Swollen Lymph Node on the Vaginal Labia: Treatment Approach
Immediate Diagnostic Priority
The first step is urgent biopsy to exclude malignancy—never initiate treatment without tissue diagnosis, as squamous cell carcinoma accounts for 90% of vulvar cancers and most commonly originates in the labia majora. 1
Initial Evaluation
- Obtain detailed history including duration and growth pattern of the swelling, associated symptoms (pain, discharge, ulceration), sexual history, STI risk factors, and any prior pelvic surgery or radiation therapy 1
- Document surface characteristics including whether the mass is smooth versus irregular, presence of intact skin versus ulceration, and whether it is truly a lymph node versus other labial pathology 1
- Perform STI screening with gonorrhea and chlamydia nucleic acid amplification tests if Bartholin or Skene gland involvement is suspected 1
- Order ultrasound as first-line imaging to characterize the lesion and determine organ of origin 1
- Consider MRI pelvis without and with IV contrast for large masses to assess tissue relationships and plan surgical approach 1
Differential Diagnosis Framework
The swelling may represent:
- Malignancy: Vulvar squamous cell carcinoma (90% of vulvar cancers), with risk factors including HPV infection, older age, tobacco use, and chronic vulvar inflammation 1
- Infectious/inflammatory: Bartholin gland abscess, lymphadenitis from STI pathogens 1
- Benign masses: Fibroepithelial polyps, lipomas, or other soft tissue tumors 1
- Lymphangioma circumscriptum: Particularly if there is history of prior pelvic surgery and radiation therapy for cervical or other gynecologic cancers 2, 3, 4
Treatment Based on Diagnosis
If Malignancy is Confirmed
For localized vulvar cancer (T1 lesions ≤2 cm), perform radical local excision with 1-2 cm margins and inguinofemoral lymph node evaluation via sentinel lymph node biopsy or complete lymphadenectomy. 5, 6
- Sentinel lymph node biopsy is appropriate for patients with negative clinical groin examination, unifocal tumor <4 cm, and no previous vulvar surgery that may have disrupted lymphatic flow 5
- Use both radiocolloid (technetium-99m sulfur colloid) and blue dye for increased sensitivity of sentinel node detection, with radiocolloid injected 2-4 hours prior to surgery 5
- Complete inguinofemoral lymphadenectomy is required if sentinel lymph node is not detected or if sentinel node is positive 5
- Adjuvant radiation therapy is indicated for positive lymph nodes, lymphovascular invasion, or close margins (<8 mm) 6
If Lymphangioma Circumscriptum is Diagnosed
Major labiaectomy is the most effective surgical treatment for vulvar lymphangioma circumscriptum, particularly when extensive and deep resection margins are achieved. 2, 3
- This condition typically develops years after radical hysterectomy with pelvic lymph node dissection and adjuvant radiotherapy for cervical cancer 2, 3, 4
- Symptoms include persistent edema, papules, vesicles of the labia majora, and lymph oozing from papules 3, 4
- CO2 laser vaporization is an alternative but carries risk of keloid formation and may be less effective than major labiaectomy 4
If Benign Inflammatory/Infectious Process
- Treat underlying STI pathogens if Bartholin or Skene gland involvement is confirmed 1
- Consider incision and drainage for abscess formation
- Prescribe appropriate antibiotics based on culture results
Critical Pitfalls to Avoid
- Never assume benignity based on mobility alone—fibroepithelial polyps and other benign lesions can mimic malignancy and require histologic confirmation 1
- Do not delay biopsy in postmenopausal women or those with risk factors for vulvar cancer, as early detection significantly impacts survival 1
- Never skip lymph node evaluation if invasive cancer is confirmed on final pathology, as lymph node status is the single most important prognostic factor in vulvar cancer 5
- Do not perform vulvectomy as first-line treatment without tissue diagnosis 7
Follow-Up Surveillance
If malignancy is treated, follow-up should include interval history and physical examination every 3-6 months for 2 years, then every 6-12 months for years 3-5, then annually. 6