Fungal cultures are useful when candidiasis is suspected but the office wet mount is nondiagnostic. Routine use of bacterial cultures of the vagina is not indicated due to the wide range of bacteria included in the normal flora. Vulvar lesions suspicious for genital herpes or the other sexually transmitted infections reviewed above should have appropriate cultures or serology testing performed. In the patient with findings suggestive of allergic dermatitis, referral for patch testing may be warranted. Cutaneous sensory testing is useful in patients with chronic vulvar pain consistent with vulvodynia. The patient should rate her discomfort using a 10-point pain scale when light pressure is applied with a cotton-tipped applicator. In addition, these women often experience tenderness or spasm on palpation of the levator muscles. Diagnostic imaging is rarely useful in evaluating vulvar lesions.
Colposcopic findings, i.e., a magnified view of vulvar dysplasia can be variable. Compared to cervical dysplasia, which most often has an acetowhite appearance with atypical vascular changes, vulvar dysplasia can occur with minimal colposcopic findings. A mild acetowhite appearance of the vestibule can occur and should not be confused with dysplasia. Examination of the non-hair-bearing areas is most amenable to colposcopy and most often mirrors similar processes on the cervix. Lesions on hair-bearing, keratinized portions can be subtler; these lesions may extend into the pilosebaceous apparatus and may not be entirely visible. An important feature of vulvoscopy is how a lesion looks in comparison to its surroundings.
Lesions that show "leukoplakia" are white and sometimes raised; they can be associated with dysplasia and cancer. "Erythroplakia" refers to a reddened area and is most likely due to an increased density of underlying atypical blood vessels; they can be flat or raised and may show atypical vessels under colposcopic examination. "Melanotic" lesions that are associated 30% of the time with high-grade vulvar dysplasias do not show acetowhitening and rarely show the typical evidence of neoangiogenesis, mosaicism, and punctuations.
A hallmark of cancer is frank demarcation from its surroundings similar to an ulcer. However, not all cancers are ulcerous and they can hide within a premalignant zone. These differences fuel the debate over whether a vulvar cancer arises from a progressive dysplasia or de novo.
Biopsy of the Vulva
The indications for vulvar biopsy include
• lesion with an appearance suggesting malignancy,
• clinical suspicion of chronic dermatologic disease,
• poor response to an initial trial of management, and
• absence of a clear diagnosis.
The indication and an explanation of the procedure should be reviewed with the patient and informed consent obtained. After the site is prepped with an antiseptic solution, local infiltration with lidocaine should be performed. Most practitioners use a Keyes-type punch biopsy instrument to obtain a specimen of at least 3 mm, but a Kevorkian or Kraus biopsy forceps could also be used. In the case of a single lesion to be completely excised, a scalpel should be used. Small biopsy sites (generally less than 5 mm) may usually be made hemostatic with pressure and application of silver nitrate. Larger lesions should be reapproximated with suture. The patient should be counseled on postprocedure care including sitz baths to keep the area clean and use of oral over-the-counter analgesics as needed. A follow-up appointment should be scheduled within two weeks to check biopsy site healing and review pathology and culture results.
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