Recognise suspicious vulval and vaginal findings promptly, separate symptomatic diagnosis from cervical screening, and initiate consented examination, urgent referral, biopsy and specialist staging safely.
Vulval and vaginal cancers are uncommon, but diagnostic delay is frequent because itch, soreness, discharge and skin change resemble benign inflammatory or infectious disease. Ask the person to localise the symptom, describe progression and identify bleeding, ulceration, a new lump, treatment failure and functional effects. Avoid assuming that the word vagina accurately identifies the anatomical site.
Most vulval malignancies are squamous cell carcinomas. One pathway is related to persistent high-risk human papillomavirus infection and vulval high-grade squamous intraepithelial lesion. Another is HPV-independent, often arising through differentiated vulval intraepithelial neoplasia in skin affected by lichen sclerosus or another chronic dermatosis. Melanoma, basal-cell carcinoma, Bartholin-gland carcinoma, sarcoma and extramammary Paget disease require different pathological and treatment approaches.
Vaginal cancer is rarer and most primary tumours are squamous. Persistent oncogenic HPV, smoking, immunosuppression and previous cervical or vulval intraepithelial disease increase risk. Clear-cell adenocarcinoma has a historical association with in-utero diethylstilbestrol exposure, while melanoma and sarcoma are uncommon alternatives. A vaginal lesion may also be direct extension or metastasis from the cervix, vulva, endometrium, bladder or rectum.
Persistent oncogenic HPV can produce high-grade squamous intraepithelial lesions that progress to invasive vulval or vaginal squamous carcinoma, particularly with smoking or impaired immunity.
Differentiated vulval intraepithelial neoplasia can arise within lichen sclerosus or another chronic dermatosis and progress through molecular changes such as abnormal p53 signalling.
Melanocytes, glandular epithelium, Bartholin tissue, connective tissue and extramammary Paget cells can generate malignancies whose behaviour differs from squamous cancer.
Previous lower-genital-tract neoplasia, pelvic radiotherapy, immunosuppression and smoking increase risk by promoting persistent epithelial injury, oncogenic infection or impaired immune clearance.
Accumulating epithelial genetic damage breaches the basement membrane, allowing malignant cells to invade vulval or vaginal stroma and produce induration, ulceration and bleeding.
Tumour can spread into the urethra, vagina, anus, bladder, rectum or pelvic tissues, causing pain, dysuria, fistula, haemorrhage and obstructive symptoms.
Vulval tumours commonly drain towards inguinofemoral nodes, while vaginal drainage varies by tumour level and can involve pelvic or groin nodal basins.
Persistent HPV-related change or chronic vulval dermatosis can affect a broad epithelial field, creating multifocal precursor lesions and continuing risk outside the dominant tumour.
A new lump, irregular ulcer, bleeding growth, focal thickening, pigment change or persistent treatment-resistant area is suspicious, particularly on a background of lichen sclerosus or previous vulval intraepithelial neoplasia.
A palpable vaginal mass is the explicit NICE referral finding, while postcoital or postmenopausal bleeding, blood-stained discharge, dyspareunia and persistent pain should prompt diagnostic examination.
Firm, enlarged or fixed inguinal nodes alongside a vulval lesion raise concern for lymphatic spread and should be documented by side before specialist imaging or sampling.
Extension towards the urethra, anus, bladder or rectum, fistula, severe pain, urinary difficulty, obstruction or major bleeding indicates urgent complex multidisciplinary assessment.
Multifocal HPV-related disease or chronic pale, thickened, fissured vulval dermatosis can surround a small invasive focus, so the whole epithelial field requires inspection.
Lichen sclerosus, lichen planus, eczema and psoriasis can cause itch, fissuring and colour change but may coexist with precursor or invasive disease.
Candidiasis, herpes, bacterial infection and inflammatory vaginitis can cause soreness, ulceration or discharge; persistence after appropriate care requires diagnostic reassessment.
Bartholin, inclusion and Gartner-duct cysts may present as masses, but a solid, irregular, fixed or persistent lesion needs specialist evaluation.
Vulval or vaginal intraepithelial neoplasia can be symptomatic and multifocal, and biopsy is needed to exclude an occult invasive focus.
Cervical, endometrial, bladder, rectal or vulval malignancy may involve the vagina, changing both staging and the treatment plan.
Friable tumour surfaces can bleed repeatedly or heavily, causing iron deficiency, transfusion need or acute haemodynamic compromise.
Local invasion, oedema or treatment effects may cause retention, incontinence, obstruction, fistula, dysuria or painful defaecation.
Cancerous groin nodes and nodal treatment can impair lymphatic drainage, producing infection-prone swelling of the leg or genital region.
Pain, altered anatomy, vaginal stenosis, sensory change and fear of recurrence can affect intimacy, identity and mental health.
Recurrence may appear as a new focal lesion, persistent pain, groin mass or systemic illness and requires renewed tissue and imaging assessment.
