- Email: [email protected]
Differentiating Between Normal, Benign, and Potentially Serious Vulvar Conditions
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Foreword D i ff e r e n t i a t i n g B e t w e e n Normal, Benign, and Potentially S e r i o u s Vu l v a r Co n d i t i o n s
William Rayburn, MD, MBA Consulting Editor
This issue of the Obstetrics and Gynecology Clinics of North America, edited by Aruna Venkatesan, MD, is dedicated to the diagnosis and management of vulvar disorders. This subject has not been discussed in past issues, and coverage has long been overdue. A wide spectrum of normal, benign, premalignant, and malignant lesions may occur on the vulva. For many physicians, patient symptoms require a rapid inspection and probably a prescription of medication and hygiene recommendations, with a follow-up as necessary. Furthermore, any vulvar conditions may be asymptomatic and, with fewer pelvic exams being performed routinely, there is more opportunity for any disorder to worsen. The first article begins with the diagnostic evaluation of women with vulvar lesions. A history is obtained by asking questions relating to how long the lesion was present, when it first appeared, and any accompanying symptoms (eg, itching, burning, pain, discharge). Other questions relate to any lesions located orally, vaginally, or anally; accompanying incontinence; family history of similar vulvar disease; and skin care and hygiene routines. Prescription or over-the-counter medications, personal care products, and home remedies should be sought and any response to therapy. Before physical examination, it would be prudent to have a female assistant in the room, sufficient lighting, any magnifying lens such as a colposcope, a mirror for the patient to identify the lesion, a ruler, and a camera. Any lesions should be recorded according to its size and shape, type (eg, macule, nodule, ulcer, plaque, pustule, cyst), edge, number and location, color, consistency and feel, and discomfort from inflammation. For completeness, other structures, such as the anus, vagina, cervix, regional lymph nodes, bruises or lacerations, and eye, mouth, and nares, should be examined routinely, since vulvar lesions may indicate a more widespread disease. Obstet Gynecol Clin N Am - (2017) -–http://dx.doi.org/10.1016/j.ogc.2017.06.002 0889-8545/17/ª 2017 Published by Elsevier Inc.
obgyn.theclinics.com
ii
Foreword
The diagnosis of many vulvar conditions is frequently clinical and does not require any procedures. However, a vaginal pH and wet mount may be helpful for patients with an accompanying vaginal discharge and evaluation of a sexually transmitted disease, especially if an ulceration is evident. Vulvar cytology is discouraged because of its poor correlation with tissue diagnosis. Lesions, especially on magnification, are to be biopsied when suspicious for malignancy, do not resolve after standard therapy, or cannot be diagnosed with confidence especially when accompanied by further patient concerns. A drawing or photograph of the lesion(s) is often helpful. The second article pertaining to high-yield histopathology provides an excellent oversight about the range of vulvar disorders. The authors bring their expertise in describing the specific means for diagnosing and treating common conditions such as neoplasms, dermatitis, pruritic lesions, lichen sclerosus, erosive lichen planus, and erosive or ulcerative vulvar conditions. The article pertaining to vulvovaginal graft-versus-host disease provides much insight into an unusual condition. In contrast, vulvodynia is more common, which can be a source of frustration in diagnosis and especially management. The description of pelvic floor physical therapy is a practical overview. This Obstetrics and Gynecology Clinics of North America issue should be an invaluable contribution to any obstetrician-gynecologist’s library. It should serve as an excellent resource in the office setting. I appreciate Dr Venkatesan’s effort in organizing this publication and in enlisting the cooperation of expert dermatologists, obstetrician-gynecologists, pathologists, and physical therapists who shared their experience in a balanced, evidence-based, and enlightening manner. William Rayburn, MD, MBA Obstetrics and Gynecology Continuing Medical Education and Professional Development University of New Mexico School of Medicine MSC 10 5580, 1 University of New Mexico Albuquerque, NM 87131-0001, USA E-mail address: [email protected]
