Female Genitalia
Members of generation are common to both sexes, or peculiar to one; which, because they are impertinent to my purpose, I do voluntarily omit.
—ROBERT BURTON, ANATOMY OF MELANCHOLY, PART 1, SECTION 1, MEMBER 2, SUBSECTION 4
POINTS TO REMEMBER:
Always obtain a complete menstrual and obstetric history.
The pelvic examination is pertinent in any woman with abdominal signs or symptoms, fever of unknown origin, or urinary symptoms.
Take care to respect the patient’s modesty and to make her comfortable, explaining what to expect. Having a chaperone present is essential if the examiner is a man, and often desirable even if the examiner is a woman.
Inspect external genitalia, vaginal mucosa, and cervix, and take appropriate specimens for the laboratory. Besides screening for cervical cancer, frequent screening for Chlamydia in at-risk women is important because of the risk of infertility owing to asymptomatic infections.
Palpate cervix, uterus, and adnexae for tenderness, consistency, mobility, size, and masses, and do not neglect the rectal and rectovaginal examination.
Overview
Importance of the Pelvic Examination in General Medicine
For many women, a pelvic examination is a traumatic event, sometimes because of past experience with insensitive examiners (Magee, 1975). Apparently, many physicians find it bothersome also, judging from the frequency with which the examination is “deferred” (i.e., not done). This omission can cause an important diagnosis to be missed (e.g., pregnancy). A surprising number of women in their first trimester have had major surgical procedures that would have been postponed had the surgeon known of the pregnancy, and many inappropriate medications have been prescribed. To avoid such errors, the date of the last menstrual period should be ascertained at each visit, even if the pelvic examination is done by the patient’s gynecologist when indicated.
The pelvic examination is particularly crucial, even if not “due,” in patients with abdominal signs or symptoms, fever of unknown origin, or urinary complaints. Many a pelvic abscess has remained undiagnosed for days, and many a case of vaginitis has been inappropriately treated as “cystitis.” Although they are hidden, the female organs are seldom impertinent to the physician’s medical purpose.
A Case History
An immensely obese, alcoholic patient was admitted late at night to the medical service of a well-known county hospital. The chief complaint was abdominal pain. The intern diagnosed pancreatitis, passed a nasogastric tube, ordered intravenous fluids, and went to bed.
The next morning, the nurse called frantically to inform him of the presence of a newborn infant in the patient’s bed.
The Environment
Every effort should be made to protect the patient’s privacy. When equipping a room for performing pelvic examinations, be sure that the table does not have its foot facing the door. The patient will be worried about someone opening the door and will not be able to relax. The room should be provided with a curtainedoff area where the patient can undress and leave her clothing. This area should be supplied with tissues, individually packaged sanitary pads, and a wastebasket, for the patient’s use after the examination. It goes without saying that the room should be kept warm, with an extra space heater if necessary.
Equipment
The physician will need the following for the routine pelvic examination.
A good light source. A light source in the speculum itself (Fig. 22-1) is best. A gooseneck lamp is usually the best available. A flashlight, with someone to hold it, is the bare minimum.
An examining table with stirrups, and a low stool with wheels. If it is absolutely necessary to examine a hospitalized patient in bed, an upside-down bedpan may be used to elevate her hips. This should give adequate elevation for performing the speculum examination (vide infra).
Remember that the stirrups are always both cold and hard. Oven mittens of the type with the thumb in the middle (Fig. 22-2) make adequate coverings if you do not have the sheepskin kind. Alternatively, the patient may wish to leave her shoes on.
Three disposable gloves. You may want to begin with two gloves on the hand that will eventually be used for the rectovaginal examination.
Lubricant, such as KY jelly. Previously, physicians were instructed not to lubricate the speculum so as not to interfere with interpretation of the cytologic smear. Many gynecologists now say that water-soluble lubricants can be used.
A cytobrush, wooden scraper, or whatever collection devices are preferred by the histopathologist in the laboratory that
will do the Papanicolaou (Pap) smear. The Wallach Papette or broom-collection device, or the Pap Perfect Plastic Spatula, may be needed if the lab is using the newer, more expensive ThinPrep Pap test (Papillo et al., 1998). Read the instructions supplied by the laboratory carefully. Some techniques permit viral typing as well as cytologic examination.
Slides and fixative as needed by the laboratory for the Pap smear. (Long ago, one pathology laboratory simply pasted a different label on a can of commercial hair spray.)
Several other slides and coverslips for examining cervical mucous and/or vaginal discharge, if you have a microscope and are permitted to use it.
