Fiona M. Lewis In recent years, patients have become much more aware of their own health and better informed about their disease, diagnosis, and management. However, attitudes to vulvovaginal disease continue to be very much affected by the contemporary social and cultural background. Despite campaigns to educate women about vulval self‐examination, encouraging them to talk openly about their symptoms and to seek help early, there is still a certain amount of stigma attached to genital disease. Women are often embarrassed to discuss vulval problems [1] and often fear their symptoms may be due to a sexually transmitted infection. Trotula in the eleventh century said ‘since these organs happen to be in a retired location, women on account of modesty and the fragility and delicacy of the state of these parts dare not reveal the difficulties of their sickness to a male doctor’, and this is still true for some women today. The sex of the patient and the healthcare professional has a big influence on patient preference when it comes to genital examination, and some women do still often wish to be seen by a female doctor. Interestingly, those with vulval problems are more likely to be referred to a specialised vulval clinic if seen by a female general practitioner [2]. However, not only does the patient find seeking medical advice about vulval symptoms challenging, but many clinicians also find it difficult. Surveys of paediatric [3] and paediatric surgical trainees [4] report a lack of confidence in dealing with vulval and vaginal conditions and a need for more training. The same is true for dermatology and gynaecology trainees [5,6], where exposure to vulval teaching was very variable. When patients are referred to a vulval clinic, a diagnosis is offered in less than half the cases by the referring physician, and 27% of these were changed after the patient had been seen [7]. A questionnaire survey of fellows of the International Society for the Study of Vulval Disease (ISSVD) revealed that 29% were self‐taught [8]. The formation of international societies with members who demonstrate a specific interest in vulvovaginal disorders has helped to develop vulval disease as a sub‐specialty. This collaboration between relevant specialists aims to increase knowledge and ultimately improve care for women with these conditions. Several countries now have multidisciplinary groups that meet regularly and also organise postgraduate courses dedicated to teaching about vulval disease. Vulval complaints are common, with 45% of general practitioners seeing more than one patient a month with recurrent symptoms [9]. Patients with vulval problems present to a variety of health professionals, including gynaecologists, dermatologists, genitourinary physicians, urologists, physiotherapists, and paediatricians. This can often lead to confusion and inappropriate management, with varying approaches according to specialty. Specific clinics dedicated to vulval and vaginal disorders provide the most appropriate setting for any patient with these symptoms to be seen. They should be run by trained medical and nursing staff, with the equipment necessary for diagnostic investigation readily available. This combined approach is a valuable resource, beneficial in management, teaching, and research. The first vulval clinic was held at Tulane University School of Medicine, Louisiana, in 1957 [10]. The number of vulval clinics available has increased dramatically, and the benefits of such clinics have been shown [11–13]. There are published standards of care of vulval clinics in the United Kingdom [14], but audits show that there is still some way to go with full compliance [15]. There are many vulval conditions which require the input of different specialists, and multidisciplinary working is the best way of approaching this. The way that individual clinics are run can vary but should be led by adequately trained sub‐specialists who continue to develop their skills in the field. It can be helpful to hold combined clinics with other specialists present to see the patient at the same time, but it is most important to build links with other specialties who may be needed at different times to manage specific issues related to the patient’s vulval condition. A good example is that of erosive lichen planus, where complications at distant sites such as the lacrimal duct and external auditory meatus would need referral to ophthalmology and otorhinolaryngology consultants, respectively. A wide range of other specialties may need to be involved in some aspect of patient care (Figure 5.1), but this should be coordinated through the vulval clinic. Figure 5.1 The multidisciplinary specialities that are required for patients with vulval disease. Another vital facet of multidisciplinary working relates to clinicopathological correlation, and working closely with the pathologist is essential. It is important that the clinical and histological diagnosis concur, and if there is doubt, biopsies may need to be repeated. Agreement and understanding of changing classifications and terminology must also occur between clinicians and pathologists to avoid confusion. It has been shown that cooperation between gynaecology and dermatology pathologists improves the accuracy of reporting of vulval biopsies [16]. The importance of an accurate and thorough history cannot be overemphasised. Many find it convenient to have a formal proforma as a basis for history taking, and to then enlarge upon particular aspects in the light of the individual patient’s problem. A structured form ensures that essential information is collected. It is also useful to have similar baseline data for each patient to be used for future comparative clinical research. Some clinicians advocate the use of pre‐clinic questionnaires where the patient can provide basic information which can then act as the basis for more detailed face‐to‐face questioning [17]. However, it is possible to be misled and easy to miss non‐verbal cues from the patient with this approach. It can be helpful to use validated questionnaires to give a quantifiable assessment of how the vulval problem affects quality of life. It is common for even mild vulval disease to have a severe impact on the patient [18], which can be overlooked in history taking. Several tools are available, but these are usually generic and not specific to the vulva [19]. A Vulval Disease Quality of Life Index in lichen sclerosus has recently been published [20]. The Dermatology Quality of Life Index (DLQI) [21], Female Sexual Function Index (FSFI) [22], Female Sexual Distress Scale (FSDS) [23], and Hospital Anxiety and Depression Scale (HADS) [24] are frequently used in practice. In patients with pain, the McGill Pain Questionnaire [25] is most often used but several outcome measures are used in studies, which make results difficult to compare [26]. It is important that the initial interview should take place in a relaxed and sympathetic atmosphere, as this is the first encounter with the patient. Building a good rapport at this stage will help them gain confidence in the consultation. If there are language difficulties which will impede good history taking, an interpreter is needed, but this can unfortunately limit the information that the patient is willing to give. A professional interpreter should always be used in order to ensure that you are receiving the correct information, which may not be given accurately by a family member. In the setting of a teaching clinic, it is essential to ensure that the patient is content to have a student or observer present before starting to take the history. There are several areas to be covered in the consultation, which are listed in Table 5.1. It is often best to start with an open‐ended question so that the patient can express the main problem. Details of the presenting complaint should include duration and initiating, provoking, and alleviating factors.
5
The Vulval Clinic, History, and Examination
The vulval clinic
The consultation
History
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