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Last modified 22/04/2025

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V

Vaginal Bleeding

ANY GESTATIONAL AGE

• Cervical lesions: polyps, decidual reaction, neoplasia
• Vaginal trauma
• Cervicitis/vulvovaginitis
• Postcoital trauma
• Bleeding dyscrasias

GESTATION <20 WEEKS

• Spontaneous abortion
• Presence of intrauterine device
• Ectopic pregnancy
• Molar pregnancy
• Implantation bleeding
• Low-lying placenta

GESTATION >20 WEEKS

• Molar pregnancy
• Placenta previa
• Placental abruption
• Vasa previa
• Marginal separation of the placenta
• Bloody show at term
• Preterm labor

Vaginal Bleeding, Pregnancy7

FIRST TRIMESTER

• Implantation bleeding
• Abortion

• Threatened
• Complete
• Incomplete
• Missed

• Ectopic pregnancy
• Neoplasia
• Hydatidiform mole
• Cervix

THIRD TRIMESTER

• Placenta previa
• Placental abruption
• Premature labor
• Choriocarcinoma

Vaginal Discharge, Prepubertal Girls20

• Irritative (bubble baths, sand)
• Poor perineal hygiene
• Foreign body
• Associated systemic illness (group A streptococci, chickenpox)
• Infections

• Escherichia coli with foreign body
• Shigella organisms
• Yersinia organisms

• Infections (consider sexual abuse)

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Trichomonas vaginalis

• Tumor (rare)

Varicocele

• Hydrocele
• Spermatocele
• Epididymal orchitis
• Testicular tumor

Varicose Veins

CONDITIONS THAT CAN LEAD TO SUPERFICIAL VENOUS STASIS OTHER THAN PRIMARY VALVULAR INSUFFICIENCY

• Arterial occlusive disease
• Diabetes
• Deep vein thrombophlebitis
• Peripheral neuropathies
• Unusual infections
• Carcinoma

Vasculitis, Classification27

LARGE-VESSEL DISEASE

Arteritis

• Giant cell arteritis
• Takayasu’s arteritis
• Arteritis associated with Reiter’s syndrome, ankylosing spondylitis

MEDIUM- AND SMALL-VESSEL DISEASE

Polyarteritis Nodosa

• Primary (idiopathic)
• Associated with viruses (hepatitis B or C, cytomegalovirus [CMV], HIV, herpes zoster)
• Associated with malignant disease (hairy cell leukemia)
• Familial Mediterranean fever

Granulomatous Vasculitis

• Wegener’s granulomatosis
• Lymphomatoid granulomatosis
• Behçet’s syndrome
• Kawasaki’s disease (mucocutaneous lymph node syndrome)

PREDOMINANTLY SMALL-VESSEL DISEASE

Hypersensitivity Vasculitis (Leukocytoclastic Vasculitis)

• Henoch-Schönlein purpura
• Mixed cryoglobulinemia
• Serum sickness
• Vasculitis associated with connective tissue diseases (systemic lupus erythematosus [SLE], Sjögren’s syndrome)
• Vasculitis associated with specific syndromes: primary biliary cirrhosis, Lyme disease, chronic active hepatitis, drug-induced vasculitis
• Churg-Strauss syndrome
• Goodpasture’s syndrome
• Erythema nodosum
• Panniculitis
• Buerger’s disease (thrombophlebitis obliterans)

Vasculitis, Diseases That Mimic Vasculitis29

EMBOLIC DISEASE

• Infectious or marantic endocarditis
• Cardiac mural thrombus
• Atrial myxoma
• Cholesterol embolization syndrome

NONINFLAMMATORY VESSEL WALL DISRUPTION

• Atherosclerosis
• Arterial fibromuscular dysplasia
• Drug effects (vasoconstrictors, anticoagulants)
• Irradiation
• Genetic disease (neurofibromatosis, Ehlers-Danlos syndrome)
• Amyloidosis
• Intravascular malignant lymphoma

DIFFUSE COAGULATION

• Disseminated intravascular coagulation (DIC)
• Thrombotic thrombocytopenic purpura
• Hemolytic-uremic syndrome
• Protein C and S deficiencies, factor V Leiden mutation
• Antiphospholipid syndrome

