Vulval Swelling
Differential Diagnosis
Common Diagnoses
- Boils
- Sebaceous Cysts
- Viral Warts (Condylomata Acuminata)
- Bartholin’s Cyst
- Inguinal Hernia (May Extend Down to Labium Major)
Occasional Diagnoses
- Varicose Vein, Varicocoele of Vulva
- Bartholin’s Abscess (Infected Bartholin’s Cyst)
- Fibroma, Lipoma, Hidradenoma
- Uterine Prolapse, Cystocoele, Rectocoele, Enterocoele (Hernia of the Pouch of Douglas)
- Urethral Caruncle (Meatal Prolapse)
Rare Diagnoses
- Cervical Polyp
- Carcinoma (95% are Squamous)
- Endometrioma
- Hydrocoele of the Canal of Nuck
- Traumatic Haematoma
Ready Reckoner
Key distinguishing features of the most common diagnoses
Boil | Sebaceous Cyst | Viral Warts | Bartholin’s Cyst | Inguinal Hernia | |
---|---|---|---|---|---|
Tender | Yes | No | No | No | No |
Reducible | No | No | No | No | Yes |
Multiple | Possible | Possible | Yes | No | No |
Epidermal | Yes | Yes | Yes | No | No |
Central Punctum | No | Yes | No | No | No |
Possible Investigations
- There are no investigations likely to be performed in primary care: the diagnosis is almost always established by history and examination. If it isn’t, then referral is usually required.
Top Tips
- Remember that, to many patients, a lump means cancer until proven otherwise. You may only require a cursory glance to reassure yourself that the problem is insignificant – but the patient may interpret your approach as dismissive or inadequate. Ensure that the patient’s anxieties are resolved by adequate examination and explanation.
- If the lump is not obviously apparent, or is poorly defined, examine the patient standing – this may reveal a hernia, varicocoele or prolapse.
- A varicocoele of the vulva has a characteristic ‘bag of worms’ feel. It often appears and gets worse during pregnancy.
Red Flags
- A persistent, ulcerating lump in the vulva must always be referred for biopsy to exclude carcinoma, even though some benign lumps can ulcerate (e.g. hidradenoma).
- Check for lymphadenopathy: Hard inguinal nodes with a painless lump are highly suggestive of malignancy. The lump can occasionally be a metastasis itself.
- Women with genital warts may have coexisting sexually transmitted infection – refer to the local GUM clinic for appropriate investigation and, if necessary, contact tracing.