Transport medium that the laboratory provides for gonococcal cultures. Many labs supply a solution for a DNA probe.
Supplies for other tests if indicated (polymerase chain reaction [PCR] for herpes, viral cultures, slides for Chlamydia, and so on, obtained from the laboratory that is to perform the tests). The viral medium may need to be kept frozen and thawed just before it is inoculated. Be sure to read the laboratory’s directions before obtaining the specimens.
Nitrazine paper, available through various mail order catalogues offering medical or chemistry supplies, for checking the pH of vaginal secretions. This must be specific for pH greater than or less than 4.5; a different range is used for testing amniotic fluid. Take care to avoid cervical and menstrual secretions when testing pH as these tend to be alkaline (McCue, 1989).
A selection of vaginal speculums. The Graves (duckbill) speculum (Fig. 22-3) comes in various widths and lengths. The Pederson speculum, which is narrower and flatter, can be used in virginal patients and those with a narrow introitus due to senescence, scars, or radiation; some physicians prefer to use it for most patients. Disposable plastic speculums have the advantage that the vaginal wall can be seen through the speculum. However, the ratchets do not permit as fine an adjustment as the screw on the metal speculums. The plastic speculum shown in Fig. 22-1 is her patient’s choice, according to Dr Devra Marcus of Washington, DC.
Guaiac card for testing the stool for occult blood.
A microscope, some 10% KOH solution, and a Gram stain kit (see Chapter 28). The microscopic examination of any abnormal vaginal discharge should be considered an intrinsic part of the physical examination. Unfortunately, the so-called Clinical Laboratory Improvement Act has caused these very useful aids to disappear from many offices and clinics.
 FIGURE 22-1 A plastic speculum with attachable light source. (Courtesy of Dr Devra Marcus, Washington, DC.) |
 FIGURE 22-2 Oven mitts can serve as coverings for the stirrups. |
 FIGURE 22-3 Graves speculum. A: Lateral set screw. B: Thumbpiece. C: Central set screw. |
A Self-study
Before attempting to examine a patient, the neophyte physician needs to examine the speculum and to practice manipulating it. Move the distal ends of the blades apart (like a duckbill) by pushing on the thumbpiece (which elevates the anterior blade) and pulling on the handle with your fingers (to lower the posterior blade). The blades are then held in position by tightening the screw located laterally. The center set screw allows for adjustment of the distance between the proximal ends of the blades (Fig. 22-3).
Preparing for the Examination
A few simple courtesies can make the examination less distressing to the patient and easier for the doctor. Besides the obvious humanitarian considerations, it is not possible to do a good examination of a patient who is uncomfortable and tense.
Whenever possible, interview the patient while she is fully dressed, preferably in a consultation room. Never introduce yourself to the patient for the first time while she is in the stirrups, unless forced by circumstances such as precipitous delivery or other emergency. Even if you are simply being asked to confirm a finding on the pelvic examination, the patient should at least be allowed to sit up for the introduction (Magee, 1975). Provide for adequate draping. The double draping technique described in Chapter 15, with the gown opening in the back, permits the upper body to be well covered during the pelvic examination. The sheet is draped over the patient’s abdomen and knees.
It is best to have a female attendant present during the examination, even if the physician is a woman, to reassure the patient and to help with the procedure. For male physicians, this is absolutely necessary. If a patient accuses a physician of sexual harassment or assault, the testimony of the attendant may be the best defense. (Dr Sara Imershein states that some patients object to the presence of any chaperone as they feel inhibited about discussing personal concerns. To them, the presence of a third person may imply that the physician does not trust the patient. Physicians must be sensitive to their patients but they should not allow themselves to be manipulated; they should follow their own best judgment. To facilitate discussion of personal concerns, physicians should see the patient at least briefly after the examination, with the patient fully dressed and without other persons in the room.)
Before you begin the examination, the patient should be given the opportunity to go to the bathroom. A full bladder can obscure or be confused with pelvic pathology. Similarly, a full rectum can make the examination inconclusive. (If there is any difficulty in distinguishing hard stool from an area of nodularity, the patient would have to be reexamined after emptying the rectum anyway.)
The dorsal lithotomy position is preferred (i.e., feet in the stirrups, hips abducted as widely as possible, buttocks at the very edge of the table). In patients who are unable to abduct the hips, the Sims position may be used (the patient on her side, with the lower arm behind the back and the thighs flexed, the upper more than the lower.)
It should be a matter of simple common sense that an attendant should never put the patient in the dorsal lithotomy position and then leave her alone in the room.
