Vulval disease remains a neglected area of gynaecology and vulval examinations are often rushed past during the bimanual or speculum examination. Conditions that affect the vulva can appear dermatological in nature, making generalists hesitant in their diagnosis and management. However, it is not uncommon for vulval lumps and bumps to present in emergency departments or to general gynaecology clinic. This article aims to provide guidance for diagnosing and managing discrete benign vulval lesions. Dermatoses such as lichen sclerosus, lichen planus and desquamative inflammatory vaginitis (DIV) are not included, neither is discussion of premalignant lesions such as vulval intraepithelial neoplasia (VIN).

Normal variations

One of the key components of vulval medicine is being confident in your knowledge of normal anatomy so patients who have normal variations can be appropriately reassured without the need to biopsy. Incorporating a brief vulval examination at the beginning of all speculum examinations can build confidence in assessing normal anatomy and reassurance to women in an area that is difficult to self-inspect. Some normal variants noticed by women, their partners or their general practitioners (GPs) can be cause for concern and referral to gynaecology clinic include:

Vulval papillomatosis: multiple small papillae (raised lesions) on the inner aspect of the labia minora. Flesh coloured, with a smooth surface and symmetrical distribution across the labia they can be mistaken for warts but do not have a rough thickened top.

Prominent sebaceous glands: the inner aspect of the labia minora is rich in sebaceous glands which are generally imperceptible. In some people they may be more prominent appearing as multiple yellow flat or slightly raised lesions 1-2 mm in diameter.

Prominent or uneven hymenal remnants can present as a finger like projection of mucosa out with the vaginal orifice. Removal is only necessary if the patient is experiencing distress.

Lumps

Sebaceous cysts

A common cause of white or flesh coloured vulval lumps that range from a few millimetres to a couple of centimetres in diameter. They may be itchy, and patients can present with multiple lesions across the labia majora. They are uncommon in younger women and adolescents and are more frequent in women with a raised BMI. They can become infected and then may release their contents. They can generally be managed conservatively but some women request surgical excision due to irritation however, there is a significant risk of recurrence following excision.

Vulval angiokeratomas

Small, dark red or purple lesions found across the labia majora that are usually asymptomatic. They are common and seen from middle age onwards. Occasionally they will bleed if knocked or scratched and they can be treated with diathermy if this is an issue.

Hidradenitis suppurativa

A relatively common chronic inflammatory condition of the apocrine sweat glands and so is found in the axillae, groin, vulva and under the breasts. It is not seen before puberty and is more common in overweight people and smokers. It presents as recurrent tender painful lumps that may drain pus with associated sinuses, abscesses and comedones. It is thought to be due to blocked apocrine glands rupturing within the skin and causing inflammation. The main differential diagnosis is recurrent boils associated with Staphylococcus aureus infection but in hidradenitis skin swabs are usually normal.

The condition is thought to result from hypersensitivity of the apocrine glands to normal testosterone levels and so if contraception is being used an anti-androgenic progesterone can be useful in a combined or progesterone only pill. Management is coordinated by dermatologists and involves prolonged courses of antibiotics, intra-lesional steroid injections, newer biological agents and once the disease is under control excisional surgery can be considered.

Ulcers

Herpes

The most common infective cause of genital ulcers, caused by both Herpes Simplex Virus (HSV) 1 and 2. These begin as vesicular lesions that erode to become ulcers ranging from 3-10 mm in size and can also have a serpiginous shape. They can be found across the vulva, extending onto the thighs and buttocks and cause cervicitis and urethritis. The primary episode is usually the worst and associated with regional lymphadenopathy and feeling unwell. Viral swabs are useful to confirm the diagnosis and differentiate between HSV 1 and 2. Genital herpes is more frequently due to HSV 2 and although both are associated with recurrent flares, they are more frequent in HSV 2 – on average four times a year, rather than once a year in HSV 1.

Starting treatment at the time of diagnosis reduces the length of the flare by days to weeks but does not prevent recurrences. Treatment includes anti-virals such as valaciclovir or acyclovir, alongside symptomatic treatment including analgesia, topical lignocaine gel, cool baths, and urinary catheterisation if in retention. Recurrent episodes are less severe and usually easier to diagnose due to patient awareness.

Herpes ulcers can also complicate other vulval skin conditions such as lichen sclerosus or lichen planus if the patient is on immunosuppressants or high dose topical corticosteroids.

Aphthous ulcers

An uncommon finding of acute painful vulval ulcers usually in patients under 20, also known as Lipschütz ulcers or non-sexually acquired acute genital ulceration (NSAGU). They present as sudden onset acutely painful ulcers that may prevent mobilisation or urination and vary in size from 3-20mm often bilateral or kissing ulcers. They can be associated with Epstein–Barr Virus (EBV) and if so, the patient will have general malaise symptoms. The ulcers resemble oral aphthous ulcers, often with a sloughy based and a slightly raised erythematous rim often oval in shape.

The most important part of management is an early accurate diagnosis and reassurance to relieve the distress of the usually adolescent girl and her parents. The ulcers will heal without leaving scars in most cases. It is important to enquire after symptoms that might suggest Crohn’s disease or Behçet’s which are the part of the differential diagnosis. Viral swabs are usually taken to rule out HSV.

The treatment is then symptomatic with analgesia, catheterisation if necessary, topical lignocaine and ultra-potent steroids topically for small ulcers or systemically for severe disease.

Vulval Crohn’s

In patients with Crohn’s disease who present with genital ulcers the possibility of vulval Crohn’s should be considered. Similar to aphthous ulcers in appearance but more like a knife cut in shape and associated with significant vulval swelling and fissuring. Vulval Crohn’s may precede gastrointestinal Crohn’s diagnosis by several years.

The diagnosis is made on biopsy showing typical granuloma if there is not a pre-existing history of Crohn’s. They respond well to steroids and need referral for ongoing management to a gastroenterologist.

Behçet’s disease

This is a chronic vasculitis most common in those whose heritage can be traced back to the Silk Road that stretched from China, across North Asia to the Middle East and particularly Türkiye. The most common manifestation is oral aphthous ulcers and 75% of sufferers also have genital aphthous ulcers that are painful. Cutaneous ulcers are also common as is uveitis.

Consider this diagnosis in patients presenting with painful genital aphthous ulcers and have signs of disease elsewhere – oral ulcers, eye symptoms or less commonly central nervous system or pulmonary disease. In such cases, biopsy of the ulcer edge to confirm vasculitis is valuable, and referral to a rheumatologist is recommended. For aphthous ulcers with no signs of systemic disease biopsy is not necessary.

Hopefully, this article has encouraged you to integrate routine vulval examination into your clinical practice and it improves your confidence in identifying and managing some of the common benign vulval lesions.