Vulval disorders are not uncommon in obstetric practice. This chapter aims to enhance clinical skills in patient assessment, vulval examination and treatment of common benign vulval skin disease and infections. Basic treatments often benefit the patient (e.g. use of emollients and topical steroids). Some patients have complex disease and can present with more than one condition, so careful assessment and individualised management is essential. Understanding of when to refer onwards to a gynaecologist and even a vulval specialist service is important to optimise clinical outcomes.

Trans people who transition medically are typically hoping to live their lives simply as members of the sex with which their gender corresponds but may wish to make full use of the capabilities of their physical bodies, which may differ from typical male or female bodies. This chapter, co-authored by a trans man who is a transgender health advocate and a trans woman who is a physician, provides an overview of the kind of physical changes that are experienced by trans people, both those who transition from female to or toward male and those from male to or toward female, and alerts gynecologists and other medical healthcare professionals to the trans person’s perspective in clinical encounters.

Bothersome genital symptoms (pruritus, irritation, dyspareunia, vaginal discharge, malodour, burning) are common problems. The main challenge for clinicians is to correctly diagnose the cause of the symptoms as they are non-specific and often have multiple overlapping aetiologies. The aim of this chapter, written by a multidisciplinary team of vulvovaginal experts (gynaecology, dermatology and infectious disease) is to present a clinical flow chart algorithm that can help the clinician reason through overlapping symptoms to obtain a more accurate diagnoses. Six principles were endorsed: (1) locating the discomfort (vulva, clitoris, vestibule, vagina, cervix, pelvis); (2) considering more than one entity; (3) evaluating each symptom separately (4) using pH and wet mount microscopy; (5) obtaining a follow-up visit after 2–4 weeks; (6) performing a biopsy for dermatological conditions that are resistant to treatment.

A 24-year-old woman presents to the office with complaint of bumps on her vulva. She first noticed them several months ago and feels they have grown since then. She currently feels the lesions are the size of grapes and bumpy in texture. The site is not painful, but there is discomfort and irritation when the lesions rub against her clothing. Recently, she has been avoiding intercourse because of the bumps. She has been sexually active with a new partner in the last year and they do not consistently use condoms. Her gynecologic history is significant for regular withdrawal bleeding on oral contraceptive pills with good compliance. She has seasonal allergic rhinitis and exercise-induced asthma but otherwise denies medical or surgical history. She denies medication allergies and has no contributory family history.

Female genital mutilation/cutting (FGM/C) is defined by the WHO as the partial or total removal of the external genitalia or other injury to the female genital organs for non-medical reasons. FGM/C can negatively affect women’s and girls’ psychophysical health with possible infectious, urogynaecological, obstetric, sexual and psychological complications. It is a practice that is illegal in many high-prevalence and -migration countries and is considered to be a violation of human rights. Health professionals have a fundamental role in preventing the practice in future generations, providing health education, avoiding the ‘medicalization’ of FGM/C and in offering appropriate information, counselling, clinical (diagnosis, treatment and psychosexual care) and surgical care (defibulation and clitoral reconstruction) in the case of complications.

A 70-year-old presents with left-sided vulvar itching and pain, which has worsened over the past 12 months. She has been treated with antifungals several times with no relief. The pain keeps her up at night. She is using a petroleum-based ointment to prevent her labia from sticking to her underwear. She has had no vaginal bleeding or urinary leakage. The patient experienced menopause in her early 50s. Her gynecologic history is unremarkable: she has never had an abnormal Pap smear or any sexually transmitted diseases. Her regular, yearly screening mammograms and colonoscopy done 10 years ago have been normal. Her hypertension is well controlled on medications. She denies any surgeries or medication allergies.

A 50-year-old female, gravida 2, para 2, presents to the office with vulvar pain. For the past three months, she reports noticing a “walnut” sized bump on the left vulva that has increased in size in the past week. She reports it is tender, and it is difficult to sit for long periods of time. She also reports dyspareunia. She is currently taking ibuprofen for pain and using warm compresses without alleviation of symptoms. She reports similar symptoms on the same side that required incision and drainage, once in her 30s and, more recently, four months ago when a Word catheter was placed. She denies fevers, chills, and nausea/vomiting. Her last menstrual period was two weeks ago and has regular monthly cycles with light bleeding. Past medical history is significant for hypertension, obesity, and hyperlipidemia. Past surgical history is significant for bilateral tubal ligation. She is sexually active with husband of 25 years.