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A casual survey of my dermatology co-residents yielded overwhelmingly unanimous results: A complete skin check goes from head to toe but does not routinely include an examination of the genital area. This observation contrasts starkly with the American Academy of Dermatology’s Basic Dermatology Curriculum, which recommends inspection of the entire skin surface including the mucous membranes (ie, eyes, mouth, anus, genital area) as part of the total-body skin examination (TBSE).1 It even draws attention to so-called hidden areas where lesions easily can be missed, such as the perianal skin. My observation seems far from anecdotal; even a recent attempt at optimizing movements in the TBSE neglected to include examination of the genitalia in the proposed method,2-4 and many practicing dermatologists seem to agree. A survey of international dermatologists at high-risk skin cancer clinics found male and female genitalia were the least frequently examined anatomy sites during the TBSE. Additionally, female genitalia were examined less frequently than male genitalia (labia majora, 28%; penis, 52%; P=.003).5 Another survey of US academic dermatologists (23 dermatologists, 1 nurse practitioner) found that only 4% always visually inspected the vulva during routine annual examinations, and 50% did not think that vulvar examination was the dermatologist’s responsibility.6 Similar findings were reported in a survey of US dermatology residents.7
Why is the genital area routinely omitted from the dermatologic TBSE? Based on the surveys of dermatologists and dermatology residents, the most common reason cited for not examining these sites was patient discomfort, but there also was a dominant belief that other specialties, such as gynecologists, urologists, or primary care providers, routinely examine these areas.5,7 Time constraints also were a concern.
Although examination of sensitive areas can be uncomfortable,8 most patients still expect these locations to be examined during the TBSE. In a survey of 500 adults presenting for TBSE at an academic dermatology clinic, 84% of respondents expected the dermatologist to examine the genital area.9 Similarly, another survey of patient preferences (N=443) for the TBSE found that only 31.3% of women and 12.5% of men preferred not to have their genital area examined.10 As providers, we may be uncomfortable examining the genital area; however, our patients mostly expect it as part of routine practice. There are a number of barriers that may prevent incorporating the genital examination into daily dermatologic practice.
Training in Genital Examinations
Adequate training may be an issue for provider comfort when examining the genital skin. In a survey of dermatology residency program directors (n=38) and residents (n=91), 61.7% reported receiving formal instruction on TBSE technique and 38.3% reported being self-taught. Examination of the genital skin was included only 40% of the time.11 Even vulvar disorder experts have admitted to receiving their training by self-teaching, with only 19% receiving vulvar training during residency and 11% during fellowship.12 Improving this training appears to be an ongoing effort.2
Passing the Buck
It may be easier to think that another provider is routinely examining genital skin based on the relative absence of this area in dermatologic training; however, that does not appear to be the case. In a 1999 survey of primary care providers, only 31% reported performing skin cancer screenings on their adult patients, citing lack of confidence in this clinical skill as the biggest hurdle.13 Similarly, changes in recommendations for the utility of the screening pelvic examination in asymptomatic, average-risk, nonpregnant adult women have decreased the performance of this examination in actual practice.14 Reviews of resident training in vulvovaginal disease also have shown that although dermatology residents receive slightly less formal training hours on vulvar skin disease, they see more than double the number of patients with vulvar disease per year when compared to obstetrics and gynecology residents.15 In practice, dermatologists generally are more confident when evaluating vulvar pigmented lesions than gynecologists.6
The Importance of the Genital Examination
Looking past these barriers seems essential to providing the best dermatologic care, as there are a multitude of neoplastic and inflammatory dermatoses that can affect the genital skin. Furthermore, early diagnosis and treatment of these conditions potentially can limit morbidity and mortality as well as improve quality of life. Genital melanomas are a good example. Although they may be rare, it is well known that genital melanomas are associated with an aggressive disease course and have worse outcomes than melanomas found elsewhere on the body.16,17 Increasing rates of genital and perianal keratinocyte carcinomas make including this as part of the TBSE even more important.18
We also should not forget that inflammatory conditions can routinely involve the genitals.19-21 Although robust data are lacking, chronic vulvar concerns frequently are seen in the primary care setting. In one study in the United Kingdom, 52% of general practitioners surveyed saw more than 3 patients per month with vulvar concerns.22 Even in common dermatologic conditions such as psoriasis and lichen planus, genital involvement often is overlooked despite its relative frequency.23-27 In one study, 60% of psoriasis patients with genital involvement had not had these lesions examined by a physician.28
Theoretically, TBSEs that include genital examination would yield higher and earlier detection rates of neoplasms as well as inflammatory dermatoses.29-32 Thus, there is real value in diagnosing ailments of the genital skin, and dermatologists are well prepared to manage these conditions. Consistently incorporating a genital examination within the TBSE is the first step.
