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Chapter 78. Diseases and Disorders of the Female Genitalia

Lynette J. Margesson; F. William Danby

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Vulvovaginal Diseases at a Glance
  • Common problems, including the following:
    • Infections
    • Inflammatory dermatoses
    • Bullous and erosive diseases
    • Ulcers
    • Vulvodynia
  • Evaluation, diagnosis, and management are challenging because:
    • Normal vulvar anatomy is often unfamiliar to the physician.
    • Morphology and histologic features of dermatoses are often nonspecific.
    • Causes are often multiple and complex.
    • Patient anxiety and depression are often severe and can worsen symptoms.

The incidence and prevalence of dermatoses affecting the female genitalia are generally not well established. The vulva has been referred to as “the forgotten pelvic organ.” Despite being the visible female genital structure, it is least described in the medical literature.1 Teaching about vulvar conditions and even the normal vulva is sadly lacking for most medical practitioners, so it is not surprising that vulvar conditions are both underreported and underdiagnosed. Approximately 16% of women report undiagnosed chronic vulvovaginal pain at some time in their lives.2,3

The etiology and pathogenesis of many diseases of the female genitalia are likewise not well understood. Those that also affect other areas of the body are better characterized, but the environment of the vulva strongly affects the course of disease.

History

The approach to the patient with vulvar complaints requires directed history taking, as outlined in Box 78-1.

Box 78-1 Elements of History Taking for Patients with Vulvovaginal Complaints
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Box 78-1 Elements of History Taking for Patients with Vulvovaginal Complaints
  • Symptoms: onset, initial trigger, duration, alleviating, and exacerbating factors
  • Previous treatments: duration and effectiveness
  • Copies of previous physicians’ evaluations, culture, and biopsy reports
  • Daily cleansing and care practices
  • Contactants: tampons, pads, lubricants, deodorants, fragrances
  • Gynecologic history
  • Menstruation/menopause/estrogen and other hormone replacement
  • Pap test results
  • Contraception
  • Pregnancy
  • Sexual activity
  • Sexually transmitted diseases
  • Surgeries
  • Urologic history
  • Continence/incontinence
  • Surgery
  • Gastrointestinal history
  • Diarrhea
  • Constipation
  • Psychiatric history

Cutaneous Lesions and Symptoms

The warm moist environment of the vulva often alters disease morphology or symptomatology. For example, usually scaling dermatoses may lack clinically obvious scale, and in diseases that usually exhibit well-demarcated plaques, the lesions may be less distinct. In addition, diseases that normally do not produce scarring of keratinized skin or oral mucosa can induce resorption of the labia minora, narrowing of the introitus, and scarring of the clitoral hood. Vulvar scarring can occur from any inflammatory condition.4

When examining the vulva, it is important to make sure there are no physical abnormalities, particularly, that all normal anatomy is present. Using a diagram can help and this also can be shared for patient education (Fig. 78-1). Unimpressive physical findings are sometimes associated with severe itching and vulvar pain. Lichenification manifested only by a slight change in texture can present with severe pruritus deserving of and responsive to aggressive therapy. Finally, a complete mucocutaneous examination is crucial, because extragenital findings can ...

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