Practice Tip: “SAIL” through a vulvovaginal examination

Dr. Leslie Sadownik (biography, no disclosures)

What care gaps I have noticed

Empiric treatment of vulvovaginal symptoms is common but usually not helpful. Symptoms of vulvar disorders may be non-specific. The differential for “vulvar itch” is broad and includes: infectious, inflammatory, premalignant, and malignant causes. Yet many women with chronic symptoms are treated over and over again for presumed vaginitis.

What data addresses this gap

Approximately 20% of women will have > 3 months of significant vulvar symptoms during their lifetime.¹ Women with chronic vulvar disorders will often report years of symptoms before an accurate diagnosis is made, and effective treatment is started.^2,3 In some cases, this delay in diagnosis will increase the morbidity and mortality associated with the specific vulvar condition.³ In a retrospective review of 102 women with vulvar cancer, 31% had more than three consultations relating to vulvar symptoms more than 6 months before the diagnosis of cancer.⁴

What I recommend (practice tip)

Women with vulvar skin disorders benefit from a systematic examination of the anogenital region. Use these 2 clinical tips to increase your diagnostic acumen – (1) Use a standard systematic approach (SAIL) to clinically assess each woman reporting a vulvar concern⁵ and (2) generate a broad differential diagnosis based on the morphology of the lesion.⁶

The SAIL approach:

Women often present with an area that is symptomatic or a lesion that is concerning; however, it is useful to get in the habit of systematically examining the genitilia of every woman presenting with a vulvovaginal concern.

Skin – Is the skin normal?

Before you look “down there” begin your assessment by inspecting other areas of problematic skin or mucosal surfaces. Skin conditions noted elsewhere, eg. psoriasis or eczema, can also appear on the vulva. Next inspect the genitalia.

Take a moment to inspect the vulva before touching. Touch the surface of the vulva gently with a moistened cotton swab. Minimize the number of times you touch the vulva. It is better to gently lift the labia up (towards the examiner) to inspect the vestibule, rather than applying tension across the midline by spreading the labia. Have women lie on their side to inspect the perianal and or inter-gluteal cleft. If patient’s have significant vestibular discomfort, apply 2 % xylocaine gel to the vestibule with a cotton swab prior to inspecting the vestibule and vagina.  Inspect the skin of the vulva, perineal, perianal and intergluteal folds. Vulvar skin conditions are often associated with perianal involvement.

Evaluate the color and texture of the skin. Changes in texture are important clues of dermatoses and premalignant lesions.

Anatomy – Are there any changes to the vulvar anatomy/architecture?

Clinicians should be familiar with the large variations in normal anatomy. Routinely note the following structures: hood & glans of the clitoris, labia majora, inter-labial folds, and labia minora. Are these structures well defined? Phimosis of the glans of the clitoris, flattening of inter-labial folds or no distinct labia minora are indicative of either lichen planus and lichen sclerosus.

Inflammation – Is the vulva swollen? Is the skin inflamed?

Is the rash well defined (clear border) or diffuse? Is the color pink, red or red-purple? A well defined homogenous medium red rash involving the entire vulva, perineum and perianal skin is often seen in psoriasis.

Lesions – Describe the lesion/s using accurate morphological terms – erosions vs. ulcers, macules vs plaques, cyst vs nodule, etc…

The same SAIL approach can be applied to the speculum exam of the vagina. All women with vulvar disorders should have an examination of the vagina since some vulvar disorders (eg. erosive lichen planus) are associated with inflammation and scarring within the vagina and unrecognized changes to the vagina can result in a loss of function (eg. inability to have penetrative sex).

THEN generate a differential diagnosis based on your objective findings and the morphology of the lesion.⁵

A systematic approach to examining the vulva will help the clinician to:

1. Avoid misdirection – women will often point to the area that is of concern to them. It is natural to inspect that area – but then forget to examine the rest of the vulva and vagina. Important clinical signs may be missed. For example, a woman may notice a hematoma on the upper labia majus of vulva. The presence of changes to the perineal skin (thinning) and anatomy (clitoral phimosis) in addition to the subdermal hematoma would strongly suggest Lichen Sclerosus.
2. Pick up less common but important vulvar conditions. Many patients presenting with vulvar itch are treated empirically for yeast vaginitis over and over. A broad differential diagnosis of vulvar lesions can be generated based on the type of the lesion⁵. This will help to remind the clinician about less common vulvar disorders. For example, “rashes” associated with changes to the skin (eg. red plaque) should alert the clinician that a differential diagnosis will include pre-malignant lesions.
3. Facilitate timely care for your patient. At the BC Centre for Vulvar Health we primarily use the descriptions of the objective clinical examination to triage patients. Thus a patient referred with “vulvar itch” with no associated description, will be triaged as non-urgent where as a patient with “well demarcated red vulvar plaque involving left labia” will be triaged as urgent – as the asymmetrical nature of the lesion suggests a pre-malignant/malignant condition.

References

1. Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimate the prevalence of vulvodynia? J Am Med Womens Assoc (1972). 2003;58:82. (Request with CPSBC or UBC)
2. Sadownik L. Clinical profile of vulvodynia patients – A prospective study of 300 patients. J Reprod Med. 2000;45:679-684. (Request with CPSBC or view with UBC)
3. Vandborg MP, Christensen RD, Kragstrup J, et al. Reasons for Diagnostic Delay in Gynecological Malignancies. Int J Gynecol Cancer. 2011;21:967-974. (View with CPSBC or UBC)
4. Robinson KM, Ottesen B, Christensen KB, Krasnik A. Diagnostic delay experienced among gynecological cancer patients: a nationwide survey in Denmark. Acta Obstet Gynecol Scand. 2009;88:685-692. (Request with CPSBC or view with UBC)
5. Margesson LJ, Haefner HK. Vulvar lesions: Differential diagnosis based on morphology. UpToDate.com. October 2017. Accessed November 20, 2017. (View)
6. British Association for Sexual Health and HIV Guidelines. The Management of Vulval Skin Disorders. Accessed November 20, 2017.
   1. https://www.bashh.org/documents/UK%20national%20guideline%20for%20the%20management%20of%20vulval%20conditions%202014.pdf
   2. https://www.bashhguidelines.org/current-guidelines/skin-conditions/vulval-conditions-2014/
      
   3. 2014 UK national guideline on the management of vulval conditions https://www.bashhguidelines.org/media/1056/vulval-conditions_2014-ijstda.pdf  

Handouts for Patients

Excellent handouts for patients with vulvar disorders are available through the BC Centre for Vulvar Health website (Health Information) go to:  www.bcvulvarhealth.ca

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Practice Tip: “SAIL" through a vulvovaginal examination

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