Many people use vagina for the entire genital area, so the clinician must localise the symptom before selecting an examination, swab, referral or biopsy pathway.
Cancer may coexist with lichen sclerosus or another itchy dermatosis; treatment response in most skin does not explain a persistent focal thickening or ulcer.
A negative cervical HPV result reduces neither the need to inspect a vulval lesion nor the need to investigate a palpable vaginal mass.
Before labelling a tumour vaginal, the team must exclude direct extension or metastasis from the cervix, vulva, endometrium, bladder, rectum or another site.
Sentinel-node assessment applies only to carefully selected vulval tumours; size, focality, invasion, adjacent-organ involvement and clinical or radiological nodes alter the approach.
Prescribing repeated antifungal, antibiotic or topical treatment without re-examining a persistent focal vulval symptom.
Documenting a normal smear as evidence that vulval or vaginal cancer has been excluded.
Referring unexplained bleeding without inspecting the vulva or establishing whether the source is vulval, vaginal, cervical, uterine, urinary or rectal.
Describing only a red patch without recording size, exact site, ulceration, induration, multifocality and relation to nearby structures.
Allowing a benign but non-representative biopsy to override a progressive lesion without clinicopathological review.
Ignoring sexual, urinary, bowel, lymphoedema and body-image consequences once cancer treatment has ended.
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A 71-year-old has an unexplained bleeding vulval ulcer and a firm new lump despite several weeks of topical treatment. What is the most appropriate next action?
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Vulval warning symptoms include a lump, non-healing sore, ulcer, wart-like growth, unexplained bleeding, persistent itch, burning, pain, dysuria, altered pigmentation and focal thickening. On brown or black skin, erythema or pigment change may be less conspicuous, making palpation, comparison with surrounding skin and attention to texture especially important.
Vaginal malignancy may cause a palpable mass, postcoital or postmenopausal bleeding, intermenstrual bleeding, blood-stained or offensive discharge, dyspareunia, persistent itch, pelvic pain, dysuria or urinary frequency. Although NICE names an unexplained palpable vaginal mass as the specific referral criterion, other persistent unexplained symptoms still require examination, investigation of their cause and explicit safety-netting.
Offer examination with informed consent, privacy and a chaperone according to preference and policy. Inspect the complete vulva, clitoris, labia, vestibule, urethral opening, perineum and perianal region. Describe lesions rather than writing only abnormal vulva. If acceptable, perform speculum examination of the vaginal walls and cervix, bimanual examination and groin-node palpation. Stop if consent is withdrawn or pain prevents adequate assessment and arrange a suitable specialist examination.
An unexplained vulval lump, ulceration or bleeding should enter the suspected-cancer pathway without waiting to see whether repeated empirical treatment works. An unexplained palpable vaginal mass also warrants that pathway. Severe bleeding or organ compromise needs same-day acute care rather than an outpatient referral alone.
There is no UK population screening programme for vulval or vaginal cancer. Cervical HPV screening assesses cervical cancer risk in asymptomatic eligible people; it neither visualises vulval disease nor reliably excludes a vaginal tumour. A recent negative cervical screen must not override current symptoms or examination findings.
A tissue sample is required for diagnosis. Specialist vulvoscopy or colposcopic vaginal examination helps select the most abnormal area and map multifocal disease. Biopsy technique and site should preserve anatomical orientation and future treatment planning. Multiple lesions may require separate labelled samples, and a clinically suspicious lesion needs reconciliation with pathology if an initial biopsy is non-diagnostic.
Histology identifies invasive depth, tumour type, differentiation and precursor disease. Vulval squamous cancers may need HPV-associated versus HPV-independent classification, while a vaginal tumour must be assessed against possible cervical, vulval or metastatic origin. Pathology review at the gynaecological cancer multidisciplinary team prevents management based on an imprecise anatomical label.
Imaging follows the examination and tissue diagnosis according to extent. MRI pelvis can define tumour size and involvement of the urethra, vagina, anus, bladder or rectum. Ultrasound can assess groin nodes, with image-guided sampling when indicated. CT chest, abdomen and pelvis or PET-CT may evaluate nodal and distant spread in higher-risk or advanced disease.
Treatment is individualised by histology, stage, site, nodal status, comorbidity, frailty, sexual function and patient priorities. Vulval surgery aims to remove disease while preserving continence, sexual function and body image where oncologically safe, with sentinel-node assessment reserved for selected tumours. Vaginal cancer commonly uses external-beam radiotherapy and brachytherapy, sometimes with concurrent systemic treatment; selected small lesions may be approached surgically.
Follow-up must address recurrence as well as wound problems, lymphoedema, urinary and bowel effects, vaginal stenosis, sexual pain, menopausal symptoms and psychological impact. Persistent or new focal skin change after treatment requires examination rather than attribution to scar tissue or radiotherapy alone.