of the vagina and cervix should be routine for those presenting with features suggestive of mucocutaneous diseases, HSIL, and vaginal discharge. Plastic speculums are most helpful as they allow any changes in the wall of the vagina to be easily seen. In some situations, the inguinal lymph glands will need to be palpated. Additional information and helpful diagnostic clues will be obtained from examination of the mouth, eyes, scalp, nails and other flexural sites, including the umbilicus (Figure 5.2).
History and examination in children
The history for younger children will be given by the parents, but older children can often give a good account of their symptoms. Additional questions about toileting, bladder, and bowel function are important as these are frequent issues in children with vulval symptoms. As in adults, a specific proforma for taking the history in a paediatric patient is useful.
Most older children will permit examination of the vulva and perianal area in the same position as adults in a ‘frog‐leg’ position. Younger children and babies can be held by a parent and positioned in front of them [32]. As the labia majora are not fully formed, visualisation is usually easy, and even the vestibule and hymen are often readily visible without any need to separate the labia minora. Gentle downward traction on the lower buttocks will expose the area if needed. In specific situations, such as suspicion of a foreign body, examination under anaesthesia may be required.
Figure 5.2 Diagnostic clues to be found at other sites.
Investigation of the vagina in children requires the expert help of a paediatric gynaecologist. The un‐oestrogenised vaginal mucosa can be easily damaged even with cotton‐tipped swabs [33]. An alternative is a small 5 mm endoscope with the capacity for irrigation or very small catheters to obtain secretions.
Documentation
Recording findings can be done with the aid of diagrams, but clinical photography is very helpful for monitoring changes in vulval pathology over time and also response to treatment. However, this must be done in a secure manner, with appropriate consent and the images stored with the patient record. This is especially important in the era of smartphone technology [34]. Several digital platforms and secure apps are available, and many hospitals have secure systems. An attempt to standardise views for genital photography has been made, but this is targeted towards use in cosmetic procedures [35].
Management
The diagnosis and further management should be discussed in detail with the patient after she has dressed. In some cases, specific areas in the history may need to be checked or explored in more detail and may be volunteered by patients once they are more relaxed. However, there are some instances when it may be appropriate to demonstrate certain things with the aid of a mirror while the patient is still undressed. This can be particularly helpful to explain the correct method and sites of treatment, or to provide reassurance about normal anatomical variants.
For many of the conditions, it will be appropriate to reinforce the verbal explanation and advice given at the time with information leaflets or helpful websites.
Helpful websites for patient information
These are useful websites that give patient information about several different dermatoses and infections. Other resources are given in the relevant chapters.
Dermatoses
British Association of Dermatologists
DermNet
International Society for the Study of Vulvo‐vaginal Disease
www.issvd.org/patient‐education
Sexually transmitted infections
British Association of Sexual Health and HIV
International Union against Sexually Transmitted Infection
www.iusti.org/patient‐information/
Examples of forms that can be used to take the history and document a diagram of the vulva can be found in the supplementary information in the online edition.
Last accessed September 2021.
References
1 14 Standards of care for women with vulval conditions. https://www.bad.org.uk/shared/get‐file.ashx?itemtype=document&id=6475 Last accessed March 2021.
2 32 Habeshian, K., Fowler, K., Gomez‐Lobo, V. and Marathe, K. Guidelines for pediatric anogenital examination: Insights from our vulvar dermatology clinic. Pediatr Dermatol. 2018 Sep; 35(5): 693–695.
6 Symptoms and Signs in Vulval Disease
Fiona M. Lewis
CHAPTER MENU
Symptoms in vulval disease Vulval ulceration Vulval oedema Acute vulval oedema Chronic vulval oedema
Symptoms in vulval disease
Symptoms relating to vulval disorders tend to fall into a few clear categories. Itch, soreness, and pain are the common descriptions that women will give. It is always important to clarify exactly what the patient