Order of Examination
It is assumed that the rest of the examination has already been done, at least the examination of the thyroid, breasts, and abdomen.
The pelvic examination begins with inspection and palpation of the external genitalia. Next, the vagina and cervix are gently palpated with one gloved finger, lubricated with warm water or water-soluble gel, enabling the examiner to determine the direction in which to point the speculum. Also, clues to vaginal pathology may be felt. (In some instances, the need for gynecologic consultation will become obvious at this point, and the patient can be spared a second speculum examination.) The vagina and cervix are inspected with the aid of the speculum, and specimens for cytologic and microbiologic examination are obtained. Then the internal genitalia are palpated bimanually, between the abdominal wall and the fingers within the vagina. In most instances, the rectal examination concludes the examination. Sometimes, it may be desirable also to examine the standing patient to reveal a prolapse or hernia that was not apparent in the dorsal lithotomy position. While the patient is dressing, the physician carries out the microscopic examination of the cervical and vaginal secretions, if indicated.
A Note on Examining Children
A full discussion of the pediatric examination is beyond the scope of this text. However, because all physicians are required by law to report suspected child abuse, some of the issues will be outlined briefly here.
The genital examination of a child must be carried out in a gentle, nonthreatening, sensitive manner. Generally, an external examination will suffice. Girls younger than 4 or 5 years can be examined in a semireclining position in the parent’s lap, with knees bent and soles of the feet touching. The labia, vestibule, and posterior fourchette can be examined by separating the labia with the fingertips in a lateral and downward direction. The interior of the vaginal canal can be seen better by gently and firmly grasping the labia majora between index fingers and thumb and pulling outward and slightly upward until the edges of the hymen separate. The prone knee-chest position provides excellent visualization of the vaginal canal and provides access for obtaining cultures, if indicated, without the need for instrumentation. The examiner’s thumbs, placed beneath the leading edge of the gluteus maximus at the level of the introitus, can be used to lift the perineal body and provide exposure of the introitus (McCann, 1990). A handheld otoscope can provide both light and magnification if needed (Adams, 1991).
Sometimes the best way to examine a child is under anesthesia. If abuse is being considered, the best qualified person should do the examination in the first place as repetition is needlessly traumatic (R. Allen, personal communication, 2004).
External Genitalia
Pubic Hair
The appearance of a male-type escutcheon (see Chapter 7) can be a virilizing sign. However, there is normally a continuum, and a family history may be helpful. Terminal1 hair was found on the abdomen (above the pubic triangle) of 35% of 400 English and Welsh university women (McKnight, 1964).
In patients afflicted with pubic lice, nits may be seen at the base of the hairs, along with signs of excoriation of the skin.
The Vulva
Labia Majora
The skin covering the labia majora may be afflicted with the same lesions as the skin of the rest of the body, including malignant melanomas, psoriasis, and seborrheic dermatitis. The labia are particularly rich in sebaceous glands, and hence are subject to sebaceous retention cysts and hair follicle infections. The apocrine glands may be afflicted with hidradenitis suppurativa (Fox-Fordyce
disease). Also check for condylomata and lesions of molluscum contagiosum.
disease). Also check for condylomata and lesions of molluscum contagiosum.
Because the labia majora are the analog of the scrotum, the occurrence of labioinguinal hernias, although rare, should not be surprising. In certain hermaphrodites, testicles are found in the labia majora.
An abscess of the Bartholin2 gland, when fully formed, is an obvious tender red mass in the posterior labium. Patients will walk in a peculiar way and complain of severe pain. However, considerable enlargement of the gland (as from a retention cyst or rarely an adenocarcinoma) can be missed unless it is searched for. Palpate the posterior part of the labia majora between the finger and thumb, searching for a swelling. In patients with a Bartholin abscess, there is a high incidence of sexually transmitted disease (STD); Gram stain and cultures for gonorrhea and Chlamydia should be performed, and diagnostic tests for syphilis, human immunodeficiency virus (HIV), and hepatitis B should be considered.
Hypertrophy of the labia majora occurs in lipodystrophy.
Labia Minora
Simple adherence of the labia minora (labial agglutination or labial adhesions) in young girls is to be distinguished from imperforate hymen and congenital absence of the vagina. In one study, the incidence was fivefold higher (2.9%) in children who were proven victims of sexual abuse (Muram, 1988). However, in a study of prepubertal girls selected for nonabuse, labial adhesions were detected in 35 of 90 subjects. More than 50% of these adhesions were less than 2 mm in length and detected only on review of magnified colposcopic images (McCann et al., 1990).
