Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Haemorrhage, sepsis or urinary obstruction
Major bleeding, infected necrotic tumour, rapidly spreading perineal infection, urinary retention, ureteric obstruction or fistula-related sepsis requires immediate resuscitation before full elective staging.
Action: Use ABCDE care, obtain bloods and crossmatch, give blood products, analgesia and broad-spectrum antibiotics when indicated and involve gynaecological oncology, urology, colorectal surgery, interventional radiology and radiation oncology urgently for drainage, diversion, embolisation, packing, stenting or haemostatic radiotherapy.
Synopsis
Recognise persistent vulval and vaginal symptoms, biopsy before destructive treatment, distinguish HPV-related and inflammatory pathways and coordinate organ-preserving local treatment, site-specific nodal staging, chemoradiation and functional rehabilitation.
Persistent vulval itch, soreness, ulcer, lump or architectural change requires examination and a punch or incisional biopsy; repeated antifungal or steroid treatment must not delay tissue.
Most vulval cancer is squamous: one pathway is HPV related, while the other arises through lichen sclerosus and differentiated VIN with p53 abnormalities.
Map and biopsy the lesion before wide excision so depth, histology, relation to clitoris, urethra and anus and the correct nodal plan can be agreed.
Key red flags
Persistent vulval itch, soreness, ulcer, lump, colour or texture change requires visual examination and biopsy rather than repeated empirical antifungal treatment.
Necrotising infection or haemorrhage
Crepitus, spreading erythema, shock, severe disproportionate pain or brisk bleeding requires immediate resuscitation and source control.
Investigation priorities
01
First-line complete vulvovaginal examinationFirst stepFirst line
Map lesion number, size, site, colour, texture and relation to clitoris, urethra, vagina, anus and groin nodes.
02
Preferred pelvic MRIPreferred
Define tumour depth, vagina, urethra, anus, bladder, rectum, pelvic sidewall and nodes for surgery and radiotherapy.
Management branches
Persistent lesionBiopsy before repeated empirical treatment
Vulval or vaginal itch, pain, bleeding, ulcer, lump or texture change persists or recurs.
Perform a complete trauma-informed vulval, vaginal, cervical, anal and groin examination and assess infection, immune suppression and lichen-sclerosus history.
Obtain one or more labelled punch or incisional biopsies from the most suspicious areas before ablation, imiquimod or wide excision.
Key medicines
Cisplatin with definitive radiotherapyGive cisplatin 40 mg/m² intravenously once weekly during external-beam radiotherapy, often for five or six doses, using the exact centre hydration, renal and dose-cap protocol.
Clobetasol propionate for lichen sclerosusApply clobetasol propionate 0.05% ointment thinly once nightly for 4 weeks, then on alternate nights for 4 weeks, then twice weekly for 4 weeks before review and individual maintenance.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.