What is the appropriate evaluation and management for a hard palpable vulvar swelling?

Evaluation and Management of Hard Vulvar Swelling

A hard palpable vulvar mass requires immediate biopsy to exclude malignancy, as vulvar cancer commonly presents as a firm, indurated mass or ulcer, and diagnosis cannot be made by physical examination alone. 1

Immediate Diagnostic Steps

Clinical Examination Priorities

• Document exact anatomic location (labia majora, labia minora, clitoris, mons, or perineum), as most vulvar cancers arise in the labia majora 1
• Measure lesion size in centimeters and assess whether it is unifocal or multifocal 1
• Determine relationship to midline structures (within 2 cm or crossing midline versus >2 cm from midline), as this dictates lymph node evaluation strategy 1
• Assess for skin changes including ulceration, induration, fixation to underlying tissue, or bleeding/discharge 1
• Palpate bilateral inguinal lymph nodes, though clinical examination has high false-negative rates 1

Mandatory Biopsy

• Perform punch biopsy of all suspicious vulvar lesions immediately, including underlying stroma while avoiding necrotic areas 1
• Hard consistency strongly suggests malignancy and requires tissue diagnosis before any other intervention 1
• Never assume a hard vulvar mass is benign based on examination alone, even in younger patients 1

Differential Diagnosis Framework

Malignant Lesions (Primary Concern)

• Vulvar squamous cell carcinoma accounts for 90% of vulvar cancers and typically presents as a firm, indurated mass with ill-defined borders 1
• HPV-negative tumors often present as single masses on labia majora/minora in older women (median age 65-70 years) 1
• HPV-positive tumors may present with multifocal lesions in younger women (median age 45-50 years) 1

Benign Lesions (Less Likely with Hard Consistency)

• Bartholin gland cysts/abscesses are typically fluctuant rather than hard 2, 3
• Epidermoid cysts grow slowly and may calcify, potentially feeling firm, but are uncommon in vulva 4, 5
• Benign masses typically have discrete, well-defined margins and soft/rubbery texture, not hard consistency 3

Complete Workup After Biopsy Confirmation

If Malignancy Confirmed

• History and physical examination including vaginal and cervical evaluation with cytologic smears due to multifocal nature of squamous intraepithelial neoplasia 1
• Laboratory tests: CBC, liver function tests, renal function tests 1
• HPV testing and smoking cessation counseling 1
• Imaging for staging: CT, PET/CT, or MRI to delineate tumor extent and treatment planning 1
• Examination under anesthesia with cystoscopy or proctoscopy if indicated based on tumor location 1

Lymph Node Assessment Strategy

• Bilateral inguinofemoral lymph node evaluation required for lesions within 2 cm of or crossing midline 1
• Unilateral lymph node evaluation acceptable for unifocal tumors <4 cm located >2 cm from midline with clinically negative nodes 1
• Sentinel lymph node biopsy is standard of care for early-stage disease in appropriate candidates, reducing morbidity without compromising detection 1

Critical Pitfalls to Avoid

• Never delay biopsy for imaging or other workup, as tissue diagnosis is mandatory for hard vulvar masses 1
• Never assume inflammatory etiology without histologic confirmation, even in younger patients 1
• Never rely on clinical lymph node examination alone, as it has high false-negative rates requiring imaging or surgical assessment 1
• Never perform excisional biopsy without proper surgical planning if malignancy is suspected, as this may compromise subsequent definitive treatment 1

Benign Lesion Management (If Biopsy Negative)

If biopsy confirms benign etiology such as epidermoid cyst:

• Total surgical excision is definitive treatment for symptomatic or enlarging cysts 4, 5
• Ultrasound imaging can characterize cystic versus solid nature and assess deep tissue extension, particularly for large lesions 6
• Alternative methods include pinch-punch excision or incision for smaller lesions 4