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The lower reproductive tract, comprising the vulva, vagina, and cervix, exhibits a wide spectrum of benign and neoplastic diseases. Disorder characteristics often overlap, and thus differentiating normal variants, benign disease, and potentially serious lesions can be challenging. Lower reproductive tract infection is a frequent cause and discussed in Chapter 3 (p. 56), whereas congenital anomalies and preinvasive neoplasia are infrequent and described in Chapters 19 (p. 406) and 29 (p. 620). The benign lesions highlighted in this chapter are common, and mastery of their identification and treatment is essential.


Vulvar skin is more permeable than surrounding tissues because of differences in structure, hydration, occlusion, and susceptibility to friction (Farage, 2004). Accordingly, pathology can develop in this area, although frequency estimates are difficult because of patient underreporting and clinician misdiagnosis. Lesions may develop from allergen or irritant exposure, infection, trauma, autoimmunity, or neoplasia. As a result, symptoms may be acute or chronic and include pain, pruritus, dyspareunia, bleeding, and discharge, which all may affect a woman’s sense of well-being. Effective therapies are available for most disorders, yet embarrassment and fear may be significant roadblocks for many women.

General Approach

The initial encounter includes reassurance that the patient’s complaints will be investigated thoroughly. Women often minimize and may be uncomfortable with describing their symptoms. They may describe protracted histories of assorted diagnoses and treatments by numerous providers and may voice frustration and doubt that relief is possible. Patients are not promised a cure but rather that efforts will be made to control their symptoms. This can require multiple visits, tissue sampling, treatment attempts, and even a multidisciplinary plan. A patient-provider partnership approach to management enhances compliance and satisfaction with care. Patients are often relieved to learn that their complaints and conditions are not unique. Thus, referral to national websites and support groups is usually welcomed.



Scheduling adequate time for the initial evaluation is a wise investment, and detailed patient questionnaires are invaluable. First, symptoms are clarified as to their onset, duration, precise location, and association with vaginal complaints. Vulvar pruritus is often referred to as “vaginal,” thus symptom location is ideally clarified. A thorough medical history addresses systemic illnesses, medications, and known allergies. Obstetric, sexual, and psychosocial histories and any potentially provocative events around the time of symptom onset often suggest etiologies. Hygiene and sexual practices are investigated in detail.

Of symptoms, vulvar pruritus is frequent with many dermatoses. Patients may have been previously diagnosed with psoriasis, eczema, or dermatitis at other body sites. Isolated vulvar pruritus may be associated with a new medication. Most often, vulvar pruritus stems from an irritant or allergic contact dermatitis. Common offenders include urine, moist wipes, or washing with strongly scented body soaps or laundry products. Excessive washing and ...

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