Diagnostic Algorithm

1. The patient presents with vulvar and/or vaginal signs or symptoms. (A)
2. Take the patient’s history. (B)
3. Complete the targeted (non-genital) physical exam. (C)
Prepare to inspect the genitalia.
5. Do not proceed without permission. For severely damaged skin, culture if able. Biopsy if absolutely necessary, but only with permission and topical anesthesia. Soak & seal at home. (D)

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.

4. Can the patient allow genital inspection and palpation? (D)

Yes

6. Begin the detailed vulvar exam. (E) Have the patient identify location of symptoms and begin pain and symptom mapping of the mons pubis, interlabial folds, labia majora, labia minora, perineum, anus, and peri-clitoral area. (See box 12 for evaluation of the vestibule.)
7. Scrutinize the vulvar anatomy and skin from the outermost to the innermost structures.

9. Review the Atlas of Vulvar Disorders, section on Architectural Changes.

Consider dermatosis. (F)

Consider biopsy. (G)

Continue with box 10.

8. Is the vulvar architecture normal? (F)

Yes

11. Locate the abnormality. Use Dermatological Terminology to describe what you see. Review the Atlas of Vulvar Disorders for the best approach to possible diagnoses.

Continue with box 12.

10. Is the vulvar skin normal in color, texture, and integrity? (H)

Yes

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)

Consider vaginal sources. (M) (N) (P)

Continue with box 17.

14. Is there a skin or architectural alteration that could account for the pain or irritative symptoms? (F) (H)
13. Is there an absence of pain or other irritative symptoms with touch in the vulva or vestibule? (I)

Yes

16. Go to the Atlas of Vulvar Disorders to review differentials.
Consider dermatosis. (F) (G)

Consider vaginal sources. (M) (N) (P)

Consider secondary provoked or spontaneous vulvodynia. (K) Continue with box 17.

Yes

17. Examine the pelvic floor with a lubricated finger. (L)

19. Consider Pelvic Floor Dysfunction/Vaginismus (L).

Continue with box 20.

18. Is the pelvic floor relaxed and free of tension? (L)

Yes

20. Perform speculum exam, using pediatric size speculum if necessary. Evaluate the cervix and vagina. (M) (N) (O)

22. Consider STI (sexually transmitted infection). Do chlamydia/gonorrhea probe, other STI testing. (P)

Consider other non-infectious causes of inflammation. (M) (P)

Consider Pap smear and HPV testing.

Consider DES or congenital changes. (M) (O)

Continue with box 23.

21. Is the cervix normal? (M)

Yes

24. Consider congenital abnormality.
Consider lichen planus, atrophy, post-operative/radiation complication. (N) Biopsy if indicated. (G)

Continue with box 25.

23. Is the vaginal architecture normal? (N)

Yes

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.

25. Is the vaginal epithelium normal? (O)

Yes

27. Note characteristics of secretions. (P) Obtain yeast culture. (P)

29. Consider active or inactive lichen planus or lichen sclerosus.
Consider radiation scarring. (O)
Consider Pelvic Floor Dysfunction/Vaginismus; consider vulvodynia.

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)

Yes

30. Go to the microscope to complete the evaluation. (P)

32. Review pH and Microscopy Table B to diagnose vaginal disorder with elevated pH (>4.5).

Continue with box 34.

31. Is the pH of the vaginal secretions ≤ 4.5? (P)

Yes

33. Review pH and Microscopy Table A to diagnose condition with pH less than or equal to 4.5.
34. Organize data by history, exam, and microscopy. Consider differential diagnoses in Table R-1 and/or the Atlas of Vulvar Disorders.

36. Remove irritants.
Provide comfort measures.
Await test results.Consult with a colleague if necessary. (R)
Review annotations, photos, tables, and Atlas.

Schedule for another evaluation to think again.

Continue with box 37.

35. After completion of the history, exam, pH, whiff test, and microscopy, can you make a probable diagnosis or diagnoses?

Yes

37. Review treatment plans and select treatment(s).
Remove irritants.
Provide comfort measures.
Await test results.
Provide patient education.
Schedule for re-evaluation for treatment response. (R)