Evaluation and Management of a Vulvar Bump
Any vulvar bump requires punch biopsy of suspicious areas to establish a definitive diagnosis, as clinical appearance alone cannot reliably distinguish benign lesions from premalignant or malignant disease. 1
Initial Clinical Evaluation
Perform a thorough vulvar examination documenting the following specific characteristics:
- Lesion size and exact location (labia majora, labia minora, clitoris, mons, perineum, or Bartholin's gland area) 1
- Distance from vulvar midline (critical for determining lymph node evaluation strategy if malignant) 1
- Relationship to adjacent structures (urethra, vagina, anus) 1
- Presence of multifocal lesions (suggests HPV-related disease) 1
- Associated symptoms: pruritus, pain, bleeding, or discharge 1
- Clinical palpation of inguinofemoral lymph nodes (though sensitivity is limited) 1
Additionally, examine the vagina and cervix with cytologic smears, as squamous intraepithelial neoplasia is often multifocal 1
Diagnostic Approach
Biopsy Technique
Perform punch biopsy of all suspicious vulvar lesions, ensuring adequate depth to include underlying stroma and avoiding necrotic areas. 1 This is essential because clinical appearance cannot differentiate benign from malignant lesions 2, 3
Common Benign Lesions (No Biopsy Required if Classic Presentation)
- Bartholin gland cyst or abscess: fluctuant, posterolateral location in lower third of labia majora 2
- Epidermoid inclusion cysts: mobile, non-tender, subcutaneous 2
- Mucinous cysts: rare, may require imaging if large 4
Critical Pitfall: Vulvar sarcomas and malignancies can masquerade as Bartholin gland cysts, leading to delayed diagnosis—maintain high suspicion for solid masses or atypical presentations 5
Management Based on Histology
If Biopsy Shows Vulvar Intraepithelial Neoplasia (VIN/HSIL)
For localized VIN lesions, perform wide local excision with 1-2 cm margins if feasible. 1, 6 The NCCN specifically recommends conservative individualized tumor excision for early vulvar lesions 6
- Excision depth: extend to the urogenital diaphragm 6
- Inguinofemoral lymph node evaluation is NOT required for carcinoma in situ or lesions with ≤1 mm depth of invasion due to negligible metastatic risk 1, 6
- Alternative treatments (if occult invasion not suspected): laser ablation or topical imiquimod (off-label) 7
Critical Pitfall: If final pathology reveals >1 mm invasion, additional surgery with lymph node evaluation becomes necessary 1, 6
If Biopsy Shows Invasive Squamous Cell Carcinoma
Stage IA (≤1 mm invasion):
Stage IB (>1 mm invasion) or Select Stage II:
For lateralized lesions ≥2 cm from midline:
- Radical partial vulvectomy with ipsilateral inguinofemoral lymph node evaluation (sentinel lymph node biopsy preferred) 1
For anterior/posterior central lesions:
- Radical partial vulvectomy with bilateral inguinofemoral lymph node evaluation 1
Target surgical margins of 1-2 cm to ensure complete excision while preserving vulvar anatomy 1, 6
If Benign Lesion Confirmed
Asymptomatic benign tumors do not require excisional treatment. 2 Observation is appropriate for:
Excision is indicated for:
- Symptomatic lesions causing pain or functional impairment 4
- Rapidly enlarging masses 5
- Diagnostic uncertainty despite biopsy 2
Workup for Suspected Malignancy
If biopsy confirms invasive cancer, complete staging workup includes:
- History and physical examination 1
- CBC, liver and renal function tests 1
- Imaging (CT, PET/CT, or MRI) to delineate tumor extent and evaluate lymph nodes 1
- Examination under anesthesia with cystoscopy/proctoscopy if indicated for locally advanced disease 1
- HPV testing and smoking cessation counseling 1
Follow-Up Strategy
For excised VIN with negative margins:
- Interval history and physical examination every 3-6 months for 2 years 6
- Then every 6-12 months for years 3-5 6
- Then annually 6
Adjuvant radiation therapy is only indicated for lymphovascular invasion, close margins (<8 mm), or if invasion is subsequently identified 6