This is the partial or complete failure to achieve a satisfactory erection. The inability to ejaculate (ejaculatory erectile dysfunction) is not dealt with here. It presents fairly often to GPs and will probably do so increasingly frequently as new treatments are developed and publicised.
COMMON
depression/anxiety
excessive alcohol intake
relationship dysfunction
vascular: arterial insufficiency (arteriopathy) or excessive venous drainage
iatrogenic (e.g. prostatic cancer treatments, hypotensives, some antidepressants)
OCCASIONAL
testosterone deficiency (may be primary or secondary)
diabetic autonomic neuropathy
trauma: pelvic or spinal fracture, trauma to penis, post-TURP
anatomical: phimosis, tight frenulum
excessive cigarette smoking
Peyronie’s disease
drug abuse (e.g. heroin, amphetamines)
RARE
fetishism (erection only possible with unusual stimuli)
spinal cord compression: tumour
thrombosis of a corpus cavernosum
neurological: tabes dorsalis, multiple sclerosis
LIKELY: urinalysis.
POSSIBLE: blood sugar or HbA1c, FBC, LFT, endocrine assays (testosterone, prolactin, FSH/LH, TSH), cholesterol.
SMALL PRINT: Doppler flow studies, angiography, intracorporeal prostaglandin injection test, MRI scanning – all likely to be specialist initiated.
Urinalysis: an essential easy screen for undiagnosed diabetes.
Blood sugar or HbA1c: to confirm diabetes.
FBC and LFT possibly helpful in alcohol excess (raised MCV and possible LFT abnormalities).
Testosterone levels reduced in primary or secondary hypogonadism. Prolactin, FSH/LH and TSH check pituitary function. Erectile dysfunction may be a sign of cardiovascular disease – so in certain patients a cholesterol level would be warranted.
Doppler flow studies of superficial and deep penile arterial flow assess arterial sufficiency. Angiography may be necessary if symptoms suggest significant lower limb arterial insufficiency associated with impotence.
Intracorporeal prostaglandin injection test: immediate and prolonged response indicates neurological problems. Good initial response with rapid failure indicates excessive venous drainage.
Possible neurological causes will occasionally require further investigation (e.g. MRI scanning for cord lesions or MS).
Establish whether the patient can get an erection at any time (e.g. early morning). If he can, then the cause is unlikely to be organic. Take a positive approach – many psychological causes are transient.
Don’t be too quick to diagnose anxiety as the underlying problem. This may be the effect, rather than the cause, of the impotence.
Erectile dysfunction is often presented as a ‘by the way’ or ‘while I’m here’ symptom. The temptation is to invite the patient to book a further appointment, but bear in mind that this may represent a lost opportunity to help, as he may not return.
Demonstrate that you are taking the problem seriously – for example, by performing an appropriate examination or by inviting the patient’s partner to attend a subsequent appointment.
Sudden onset of erectile dysfunction with saddle anaesthesia and sphincter disturbance indicates a cauda equina lesion. Refer urgently.
An erection which is consistently lost after a predictable period is likely to be organic – probably vascular – in origin.
Early morning headache and visual disturbance suggests a pituitary fossa tumour.
Do not forget that alcohol and drug abuse are possible causes. Look in the notes for clues and make specific enquiry, as these problems are unlikely to be volunteered.
Erectile dysfunction may well be a marker for vascular disease elsewhere. Extend your assessment as appropriate.
This is an uncommon presentation – but one we may see increasingly frequently as men become less reticent about coming to the doctor. As with any symptom involving leakage of blood, anxiety levels tend to run high. This shouldn’t transfer to the GP, though – it is unusual for the symptom to have a sinister cause.
COMMON
unknown (at least 50%; the majority are probably secondary to forgotten or unnoticed trauma)
prostatitis
post-operative (prostate surgery, biopsy or extracorporeal shock wave lithotripsy)
genito-urinary infection (epididymo-orchitis, urethritis, UTI)
trauma (to testicles or perineum)
OCCASIONAL
blood clotting disorder or anticoagulation
calculi in the prostate
carcinoma: prostate, testicles, bladder or seminal vesicles
RARE
tuberculosis
schistosomiasis
malignant hypertension
structural problems (such as urethral strictures or polyps)
LIKELY: urinalysis, MSU.
