Diagnosing HPV Infection for Women

Assessing the Genitalia and Rectum
As the patient is sexually active, the bumps on the genitalia could be caused by genital warts or genital herpes, due to the herpes simplex virus. Other differential diagnoses could include contact dermatitis, folliculitis, acne inversa, and Molluscum contagiosum, which is “a viral infection characterized by lesions that can occur anywhere on the body, including the vaginal area” (Leonard, 2017).
Additional information that should be obtained from the exam would include more data about the patient’s personal medical history and whether the patient is undergoing a regular menstrual cycle. The patient’s age is listed as 21 but she is married with three children, plus sexually active with more than one partner in the past year, so there may be more information that is required about this particular set of data regarding personal history. It is important to make sure all information is up to date and accurate before making a diagnosis.
Ball et al. (2017) indicate that the signs demonstrated by the patient do not indicate a clear, definitive pathogenesis of any one symptom, though the bumps on the genitalia are likely due to genital warts or genital herpes. These could be tested, but more information about the last time the patient had sexual intercourse would be needed. This information should be elicited with sensitivity for the patient’s feelings especially if the patient is married and the implication is that the sexual activity occurred outside of marriage. This should, however, not be assumed, as the patient may have not recently engaged in sexual activity outside of marriage in the time leading up to the appearance of the bumps on the genitalia. No assumptions should be made and the patient should be allowed to express herself without feeling intimidated, judged, or accused or any sort of indiscretion.
What the symptoms do reveal—particularly the genital warts—are that contact with HPV is likely (Ball et al., 2017). The finding of “vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia” indicates that this is the most like diagnosis.
Additional Subjective Information that Should be Included
· Whether any pain is present when urinating
· Discharge from vagina
· Last sexual encounter
· Knowledge of sexual partner’s sexual history
· Knowledge of sexual partner’s genital disease
· Whether the patient has had genital warts before
· Whether she has experienced fever (a symptom of genital herpes)
· Whether she has pain in genitals or legs
· Whether there is itching
Additional Objective Information that Should be Included
As the “application of 3%–5% acetic acid, which causes skin color to turn white, has been used by some providers to detect HPV-infected genital mucosa” is a way to determine clinically the presence of genital warts (CDC, 2018), this can be one method of obtaining objective information that is still required—i.e., the presence of HPV infected genital mucosa. “However, acetic acid application is not a specific test for HPV infection” and would not be a recommended method (CDC, 2018).
· Examine for cysts
· Examine for Fordyce spots
· Examine for ingrown hair follicles
· Examine for swollen glands
Would Diagnostics be Appropriate?
Diagnosing genital warts is typically made clinically by observation directly conducted in the examination room. However, genital warts can also be diagnosed by biopsy, which is a diagnostics method that can be used upon the following conditions, according to the CDC (2018):
· the diagnosis is uncertain;
· the lesions do not respond to standard therapy;
· the disease worsens during therapy;
· the lesion is atypical;
· the patient has comprised immunity;
· or the warts are pigmented, indurated, fixed, bleeding, or ulcerated.
Differential Diagnoses
Vulvar Cysts
There are several glands on the vulva, some of which are oil glands. There are also Skene’s glands and Bartholin’s glands. Cysts can develop in any of these glands if they get clogged, and the size of cysts can be different—though they commonly feel like little bumps to touch. They also are not going to be painful, though they can become so if an infection develops.
The lack of pain associated with the patient’s bumps could indicate that they are simple vulvar cysts. If biopsy comes back negative for HPV, vulvar cysts could be the diagnosis. If so, and if cysts are not infected, no treatment would be necessary as these will go away on their own. If infected, the cysts may be drained if needed and an antibiotic prescribed to fight the bacterial infection (Wilson, 2017).
Vaginal Cysts
Vaginal cysts are like small lumps on the vaginal wall that can grow to roughly the size of a small pea. These cysts, like vulvar cysts are not painful and they may present discomfort when engaged in sexual activity—however, considering the location of the cysts on the patient, this diagnosis is unlikely to be the case and the cysts are more likely to be vulvar (Wilson, 2017).
Fordyce Spots
Fordyce spots are sebaceous gland that have whitish or yellowish white bumps inside the vulva and on the lips and cheeks. They are not painful and are harmless; however, they typically develop around puberty and would not suddenly appear at the patient’s age, so this diagnosis is unlikely as well (Wilson, 2017).
Conclusion
The most likely explanation based on the available material is genital warts, considering the patient’s history, but more personal history would help to give a better basis for this diagnosis. Information about the sexual partner would be helpful, if there was one recently who may have had genital herpes or warts. If no such partner exists, there may be no basis for this diagnosis and the patient may be having vulvar cysts which should be checked for infection; if no infection is found, the patient may told that they will go away with time.


References
Ball, J. et al. (2017). Seidel’s guide to physical examination. Eslevier.
CDC. (2018). Genital warts treatment. Retrieved from
https://www.cdc.gov/std/treatment/2010/genital-warts.htm
Leonard, J. (2017). How to get rid of vaginal pimples. Retrieved from
https://www.medicalnewstoday.com/articles/317810.php
Wilson, D. (2017). Guide to vaginal lumps and bumps. Retrieved from
https://www.healthline.com/health/womens-health/vaginal-lumps-bumps