Vulvar Mass
A vulvar mass is any lump, swelling, or growth on the external genital area. The causes are wide-ranging and predominantly benign—cysts, skin tags, warts, and blocked glands account for the large majority—while vulvar cancer is uncommon. The consistent problem in this area is not diagnostic difficulty but delay: the vulva is directly visible and easily examined, yet embarrassment and the tendency to self-treat mean women frequently wait months before seeking help, and lesions are often treated as thrush or eczema for long periods before anyone looks properly. Any lump or skin change that has not resolved within a few weeks deserves examination, and anything that persists despite treatment deserves a biopsy.
What is it?
The vulva comprises the external female genital structures: the mons pubis, the labia majora and minora, the clitoris, and the vestibule surrounding the vaginal and urethral openings. Its tissues include hair-bearing skin, hairless skin, mucous membrane, sebaceous and sweat glands, the Bartholin and Skene glands, fat, and a rich network of blood and lymphatic vessels. A mass can arise from any of these, and knowing which structure a lump comes from usually identifies it.
Several findings are normal anatomy and are frequently mistaken for disease, which is worth addressing first because recognising them prevents considerable unnecessary worry.
Fordyce spots are small yellowish-white sebaceous glands visible just beneath the surface, present in most people and entirely normal. Vestibular papillae are small soft symmetrical projections around the vaginal opening, often mistaken for warts, and are a normal variant. Asymmetry of the labia is normal and extremely common. None of these requires treatment, and attempts at removal cause scarring without benefit.
The benign acquired causes account for most genuine lumps.
Epidermoid and sebaceous cysts are the most frequent. The vulva has abundant hair follicles and sebaceous glands, and blockage produces a firm, smooth, mobile cyst filled with thick keratin material, often with a visible central pore. They are frequently multiple, harmless, and need treatment only if large, uncomfortable, or repeatedly infected.
Bartholin cysts arise from the glands at the vaginal entrance at roughly four and eight o’clock. A blocked duct produces a painless swelling; infection produces an abscess that is acutely painful, red, and tense, often severe enough to prevent sitting or walking. This is one of the most common acute gynaecological presentations.
Skin tags are soft, pedunculated, and harmless, occurring particularly where skin rubs.
Genital warts caused by human papillomavirus appear as soft fleshy growths, single or clustered, and are among the most commonly diagnosed sexually transmitted infections. They are benign, though the same virus family causes vulvar cancer, which is why persistent or atypical lesions are examined rather than assumed.
Molluscum contagiosum produces small pearly papules with a central dimple and is self-limiting.
Angiokeratomas are small dark red or purple vascular papules, common, harmless, and occasionally alarming because their colour suggests something serious.
Lipomas and fibromas are benign soft tissue tumours that occur here as elsewhere.
Hidradenitis suppurativa deserves particular attention because it is common, frequently misdiagnosed, and often managed poorly. It is a chronic inflammatory condition of hair follicles affecting areas where skin folds—the groin, genital area, armpits, and under the breasts. It produces recurrent painful deep nodules and abscesses that discharge and heal with scarring, and over time produces tunnels beneath the skin called sinus tracts. It is commonly mistaken for recurrent boils or poor hygiene, and delays to diagnosis of several years are typical. It is neither an infection in the usual sense nor caused by lack of cleanliness, and effective treatments exist, including biologic therapy for more severe disease.
Endometriosis can occur in the vulva or perineum, typically within a scar from childbirth, producing a tender lump with pain and sometimes bleeding that vary with the menstrual cycle.
Inflammatory skin conditions produce changes that can present as a mass or thickening. Lichen sclerosus is the most important. It produces white, thinned, fragile, often itchy skin that may become thickened and scarred, causing the labia minora to shrink and the vaginal opening to narrow. It is frequently misdiagnosed as thrush and treated with antifungal creams for years. It matters greatly because it carries an increased risk of vulvar cancer, and because proper treatment with potent topical steroids controls symptoms, prevents scarring, and appears to reduce that cancer risk. Lichen planus and chronic eczema or psoriasis also occur here.
