Hypothesis / aims of study
Vulvar lichen sclerosus (LS) is a chronic dermatologic condition with risk of malignant transformation if left untreated[1], yet it is under-recognized and frequently misdiagnosed, leading to delays in care[2]. Opportunities for visual vulvar examination exist across multiple specialties but are often omitted. This educational initiative aimed to improve awareness, diagnostic confidence, and intent to incorporate routine vulvar examinations among clinicians who routinely examine the genitalia for other purposes. The emphasis on lichen sclerosus is particularly important given its 4-6% risk of malignant transformation and the significant delays in diagnosis documented in the literature (often 5-10 years from symptom onset).
Study design, materials and methods
A multidisciplinary educational session on LS and genitourinary syndrome of menopause (GSM), and vulvar cancer was developed following literature review, emphasizing pathophysiology, clinical identification, common misdiagnoses, and opportunities for routine vulvar examination. Residents and attendings in urology, internal medicine (IM), and family medicine (FM) completed anonymous pre- and post-session surveys, including a 9-question image-based quiz and confidence ratings (0–10 scale). Additional pre-session questions assessed prior training, perceived barriers, and symptom recognition using select-all-that-apply items. Post-session surveys assessed intended practice changes and perceived usefulness. Due to anonymous responses, pre- and post- linked data were analyzed as independent samples using two-sample t-tests, with Cohen’s d calculated to estimate effect size.
Results
Most residents and faculty reported limited prior training in vulvar dermatoses (urology 74%, internal medicine 69%, family medicine 50%) and identified key barriers including difficulty differentiating LS from other conditions and lack of formal training. Baseline knowledge gaps were evident, with dysuria frequently missed as a correct symptom (71%) and loss of vaginal rugae commonly misidentified (47%). Post-session quiz scores improved significantly across all specialties: urology (47%±17% to 83%±11%, p<0.00001, d=0.50), internal medicine (35%±9% to 66%±22%, p<0.0001, d=0.42), and family medicine (42%±17% to 89%±11%, p<0.0002, d=0.50). Confidence increased in urology (5.2±2.94 to 7.0±2.17, p=0.04, d=1.07) and family medicine (3.1±2.80 to 5.4±2.22, p=0.01, d=2.24), with a non-significant increase in internal medicine (4.2±1.79 to 5.4±1.69, p=0.16, d=0.83). Most participants reported intent to incorporate routine vulvar examinations into practice (urology 90%, family medicine 89%, internal medicine 65%), and over 89% found the session helpful.
Interpretation of results
These findings demonstrate gaps in identification of LS, genitourinary syndrome of menopause, and vulvar cancer across multiple specialties, with identifiable challenges in symptom recognition and diagnostic differentiation, highlighting the need for continued education in vulvar dermatology. Reported barriers, including lack of formal training and difficulty distinguishing LS from similar conditions, likely contribute to under-recognition in clinical practice. Results showed significant improvement in both knowledge and diagnostic confidence with a simple 20-minute intervention, with moderate-to-large effect sizes observed across groups. High rates of intended practice change suggest that this intervention may translate into increased utilization of routine vulvar examinations.