POSSIBLE: FBC, ESR/CRP, PSA, urethral swab.
SMALL PRINT: INR, clotting screen, seminal fluid culture, transrectal ultrasound, prostate biopsy, urethroscopy.
Urinalysis: protein, nitrites, leucocytes and possible haematuria in any genito-urinary infection or prostatitis. Haematuria possible in malignancy and schistosomiasis.
MSU: to confirm infection and identify pathogen.
FBC and ESR/CRP: WCC may be elevated in infection; Hb may be reduced and ESR/CRP raised in malignancy; ESR/CRP also raised in infection.
PSA: the pros and cons of this test might be discussed as a pointer to prostatic carcinoma.
Urethral swab: if urethritis suspected (best taken at GUM clinic).
INR, clotting screen: if patient on warfarin or a bleeding disorder suspected.
Other investigations (usually hospital-based): these might include seminal fluid culture to investigate deep-seated infection; transrectal ultrasound and prostatic biopsy for detailed investigation of prostate; urethroscopy/cystoscopy if felt to be a structural urethral or bladder problem.
A frank and open approach, using plain language, is important for the patient to feel comfortable and capable of describing an accurate history.
Do not underestimate the patient’s level of anxiety – and ensure it’s properly addressed. Most men with this symptom are convinced they have serious pathology.
The approach with this symptom has more to do with deciding on further action than establishing a precise diagnosis. This is because assessment in primary care rarely reveals any underlying pathology – management is more likely to be influenced by the patient’s age and the history than the clinical findings (see below).
Men under the age of 40 with short-lived symptoms do not require referral, as the chance of significant pathology is miniscule. Older men – and those with persistent or recurrent haemospermia, or abnormalities on initial assessment – require referral for further assessment.
A serious underlying cause is rare but should be considered in men over the age of 40 who have more than one episode.
The chances of significant pathology are increased by the finding of microscopic haematuria – refer these cases.
This term is taken to apply to women. It causes much misery and may be embarrassing for a woman to discuss with her doctor. As a result, it may be the ‘hidden agenda’, presenting as a nonexistent ‘discharge’ or vague ‘soreness down below’. Alternatively, it may be the underlying cause of a presentation of infertility or stress. Tact and sensitivity are the most valuable diagnostic and therapeutic tools in these situations.
COMMON
pure vaginismus: psychogenic spasm and dryness
vulvovaginitis (especially infection, e.g. bacterial or fungal vaginosis, ulceration, bartholinitis)
menopausal vaginal dryness (atrophic vaginitis)
endometriosis
pelvic inflammatory disease (PID) and cervicitis
OCCASIONAL
post-partum perineal repair
pelvic congestion (pelvic pain syndrome)
fibroid and retroverted uterus, ovaries in pouch of Douglas
pelvic adhesions (post-surgical or PID)
cystitis, urethritis
RARE
congenital abnormality
large ovarian cyst or tumour
vulval dysplasia
urethral caruncle
unruptured hymen
anal fissure, thrombosed piles, perianal abscess
LIKELY: high vaginal/cervical swabs.
POSSIBLE: urinalysis, MSU, urethral swab, ultrasound, laparoscopy (in secondary care).
SMALL PRINT: FBC, ESR/CRP, vulval biopsy (secondary care).
Urinalysis for nitrite, pus cells and blood useful to rule out UTI.
MSU will help guide treatment in UTI.
If abnormal discharge, take high vaginal and cervical swabs to establish nature of pathogen. Urethral swab useful if possible urethritis (usually at genito-urinary medicine (GUM) clinic).
FBC may show raised WCC in chronic PID.
ESR/CRP elevated in PID.
Pelvic ultrasound can define lie of the uterus and ovaries, presence of cysts and gross endometriosis.
Investigations after referral may include laparoscopy (e.g. for endometriosis and PID) and vulval biopsy (for suspected dysplasia).
Superficial dyspareunia (pain at the introitus) is usually caused by infection, vaginismus or atrophy; deep dyspareunia (deep pain) may be caused by pelvic pathology.
If a sexually transmitted infection could be the cause, refer to a GUM clinic: these are best equipped for thorough screening, counselling and contact tracing.
The patient complaining that her ‘vagina feels too small’ to accommodate her partner’s penis probably has vaginismus.
