The presence of vulvar symptoms such as itching or burning may prompt a patient to seek care; however, this anatomic site is not one that is easily inspected by the patient. Thus, vulvar lesions may be found on examination that were not noticed by the patient. Vulvar self-examination should be encouraged and could potentially result in the earlier diagnosis of vulvar lesions such as melanoma. Adolescents presenting with vulvar itching may have lichen sclerosus; this condition can be relatively asymptomatic, even when an examination reveals loss of anatomic structures and scarring (11) (Fig. 14.4).
Adolescents and adults often incorrectly self-diagnose vulvovaginal candidiasis; in one study, only one-third of women with self-diagnosed yeast vaginitis were found to have this infection (131) (see Chapter 18). A clinical examination and appropriate testing can be performed even on young adolescents using a clinician or self-obtained cotton swab to obtain vaginal secretions for pH testing and microscopic examination (Fig. 14.17).
Vulvar condyloma is an extremely common cause of vulvar lesions in adolescents (see Chapter 18). Genital warts can affect the vulva, perineum, and perianal skin, and the vagina, urethra, and anus (Fig. 14.18). Condyloma in adolescents typically is sexually transmitted. It may be asymptomatic or cause symptoms of itching, irritation, or bleeding. Symptomatic, enlarging, or extensive vulvar condyloma can be managed with topical medication applied by the patient or clinician. The choice of treatment should be guided by patient preference, available resources, and the clinician’s experience; no one treatment is superior to the others (132). The availability of a quadrivalent human papillomavirus (HPV) vaccine that includes HPV types 6 and 11 potentially will have a beneficial impact on the incidence of vulvar condyloma and HPV-related vulvar intraepithelial neoplasia (VIN) (133).
Figure 14.17 Candidal vulvitis.
Figure 14.18 Extensive vulvar condyloma.
Vulvovaginal symptoms in adolescents may be caused by a variety of conditions, ranging from vulvar lichen sclerosus to urinary tract infection to C. trachomatis to non-STD-related vaginitis. Urinary or vaginal symptoms do not differentiate well between urinary tract infections (UTIs) and vaginitis. Adolescent girls who are screened for both C. trachomatis and UTI have high rates of concurrent disease (134). Because clinical diagnosis based on symptoms is imprecise, female adolescents with vaginal or urinary symptoms should be tested for both
C. trachomatis and UTI. Testing with DNA-based procedures may be performed on samples obtained from the cervix, from swabs of vaginal secretions (either clinician or patient obtained), and from urine specimens. Testing that does not involve a speculum examination may be particularly helpful for adolescents; a rigorous review concluded that noninvasive chlamydia testing was comparable to cervical or urethral screening, although this was not the case with testing for gonorrhea (126,135).
Discharge is one of the most common vaginal symptoms. Conditions ranging from vaginal candidiasis to chlamydia cervicitis to bacterial vaginosis may cause vaginal discharge in adolescents. Infectious vaginal conditions are described in more detail in Chapter 18. The risks of self-diagnosis of vaginal discharge in adolescents may be greater than in adult women, as infection with STDs—including Neisseria gonorrhoea, Trichomonas vaginalis, C. trachomatis, herpes simplex, and Condyloma acuminata—are common in adolescents and may be less likely recognized.