Physical Examination

To perform an adequate physical examination, the clinician must identify the normal anatomic structures of the vulva (Fig. 1). The clinician should identify

Hymen Cribriform
Figure 1 Anatomy of the vulva. Source: Courtesy of Elsevier. (See color insert p. 1.)

and examine the mons pubis, the labia majora and minora, and the clitoris, as well as the vulvar vestibule for Hart's line, the major vestibular ducts (Bartholin's glands), and the lesser vestibular ducts, including the periurethral ducts, Skene's ducts, and the hymenal ring.

After identifying the normal anatomy, the clinician should inspect the vulva visually to identify any primary lesions, such as macules, papules, plaques, nodules, pustules, vesicles, bullae, or hives, as well as any secondary lesions, such as scaling, crusting, erosions, ulcerations, fissures, atrophy tissue, and scars. Frequent changes of the vulva include erythema, edema, atrophy, hyperkeratosis, and/or hypo- and hyper-pigmented areas/lesions.

Next, the vaginal discharge should be evaluated microscopically. This is accomplished with a wet-smear preparation of the vaginal discharge. From this sample, a maturation index is performed to identify maturity of squamous cells to determine whether an atrophic or erosive condition is occurring. The sample should be evaluated microscopically for the presence or the absence of white blood cells (WBCs), red blood cells, Lactobacilli, budding yeast, hyphae, or Trichomonads. A yeast culture of vaginal discharge is useful either for identification of a subclinical yeast infection or for yeast strain identification.

In addition, a biopsy of any vulvar lesions may be necessary to identify a precancerous condition. Based on the patient's history and physical examination, additional cultures, hematologic, and/or serologic testing may be indicated as well.

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