Deep dyspareunia which is long-standing and positional is ‘collision’ dyspareunia and is very unlikely to be due to significant pathology.
Deep dyspareunia usually resolves immediately on withdrawal; if it lasts a day or two after intercourse, it may well have a psychological basis.
Relationship problems may cause dislike of intercourse which presents as pain. Disharmony may be the cause rather than result of the problem.
Cyclical dyspareunia with generalised pelvic pain and heavy, painful periods suggest endometriosis or PID: refer for gynaecological opinion.
Pelvic tumour is rare in this context, but consider this possibility in the older woman presenting with deep dyspareunia of recent onset.
Examine the menopausal or perimenopausal woman complaining of persistent superficial dyspareunia – vulval dysplasia, rather than atrophic vaginitis, may be the cause.
Pain in the penis occurs not just as a result of local causes, but also by referral from remote lesions. It frequently generates embarrassment for the patient, who may also be frightened that he has a sexually transmitted disease. The diagnosis will often be clear after a carefully taken history and appropriate examination.
COMMON
balanitis (fungal, bacterial or allergic)
acute urethritis
phimosis (e.g. balanitis xerotica obliterans)
urinary calculus (at any point in ureter or urethra)
prostatitis/prostatic abscess
OCCASIONAL
herpes simplex (and rarely zoster)
carcinoma of bladder or prostate
trauma: torn frenulum, zipper injury, urethral injury or foreign body
acute cystitis
Peyronie’s disease (pain usually on erection)
paraphimosis
tight frenulum
RARE
anal fissure/inflamed haemorrhoid
carcinoma of penis
carcinoma of rectum/anus
tuberculosis of urinary tract
schistosomiasis (Schistosoma haematobium): common in Africa and the Middle East
LIKELY: urinalysis, MSU, swabs.
POSSIBLE: FBC, ESR/CRP, PSA.
SMALL PRINT: IVU, cystoscopy, terminal stream urine.
Urinalysis: may reveal proteinuria, haematuria, pus cells and nitrites in the presence of infection; haematuria alone with a stone. Will also reveal glycosuria in the previously undiagnosed diabetic (may present with candidal balanitis).
MSU (for MC&S): to establish pathogen in UTI (may also reveal infective agent in prostatitis).
Swabs for microbiology: urethral swab if urethritis likely (best performed at GUM clinic). In balanitis with discharge, a swab may help guide treatment.
FBC and ESR/CRP: WCC and ESR/CRP raised in significant infection and inflammation (e.g. prostatitis or prostatic abscess). ESR/CRP may be raised in malignancy.
PSA: consider this test if carcinoma of the prostate a possibility.
IVU more useful than ultrasound to investigate the urinary tract if stone or carcinoma suspected, or if chronic UTI suspected.
Terminal stream urine: for schistosomiasis.
Cystoscopy: may be required in secondary care to confirm and treat stone or tumour.
The man who has symptoms suggesting cystitis but who has sterile pyuria on MSU probably has urethritis.
GUM clinics are organised to undertake full investigation, counselling and contact tracing. Referral is essential if STD is likely.
Prostatitis is often forgotten as a diagnosis – but is very difficult to diagnose with certainty, especially when chronic. A trial of a prolonged course of antibiotics may be justified.
Painful intercourse – usually a sudden pain – accompanied by bleeding suggests a torn frenulum. This often occurs in a younger man who is frequently very alarmed by the event. Reassure him explaining that this is not sinister and is easily treatable.
Pain after micturition suggests cystitis. This is unusual in men, and further investigation is indicated if recurrent.
Intermittent pain with passage of blood clots interspersed with painless haematuria suggests a carcinoma (bladder, ureter (rare) or kidney).
Remember that candidal balanitis may be the first sign of diabetes.
Refer the elderly man with an adherent foreskin and balanitis. There could be an underlying carcinoma.
Presentation of this symptom is nearly always accompanied by fear of sexually transmitted disease, even in elderly or no longer sexually active men. There are a number of other causes, many of which are significant and require investigation.
