The vulvar surface requires a comprehensive magnified inspection from above the mons pubis to behind to the anus. Lithotomy stirrups that support the patient’s knees are comfortable and less tiring for a patient. Use a handheld magnifier or colposcope and a light source without a bulb that heats up during a long exam, as burns can occur.
The patient can be your best assistant: have her hold a magnifying mirror in one hand and prop herself up by leaning on her opposite elbow so she can view her vulva in the mirror. She can point out her painful areas and feel in control as she participates in and observes your exam. Have her open her labia and retract her clitoral hood herself, as she can more easily tolerate her own touch. All skin and mucosa should be inspected for red, white, or dark lesions, erosions, ulcers, nodules, edema, architectural changes, and fissures. Ask the patient to rate on a scale of 0 to 5 the pain she may feel with touch. Use vulvar diagrams to record findings; documenting with digital photography helps assess the benefits of therapy later.
Do not perform a typical bimanual exam until the very end of the evaluation of all layers, after deciding if it will add information. In cases of chronic sexual pain it usually will not, and often triggers surface pain or muscle spasms that hinder the rest of the exam.
By far the most common cause of sexual pain in premenopausal women is localized provoked vestibulodynia (LPV). Research is leading to a better understanding of this mucosal disorder.17,18 It is crucial that LPV not be missed. After your general inspection, give specific attention to the vestibule, at first without touching it, using your patient-assistant for exposure. Note and document all areas of erythema, even if tiny and subtle. To identify LPV’s diagnostic feature, allodynia, the Q-tip (swab) test is key. Begin checking for provoked pain systematically at the outer labial skin, an area unlikely to startle the patient. Gently press the cotton tip enough to dent the surface just 1 mm, and note her pain level, as well as superficial muscle responses. Repeat, gradually moving inward to the smooth vestibule mucosa between Hart’s line and the hymenal ring, to delineate tender areas. Repeat this testing “around the clock” with the midpoint of the introitus the clock’s center. Be sure to assess the vestibule around the urethra, and the urethra itself, as its mucosa is contiguous and often involved in LPV.
Chronic or recurrent fissures in the posterior fourchette are another cause of introital dyspareunia. Inspect for midline scars in this area, because it may tear, heal, remain weak, then re-tear with the next penetration, so fissures may only be seen soon after sex. Complete your surface evaluation by assessing for vulvovaginal infections or inflammation, such as desquamative inflammatory vaginitis, with the use of a warmed, lubricated, very narrow speculum, or obtain wet smears and cultures with just a swab. Patients with LPV and pelvic floor (PF) disorders often cannot tolerate a speculum, and in these conditions it is usually not necessary, at least at initial exam. Use of dilute acetic acid may also cause significant pain and is rarely needed.
Vulvar biopsies are best avoided unless a lesion is suspicious for neoplasia, because results rarely affect management. A biopsy of the vestibule is not needed. Biopsies of specific lesions to diagnose vulvar dermatoses can be delayed until a follow-up visit, after potential causes of pain in other layers have been assessed. Many patients attribute worsening pain to previous biopsies, so if one is needed, take as small a piece of tissue as possible and use a pathologist experienced in vulvar dermatology.