Check for condylomata, herpetic lesions, and erythema.
The Clitoris
Enlargement of the clitoris is an unmistakable sign of virilization. The adult clitoral index, defined as the vertical times the horizontal dimensions, is normally from 9 to 35 mm (Rittmaster and Loriaux, 1987). Borderline values, often seen in idiopathic hirsutism, are from 36 to 99 mm. If the index is 100 mm or more, it is a sign of severe hyperandrogenicity (Tagatz et al., 1979), and demands an explanation. In the infant, clitoral enlargement may signal an adrenogenital syndrome or a maternal ovarian tumor.
The Urethra
A purulent discharge from the urethra can result from gonorrhea, a urethral diverticulum, or another cause of urethritis. Sometimes the discharge is apparent only after stroking the anterior vaginal wall in the direction of the meatus. A urethral caruncle, a tender, inflamed red mass at the meatus, may be a complication of urethritis. A prolapsed urethra may form a hemorrhagic, painful mass, superficially resembling a cancer because of its friability. The condition may occur in children or elderly women, especially after straining. In gonorrhea, pus may be expressed from the ducts of Skene glands located just lateral and somewhat posterior to the urethral orifice. They may be quite difficult to see.
Advanced. A special maneuver in a woman complaining of urinary incontinence is to place a lubricated cotton swab in the urethra to the level of the bladder neck while she is in the lithotomy position. Ask her to perform a Valsalva maneuver, and measure the change in the axis of the free end of the swab. It should remain horizontal if no anatomical defect is present. A positive test is not very helpful, but a negative one decreases the likelihood of stress incontinence (negative likelihood ratio 0.41). The Q tip test is primarily used by specialists as part of an evaluation for incontinence surgery (Holroyd-Leduc et al., 2008).
The Hymen
Inspection of the genitalia should be part of the examination of all infant girls in order to check for the presence of a vagina and for imperforate hymen. In the event of the latter, performance of a rectal examination with the little finger may reveal a bulging in the vagina due to an accumulation of endocervical mucus (hydrocolpos) from maternal hormone secretion. This bulge can become very large and has led to laparotomy for “abdominal mass” (Green, 1971). An imperforate hymen is an indication for an ultrasound examination.
Imperforate hymen should be ruled out in adolescent girls with abdominal pain. Painful hematocolpos and hematosalpinx, sometimes with rupture into the abdomen, have resulted from failure to recognize this condition before several menstrual periods have occurred. Even before menarche, mucus accumulation behind an imperforate hymen has on rare occasions caused obstruction of the ureters and bilateral hydronephrosis.
An excessive amount of tough, fibrous tissue can be the cause of dyspareunia.
Hymenal changes attributed to sexual abuse are discussed below.
Sexually Transmitted Diseases
Lesions that can occur on the penis (see Chapter 21) can also occur on the vulva or inside the vagina. These lesions include the primary chancre of syphilis (Fig. 22-4), the lesion of lymphogranuloma venereum, granuloma inguinale, chancroid, the ulcerating vesicles of herpes, condylomata lata (due to secondary syphilis; Fig. 22-5), and condylomata acuminata (venereal warts; Fig 22-4).
Condylomata acuminata are variably sized, flesh colored to purplish papillomatous growths generally confined to the anogenital region. Giant, nodular lesions with a strawberry-like surface may occasionally be seen in children. Perianal or vulvar lesions may also be associated with warts in the anal canal or in the vagina or cervix.
Condylomata may be flat and visible only with application of dilute acetic acid, or under the colposcope. A careful search is part of the workup for persistent vulvovaginitis; clearing up one condition helps to clear the other (R. Allen, personal communication, 2004).
Condylomata acuminata are caused by the human papilloma virus (HPV), some serotypes of which have been implicated in
the recent increased incidence of cervical carcinoma, especially in younger women (Raymond, 1987a,b), as well as vulvar carcinoma (vide infra). The prevalence of HPV in asymptomatic, sexually active young women is 20% to 40%, using amplified or nonamplified DNA hybridization methods to detect the virus (Ansink, 1996).
the recent increased incidence of cervical carcinoma, especially in younger women (Raymond, 1987a,b), as well as vulvar carcinoma (vide infra). The prevalence of HPV in asymptomatic, sexually active young women is 20% to 40%, using amplified or nonamplified DNA hybridization methods to detect the virus (Ansink, 1996).