Venous Lake

• Hemangioma
• Melanoma
• Blue nevus
• Angiokeratoma
• Melanosis of buccal mucosa

Venous Leg Ulcers

• Peripheral arterial disease (with ischemia and necrosis)
• Diabetic ulceration (often secondary to neuropathy)
• Decubitus ulceration (due to pressure over a bone prominence)
• Vasculitis (with erythema and bullae)
• Necrotic ulceration from infection
• Basal cell carcinoma or squamous cell carcinoma

Ventricular Failure

LEFT VENTRICULAR FAILURE

• Systemic hypertension
• Valvular heart disease (aortic stenosis [AS], atrial regurgitation [AR], mitral regurgitation [MR])
• Cardiomyopathy, myocarditis
• Bacterial endocarditis
• Myocardial infarction
• Idiopathic hypertrophic subaortic stenosis

RIGHT VENTRICULAR FAILURE

• Valvular heart disease (mitral stenosis)
• Pulmonary hypertension
• Bacterial endocarditis (right sided)
• Right ventricular infarction

BIVENTRICULAR FAILURE

• Left ventricular failure
• Cardiomyopathy
• Myocarditis
• Arrhythmias
• Anemia
• Thyrotoxicosis
• Arteriovenous fistula
• Paget’s disease
• Beriberi

Ventricular Septal Defect

OTHER CAUSES OF SYSTOLIC MURMURS

• Mitral regurgitation
• Aortic stenosis
• Asymmetric septal hypertrophy
• Pulmonary stenosis

Vertebral Compression Fractures

• Hyperparathyroidism
• Osteomalacia
• Granulomatous diseases (e.g., tuberculosis)
• Hematologic/oncologic diseases (e.g., multiple myeloma, malignant neoplasm)

Vertigo

PERIPHERAL

• Otitis media
• Acute labyrinthitis
• Vestibular neuronitis
• Benign positional vertigo
• Meniere’s disease
• Ototoxic drugs: streptomycin, gentamicin
• Lesions of the eighth nerve: acoustic neuroma, meningioma, mononeuropathy, metastatic carcinoma
• Mastoiditis

CNS OR SYSTEMIC

• Vertebrobasilar artery insufficiency
• Posterior fossa tumor or other brain tumors
• Infarction/hemorrhage of cerebral cortex, cerebellum, or brainstem
• Basilar migraine
• Metabolic: drugs, hypoxia, anemia, fever
• Hypotension/severe hypertension
• Multiple sclerosis (MS)
• CNS infections: viral, bacterial
• Temporal lobe epilepsy
• Arnold-Chiari malformation, syringobulbia
• Psychogenic: ventilation, hysteria

Vesiculobullous Diseases14

• Immunologically mediated diseases

• Bullous pemphigoid
• Herpes gestationis
• Mucous membrane pemphigoid
• Epidermolysis bullosa acquisita
• Dermatitis herpetiformis
• Pemphigus (vulgaris, foliaceus, paraneoplastic)

• Hypersensitivity diseases

• Erythema multiforme minor
• Erythema multiforme major (Stevens-Johnson syndrome)
• Toxic epidermal necrolysis

• Metabolic diseases

• Porphyria cutanea tarda
• Pseudoporphyria
• Diabetic blisters

• Inherited genetic disorders

• Epidermolysis bullosa: simplex, junctional, dystrophic

• Infectious diseases

• Impetigo
• Staphylococcal scalded skin syndrome
• Herpes simplex
• Varicella
• Herpes zoster

Vesiculopustules, Newborn Infants16

• Congenital cutaneous candidiasis
• Congenital herpes simplex
• Erythema toxicum neonatorum
• Genodermatosis
• Impetigo
• Miliaria
• Scabies
• Syphilis
• Transient neonatal pustulosis

Vestibular Neuronitis

• Labyrinthitis: similar cause but includes hearing loss
• Labyrinthine infarction
• Perilymph fistula
• Brainstem and cerebellar infarction
• Migraine-associated vertigo
• Multiple sclerosis

Vision Loss, Acute, Painful

• Acute angle-closure glaucoma
• Corneal ulcer
• Uveitis
• Endophthalmitis
• Factitious
• Somatization syndrome
• Trauma

