The management of presumed benign ovarian masses with operative laparoscopy is now routine, although complication rates may be higher with complicated operative laparoscopic procedures such as those required for extensive endometriosis (Fig. 14.29) (229). The choice of surgical approach (laparotomy or laparoscopy) should be based on the surgical indications, the patient’s condition, the surgeon’s expertise and training, informed patient preference, and the most recent data supporting the chosen approach. The advantage of this technique is the shorter hospital stay, shorter recovery time, and lessened postoperative pain. A Cochrane review concluded that these findings should be interpreted with caution, given the small numbers of high-quality studies that provide comparisons (230).
The role of laparoscopy is even more controversial in the removal of dermoid cysts than with other benign masses. Concern focuses on preventing the spill of the cyst contents. Randomized clinical trials reported variable findings regarding spill; some studies suggest that cyst contents are more likely to spill with laparoscopy, whereas others do not find a difference or note no increase in morbidity when spillage occurred. Culdotomy and the use of an endoscopic specimen bag are associated with lower rates of tumor spillage (217).
In postmenarchal individuals, vulvar symptoms are most often related to a primary vaginitis and a secondary vulvitis. The mere presence of vaginal discharge can lead to vulvar irritative symptoms, or candidal vulvitis may be present (Fig. 14.17). The causes of vaginitis and cervicitis are covered in Chapter 18. Adult women describe vulvar symptoms using a variety of terms (itching, pain, discharge, discomfort, burning, external dysuria, soreness, pain with intercourse or sexual activity). Burning with urination from noninfectious causes may be difficult to distinguish from a urinary tract infection, although some women can distinguish pain when the urine hits the vulvar area (an external dysuria) from burning pain (often suprapubic in location) during urination. Itching is a very common vulvar symptom. A variety of vulvar conditions and lesions can present with pruritus. As in adolescents, vulvovaginal symptoms may be caused by STDs, nonsexually transmitted vaginitis, or UTIs. The distinction between symptoms related to a UTI and those of vaginitis is difficult, and consideration should be given to testing for both C. trachomatis and obtaining a urine culture, particularly in young reproductive-age women (134).
Table 14.14 Subacute and Chronic Skin Recurrent Conditions of the Vulva a Etiology unknown, often secondarily infected.
A number of skin conditions that occur on other areas of the body may occur on the vulvar area. Table 14.14 contains a list of these conditions classified by either infectious or noninfectious causes. Whereas the diagnosis of some of these conditions is apparent from inspection alone (e.g., a skin tag), any lesions that appear atypical or in which the diagnosis is not clear should be analyzed by biopsy, because the risks of malignant lesions increases with age (Fig. 14.30).
Figure 14.30 Large benign skin tag from left labium majus.
Figure 14.31 Pigmented vulvar lesion.