An Approach to the Genital Skin Examination
As with the TBSE, no standardized protocol for the genital skin examination exists, and there is no consensus for how best to perform this evaluation. Ideally, both male and female patients should remove all clothing, including undergarments, though one study found patients preferred to keep undergarments on during the genital examination.10,33,34
In general, adult female genital anatomy is best viewed with the patient in the supine position.6,33,35 There is no clear agreement on the use of stirrups, and the decision to use these may be left to the discretion of the patient. One randomized clinical trial found that women undergoing routine gynecologic examination without stirrups reported less physical discomfort and had a reduced sense of vulnerability than women examined in stirrups.36 During the female genital examination, the head of the bed ideally should be positioned at a 30° to 45° angle to allow the provider to maintain eye contact and face-to-face communication with the patient.33 This positioning also facilitates the use of a handheld mirror to instruct patients on techniques for medication application as well as to point out sites of disease.
For adult males, the genital examination can be performed with the patient standing facing a seated examiner.35 The patient’s gown should be raised to the level of the umbilicus to expose the entire genital region. Good lighting is essential. These recommendations apply mainly to adults, but helpful tips on how to approach evaluating prepubertal children in the dermatology clinic are available.37
The presence of a chaperone also is optional for maximizing patient comfort but also may be helpful for providing medicolegal protection for the provider. It always should be offered regardless of patient gender. A dermatology study found that when patients were examined by a same-gender physician, women and men were more comfortable without a chaperone than with a chaperone, and patients generally preferred fewer bodies in the room during sensitive examinations.9
Educating Patients About the TBSE
The most helpful recommendation for successfully incorporating and performing the genital skin examination as part of the TBSE appears to be patient education. In a randomized double-arm study, patients who received pre-education consisting of written information explaining the need for a TBSE were less likely to be concerned about a genital examination compared to patients who received no information.38 Discussing that skin diseases, including melanoma, can arise in all areas of the body including the genital skin and encouraging patients to perform genital self-examinations is critical.35 In the age of the electronic health record and virtual communication, disseminating this information has become even easier.39 It may be beneficial to explore patients’ TBSE expectations at the outset through these varied avenues to help establish a trusted physician-patient relationship.40
Final Thoughts
Dermatologists should consistently offer a genital examination to all patients who present for a routine TBSE. Patients should be provided with adequate education to assess their comfort level for the skin examination. If a patient declines this examination, the dermatologist should ensure that another physician—be it a gynecologist, primary care provider, or other specialist—is routinely examining the area.6,7
- The skin exam. American Academy of Dermatology. https://digital-catalog.aad.org/diweb/catalog/launch/package/4/did/327974/iid/327974
- Helm MF, Hallock KK, Bisbee E, et al. Optimizing the total-body skin exam: an observational cohort study. J Am Acad Dermatol. 2019;81:1115-1119.
- Nielson CB, Grant-Kels JM. Commentary on “optimizing the total-body skin exam: an observational cohort study.” J Am Acad Dermatol. 2019;81:E131.
- Helm MF, Hallock KK, Bisbee E, et al. Reply to: “commentary on ‘optimizing the total-body skin exam: an observational cohort study.’” J Am Acad Dermatol. 2019;81:E133.
- Bajaj S, Wolner ZJ, Dusza SW, et al. Total body skin examination practices: a survey study amongst dermatologists at high-risk skin cancer clinics. Dermatol Pract Concept. 2019;9:132-138.
- Krathen MS, Liu CL, Loo DS. Vulvar melanoma: a missed opportunity for early intervention? J Am Acad Dermatol. 2012;66:697-698.
- Hosking AM, Chapman L, Zachary CB, et al. Anogenital examination practices among U.S. dermatology residents [published online January 9, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.12.061
- Grundström H, Wallin K, Berterö C. ‘You expose yourself in so many ways’: young women’s experiences of pelvic examination. J Psychosom Obstet Gynaecol. 2011;32:59-64.
- McClatchey Connors T, Reddy P, Weiss E, et al. Patient comfort and expectations for total body skin examinations: a cross-sectional study. J Am Acad Dermatol. 2019;81:615-617.
- Houston NA, Secrest AM, Harris RJ, et al. Patient preferences during skin cancer screening examination. JAMA Dermatol. 2016;152:1052-1054.
- Milchak M, Miller J, Dellasega C, et al. Education on total body skin examination in dermatology residency. Poster presented at: Association of Professors of Dermatology Annual Meeting; September 25-26, 2015; Chicago, IL.
- Venkatesan A, Farsani T, O’Sullivan P, et al. Identifying competencies in vulvar disorder management for medical students and residents: a survey of US vulvar disorder experts. J Low Genit Tract Dis. 2012;16:398-402.
- Kirsner RS, Muhkerjee S, Federman DG. Skin cancer screening in primary care: prevalence and barriers. J Am Acad Dermatol. 1999;41:564-566.
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for gynecologic conditions with pelvic examination: US Preventive Services Task Force recommendation statement. JAMA. 2017;317:947-953.
- Comstock JR, Endo JO, Kornik RI. Adequacy of dermatology and ob-gyn graduate medical education for inflammatory vulvovaginal skin disease: a nationwide needs assessment survey. Int J Womens Dermatol. 2020;6:182-185.