COMMON
herpes simplex virus (HSV)
boil/infected sebaceous cyst
balanitis: bacterial or fungal
trauma: zipper injury commonest; also torn frenulum, bites, self-mutilation
balanitis xerotica obliterans (BXO)
OCCASIONAL
herpes zoster
Reiter’s syndrome: circinate balanitis
allergic contact eczema
chancroid (soft sore: Haemophilus ducreyi)
granuloma inguinale (Klebsiella granulomatis: tropical infection)
lymphogranuloma venereum (tropical infection)
RARE
syphilis (chancre)
carcinoma of the penis
tuberculosis
dermatological conditions, e.g. Behçet’s syndrome, lichen planus
fixed drug eruption
LIKELY: swab, syphilis serology.
POSSIBLE: urinalysis, FBC, ESR/CRP.
SMALL PRINT: patch testing, biopsy.
Urinalysis: in balanitis, may detect undiagnosed diabetes.
Swab: may reveal infectious cause, e.g. herpes simplex, Candida, chancroid, lymphogranuloma venereum and granuloma inguinale (if STD suspected, then other appropriate swabs and blood tests for coexistent disease will be performed at GUM clinic).
FBC and ESR/CRP: raised WCC and ESR/CRP in significant infection or inflammation (e.g. Reiter’s syndrome).
Syphilis serology: if syphilis suspected (Note: may take up to 3 months to become positive after initial infection).
Patch testing: if allergic contact eczema a possibility.
Biopsy (in secondary care): to confirm suspected malignancy or reveal underlying skin condition (e.g. lichen planus).
Take a full sexual history, even in the older patient. If STD is suspected, refer to a GUM clinic for investigation, counselling and contact tracing.
A diagnosis of HSV may induce a number of worries in the patient, some of them well founded, others less so. Give the patient plenty of time to talk through the diagnosis and its implications properly.
Whatever the cause, the patient is very likely to fear a STD. Ensure that inappropriate anxieties are resolved.
Enquire after coexistent or previous dermatological problems in obscure cases – this may provide the diagnosis (e.g. lichen planus).
A history of travel or sexual contact with travellers is important: a number of the more obscure causes are ‘tropical’.
Take a sexual history: syphilis is rare generally but is more common in homosexuals.
Balanitis and urethritis, arthritis and conjunctivitis form the triad of Reiter’s syndrome. Always make a thorough general systemic enquiry.
A single, unexplained, persistent ulcer needs thorough investigation as significant disease (infection or malignancy) is likely.
Remember the possibility of underlying diabetes in severe or recurrent candidal balanitis.
Scrotal swellings can occur at any age. They arise most commonly from the testicle and its coverings, the spermatic cord and the skin. Greater awareness of testicular cancer has resulted in increasing numbers of young men attending the GP, usually with benign lumps.
COMMON
inguinal hernia
sebaceous cyst
hydrocoele
epididymal cyst
epididymo-orchitis (EO)
OCCASIONAL
torsion of the testis
iatrogenic sepsis: surgery and catheterisation
haematocoele
varicocoele
congestive heart failure
post-vasectomy swelling (aseptic), including haematoma, inflammatory reaction to spilt sperm
trauma – haematoma
RARE
testicular tumour (seminoma, teratoma)
ascites
inferior vena caval thrombosis
tuberculosis and syphilis (not rare abroad)
elephantiasis (filariasis)
LIKELY: none.
POSSIBLE: urinalysis, MSU, ultrasound.
SMALL PRINT: FBC, U&E, LFT, CXR, urethral swab, AFP and β-HCG.
Urinalysis may show signs of UTI, but may be negative in epididymo-orchitis, as may MSU.
If urethra discharging take urethral swab for gonococcus and Chlamydia.
Ultrasound useful to distinguish solid from cystic swelling.
FBC, AFP and β-HCG essential baseline investigations if solid tumour suspected – would be arranged by the specialist after referral.
CXR may show cannonball metastases if carcinoma has spread.
May require further investigations such as U&E, LFT, syphilis serology if underlying pathology (e.g. ascites, cardiac failure, syphilis) suspected.
Don’t forget that the patient’s main fear is likely to be cancer. Broach this even if the swelling is obviously benign.
Examine the patient standing. Many lumps are easier to feel this way and some – especially varicocoeles – may disappear on lying down.
In the older patient, with bilateral swelling, there is likely to be some underlying disease process such as cardiac failure.
Consider arranging an ultrasound if a patient remains very anxious about an obviously cystic swelling, or if you have any doubt yourself – a normal result will relieve both parties.
