Annotation C: Targeted (non-genital) physical examination

Click here for Key Points to Annotation

The goal of the physical examination at the initial vulvovaginal visit is to validate symptoms, reproduce and localize any pain, detect pathology, educate the woman about normal vulvovaginal anatomy as well as her particular problem, diagnose and treat. It is therefore not necessary to examine every body part in detail, but rather to focus on those that are known to be related to vulvovaginal disorders. Because vulvovaginal disorders can be associated with disease states, lifestyle issues and atopy, it is not enough to examine the vulva and vagina alone. Success in vulvovaginal diagnosis depends on connecting a woman’s personal story, her medical history and physical findings throughout the body, with vulvovaginal symptoms and findings. The entire algorithm addresses this exam process. This annotation addresses the parts of the physical exam outside of the vulva and vagina that we consider important as part of your initial evaluation. Follow up visits do not need to be so thorough, unless a new problem has arisen. It is important that the woman realize that, although you are being attentive in your history taking and thorough in your exam, unless you ARE her primary care provider, you will not be managing her cholesterol screening, her mammograms, her Pap smears, or even her contraception. Women often assume that any gynecological exam includes a Pap smear.

 

An organized step-by-step progression is essential. Omission of steps or a change in the order can result in overlooked clues and missed diagnosis. Once routine, this part of the exam only takes a few minutes. The logical progression of steps in the entire exam also reserves the least comfortable portions of the examination for the end.


Stature, weight, BMI, posture

  • Significantly underweight women may have signs of atrophy associated with hypothalamic amenorrhea. Short stature, webbed neck may represent Turner’s syndrome with ovarian failure and vulvovaginal atrophy.
  • Trunkal obesity, buffalo hump, and striae suggest Cushing disease that will influence therapy when steroids are indicated.
  • Obesity (BMI of 30 or higher) may be a factor in diagnosing and managing vulvar dermatoses since perspiration and friction between skin surfaces reduce ability to see the vulva in order to apply topical medications, and cutaneous Candida may be operant. Sitz baths may not be possible, making compresses or use of hand-held shower important for epithelial hydration.
  • The position of the patient as she awaits examination may suggest pathology. Standing may suggest avoidance of pain increased by sitting. Sustained rotation of the hips or sitting with one foot tucked under the buttocks to avoid pressure against a painful vulva may lead to imbalance of the pelvic girdle, pudendal compression, or neuropathic pain.
  • Marked musculoskeletal defects (e.g. severe scoliosis, marked rotation of the ilium) affect pelvic alignment, creating muscle, ligament, and joint inflammation that may in turn lead to pelvic floor muscle pain and inflame the pudendal nerve on its course through the bony pelvis.

 

Mouth:

  • Lacy white reticules (Wickham’s striae) in the buccal mucosa or along the margins of the tongue or gingivae, and/or cherry red gingival inflammation may be seen with lichen planus. Up to 75% of women with oral lichen planus have genital involvement.1
  • Aphthae seen in the mouth may also occur on the vulva at the same time or at other times.
  • Recurrent oral and genital ulcers may represent complex aphthosis that may be idiopathic, or represent Crohn disease, Reiter syndrome, or cyclical neutropenia. The ulceration may be non-aphthous including bullous disorders, erythyma multiform, erosive lichen planus or, very rarely, evolving Behcet syndrome.2
  • Cold sores represent HSV 1 that may be transferred from mouth to the vulva by the woman herself or her partner.3

Skin and nails

  • Facial acne should prompt awareness of possible extended antibiotic treatment leading to Candida, or extended use of the oral contraceptive pill (OCP), a possible cause of vulvar pain.4 Acne is associated with androgen dominance suggested as a predisposing factor in hidradenitis,5 cause of groin and vulvar papules, nodules, and draining sinuses.
  • Circumscribed, rough skin patches could suggest psoriasis, often accompanied by vulvar psoriasis affecting the labia majora.6 Any dermatosis seen may be treated with immunosuppressants leading to Candida.
  • Eczema suggests atopy, sensitive skin, possible intolerance to standard topical treatments, and increased likelihood of dermatoses such as lichen sclerosus. Vulvar eczema, especially contact dermatitis, is common.7
  • Purple polygonal plaques on wrists, ankles and at the base of the spine suggest cutaneous lichen planus and prompt a search for vulvovaginal lichen planus. Mucosal disease of the gingivae, vestibule, and vagina (vulvovaginal gingival variant) of lichen planus may be present.
  • White patches suggest lichen sclerosus or vitiligo that may be present on the vulva.
  • Check the nails because pitting, inflammation, cracking, broken or thickened nails suggest lichen planus or psoriasis

Back

  • Inspect the skin of the back for lesions the patient may not even be aware of or lesions that may reflect general skin disease, e.g. purple, polygonal plaques over the sacrum of lichen planus.
  • Check the bony prominences for tender points; check for scoliosis or uneven hips.