- Sanchez A, Rodríguez D, Allard CB, et al. Primary genitourinary melanoma: epidemiology and disease-specific survival in a large population-based cohort. Urol Oncol. 2016;34:E7-E14.
- Vyas R, Thompson CL, Zargar H, et al. Epidemiology of genitourinary melanoma in the United States: 1992 through 2012. J Am Acad Dermatol. 2016;75:144-150.
- Misitzis A, Beatson M, Weinstock MA. Keratinocyte carcinoma mortality in the United States as reported in death certificates, 2011-2017. Dermatol Surg. 2020;46:1135-1140.
- Sullivan AK, Straughair GJ, Marwood RP, et al. A multidisciplinary vulva clinic: the role of genito-urinary medicine. J Eur Acad Dermatol Venereol. 1999;13:36-40.
- Goncalves DLM, Romero RL, Ferreira PL, et al. Clinical and epidemiological profile of patients attended in a vulvar clinic of the dermatology outpatient unit of a tertiary hospital during a 4-year period. Int J Dermatol. 2019;58:1311-1316.
- Bauer A, Greif C, Vollandt R, et al. Vulval diseases need an interdisciplinary approach. Dermatology. 1999;199:223-226.
- Nunns D, Mandal D. The chronically symptomatic vulva: prevalence in primary health care. Genitourin Med. 1996;72:343-344.
- Meeuwis KA, de Hullu JA, de Jager ME, et al. Genital psoriasis: a questionnaire-based survey on a concealed skin disease in the Netherlands. J Eur Acad Dermatol Venereol. 2010;24:1425-1430.
- Ryan C, Sadlier M, De Vol E, et al. Genital psoriasis is associated with significant impairment in quality of life and sexual functioning. J Am Acad Dermatol. 2015;72:978-983.
- Fouéré S, Adjadj L, Pawin H. How patients experience psoriasis: results from a European survey. J Eur Acad Dermatol Venereol. 2005;(19 suppl 3):2-6.
- Eisen D. The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88:431-436.
- Meeuwis KAP, Potts Bleakman A, van de Kerkhof PCM, et al. Prevalence of genital psoriasis in patients with psoriasis. J Dermatolog Treat. 2018;29:754-760.
- Larsabal M, Ly S, Sbidian E, et al. GENIPSO: a French prospective study assessing instantaneous prevalence, clinical features and impact on quality of life of genital psoriasis among patients consulting for psoriasis. Br J Dermatol. 2019;180:647-656.
- Rigel DS, Friedman RJ, Kopf AW, et al. Importance of complete cutaneous examination for the detection of malignant melanoma. J Am Acad Dermatol. 1986;14(5 pt 1):857-860.
- De Rooij MJ, Rampen FH, Schouten LJ, et al. Total skin examination during screening for malignant melanoma does not increase the detection rate. Br J Dermatol. 1996;135:42-45.
- Johansson M, Brodersen J, Gøtzsche PC, et al. Screening for reducing morbidity and mortality in malignant melanoma. Cochrane Database Syst Rev. 2019;6:CD012352.
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:429-435.
- Mauskar MM, Marathe K, Venkatesan A, et al. Vulvar diseases: approach to the patient. J Am Acad Dermatol. 2020;82:1277-1284.
- Chen C. How full is a full body skin exam? investigation into the practice of the full body skin exam as conducted by board-certified and board-eligibile dermatologists. Michigan State University. Published April 24, 2015. Accessed February 4, 2021. https://cdn.ymaws.com/www.aocd.org/resource/resmgr/2015SpringMeeting/ChenSpr15.pdf
- Zikry J, Chapman LW, Korta DZ, et al. Genital melanoma: are we adequately screening our patients? Dermatol Online J. 2017;23:13030/qt7zk476vn.
- Seehusen DA, Johnson DR, Earwood JS, et al. Improving women’s experience during speculum examinations at routine gynaecological visits: randomised clinical trial [published online June 27, 2006]. BMJ. 2006;333:171.
- Habeshian K, Fowler K, Gomez-Lobo V, et al. Guidelines for pediatric anogenital examination: insights from our vulvar dermatology clinic. Pediatr Dermatol. 2018;35:693-695.
- Leffell DJ, Berwick M, Bolognia J. The effect of pre-education on patient compliance with full-body examination in a public skin cancer screening. J Dermatol Surg Oncol. 1993;19:660-663.
- Hong J, Nguyen TV, Prose NS. Compassionate care: enhancing physician-patient communication and education in dermatology: part II: patient education. J Am Acad Dermatol. 2013;68:364.e361-310.