 FIGURE 22-4 Condylomata acuminata and a chancre due to primary syphilis. This is a reminder that patients with one sexually transmitted disease (STD) frequently have one or more others also. (Courtesy of Division of Sexually Transmitted Diseases, Center for Prevention Services, Centers for Disease Control, Atlanta, GA.) |
 FIGURE 22-5 Vulvar condylomata lata due to secondary syphilis in a child who had been sexually molested. (Courtesy of Division of Sexually Transmitted Diseases, Center for Prevention Services, Centers for Disease Control, Atlanta, GA.) |
There is an increased incidence of genital warts in persons seropositive for HIV (Boyd, 1990). Thus, this lesion suggests the need to be on the alert for accompanying conditions, including sexual abuse in children (vide infra).
A diffuse reddening and edema of the vulva may result from the presence of certain types of vaginal discharge (Table 22.1).
Gonorrheal vaginitis may be distinguished by its tendency to involve the urethra, the vulvovaginal glands, and the Bartholin and Skene glands.
Evidence of one STD should raise the index of suspicion for others, especially those that are often asymptomatic for long periods, such as Chlamydia. Cultures or even presumptive treatment may be indicated to prevent long-term complications such as infertility.
With increased sexual activity with more partners at younger ages, the prevalence of STDs is very high. More than one in five Americans over the age of 12 is infected with genital herpes, and less than 10% of those who tested positive in a household survey realized that they were infected. Silent spread of the infection is the rule. The prevalence increased by 30% from the late 1970s to early 1990s (Fleming et al., 1997). Most striking is the increase in young persons: seroprevalence quintupled in white teenagers and doubled in white persons in their twenties (Arvin and Prober, 1997).
For further discussion of STDs, see the section on “Vaginal Discharge” below.
Condom Use
Although meticulous use of condoms is advocated, the efficacy of condoms in preventing transmission of all potential infectious agents is not precisely known and it is certainly far from perfect. In one study of participants with known gonococcal or chlamydial exposure, consistent use of condoms effected a reduction in prevalence of gonorrhea and chlamydia from 43% to 30% (Warner et al., 2004). Data are limited on the effectiveness of female condoms at preventing STDs. In a study of female patients attending an STD clinic, postintervention STD incidence (of early syphilis, gonorrhea, chlamydia, or trichomoniasis) per 100 woman-months of observation was 6.8 in the female condom group and 8.5 in the male condom group. The difference was not statistically significant (French et al., 2003).
A review of published studies on the effect of condom use on transmission of HPV found that all methods had significant limitations. Three studies found a protective effect, but most did not (CDC, 2004).
Although physicians will inquire about condom use, they should not allow assurances about consistent use to impede a careful search for STDs. Nor should they overstate the effectiveness of condoms when counseling patients about sexual activity. Sexual intercourse is an extremely effective mechanism for transferring biologic material for the perpetuation of the species. No technology has come close to equalling the effectiveness of monogamy, sexual fidelity, and premarital abstinence in curtailing the spread of STDs.
Other Infectious Diseases Affecting the Vulva
The vulva may be involved by parasites such as pinworms (especially in children) or scabies. Impetigo, a staphylococcal and/or streptococcal lesion characterized by yellow-crusted erosions, is a common accompaniment of scabies (Whiting, 1983).
Numerous fungi are saprophytes in the vulvar area and may become pathogens under conditions of lowered resistance, increased heat, or friction. Predisposing conditions include pregnancy, diabetes, oral contraceptives, and the use of broad-spectrum antibiotics. The most common fungi are tinea cruris and Candida (monilia). The rash of tinea cruris tends to have a butterfly
appearance, with clearly defined, raised, scaly borders, also affecting the upper, inner thighs. A curdy, white vaginal discharge is diagnostic of candidal vulvitis. There may be red maculopapular lesions, “satellite lesions,” lying beyond the border of the inflamed area. However, the characteristic discharge is present in fewer than 50% of the cases; more often, there is redness, possibly a watery discharge, and intense discomfort (R. Allen, personal communication, 2004).
appearance, with clearly defined, raised, scaly borders, also affecting the upper, inner thighs. A curdy, white vaginal discharge is diagnostic of candidal vulvitis. There may be red maculopapular lesions, “satellite lesions,” lying beyond the border of the inflamed area. However, the characteristic discharge is present in fewer than 50% of the cases; more often, there is redness, possibly a watery discharge, and intense discomfort (R. Allen, personal communication, 2004).