Breasts and axillae

  • Intertrigo (irritation between two skin surfaces) under the breasts may be found in the groin, as well. Cutaneous Candida under the breasts prompts a search for vulvovaginal Candida.
  • Scarring or nodules under or between the breasts, or in the axillae may represent hidradenitis that may involve the groin and vulva as well.8
  • The traditional breast exam for masses, abnormal nipple discharge, and skin changes is not done routinely during the vulvovaginal evaluation.

Thyroid

  • Enlargement and hypothyroidism as well as other autoimmune diseases are associated with lichen sclerosus.9

Abdomen

  • Palpate the abdominal wall with attention to any tender area the patient points out. Such painful spots can represent myofascial injury, or trigger points for pain referred from intra-peritoneal disease within the abdomen or pelvis.
  • If these areas are still tender to palpation as the patient flexes her abdominal wall muscles (by raising her shoulders off the table), the source is likely the muscle itself.
  • Perform deep palpation of the lower quadrants to identify deep tenderness, a mass that would require investigation, or bladder tenderness sometimes found with interstitial cystitis.
  • Palpate the groin for adenopathy and normal femoral pulses.


SITE EXAMPLE SIGNIFICANCE
Nails Pitted, thickened, cracked nails Suggests lichen planus or psoriasis.
Obesity Enlarged pannus and thighs Difficulty viewing vulva and applying topical medications; source of friction and sweating to exacerbate disease; challenge to do sitz baths, hydrate skin
Oral cavity Aphthae May be seen with complex aphthosis of the vulva.
Wickham’s striae May be seen with vulvovaginal lichen planus.
Skin Acne Suggests hyperandrogenism, an exacerbating factor in hidradenitis; suggests use of antibiotics possibly leading to Candida albicans.
Patches of eczema Suggests atopy, tendency to react easily to irritants, vulvar eczema.
Psoriasis Psoriasis may occur on the vulva as well.
Chapped hands from frequent handwashing Suggests obsessive compulsive disorder which may complicate any diagnosis.
White patches Suggests lichen sclerosus.
Purple, polygonal plaques Suggests lichen planus.
Thyroid Enlarged thyroid may be associated with lichen sclerosus or lichen planus.
Axillae or under breast area Boils, scars, nodules, comedones Suggest hidradenitis suppurativa, which may occur in the vulvar area.
Abdomen Scars or trigger point tenderness May be source of pain referred to vulvar area
Tenderness over bladder May suggest interstitial cystitis.
Back, hips Scoliosis or uneven hips May cause referred pain to vulva.

References

  1. DiFede O, Belfiore P, Cabibi D, De Cantis S, Maresi E, Kerr A, Campisi G. Unexpectedly high frequency of genital involvement in women with clinical and histological features of oral lichen planus. Acta Derm Venereol. 2006; 86:433-438.
  2. Keogan M. Clinical immunology review series: an approach to the patient with recurrent orogenital ulceration including Behcet’s syndrome. Clin Exp Immunol. 2009; 156(1):1-11.
  3. Arduino PG, Porter SR. Herpes Simplex Virus Type 1 infection: overview on relevant clinico-pathological features. J Oral Pathol Med. 2008; 37:107.
  4. Goldstein A, Burrows L, Goldstein I. Can oral contraceptives cause vestibulodynia? J Sex Med. 2010; 7(4 Pt 1) 1585-1587.
  5. Danby EW, Margesson LJ. Pathogenesis, clinical features, and diagnosis of hidradenitis suppurativa. In UpToDate, Basow DS (Ed), UpToDate, Waltham, MA, 2015.
  6. Lynch P, Edwards L. Special issues in genital dermatology: psychosexual matters, concerns of immunosuppression, and aging. In: Edwards L, Lynch P, eds. Genital Dermatology Atlas, 2nd edition. Philadelphia, Lippincott, Williams & Wilkins, 2011. 289-310.
  7. Margesson L. Contact dermatitis. Dermatol Ther. 2004; 17:20-27.
  8. Von der Werth JM, Williams, HC. The natural history of hidradenitis suppurativa. J Eur Acad Dermatol Venereol. 2000; 14:389.
  9. Birenbaum D, Young R. High prevalence of thyroid disease in patients with lichen sclerosus. J Reprod Med. 2007; 52(1):28-30.