- Rosamilia LL. The naked truth about total body skin examination: a lesson from Goldilocks and the Three Bears. American Academy of Dermatology. Published November 13, 2019. Accessed February 4, 2021. https://www.aad.org/dw/dw-insights-and-inquiries/2019-archive/november/dwii-11-13-19-the-naked-truth-about-total-body-skin-examination-a-lesson-from-goldilocks-and-the-three-bears
A casual survey of my dermatology co-residents yielded overwhelmingly unanimous results: A complete skin check goes from head to toe but does not routinely include an examination of the genital area. This observation contrasts starkly with the American Academy of Dermatology’s Basic Dermatology Curriculum, which recommends inspection of the entire skin surface including the mucous membranes (ie, eyes, mouth, anus, genital area) as part of the total-body skin examination (TBSE).1 It even draws attention to so-called hidden areas where lesions easily can be missed, such as the perianal skin. My observation seems far from anecdotal; even a recent attempt at optimizing movements in the TBSE neglected to include examination of the genitalia in the proposed method,2-4 and many practicing dermatologists seem to agree. A survey of international dermatologists at high-risk skin cancer clinics found male and female genitalia were the least frequently examined anatomy sites during the TBSE. Additionally, female genitalia were examined less frequently than male genitalia (labia majora, 28%; penis, 52%; P=.003).5 Another survey of US academic dermatologists (23 dermatologists, 1 nurse practitioner) found that only 4% always visually inspected the vulva during routine annual examinations, and 50% did not think that vulvar examination was the dermatologist’s responsibility.6 Similar findings were reported in a survey of US dermatology residents.7
Why is the genital area routinely omitted from the dermatologic TBSE? Based on the surveys of dermatologists and dermatology residents, the most common reason cited for not examining these sites was patient discomfort, but there also was a dominant belief that other specialties, such as gynecologists, urologists, or primary care providers, routinely examine these areas.5,7 Time constraints also were a concern.
Although examination of sensitive areas can be uncomfortable,8 most patients still expect these locations to be examined during the TBSE. In a survey of 500 adults presenting for TBSE at an academic dermatology clinic, 84% of respondents expected the dermatologist to examine the genital area.9 Similarly, another survey of patient preferences (N=443) for the TBSE found that only 31.3% of women and 12.5% of men preferred not to have their genital area examined.10 As providers, we may be uncomfortable examining the genital area; however, our patients mostly expect it as part of routine practice. There are a number of barriers that may prevent incorporating the genital examination into daily dermatologic practice.
Training in Genital Examinations
Adequate training may be an issue for provider comfort when examining the genital skin. In a survey of dermatology residency program directors (n=38) and residents (n=91), 61.7% reported receiving formal instruction on TBSE technique and 38.3% reported being self-taught. Examination of the genital skin was included only 40% of the time.11 Even vulvar disorder experts have admitted to receiving their training by self-teaching, with only 19% receiving vulvar training during residency and 11% during fellowship.12 Improving this training appears to be an ongoing effort.2
Passing the Buck
It may be easier to think that another provider is routinely examining genital skin based on the relative absence of this area in dermatologic training; however, that does not appear to be the case. In a 1999 survey of primary care providers, only 31% reported performing skin cancer screenings on their adult patients, citing lack of confidence in this clinical skill as the biggest hurdle.13 Similarly, changes in recommendations for the utility of the screening pelvic examination in asymptomatic, average-risk, nonpregnant adult women have decreased the performance of this examination in actual practice.14 Reviews of resident training in vulvovaginal disease also have shown that although dermatology residents receive slightly less formal training hours on vulvar skin disease, they see more than double the number of patients with vulvar disease per year when compared to obstetrics and gynecology residents.15 In practice, dermatologists generally are more confident when evaluating vulvar pigmented lesions than gynecologists.6
The Importance of the Genital Examination
Looking past these barriers seems essential to providing the best dermatologic care, as there are a multitude of neoplastic and inflammatory dermatoses that can affect the genital skin. Furthermore, early diagnosis and treatment of these conditions potentially can limit morbidity and mortality as well as improve quality of life. Genital melanomas are a good example. Although they may be rare, it is well known that genital melanomas are associated with an aggressive disease course and have worse outcomes than melanomas found elsewhere on the body.16,17 Increasing rates of genital and perianal keratinocyte carcinomas make including this as part of the TBSE even more important.18
We also should not forget that inflammatory conditions can routinely involve the genitals.19-21 Although robust data are lacking, chronic vulvar concerns frequently are seen in the primary care setting. In one study in the United Kingdom, 52% of general practitioners surveyed saw more than 3 patients per month with vulvar concerns.22 Even in common dermatologic conditions such as psoriasis and lichen planus, genital involvement often is overlooked despite its relative frequency.23-27 In one study, 60% of psoriasis patients with genital involvement had not had these lesions examined by a physician.28
Theoretically, TBSEs that include genital examination would yield higher and earlier detection rates of neoplasms as well as inflammatory dermatoses.29-32 Thus, there is real value in diagnosing ailments of the genital skin, and dermatologists are well prepared to manage these conditions. Consistently incorporating a genital examination within the TBSE is the first step.