Seminoma may often feel smooth and mimic a large normal testis. Do not rely on the absence of clinical features of malignancy – if the patient feels there has been a change in the testis, act on it.
It can be difficult to distinguish between hernias and hydrocoeles in babies. Hernias require surgical attention; hydrocoeles may resolve within the first year of life. If in doubt, refer.
Remember that a hydrocoele may be caused by an underlying malignancy; in younger patients, always refer, while in the elderly, examine the testis carefully after aspiration.
Left supraclavicular nodes may be involved after tumour spread to para-aortic nodes (can be massive). Examine the abdomen and chest if any suspicion of malignancy.
If any suspicion of torsion – admit urgently.
This is an uncommon symptom in everyday general practice. Though commonest in the young adult, it can affect all age groups. In its acute form, it is excruciating and disabling. In the chronic form it is usually described as a dull ache or dragging sensation. It is the former which causes the GP the most diagnostic difficulty and anxiety.
COMMON
acute orchitis (mumps, and less commonly scarlet fever and flu)
acute epididymo-orchitis (EO) (UTI and sexually transmitted infection)
torsion of the testis
epididymal cyst
referred from ureteric stone
OCCASIONAL
varicocoele
haematocoele
hydrocoele
trauma (fractured testis)
undescended or misplaced testis
torsion of the appendix testis
post-vasectomy pain
idiopathic chronic testicular pain (accounts for 25% of chronic cases)
RARE
testicular carcinoma (teratoma and seminoma)
incarcerated or strangulated inguinoscrotal hernia
syphilis
referred from spinal tumours
neuralgia testis
tuberculosis of the testis
LIKELY: urinalysis, MSU.
POSSIBLE: urethral swab, ultrasound.
SMALL PRINT: lumbosacral spine and abdominal X-rays, syphilis serology.
Urinalysis: protein, blood and pus cells in EO. Blood alone with stone.
MSU: will identify UTI.
Urethral swab for gonococcus and Chlamydia necessary if STD suspected.
Plain lumbosacral spine and abdominal X-rays are valuable to investigate referred testicular pain (stones and spinal pathology).
Ultrasound is good at ‘seeing’ if a testicular mass arises from the body of the testis or its coverings, and whether solid or not.
Syphilis serology: if syphilis suspected.
In an adult, relief of pain by elevating the testicle suggests epididymitis.
A negative urinalysis does not exclude epididymitis.
In mild, chronic testicular ache, examine the patient standing up, otherwise you may miss a varicocoele.
A sudden onset of excruciating pain associated with nausea suggests torsion of testis – especially in children and adolescents. Admit immediately.
Repeated episodes of spontaneously resolving pain may represent recurrent, self-correcting torsion. Refer for possible orchidopexy and warn the patient to report urgently if there is severe and persisting pain.
If non-gonococcal/chlamydial epididymitis is clinically suspected, treat immediately with a broad-spectrum antibiotic.
If epididymitis does not settle with antibiotics, consider abscess formation – admit for IV antibiotics or surgical drainage.
Vaginal discharge is usually a symptom of the reproductive years, but can occur at any age. It can be influenced by the menstrual cycle, use of ‘the pill’, age, pregnancy and sexual activity. Treatment is often simple, but if it fails, or if there are risk factors for STDs, it is sensible to refer to a GUM clinic.
COMMON
excessive normal secretions
thrush
bacterial vaginosis (BV)
trichomonal vaginosis (TV)
cervicitis (gonococcus, Chlamydia, herpes)
OCCASIONAL
cervical ectropion
cervical polyp
lost tampon, ring pessary or other foreign body
IUCD
bartholinitis
salpingitis
RARE
vulvovaginal neoplasia
cervical or uterine neoplasia
sloughing intrauterine fibroid
pyometra
pelvic fistula
LIKELY: high vaginal swab (HVS).
POSSIBLE: endocervical swab, urethral swab, urine testing for Chlamydia, blood sugar or HbA1c.
SMALL PRINT: other specialist investigations.
Most GPs would confine themselves to the HVS, endocervical swab and urine test. Those with a special interest might undertake the microscopy themselves.
HVS is simple and readily detects Candida, BV and TV.
Wet saline microscopy shows clue cells in BV, motile trichomonads in TV.
Gram stain of cervical or urethral exudate shows negatively staining diplococci in up to 85% of gonococcal infections.