Vision Loss, Acute, Painless

• Retinal artery occlusion
• Optic neuritis
• Retinal vein occlusion
• Vitreous hemorrhage
• Retinal detachment
• Exudative macular degeneration
• Cerebrovascular accident (CVA)
• Ischemic optic neuropathy
• Factitious
• Somatization syndrome, anxiety reaction

Vision Loss, Chronic, Progressive

• Cataract
• Macular degeneration
• Cerebral neoplasm
• Refractive error
• Open-angle glaucoma

Vision Loss, Monocular, Transient

• Thromboembolism
• Vasculitis
• Migraine (vasospasm)
• Anxiety reaction
• CNS tumor
• Temporal arteritis
• Multiple sclerosis (MS)

Vitiligo

ACQUIRED

• Chemical induced
• Halo nevus
• Idiopathic guttate hypomelanosis
• Leprosy
• Leukoderma associated with melanoma
• Pityriasis alba
• Postinflammatory hypopigmentation
• Tinea versicolor
• Vogt-Koyanagi syndrome (vitiligo, uveitis, deafness)

CONGENITAL

• Albinism, partial (piebaldism)
• Albinism, total
• Nevus anemicus
• Nevus depigmentosus
• Tuberous sclerosis

Vocal Cord Paralysis

• Neoplasm: primary or metastatic (e.g., lung, thyroid, parathyroid, mediastinum)
• Neck surgery (parathyroid, thyroid, carotid endarterectomy, cervical spine)
• Idiopathic
• Viral, bacterial, or fungal infection
• Trauma (intubation, penetrating neck injury)
• Cardiac surgery
• Rheumatoid arthritis
• Multiple sclerosis (MS)
• Parkinsonism
• Toxic neuropathy
• Cerebrovascular accident (CVA)
• CNS abnormalities: hydrocephalus, Arnold-Chiari malformation, meningomyelocele

Volume Depletion1

• Gastrointestinal losses

• Upper: bleeding, nasogastric suction, vomiting
• Lower: bleeding, diarrhea, enteric or pancreatic fistula, tube drainage

• Renal losses

• Salt and water: diuretics, osmotic diuresis, postobstructive diuresis, acute tubular necrosis (recovery phase), salt-losing nephropathy, adrenal insufficiency, renal tubular acidosis
• Water loss: diabetes insipidus

• Skin and respiratory losses: sweat, burns, insensible losses
• Sequestration without external fluid loss: intestinal obstruction, peritonitis, pancreatitis, rhabdomyolysis, internal bleeding

Volume Excess1

PRIMARY RENAL SODIUM RETENTION (INCREASED EFFECTIVE CIRCULATING VOLUME)

• Renal failure, nephritic syndrome, acute glomerulonephritis
• Primary hyperaldosteronism
• Cushing’s syndrome
• Liver disease

SECONDARY RENAL SODIUM RETENTION (DECREASED EFFECTIVE CIRCULATING VOLUME)

• Heart failure
• Liver disease
• Nephrotic syndrome (minimal change disease)
• Pregnancy

Vomiting

• GI disturbances

• Obstruction: esophageal, pyloric, intestinal
• Infections: viral or bacterial enteritis, viral hepatitis, food poisoning, gastroenteritis
• Pancreatitis
• Appendicitis
• Biliary colic
• Peritonitis
• Perforated bowel
• Diabetic gastroparesis
• Other: gastritis, peptic ulcer disease (PUD), inflammatory bowel disease (IBD), GI tract neoplasms

• Drugs: morphine, digitalis, cytotoxic agents, bromocriptine
• Severe pain: myocardial infarction (MI), renal colic
• Metabolic disorders: uremia, acidosis/alkalosis, hyperglycemia, diabetic ketoacidosis (DKA), thyrotoxicosis
• Trauma: blows to the testicles, epigastrium
• Vertigo
• Reye’s syndrome
• Increased intracranial pressure
• CNS disturbances: trauma, hemorrhage, infarction, neoplasm, infection, hypertensive encephalopathy, migraine
• Radiation sickness
• Nausea and vomiting of pregnancy, hyperemesis gravidarum
• Motion sickness
• Bulimia, anorexia nervosa
• Psychogenic: emotional disturbances, offensive sights or smells
• Severe coughing
• Pyelonephritis
• Boerhaave’s syndrome
• Carbon monoxide poisoning