An Approach to the Genital Skin Examination
As with the TBSE, no standardized protocol for the genital skin examination exists, and there is no consensus for how best to perform this evaluation. Ideally, both male and female patients should remove all clothing, including undergarments, though one study found patients preferred to keep undergarments on during the genital examination.10,33,34
In general, adult female genital anatomy is best viewed with the patient in the supine position.6,33,35 There is no clear agreement on the use of stirrups, and the decision to use these may be left to the discretion of the patient. One randomized clinical trial found that women undergoing routine gynecologic examination without stirrups reported less physical discomfort and had a reduced sense of vulnerability than women examined in stirrups.36 During the female genital examination, the head of the bed ideally should be positioned at a 30° to 45° angle to allow the provider to maintain eye contact and face-to-face communication with the patient.33 This positioning also facilitates the use of a handheld mirror to instruct patients on techniques for medication application as well as to point out sites of disease.
For adult males, the genital examination can be performed with the patient standing facing a seated examiner.35 The patient’s gown should be raised to the level of the umbilicus to expose the entire genital region. Good lighting is essential. These recommendations apply mainly to adults, but helpful tips on how to approach evaluating prepubertal children in the dermatology clinic are available.37
The presence of a chaperone also is optional for maximizing patient comfort but also may be helpful for providing medicolegal protection for the provider. It always should be offered regardless of patient gender. A dermatology study found that when patients were examined by a same-gender physician, women and men were more comfortable without a chaperone than with a chaperone, and patients generally preferred fewer bodies in the room during sensitive examinations.9
Educating Patients About the TBSE
The most helpful recommendation for successfully incorporating and performing the genital skin examination as part of the TBSE appears to be patient education. In a randomized double-arm study, patients who received pre-education consisting of written information explaining the need for a TBSE were less likely to be concerned about a genital examination compared to patients who received no information.38 Discussing that skin diseases, including melanoma, can arise in all areas of the body including the genital skin and encouraging patients to perform genital self-examinations is critical.35 In the age of the electronic health record and virtual communication, disseminating this information has become even easier.39 It may be beneficial to explore patients’ TBSE expectations at the outset through these varied avenues to help establish a trusted physician-patient relationship.40
Final Thoughts
Dermatologists should consistently offer a genital examination to all patients who present for a routine TBSE. Patients should be provided with adequate education to assess their comfort level for the skin examination. If a patient declines this examination, the dermatologist should ensure that another physician—be it a gynecologist, primary care provider, or other specialist—is routinely examining the area.6,7
A casual survey of my dermatology co-residents yielded overwhelmingly unanimous results: A complete skin check goes from head to toe but does not routinely include an examination of the genital area. This observation contrasts starkly with the American Academy of Dermatology’s Basic Dermatology Curriculum, which recommends inspection of the entire skin surface including the mucous membranes (ie, eyes, mouth, anus, genital area) as part of the total-body skin examination (TBSE).1 It even draws attention to so-called hidden areas where lesions easily can be missed, such as the perianal skin. My observation seems far from anecdotal; even a recent attempt at optimizing movements in the TBSE neglected to include examination of the genitalia in the proposed method,2-4 and many practicing dermatologists seem to agree. A survey of international dermatologists at high-risk skin cancer clinics found male and female genitalia were the least frequently examined anatomy sites during the TBSE. Additionally, female genitalia were examined less frequently than male genitalia (labia majora, 28%; penis, 52%; P=.003).5 Another survey of US academic dermatologists (23 dermatologists, 1 nurse practitioner) found that only 4% always visually inspected the vulva during routine annual examinations, and 50% did not think that vulvar examination was the dermatologist’s responsibility.6 Similar findings were reported in a survey of US dermatology residents.7
Why is the genital area routinely omitted from the dermatologic TBSE? Based on the surveys of dermatologists and dermatology residents, the most common reason cited for not examining these sites was patient discomfort, but there also was a dominant belief that other specialties, such as gynecologists, urologists, or primary care providers, routinely examine these areas.5,7 Time constraints also were a concern.
Although examination of sensitive areas can be uncomfortable,8 most patients still expect these locations to be examined during the TBSE. In a survey of 500 adults presenting for TBSE at an academic dermatology clinic, 84% of respondents expected the dermatologist to examine the genital area.9 Similarly, another survey of patient preferences (N=443) for the TBSE found that only 31.3% of women and 12.5% of men preferred not to have their genital area examined.10 As providers, we may be uncomfortable examining the genital area; however, our patients mostly expect it as part of routine practice. There are a number of barriers that may prevent incorporating the genital examination into daily dermatologic practice.