TABLE 22.1 Differential diagnosis of vaginal discharge | ||||||||||||||||||||||||||||||||||||||||||||||||
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Ulcerations of the vulva and vagina can be caused by Entamoeba histolytica (generally after a bout of uncontrolled diarrhea).
Other Systemic Diseases
Draining sinuses, abscesses, and deep ulcerations may result from Crohn disease. Other conditions causing vulvar ulcers include Behçet disease, pemphigus vulgaris, dermatitis herpetiformis, and erythema multiforme.
Atrophic Vulvitis
After menopause, the labia may shrink and flatten because of the loss of subcutaneous fat. The skin becomes thin and shiny, and elasticity diminishes. Changes of a similar nature generally coexist in the vagina (vide infra), and the vaginal orifice may become stenotic.
Vulvar Dystrophies
Vulvar skin is more sensitive to irritants than peripheral skin, and, additionally, is exposed to a wide variety of potential sensitizers and irritants, such as laundry powders, douches, contraceptive creams, and deodorants (Friedrich, 1985). A long-standing itchscratch cycle can cause a hyperplastic dystrophy, which is a variant of lichen simplex chronicus (neurodermatitis). This may produce a diffuse erythema, or localized, elevated lesions, often with a white appearance due to hyperkeratosis. Chronic irritation is also thought to cause malignant changes.
Lichen sclerosus (also called lichen sclerosus et atrophicus) typically produces white to pearly flat macules, which may coalesce into plaques, involving the vulva, medial thigh, and/or perianal region. The skin may come to resemble parchment or cigarette paper. Agglutination and fusion of the interlabial folds and a concentric stenosis of the introitus may occur. Half to two thirds of the patients are postmenopausal, but the disease does occur in children (of whom only 35% have genital lesions). Extragenital sites such as the axilla may be involved. A 34% incidence of clinically manifest autoimmune diseases has been reported in patients with this condition (Soper and Creasman, 1986).
Carcinoma develops in about 3% of patients with lichen sclerosus (Soper and Creasman, 1986). Conversely, lichen sclerosus was an associated lesion in 16 of 30 (53%) patients with invasive vulvar carcinoma (Punnonen et al., 1985).
At the time of presentation, 2% to 5% of women with a vulvar dystrophy have an invasive carcinoma of the vulva, and an additional 4% to 8% have some cellular atypia (Soper and Creasman, 1986).
Carcinoma In Situ of the Vulva
The lesions of squamous cell carcinoma in situ (sometimes referred to by the ambiguous terms Bowen disease or erythroplasia of Queyrat) can be unifocal or multifocal and discrete or coalescent. About 20% of the lesions are pigmented; the remainder are white or red. The relationship of the lesions to invasive carcinoma is not as strong as that with cervical carcinoma in situ. Previously considered
a disease of older women, there is an increasing incidence in younger women, with cases occurring in women as young as 17 (Al-Ghamdi et al., 2002) years. Between the periods 1985-1988 and 1994-1997, the incidence of high-grade vulvar intraepithelial neoplasia in women aged 50 or under increased by 392%, and the incidence of invasive vulvar cancer by 157% (Joura et al., 2000). Most but not all tumors are associated with HPV. Suspicious lesions must be biopsied.
a disease of older women, there is an increasing incidence in younger women, with cases occurring in women as young as 17 (Al-Ghamdi et al., 2002) years. Between the periods 1985-1988 and 1994-1997, the incidence of high-grade vulvar intraepithelial neoplasia in women aged 50 or under increased by 392%, and the incidence of invasive vulvar cancer by 157% (Joura et al., 2000). Most but not all tumors are associated with HPV. Suspicious lesions must be biopsied.
Paget Disease
Although formerly considered synonymous with carcinoma in situ, Paget disease of the vulva is a separate entity (Nichols and Evrard, 1985), an intraepithelial adenocarcinoma, occasionally associated with an underlying invasive adenocarcinoma. It presents as a sharply demarcated, florid, red, pruritic, moist area, with occasional crusting. Islands of whitened skin appear between the reddened areas. The lesion may spread to the perineum and thighs.
Invasive Carcinoma of the Vulva
Vulvar cancer is extremely variable in appearance. In its early form, it may be an elevated papule or a small ulcer and may be easily confused with condyloma acuminatum, papillomata, ulcerated chancroid, gumma, or tuberculosis. (Thus, biopsy is very important.) A typical later lesion is an ulcerating mass. Previously, about 70% of patients were postmenopausal (Kistner, 1986), but younger women are now more commonly afflicted, consequent to changes in sexual mores (vide supra).
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