outcome in 405 women. Obstet Gynecol. 2005 Dec;106(6):1319-26. [abstract]
  4. Barhan S; Vulvar Problems in Elderly Women. Postgraduate Medicine On-line. October, 1997.
  5. Feuer GA, Shevchuk M, Calanog A; Vulvar Paget's disease: the need to exclude an invasive lesion. Gynecol Oncol. 1990 Jul;38(1):81-9. [abstract]
  6. Creasman WT; Malignant Vulvar Lesions. eMedicine, July 2007.
  7. FIGO; Staging Vulval cancer. 2001.
  8. NICE; Referral Guidelines for Suspected Cancer. July 2005.

Internet and further reading Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 1560
Document Version: 22
DocRef: bgp56
Last Updated: 6 Sep 2006
Review Date: 5 Sep 2008




















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