Training in Genital Examinations
Adequate training may be an issue for provider comfort when examining the genital skin. In a survey of dermatology residency program directors (n=38) and residents (n=91), 61.7% reported receiving formal instruction on TBSE technique and 38.3% reported being self-taught. Examination of the genital skin was included only 40% of the time.11 Even vulvar disorder experts have admitted to receiving their training by self-teaching, with only 19% receiving vulvar training during residency and 11% during fellowship.12 Improving this training appears to be an ongoing effort.2
Passing the Buck
It may be easier to think that another provider is routinely examining genital skin based on the relative absence of this area in dermatologic training; however, that does not appear to be the case. In a 1999 survey of primary care providers, only 31% reported performing skin cancer screenings on their adult patients, citing lack of confidence in this clinical skill as the biggest hurdle.13 Similarly, changes in recommendations for the utility of the screening pelvic examination in asymptomatic, average-risk, nonpregnant adult women have decreased the performance of this examination in actual practice.14 Reviews of resident training in vulvovaginal disease also have shown that although dermatology residents receive slightly less formal training hours on vulvar skin disease, they see more than double the number of patients with vulvar disease per year when compared to obstetrics and gynecology residents.15 In practice, dermatologists generally are more confident when evaluating vulvar pigmented lesions than gynecologists.6
The Importance of the Genital Examination
Looking past these barriers seems essential to providing the best dermatologic care, as there are a multitude of neoplastic and inflammatory dermatoses that can affect the genital skin. Furthermore, early diagnosis and treatment of these conditions potentially can limit morbidity and mortality as well as improve quality of life. Genital melanomas are a good example. Although they may be rare, it is well known that genital melanomas are associated with an aggressive disease course and have worse outcomes than melanomas found elsewhere on the body.16,17 Increasing rates of genital and perianal keratinocyte carcinomas make including this as part of the TBSE even more important.18
We also should not forget that inflammatory conditions can routinely involve the genitals.19-21 Although robust data are lacking, chronic vulvar concerns frequently are seen in the primary care setting. In one study in the United Kingdom, 52% of general practitioners surveyed saw more than 3 patients per month with vulvar concerns.22 Even in common dermatologic conditions such as psoriasis and lichen planus, genital involvement often is overlooked despite its relative frequency.23-27 In one study, 60% of psoriasis patients with genital involvement had not had these lesions examined by a physician.28
Theoretically, TBSEs that include genital examination would yield higher and earlier detection rates of neoplasms as well as inflammatory dermatoses.29-32 Thus, there is real value in diagnosing ailments of the genital skin, and dermatologists are well prepared to manage these conditions. Consistently incorporating a genital examination within the TBSE is the first step.
An Approach to the Genital Skin Examination
As with the TBSE, no standardized protocol for the genital skin examination exists, and there is no consensus for how best to perform this evaluation. Ideally, both male and female patients should remove all clothing, including undergarments, though one study found patients preferred to keep undergarments on during the genital examination.10,33,34
In general, adult female genital anatomy is best viewed with the patient in the supine position.6,33,35 There is no clear agreement on the use of stirrups, and the decision to use these may be left to the discretion of the patient. One randomized clinical trial found that women undergoing routine gynecologic examination without stirrups reported less physical discomfort and had a reduced sense of vulnerability than women examined in stirrups.36 During the female genital examination, the head of the bed ideally should be positioned at a 30° to 45° angle to allow the provider to maintain eye contact and face-to-face communication with the patient.33 This positioning also facilitates the use of a handheld mirror to instruct patients on techniques for medication application as well as to point out sites of disease.
For adult males, the genital examination can be performed with the patient standing facing a seated examiner.35 The patient’s gown should be raised to the level of the umbilicus to expose the entire genital region. Good lighting is essential. These recommendations apply mainly to adults, but helpful tips on how to approach evaluating prepubertal children in the dermatology clinic are available.37
The presence of a chaperone also is optional for maximizing patient comfort but also may be helpful for providing medicolegal protection for the provider. It always should be offered regardless of patient gender. A dermatology study found that when patients were examined by a same-gender physician, women and men were more comfortable without a chaperone than with a chaperone, and patients generally preferred fewer bodies in the room during sensitive examinations.9
Educating Patients About the TBSE
The most helpful recommendation for successfully incorporating and performing the genital skin examination as part of the TBSE appears to be patient education. In a randomized double-arm study, patients who received pre-education consisting of written information explaining the need for a TBSE were less likely to be concerned about a genital examination compared to patients who received no information.38 Discussing that skin diseases, including melanoma, can arise in all areas of the body including the genital skin and encouraging patients to perform genital self-examinations is critical.35 In the age of the electronic health record and virtual communication, disseminating this information has become even easier.39 It may be beneficial to explore patients’ TBSE expectations at the outset through these varied avenues to help establish a trusted physician-patient relationship.40
Final Thoughts
Dermatologists should consistently offer a genital examination to all patients who present for a routine TBSE. Patients should be provided with adequate education to assess their comfort level for the skin examination. If a patient declines this examination, the dermatologist should ensure that another physician—be it a gynecologist, primary care provider, or other specialist—is routinely examining the area.6,7
- The skin exam. American Academy of Dermatology. https://digital-catalog.aad.org/diweb/catalog/launch/package/4/did/327974/iid/327974
- Helm MF, Hallock KK, Bisbee E, et al. Optimizing the total-body skin exam: an observational cohort study. J Am Acad Dermatol. 2019;81:1115-1119.
- Nielson CB, Grant-Kels JM. Commentary on “optimizing the total-body skin exam: an observational cohort study.” J Am Acad Dermatol. 2019;81:E131.
- Helm MF, Hallock KK, Bisbee E, et al. Reply to: “commentary on ‘optimizing the total-body skin exam: an observational cohort study.’” J Am Acad Dermatol. 2019;81:E133.
