In terms of presentation, HPV-related VIN (VIN usual) tends to be asymptomatic and is often discovered at the time of evaluation for an abnormal Pap smear or genital warts. Lesions may occur anywhere on the vulva, including the periurethral and perianal areas, and are often multifocal. Lesions are usually elevated and have a rough surface, although flat lesions can be seen. The color can be brown, white, gray or red. Biopsy of any suspicious areas should be liberally undertaken. Because multicentric disease is commonly encountered, particularly in younger women, a complete exam should include the cervix and vagina. Up to 50% of women with VIN will have antecedent or concomitant lower genital tract neoplasia, usually cervical or vaginal intraepithelial neoplasia (CDC, 2006). Vulvoscopy (colposcopy of the vulva) can be of help to magnify diseased areas. Vascular changes seen on cervical colposcopy are often not seen on the vulva.
Differentiated VIN, in contrast, occurs in older women, often in the setting of other non-neoplastic epithelial disorders such as lichen sclerosus, lichen simplex chronicus, or lichen planus. Patients are usually symptomatic, with a long history of pruritus and burning. Biopsy should be done on irregular lesions, erosive or ulcerative areas, hyperpigmented and fixed or indurated lesions. The signs and symptoms of early invasive vulvar cancer are similar to those of symptomatic VIN. As invasion proceeds, a distinct tumor is likely to be recognized. The most common signs are red, pink, or white bumps, often with rough or eroded surfaces. A persistent, non-healing ulcer is also another presenting sign. Bleeding may be present. About half of the women with vulvar cancer complain of persistent itching. Other symptoms include pain, burning, and dysuria. Verrucous carcinoma, another subtype of invasive squamous cell vulvar cancer, appears with cauliflower-like growths similar to genital warts.