Prepare to inspect the genitalia.
For fear: introduce relaxation interventions.
Consider psycho-pharmacology consult or desensitization via cognitive behavioral therapy (CBT).
Examine under anesthesia only if concern for malignancy. (D)
If no lesions, consider Pelvic Floor Dysfunction/Vaginismus. Re-enter algorithm when possible to proceed with exam, Box 6.
9. Review the Atlas of Vulvar Disorders, section on Architectural Changes.
Consider dermatosis. (F)
Consider biopsy. (G)
Continue with box 10.
Continue with box 12.
12. Examine the vestibule. Regardless of architectural or skin findings, perform Q-tip test in the vestibule, including hymenal remnants. (I)
At conclusion of Q-tip test, with the patient’s permission, gently and slowly insert the dry Q-tip into the vagina and along the lower vaginal sidewall. Remove and apply swab to pH strip. Save Q-tip sample for whiff test, saline, and KOH microscopy. (P)
Mentally keep track of pain or other symptoms identified with the Q-tip test.
15. Consider lifestyle issues. (J)
Consider provoked or spontaneous vulvodynia. (K)
Continue with box 17.
Consider secondary provoked or spontaneous vulvodynia. (K) Continue with box 17.
22. Consider STI (sexually transmitted infection). Do chlamydia/gonorrhea probe, other STI testing. (P)
Consider Pap smear and HPV testing.
Continue with box 23.
Continue with box 25.
26. Note inflammation, absence of rugae, pallor, erosions, ulcerations, or other lesions.
Check for DES changes if appropriate. (O) Biopsy if indicated. (G) Delay diagnosis until microscopy is completed. (P)
Continue with box 27.
Continue with box 30.
28. Evaluate the hymenal ring and perform bimanual exam if anatomy permits and patient allows. (Q)
Is the hymenal ring distensible and without pain? (Q)
32. Review pH and Microscopy Table B to diagnose vaginal disorder with elevated pH (>4.5).
Continue with box 34.
Schedule for another evaluation to think again.
Continue with box 37.
Provide comfort measures.
Await test results.
Provide patient education.
Schedule for re-evaluation for treatment response. (R)