Endocervical swab for ELISA is the gold standard for detecting Chlamydia.
DNA amplification testing of first-catch urine (not MSU) specimens for Chlamydia is noninvasive and relatively acceptable to patients.
Blood sugar or HbA1c: to detect diabetes in severe or recurrent thrush.
Specialist investigations might include D&C or hysteroscopy (for possible malignancy) and barium enema (for pelvic fistula).
It is reasonable to diagnose and treat thrush empirically in a woman with classical symptoms who has had the problem before – many women successfully self-medicate and only attend to obtain their treatment free, via a prescription. But if in any doubt about the diagnosis, examine and investigate as appropriate.
It is worth investing time with the patient suffering confirmed recurrent thrush – advice supplemented by written patient information may help minimise future problems.
Make sure you have all the appropriate swabs (HVS, endocervical, urethral) to hand – you never know when you might need them.
Excessive concern about normal secretions might mask a sexual problem or worry – enquire discreetly about this.
Recurrent or florid thrush may be a presentation of undiagnosed diabetes mellitus. Ask about thirst, polyuria and tiredness and check a fasting glucose if any suspicion of underlying diabetes, or there is a positive family history of diabetes.
Vaginal discharge is an uncommon symptom before puberty. Don’t forget the possibilities of abuse or a foreign body.
Always conduct a full pelvic examination in the post-menopausal woman with vaginal discharge. Malignancy is one of the likeliest causes.
A florid erosion is likely to be caused by chlamydial cervicitis – take a swab and treat appropriately.
If you suspect a sexually transmitted disease, refer to the GUM clinic for full assessment and contact tracing. Refer urgently to the GUM clinic or duty gynaecologist if there are systemic flu-like symptoms and fever with pelvic pain and vaginal discharge.
Vulval irritation encompasses soreness and itch and is a very common presentation in primary care. Embarrassment may mean a ‘calling card’ symptom has first to be presented. Sometimes it is a ‘calling card’ itself, being easier to talk about than a psychosexual problem. With sensitivity, the real issues should emerge during the consultation.
COMMON
thrush: Candida infection
Trichomonas vaginalis
chemical: bubble baths, detergents, ‘feminine hygiene’ douches
trauma: insufficient lubrication during intercourse
atrophic vaginitis
OCCASIONAL
ammoniacal vulvitis from incontinence
skin disorders (e.g. eczema, psoriasis, lichen planus)
infestations: threadworms, pubic lice
psychosexual problems
other infections (e.g. genital warts or herpes)
RARE
diabetes (without Candida infection)
vulval dysplasia (various other terms for this include lichen sclerosis et atrophicus, leukoplakia)
vulval carcinoma
general disorder causing pruritus (e.g. jaundice, leukaemia, chronic renal failure, lymphoma)
psychogenic (no organic or psychosexual problem)
LIKELY: HVS (if discharge present).
POSSIBLE: urinalysis.
SMALL PRINT: FBC, LFT, U&E, fasting sugar or HbA1c, vulval biopsy.
Urinalysis for sugar: diabetes predisposes to thrush and glycosuria in itself can cause vulvitis.
FBC, LFT, U&E: if vulvitis is part of a generalised pruritus, or if the patient is generally unwell, these blood tests may reveal blood dyscrasias or renal or hepatic dysfunction.
Fasting sugar or HbA1c to diagnose or rule out underlying diabetes.
HVS: identifying the pathogen if discharge is present will help management in puzzling or recurrent cases.
Vulval biopsy (secondary care): multiple biopsies are required if vulval dysplasia or carcinoma are suspected.
It is easy to make an erroneous diagnosis of UTI in a patient with vulvitis: external dysuria and contamination of urine with pus cells and blood (especially if there is an associated discharge) may mislead the unwary. Helpful pointers are the presence of external vulval irritation and the absence of frequency or urgency.
In obscure cases, check the skin elsewhere. Vulval irritation may be a manifestation of a primary skin disorder, such as eczema or psoriasis.
The aetiology may be multifactorial with, for example, some primary cause leading to secondary chemical irritation from over-washing or the use of douches. A careful history is needed to unravel the underlying cause and exacerbating factors.
Recurrent candidal infection is a particular problem. Various therapeutic strategies are available, but it is important to take time to explore the woman’s perception of the cause, explain the diagnosis and resolve any exacerbating factors.