Vulvar Cancer

• Lymphogranuloma inguinale
• TB
• Vulvar dystrophies
• Vulvar atrophy
• Paget’s disease

Vulvar Lesions12

RED LESION

Infection/Infestation

• Fungal infection: Candida, tinea cruris, intertrigo, pityriasis versicolor
• Sarcoptes scabiei
• Erythrasma: Corynebacterium minutissimum
• Granuloma inguinale: Calymmatobacterium granulomatis
• Folliculitis: Staphylococcus aureus
• Hidradenitis suppurativa
• Behçet’s syndrome

Inflammation

• Reactive vulvitis
• Chemical irritation: detergent, dyes, perfume, spermicide, lubricants, hygiene sprays, podophyllum, topical 5-fluorouracil, saliva, gentian violet, semen
• Mechanical trauma: scratching
• Vestibular adenitis
• Essential vulvodynia
• Psoriasis
• Seborrheic dermatitis

Neoplasm

• Vulvar intraepithelial neoplasia (VIN): mild dysplasia, moderate dysplasia, severe dysplasia, carcinoma in situ
• Vulvar dystrophy
• Bowen’s disease
• Invasive cancer: squamous cell carcinoma, malignant melanoma, sarcoma, basal cell carcinoma, adenocarcinoma, Paget’s disease, undifferentiated

WHITE LESION

• Vulvar dystrophy: lichen sclerosus, vulvar dystrophy, vulvar hyperplasia, mixed dystrophy
• VIN
• Vitiligo
• Partial albinism
• Intertrigo
• Radiation treatment

DARK LESION

• Lentigo
• Nevi (mole)
• Neoplasm (vulvar)
• Reactive hyperpigmentation
• Seborrheic keratosis
• Pubic lice

ULCERATIVE LESION

Infection

• Herpes simplex
• Vaccinia
• Treponema pallidum
• Granuloma inguinale
• Pyoderma
• Tuberculosis

Noninfectious

• Behçet’s syndrome
• Crohn’s disease
• Pemphigus
• Pemphigoid
• Hidradenitis suppurativa

Neoplasm

• Basal cell carcinoma
• Squamous cell carcinoma
• Vulvar tumor <1 cm: condyloma acuminatum, molluscum contagiosum, epidermal inclusion, vestibular cyst, mesonephric duct, VIN, hemangioma, hidradenoma, neurofibroma, syringoma, accessory breast tissue, acrochordon, endometriosis, Fox-Fordyce disease, pilonidal sinus
• Vulvar tumor >1 cm: Bartholin’s cyst or abscess, lymphogranuloma venereum, fibroma, lipoma, verrucous carcinoma, squamous cell carcinoma, hernia, edema, hematoma, acrochordon, epidermal cysts, neurofibromatosis, accessory breast tissue

Vulvovaginitis, Bacterial

• Fungal vaginitis
• Trichomonas vaginitis
• Atrophic vaginitis
• Cervicitis

Vulvovaginitis, Estrogen Deficient

• Infectious vulvovaginitis
• Squamous cell hyperplasia
• Lichen sclerosus
• Vulvar malignant neoplasm
• Vaginal malignant neoplasm
• Cervical and endometrial malignant neoplasm

Vulvovaginitis, Fungal

• Bacterial vaginosis
• Trichomonas vaginitis
• Atrophic vaginitis

Vulvovaginitis, Prepubescent

• Physiologic leukorrhea
• Foreign body
• Bacterial vaginosis
• Gonorrhea
• Fungal vulvovaginitis
• Trichomonas vulvovaginitis
• Sexual abuse
• Pinworms

Vulvovaginitis, Trichomonas

• Bacterial vaginosis
• Fungal vulvovaginitis
• Cervicitis
• Atrophic vulvovaginitis
• Waldenström’s macroglobulinemia
• Monoclonal gammopathy of unknown significance (MGUS)
• Multiple myeloma
• Chronic lymphocytic leukemia
• Hairy cell leukemia
• Lymphoma

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