Vulvar intraepithelial neoplasia is precancerous change. Two forms exist. The HPV-related type occurs in younger women, is often multifocal, and may appear as raised warty or pigmented patches. The type associated with lichen sclerosus occurs in older women, is often subtle, and arises in a background of chronic skin change. Both are treatable at this stage, and detecting them prevents cancer.
Vulvar cancer is uncommon but is the diagnosis that determines how any persistent lesion is approached. Squamous cell carcinoma accounts for the large majority and arises through two pathways: HPV-related disease in younger women, and lichen sclerosus-related disease in older women, which accounts for the majority of cases overall. It typically appears as a lump, ulcer, or thickened area that does not heal, often with itching that has been present for a long time.
Melanoma is the second most common vulvar cancer, may be non-pigmented, and any pigmented lesion that is new, changing, or irregular warrants biopsy. Extramammary Paget disease presents as a persistent red scaly itchy patch routinely mistaken for eczema. Basal cell carcinoma, Bartholin gland carcinoma, and sarcomas occur less often.
Symptoms overlap substantially across causes, and this is the practical difficulty.
Itching is extremely common and is the classic symptom of lichen sclerosus, eczema, thrush, and also of vulvar cancer and its precursors. Long-standing itch that has been treated repeatedly without resolution is one of the more important presentations in this area and should prompt examination and biopsy rather than another prescription.
Pain, soreness, and burning occur with infection, inflammation, and malignancy alike. Pain on intercourse and on sitting are common.
Skin colour and texture changes—white, red, darkened, or thickened areas—warrant assessment.
An ulcer or sore that has not healed within a few weeks requires biopsy.
Bleeding from a lesion, discharge, and enlarged groin nodes are all significant.
Recurrent painful swellings that discharge and scar suggest hidradenitis.
Assessment is direct and should not be difficult.
Examination with good lighting is the primary investigation, assessing the lesion and the surrounding skin, and examining the groin for lymph nodes. Examination of the whole vulva matters, since conditions here are frequently multifocal.
Biopsy is the definitive test, usually taken under local anaesthetic in clinic with minimal discomfort. The threshold should be deliberately low. Any lesion that is ulcerated, indurated, pigmented, fixed, bleeding, enlarging, or persistent despite treatment should be biopsied rather than treated again empirically. This single principle would prevent most of the diagnostic delay that characterises vulvar cancer.
Ultrasound characterises deeper or larger swellings and distinguishes cystic from solid.
MRI defines the extent of larger lesions and is used in staging confirmed malignancy and in assessing complex hidradenitis.
Testing for sexually transmitted infections is appropriate where warts, ulcers, or infection are present.
Important to Know
Most vulvar lumps are benign and many need no treatment at all. The problem in this area is consistently delay rather than difficulty, and addressing that is the most useful thing this page can do. Care is typically coordinated by primary care clinicians, gynaecologists, dermatologists, and specialist vulval clinics.
The delay has recognisable causes. Women are often embarrassed to present with genital symptoms and self-treat with over-the-counter antifungal or steroid creams for extended periods. Clinicians sometimes prescribe repeatedly without examining, particularly where symptoms are described over the phone or attributed to thrush. And the vulva is an area that both patients and generalist clinicians examine less confidently than most. The result is that vulvar cancer is frequently diagnosed late despite being visible from the outset.
The practical remedy is straightforward: any vulvar lump or skin change that has not resolved within a few weeks should be examined, and anything that persists despite treatment should be biopsied. Requesting examination rather than another prescription is entirely reasonable, and asking for a biopsy of a persistent lesion is a legitimate request.
Benign findings need explanation rather than intervention. Fordyce spots, vestibular papillae, labial asymmetry, angiokeratomas, and skin tags are normal or harmless, and understanding this resolves the concern for most women. Attempts at self-removal cause scarring and infection.