- Bajaj S, Wolner ZJ, Dusza SW, et al. Total body skin examination practices: a survey study amongst dermatologists at high-risk skin cancer clinics. Dermatol Pract Concept. 2019;9:132-138.
- Krathen MS, Liu CL, Loo DS. Vulvar melanoma: a missed opportunity for early intervention? J Am Acad Dermatol. 2012;66:697-698.
- Hosking AM, Chapman L, Zachary CB, et al. Anogenital examination practices among U.S. dermatology residents [published online January 9, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.12.061
- Grundström H, Wallin K, Berterö C. ‘You expose yourself in so many ways’: young women’s experiences of pelvic examination. J Psychosom Obstet Gynaecol. 2011;32:59-64.
- McClatchey Connors T, Reddy P, Weiss E, et al. Patient comfort and expectations for total body skin examinations: a cross-sectional study. J Am Acad Dermatol. 2019;81:615-617.
- Houston NA, Secrest AM, Harris RJ, et al. Patient preferences during skin cancer screening examination. JAMA Dermatol. 2016;152:1052-1054.
- Milchak M, Miller J, Dellasega C, et al. Education on total body skin examination in dermatology residency. Poster presented at: Association of Professors of Dermatology Annual Meeting; September 25-26, 2015; Chicago, IL.
- Venkatesan A, Farsani T, O’Sullivan P, et al. Identifying competencies in vulvar disorder management for medical students and residents: a survey of US vulvar disorder experts. J Low Genit Tract Dis. 2012;16:398-402.
- Kirsner RS, Muhkerjee S, Federman DG. Skin cancer screening in primary care: prevalence and barriers. J Am Acad Dermatol. 1999;41:564-566.
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for gynecologic conditions with pelvic examination: US Preventive Services Task Force recommendation statement. JAMA. 2017;317:947-953.
- Comstock JR, Endo JO, Kornik RI. Adequacy of dermatology and ob-gyn graduate medical education for inflammatory vulvovaginal skin disease: a nationwide needs assessment survey. Int J Womens Dermatol. 2020;6:182-185.
- Sanchez A, Rodríguez D, Allard CB, et al. Primary genitourinary melanoma: epidemiology and disease-specific survival in a large population-based cohort. Urol Oncol. 2016;34:E7-E14.
- Vyas R, Thompson CL, Zargar H, et al. Epidemiology of genitourinary melanoma in the United States: 1992 through 2012. J Am Acad Dermatol. 2016;75:144-150.
- Misitzis A, Beatson M, Weinstock MA. Keratinocyte carcinoma mortality in the United States as reported in death certificates, 2011-2017. Dermatol Surg. 2020;46:1135-1140.
- Sullivan AK, Straughair GJ, Marwood RP, et al. A multidisciplinary vulva clinic: the role of genito-urinary medicine. J Eur Acad Dermatol Venereol. 1999;13:36-40.
- Goncalves DLM, Romero RL, Ferreira PL, et al. Clinical and epidemiological profile of patients attended in a vulvar clinic of the dermatology outpatient unit of a tertiary hospital during a 4-year period. Int J Dermatol. 2019;58:1311-1316.
- Bauer A, Greif C, Vollandt R, et al. Vulval diseases need an interdisciplinary approach. Dermatology. 1999;199:223-226.
- Nunns D, Mandal D. The chronically symptomatic vulva: prevalence in primary health care. Genitourin Med. 1996;72:343-344.
- Meeuwis KA, de Hullu JA, de Jager ME, et al. Genital psoriasis: a questionnaire-based survey on a concealed skin disease in the Netherlands. J Eur Acad Dermatol Venereol. 2010;24:1425-1430.
- Ryan C, Sadlier M, De Vol E, et al. Genital psoriasis is associated with significant impairment in quality of life and sexual functioning. J Am Acad Dermatol. 2015;72:978-983.
- Fouéré S, Adjadj L, Pawin H. How patients experience psoriasis: results from a European survey. J Eur Acad Dermatol Venereol. 2005;(19 suppl 3):2-6.
- Eisen D. The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88:431-436.
- Meeuwis KAP, Potts Bleakman A, van de Kerkhof PCM, et al. Prevalence of genital psoriasis in patients with psoriasis. J Dermatolog Treat. 2018;29:754-760.
- Larsabal M, Ly S, Sbidian E, et al. GENIPSO: a French prospective study assessing instantaneous prevalence, clinical features and impact on quality of life of genital psoriasis among patients consulting for psoriasis. Br J Dermatol. 2019;180:647-656.
- Rigel DS, Friedman RJ, Kopf AW, et al. Importance of complete cutaneous examination for the detection of malignant melanoma. J Am Acad Dermatol. 1986;14(5 pt 1):857-860.
- De Rooij MJ, Rampen FH, Schouten LJ, et al. Total skin examination during screening for malignant melanoma does not increase the detection rate. Br J Dermatol. 1996;135:42-45.
- Johansson M, Brodersen J, Gøtzsche PC, et al. Screening for reducing morbidity and mortality in malignant melanoma. Cochrane Database Syst Rev. 2019;6:CD012352.