Foreword D i ff e r e n t i a t i n g B e t w e e n Normal, Benign, and Potentially S e r i o u s Vu l v a r Co n d i t i o n s
William Rayburn, MD, MBA Consulting Editor
This issue of the Obstetrics and Gynecology Clinics of North America, edited by Aruna Venkatesan, MD, is dedicated to the diagnosis and management of vulvar disorders. This subject has not been discussed in past issues, and coverage has long been overdue. A wide spectrum of normal, benign, premalignant, and malignant lesions may occur on the vulva. For many physicians, patient symptoms require a rapid inspection and probably a prescription of medication and hygiene recommendations, with a follow-up as necessary. Furthermore, any vulvar conditions may be asymptomatic and, with fewer pelvic exams being performed routinely, there is more opportunity for any disorder to worsen. The first article begins with the diagnostic evaluation of women with vulvar lesions. A history is obtained by asking questions relating to how long the lesion was present, when it first appeared, and any accompanying symptoms (eg, itching, burning, pain, discharge). Other questions relate to any lesions located orally, vaginally, or anally; accompanying incontinence; family history of similar vulvar disease; and skin care and hygiene routines. Prescription or over-the-counter medications, personal care products, and home remedies should be sought and any response to therapy. Before physical examination, it would be prudent to have a female assistant in the room, sufficient lighting, any magnifying lens such as a colposcope, a mirror for the patient to identify the lesion, a ruler, and a camera. Any lesions should be recorded according to its size and shape, type (eg, macule, nodule, ulcer, plaque, pustule, cyst), edge, number and location, color, consistency and feel, and discomfort from inflammation. For completeness, other structures, such as the anus, vagina, cervix, regional lymph nodes, bruises or lacerations, and eye, mouth, and nares, should be examined routinely, since vulvar lesions may indicate a more widespread disease. Obstet Gynecol Clin N Am - (2017) -–http://dx.doi.org/10.1016/j.ogc.2017.06.002 0889-8545/17/ª 2017 Published by Elsevier Inc.
obgyn.theclinics.com
ii
Foreword
The diagnosis of many vulvar conditions is frequently clinical and does not require any procedures. However, a vaginal pH and wet mount may be helpful for patients with an accompanying vaginal discharge and evaluation of a sexually transmitted disease, especially if an ulceration is evident. Vulvar cytology is discouraged because of its poor correlation with tissue diagnosis. Lesions, especially on magnification, are to be biopsied when suspicious for malignancy, do not resolve after standard therapy, or cannot be diagnosed with confidence especially when accompanied by further patient concerns. A drawing or photograph of the lesion(s) is often helpful. The second article pertaining to high-yield histopathology provides an excellent oversight about the range of vulvar disorders. The authors bring their expertise in describing the specific means for diagnosing and treating common conditions such as neoplasms, dermatitis, pruritic lesions, lichen sclerosus, erosive lichen planus, and erosive or ulcerative vulvar conditions. The article pertaining to vulvovaginal graft-versus-host disease provides much insight into an unusual condition. In contrast, vulvodynia is more common, which can be a source of frustration in diagnosis and especially management. The description of pelvic floor physical therapy is a practical overview. This Obstetrics and Gynecology Clinics of North America issue should be an invaluable contribution to any obstetrician-gynecologist’s library. It should serve as an excellent resource in the office setting. I appreciate Dr Venkatesan’s effort in organizing this publication and in enlisting the cooperation of expert dermatologists, obstetrician-gynecologists, pathologists, and physical therapists who shared their experience in a balanced, evidence-based, and enlightening manner. William Rayburn, MD, MBA Obstetrics and Gynecology Continuing Medical Education and Professional Development University of New Mexico School of Medicine MSC 10 5580, 1 University of New Mexico Albuquerque, NM 87131-0001, USA E-mail address: [email protected]