Cysts require treatment only when symptomatic. Where excision is performed, removing the entire cyst wall prevents recurrence. Squeezing or puncturing cysts at home reliably introduces infection in an area that is warm and moist, and should be avoided.
Bartholin abscesses are managed by drainage, and the technique matters considerably. Simple incision provides rapid relief but is followed by recurrence in a high proportion, because the cavity seals and refills. Placing a small balloon catheter for several weeks, or stitching the cyst wall open in a procedure called marsupialisation, keeps the cavity draining while it heals and has substantially lower recurrence. Antibiotics are added where there is surrounding infection but do not substitute for drainage. A new Bartholin mass in a woman over 40 warrants assessment rather than assumption, given the rare possibility of gland carcinoma.
Lichen sclerosus requires proper treatment rather than dismissal. Potent topical corticosteroids control symptoms, prevent progressive scarring, and appear to reduce the risk of cancer developing. Long-term maintenance treatment is standard, and the widespread fear that strong steroids will thin the skin is misplaced in this condition—untreated lichen sclerosus causes far more damage than appropriately used steroid does. Long-term follow-up is recommended, and women should be taught to examine themselves and to report any new lump, ulcer, or thickened area promptly, since these arise in the affected skin.
Hidradenitis suppurativa benefits enormously from correct diagnosis. Treatment ranges from topical and oral antibiotics used for their anti-inflammatory effect, through hormonal treatments and metformin, to biologic therapy for moderate to severe disease, alongside smoking cessation and weight management, which both meaningfully affect severity. Surgery has a role for established sinus tracts. Repeated incision and drainage of individual abscesses without addressing the underlying condition is a common and unsatisfactory pattern of care.
Genital warts are treated topically or by ablation, with recurrence common. Their presence prompts discussion of HPV vaccination where relevant and testing for other sexually transmitted infections.
Vulvar intraepithelial neoplasia is treated with topical immune-modulating therapy, laser, or local excision, with ongoing surveillance, since recurrence is common and a proportion progresses if untreated.
Vulvar cancer is treated surgically, with the extent determined by the size and site of the tumour. Modern practice favours wide local excision rather than the radical procedures of the past, preserving as much normal anatomy and function as possible. Assessment of the groin lymph nodes is central to outcome, and sentinel node biopsy—identifying and sampling only the first draining node—has largely replaced full groin dissection in appropriate cases, substantially reducing lymphoedema. Radiotherapy is used in some situations. Treatment at a specialist centre is associated with better outcomes.
HPV vaccination prevents infection with the types responsible for HPV-related vulvar disease and is most effective given before exposure.
Sexual function, body image, and psychological wellbeing deserve attention rather than being treated as secondary. Conditions and treatments in this area affect intimacy and self-perception directly, and specialist vulval clinics and psychosexual services exist and are worth accessing.
Care is coordinated by primary care with gynaecology, dermatology, sexual health, and specialist vulval services as appropriate. Examination, imaging, and biopsy findings are interpreted alongside symptoms, duration, and treatment history rather than in isolation.
Patient education plays an important role. Understanding that most vulvar lumps are benign, that some findings are normal anatomy, that persistent symptoms need examination rather than repeat prescriptions, that lichen sclerosus requires long-term treatment and monitoring, and that a biopsy is a simple clinic procedure rather than something to fear all contribute to appropriate care.
Red flag symptoms include a lump or ulcer that has not healed within a few weeks; a lesion that is hard, fixed, irregular, or bleeding; any new or changing pigmented lesion; persistent itching or soreness that has not responded to treatment; white, thickened, or scarred skin; a persistent red scaly patch treated as eczema without improvement; enlarged or firm lymph nodes in the groin; bleeding or offensive discharge from a lesion; pain that is persistent or worsening; and any vulvar lesion in a woman with known lichen sclerosus. These warrant prompt medical evaluation and, for anything not clearly benign, biopsy.