APPENDIX 2 Evaluation of Vulvovaginal Disease

The evaluation of chronic vulvovaginal disease differs somewhat from that of skin disease appearing on other skin surfaces. An understanding of several general principles of the diagnosis and evaluation of skin disease or symptoms of vulvovaginal skin allows for better care (Table A2.1).

Table A2.1 Issues in the Evaluation of Women with Chronic Vulvovaginal Symptoms

Normal variants often mimic skin disease. There is wide variation in the shape, size, and symmetry of the labia minora. Some women have very small labia minora, whereas other women have large, redundant labia minora, sometimes asymmetric, and sometimes extending well below the labia majora. The origin of the labia minora is sometimes bifid, originating both from the clitoral frenulum and the edge of the clitoral hood or the medial labium majus (Figure A2.1).

Figure A2.1 Erythema of the modified mucous membranes of the vulva is not necessarily a sign of inflammation.

Most asymptomatic premenopausal women exhibit erythema of modified mucous membranes, and redness is more marked in light-complexioned women. This normal erythema of modified mucous membranes is often misinterpreted by the patient and the examiner as inflammation (Figure A2.2).

Figure A2.2 The labia minora are frequently asymmetrical, and the origin can be bifid.

Vulvar papillomatosis is sometimes mistaken for genital warts. These tubular projections are characterized by rounded tips and symmetrical distribution. Clusters of lesions show papillae that are discrete to the base, whereas genital warts produced by papillomavirus infections are fused at the base. Vulvar papillomatosis classically occurs in the vestibule, but can be seen on any surface of the modified mucous membranes (Figures A2.3–A2.5). The ostia of the vestibular glands appear primarily just external to the hymeneal caruncles, but they are sometimes seen in other areas of the vulva (Figure A2.6). These ostia range from a few to many, and they are generally symmetrical. Fordyce spots consist of enlarged sebaceous glands manifested by lobular, hypopigmented to yellowish papules which are most often noted on the medial aspect of the labia minora, but can occur on any aspect of the modified mucous membranes of the vulva except for the vestibule (Figure A2.7). While Fordyce spots vary in size and number, these are normal findings in the premenopausal woman, and they do not cause symptoms.

Figure A2.3 Vestibular papillomatosis is a normal finding consisting of discrete tubular or dome-shaped papules that are bilaterally symmetrical.

Figure A2.4 Often, vulvar papillomatosis consists of very closely set monomorphous papules that produce a cobblestoned surface, sometimes confused with diffuse human papillomavirus infection.

Figure A2.5 Vulvar papillae are found not only in the vestibule, but sometimes on the labia minora as well.

Figure A2.6 The ostia of vestibular glands are occasionally obvious, appearing as red or skin-colored pits.

Figure A2.7 Fordyce spots, ectopic sebaceous glands, are sometimes quite prominent and lobular, mimicking genital warts or cysts.

Very subtle vulvovaginal abnormalities occasionally produce striking symptoms, so the vulva and vagina should be examined carefully, with the patient in stirrups under a good light. Subtle findings may require minor magnification for adequate evaluation, but colposcopy of the vulva is not required. Trivial abnormalities should not be automatically discounted, but rather treated, since they may or may not be responsible for symptoms.

Related posts:

A Systematic Approach to the Dermatoses of Pregnancy The Papular and Pruritic Dermatoses of Pregnancy Atopic Eruption of Pregnancy Vulvar Dermatoses: the Eczematous Diseases Physiologic Skin Changes of Pregnancy Disorders of Pigmentation

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