Makindo Medical Notes

Introduction

The presence of a vulval or vaginal lump is a common presentation in gynecological practice. These lumps can result from a variety of benign or malignant causes. Accurate diagnosis is essential to provide appropriate treatment and to rule out serious pathology.

Common Causes of Vulval/Vaginal Lumps

• Benign Causes:
  • Bartholin's Cyst: Swelling of the Bartholin gland due to duct obstruction, which may become infected and form an abscess.
  • Skene’s Duct Cyst: A cyst arising from the Skene's gland, located near the urethral opening.
  • Epidermoid Cyst: A benign cyst under the skin caused by blocked hair follicles or sebaceous glands.
  • Fibroma: A benign tumour composed of fibrous or connective tissue.
  • Lipoma: A benign fatty tumour that can occur in the vulva.
  • Genital Warts (Condylomata Acuminata): due to human papillomavirus (HPV), presenting as multiple, flesh-colored lumps.
• Malignant Causes:
  • Vulval Cancer: Most common in older women, presenting as a lump, ulcer, or area of thickened skin. Often associated with itching, bleeding, or pain.
  • Vulvar Intraepithelial Neoplasia (VIN): A pre-cancerous condition that may present as a raised lesion or lump.
• Infectious Causes:
  • Genital Herpes: Caused by herpes simplex virus (HSV), presenting as painful blisters or ulcers, which can appear as lumps initially.
  • Folliculitis: Inflammation of hair follicles, causing small, tender lumps, often seen after shaving or waxing.
  • Molluscum Contagiosum: A viral infection that causes small, pearly, dome-shaped bumps with a dimple in the center.

Diagnosis

To diagnose a vulval or vaginal lump, a thorough clinical history, physical examination, and occasionally additional tests are required. The aim is to identify the underlying cause and rule out malignancy.

Key Aspects of History Taking:

• Onset and duration of the lump
• Associated symptoms such as pain, itching, discharge, or bleeding
• Sexual history, including history of sexually transmitted infections (STIs)
• History of trauma, surgery, or recent shaving
• Family history of cancer or genetic conditions

Examination and Investigations:

• Physical Examination: Inspect the vulva and vagina for any swelling, discoloration, ulceration, or tenderness. Palpate the lump to assess size, consistency, mobility, and tenderness.
• Swabs: For suspected infections like HSV, bacterial infections, or fungal infections.
• Biopsy: If malignancy is suspected, biopsy is essential for histological diagnosis.
• Ultrasound: May be used to assess the characteristics of deeper lumps or cysts.

Management

• Bartholin’s Cyst/Abscess: Small, asymptomatic cysts may require no treatment. For symptomatic or infected cysts, management may include:
  • Incision and drainage for abscesses.
  • Marsupialization for recurrent cysts to prevent reformation.
  • Antibiotics if an infection is present.
• Skene’s Duct Cyst: Asymptomatic cysts may require no treatment. Symptomatic cysts may need surgical excision.
• Epidermoid Cyst: Usually benign and self-limiting, but can be excised if symptomatic or infected.
• Genital Warts (HPV): Treatment options include:
  • Topical agents like imiquimod or podophyllotoxin.
  • Cryotherapy or surgical excision for larger warts.
• Vulval Cancer: Management depends on the stage of the cancer and may include:
  • Surgical excision or vulvectomy.
  • Radiotherapy or chemotherapy for advanced disease.
• Genital Herpes: Managed with antiviral therapy (e.g., acyclovir) to reduce symptoms and prevent recurrences.
• Molluscum Contagiosum: Usually self-limiting but can be treated with cryotherapy or curettage for symptomatic or persistent lesions.
• Folliculitis: Managed by improving hygiene, avoiding tight clothing, and using topical antibiotics if necessary.

When to Refer

• Suspicion of malignancy, requiring specialist evaluation and biopsy.
• Recurrent or complex Bartholin’s abscesses that fail conservative management.
• Lumps that persist despite initial treatment or increase in size.

Conclusion

Vulval and vaginal lumps can result from a wide variety of benign and malignant conditions. Accurate diagnosis is essential for appropriate management, and biopsy should be performed when malignancy is suspected. Benign conditions like cysts or infections are common, but timely referral to a specialist is necessary for persistent or suspicious lumps.