Post-menopausal atrophic vaginitis causes soreness rather than itch. Dysplasias and some carcinomas produce intense irritation. Examine these patients and, if in doubt, refer for biopsy.
Consider diabetes in florid or refractory cases of Candida infection.
Significant psychosexual problems may present with vulval irritation. Adopt a sympathetic, open approach. Take particular note of any comments made during the physical examination as this sometimes prompts the patient to reveal the true problem.
Persistent vulval irritation may rarely be a symptom of significant systemic disease. Consider this if the patient has generalised pruritus elsewhere and seems unwell in herself.
If the cause is sexually transmitted (e.g. genital herpes or warts), exclude other infections by referring to a GUM clinic.
Vulval swellings may originate in the vulva, or appear there after displacement from their origin. They often present as ‘a lump down below’ – an expression which belies the variety of possible causes. They generate a lot of anxiety but are rarely sinister.
COMMON
boils
sebaceous cysts
viral warts (condylomata acuminata)
Bartholin’s cyst
inguinal hernia (may extend down to labium major)
OCCASIONAL
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
cervical polyp
carcinoma (95% are squamous)
endometrioma
hydrocoele of the canal of Nuck
traumatic haematoma
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.
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.
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.
This often unpleasant symptom is uncommon, but very important, as many causes are significant and require specialist investigation, treatment and follow-up. Patients often have difficulty visualising or describing these types of lesions, so adequate examination is vital in establishing the diagnosis.
COMMON
herpes simplex virus (HSV)
thrush (particularly if very excoriated)
vulval dysplasia
squamous cell carcinoma (SCC): 95% of vulval malignancies
excoriated scabies
OCCASIONAL
allergic contact eczema
chancroid: H. ducreyi (tropical)
granuloma inguinale: K. granulomatis (tropical)
lymphogranuloma venereum: Chlamydia trachomatis (tropical)
other malignancies (e.g. BCC, melanoma, adenocarcinoma, sarcoma)
herpes zoster
RARE
syphilis and yaws
Behçet’s syndrome
tuberculosis
fixed drug eruption
dermatological disorders (e.g. pemphigus and pemphigoid)
LIKELY: urinalysis, swab.
POSSIBLE: fasting sugar or HbA1c, and (in secondary care) biopsy.
SMALL PRINT: syphilis serology, patch testing.
Urinalysis: glycosuria may be present in undiagnosed diabetes presenting with severe or recurrent Candida infection. Fasting sugar or HbA1c to rule out or diagnose undiagnosed diabetes.
Swab for microscopy and culture: may help in the diagnosis of various infections such as HSV, Candida, chancroid, granuloma inguinale and lymphogranuloma venereum (if STD suspected, then other relevant swabs and blood tests for coexistent infection will be performed at GUM clinic).
Syphilis serology: if syphilis a possibility (Note: serology may not become positive for up to 3 months after infection).
Patch testing: may help in the diagnosis of allergic contact eczema.
Biopsy (in secondary care): for any persistent ulcer to confirm diagnosis – may reveal carcinoma, vulval dysplasia or underlying skin disorder.
A diagnosis of HSV can be traumatic for a woman. Spend time discussing the nature of the problem and its recurrent nature, including implications for sexual partners and future pregnancies.
If the patient suffers recurrent vulval ulceration, offer to see her as an ‘urgent’ during the next attack to visualise the lesions and arrange microbiological testing.
In obscure cases do not confine the history and examination to the vulva. Lesions elsewhere (e.g. with pemphigus or Behçet’s syndrome) may give the clue needed to make the diagnosis.
History of travel and sexual contact with travellers is very important as there are a number of ‘tropical’ causes.
The more straightforward causes (HSV and severe excoriated thrush) usually result in multiple ulcers, with the diagnosis being obvious from the history and examination. Take very seriously any single persistent vulval sore: significant disease is likely.
If you suspect a sexually transmitted disease, refer urgently to the local GUM clinic for appropriate investigations and contact tracing.
Remember the possibility of undiagnosed diabetes in severe Candida infection.
The pregnant woman near term with primary HSV is in danger of transmitting the virus to her newborn – a situation with a significant mortality and morbidity. Contact the obstetrician urgently to arrange probable elective Caesarian section.