Vulvar Biopsy and Excision of Vulvar Lesions
Oluwatosin Goje
General Principles
Definition
Vulvar lesions represent a wide spectrum of disorders found in the vulvar and perianal regions.1,2 The correct diagnosis is based on clinical history, physical examination, and sometimes laboratory tests. The greatest challenge is to differentiate what is normal, or a normal variant, from the abnormal and also to identify potentially serious disease or infection.3 The most concerning vulvar lesions are intraepithelial neoplasia (VIN) and cancer. The most bothersome are the lichen diseases that are characterized by intense pain and pruritus.
Differential Diagnosis
Vulvar dermatoses: These are inflamed, scaling skin diseases of the vulvar and fall into two morphologic groups: papulosquamous disease and eczematous disease. Papulosquamous diseases are well demarcated and usually show little evidence of rubbing and scratching while eczematous disease has poorly demarcated borders, and characterized by excoriations or thickening of skin from rubbing.
Infectious vulvar lesions may result from candida or herpes simplex virus (HSV) infection. Acquisition of human papilloma virus (HPV) and syphilis may manifest as condyloma accuminata and condyloma lata, respectively. In turn, these lesions are treated with antifungal, antiviral, and antibiotics.
Other benign vulvar lesions include lichen planus, lichen sclerosus, lichen simplex chronicus. Lesions may also develop from chronic irritation secondary to contact/allergic irritants.
Vulvar ulcers: Ulcers are deep with the defect extending into the dermis. They could be infectious or noninfectious. Examples of noninfectious ulcers include Behcet’s disease, apthous ulcers, complex aphthosis, and Crohn’s disease. Vulvar ulcers are often treated with steroids and immunotherapy such as tacrolimus.
Premalignant or malignant vulvar lesions include vulvar intraepithelial neoplasia (VIN), melanoma, basal cell carcinoma, and squamous cell carcinoma. At the very minimum, these lesions require biopsy and excision.
Nonoperative Management
There are no special considerations prior to performing a vulvar biopsy, but patients undergoing excisional biopsy may need to be optimized. Controlling blood sugar in diabetics improves wound healing, anti-coagulated and chronically immunosuppressed patient needs a multidisciplinary approach for optimization prior to surgery. If a patient is anti-coagulated and the international normalized ratio is within the therapeutic window, the procedure can be performed, but physician must have electrical or chemical cautery available for hemostasis.
Imaging and Other Diagnostics
Diagnosis should be made prior to initiating treatment. It is imperative for the clinician to ascertain if the etiology is infectious in nature. This may lead to ancillary blood tests, vulvar and vaginal swabs for culture, polymerase chain reaction (PCR), and biopsies. For example, a patient with vulvar ulcer should be screened for syphilis and HSV using serology. The ulcer should be swabbed and sent for HSV culture or PCR, and dark-field microscopy. Ulcer should be biopsied and sent to pathology.
Vulvar colposcopy: High-grade intraepithelial lesions of the vulvar (HSIL) or VIN are usually multifocal and located on the nonhairy part of the vulvar. Lesions may be raised and variegated with hues of white, red, pink, brown, or grey. Thorough vulvar colposcopy identifies additional lesions and assists in biopsy planning.
Perform colposcopy by covering the area with gauze soaked in 3% to 5% acetic acid for 3 to 5 minutes. Abnormal areas may appear white (acetowhite) and should be biopsied.4 Other areas may present with irregular borders and uneven pigmentation. VIN usually presents as sharply marginated flat-topped papules and plaques (see Pearls and Pitfalls section).
Vulvar biopsy should also be performed on lesions with the following: asymmetry, color variation, irregular borders, rapid change in size or appearance, and bleeding or nonhealing ulcers.
Recalcitrant, nonimproving lesions must be biopsied. A common scenario is an elderly woman who was adequately treated for candida infection but continues to experience persistent itching. On examination, her vulva remains erythematous, with or without fissures and excoriations. Such a patient may have contact or allergic dermatitis, lichen sclerosus, or a premalignant lesion.
Diagnostic vulvar biopsies are office procedures, whereas wide local excisions are performed in the operating room to ensure all affected tissues are excised down to the subcutaneous tissue level.
Prior to procedure, discuss the indication and steps of the procedure with the patient. Counsel her on the risk of pain, bleeding, infection, scarring, and the possibility of a nondiagnostic sample. Finally, obtain the patient’s written consent.
Ensure all equipment and supplies are arranged and available (Table 14.1).
Table 14.1 Biopsy Box Supplies
Biopsy Box Supplies
Baby shampoo/povidone–iodine, or chlorhexidine solutions
Lidocaine injection (1–2%) with or without epinephrine
Surgical gloves
Lidocaine gel 2%
Disposable drape
Syringe—30-gauge tuberculin syringe (1 mL) or 1- or 3-mL syringe
Needles—22–25 gauge (draw up solutions), 25–30 gauge (for injection)
Sterile gauze 2 × 2 or 3 × 3 or 4 × 4
Disposable surgical Scalpel #15
Disposable Keyes punch biopsies, 3–6 mm
Small tissue forceps and Metzenbaum or Iris scissors or disposable kit with forceps and scissors
Needle drivers
3-0 and 4-0 Vicryl suture
Alcohol swabs
Bandages and band-aids
Formalin specimen bottle
Patient instructions
Surgical marking pen
Silver nitrate sticks/Monsel’s solution
Hyfrecator/electrosurgical unit 
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