Atlas of Vulvar Disorders

Part 1

Unlike in the cervix and vagina, cytology plays little role in the diagnosis of vulvar disease. Because the vulva is clearly visible and easily magnified with the aid of a colposcope, suspicious changes are easily observed as areas that are different from the surrounding normal skin. The diagnosis of vulvar disorders is always confirmed by biopsy.

Embryonic

Fig. 63.1 shows a rather common finding of a softish papillary lesion located lateral to the lower labium majus. Excisional biopsy reveals this to be a remnant of the embryonic milk line. Fig. 63.2 is an excellent illustration of Hart’s line on the inner surface of the labium minus.

Infections

Parasitic Infections

Vulvar infection with the crab louse is contracted through intimate contact with infected genitalia. The symptoms are intense itching in the hair-bearing areas. The colposcope permits scanning and localization of eggs or moving lice ( Fig. 63.3 ).

Bacterial Infections

Several organisms cause acute vulvitis. Diffuse erythema may be associated with vascular ectasia in the form of fine punctation ( Fig. 63.4A and B ). This pattern is characteristic of infection with enteric organisms, such as enterococcus, Escherichia coli, mycoplasma, and Ureaplasma species. Another pattern is large, punched-out shallow ulcers that may be seen with mixed gram-positive organisms, such as streptococcus and staphylococcus (see Fig. 63.4C and D ). Colposcopy shows heaped-up white epithelium at the periphery of the ulcers. The lesions, as a group, cause pain, itching, and a sense of dryness and swelling (see Fig. 63.4E ).

Fungal Infections

Fungal vulvitis causes massive, diffuse erythema; scaling associated with chronicity; and folliculitis ( Fig. 63.5A to C ). With acute fungal or bacterial infection, a fiery, red vulva may be seen (see Fig. 63.5D ). Fungal vulvitis begins with pruritus and progresses to burning pain. Scaling suggests long-standing fungal infection (see Fig. 63.5E and F ).