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:429-435.
- Mauskar MM, Marathe K, Venkatesan A, et al. Vulvar diseases: approach to the patient. J Am Acad Dermatol. 2020;82:1277-1284.
- Chen C. How full is a full body skin exam? investigation into the practice of the full body skin exam as conducted by board-certified and board-eligibile dermatologists. Michigan State University. Published April 24, 2015. Accessed February 4, 2021. https://cdn.ymaws.com/www.aocd.org/resource/resmgr/2015SpringMeeting/ChenSpr15.pdf
- Zikry J, Chapman LW, Korta DZ, et al. Genital melanoma: are we adequately screening our patients? Dermatol Online J. 2017;23:13030/qt7zk476vn.
- Seehusen DA, Johnson DR, Earwood JS, et al. Improving women’s experience during speculum examinations at routine gynaecological visits: randomised clinical trial [published online June 27, 2006]. BMJ. 2006;333:171.
- Habeshian K, Fowler K, Gomez-Lobo V, et al. Guidelines for pediatric anogenital examination: insights from our vulvar dermatology clinic. Pediatr Dermatol. 2018;35:693-695.
- Leffell DJ, Berwick M, Bolognia J. The effect of pre-education on patient compliance with full-body examination in a public skin cancer screening. J Dermatol Surg Oncol. 1993;19:660-663.
- Hong J, Nguyen TV, Prose NS. Compassionate care: enhancing physician-patient communication and education in dermatology: part II: patient education. J Am Acad Dermatol. 2013;68:364.e361-310.
- Rosamilia LL. The naked truth about total body skin examination: a lesson from Goldilocks and the Three Bears. American Academy of Dermatology. Published November 13, 2019. Accessed February 4, 2021. https://www.aad.org/dw/dw-insights-and-inquiries/2019-archive/november/dwii-11-13-19-the-naked-truth-about-total-body-skin-examination-a-lesson-from-goldilocks-and-the-three-bears
- The skin exam. American Academy of Dermatology. https://digital-catalog.aad.org/diweb/catalog/launch/package/4/did/327974/iid/327974
- Helm MF, Hallock KK, Bisbee E, et al. Optimizing the total-body skin exam: an observational cohort study. J Am Acad Dermatol. 2019;81:1115-1119.
- Nielson CB, Grant-Kels JM. Commentary on “optimizing the total-body skin exam: an observational cohort study.” J Am Acad Dermatol. 2019;81:E131.
- Helm MF, Hallock KK, Bisbee E, et al. Reply to: “commentary on ‘optimizing the total-body skin exam: an observational cohort study.’” J Am Acad Dermatol. 2019;81:E133.
- Bajaj S, Wolner ZJ, Dusza SW, et al. Total body skin examination practices: a survey study amongst dermatologists at high-risk skin cancer clinics. Dermatol Pract Concept. 2019;9:132-138.
- Krathen MS, Liu CL, Loo DS. Vulvar melanoma: a missed opportunity for early intervention? J Am Acad Dermatol. 2012;66:697-698.
- Hosking AM, Chapman L, Zachary CB, et al. Anogenital examination practices among U.S. dermatology residents [published online January 9, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.12.061
- Grundström H, Wallin K, Berterö C. ‘You expose yourself in so many ways’: young women’s experiences of pelvic examination. J Psychosom Obstet Gynaecol. 2011;32:59-64.
- McClatchey Connors T, Reddy P, Weiss E, et al. Patient comfort and expectations for total body skin examinations: a cross-sectional study. J Am Acad Dermatol. 2019;81:615-617.
- Houston NA, Secrest AM, Harris RJ, et al. Patient preferences during skin cancer screening examination. JAMA Dermatol. 2016;152:1052-1054.
- Milchak M, Miller J, Dellasega C, et al. Education on total body skin examination in dermatology residency. Poster presented at: Association of Professors of Dermatology Annual Meeting; September 25-26, 2015; Chicago, IL.
- Venkatesan A, Farsani T, O’Sullivan P, et al. Identifying competencies in vulvar disorder management for medical students and residents: a survey of US vulvar disorder experts. J Low Genit Tract Dis. 2012;16:398-402.
- Kirsner RS, Muhkerjee S, Federman DG. Skin cancer screening in primary care: prevalence and barriers. J Am Acad Dermatol. 1999;41:564-566.
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for gynecologic conditions with pelvic examination: US Preventive Services Task Force recommendation statement. JAMA. 2017;317:947-953.
- Comstock JR, Endo JO, Kornik RI. Adequacy of dermatology and ob-gyn graduate medical education for inflammatory vulvovaginal skin disease: a nationwide needs assessment survey. Int J Womens Dermatol. 2020;6:182-185.
- Sanchez A, Rodríguez D, Allard CB, et al. Primary genitourinary melanoma: epidemiology and disease-specific survival in a large population-based cohort. Urol Oncol. 2016;34:E7-E14.
- Vyas R, Thompson CL, Zargar H, et al. Epidemiology of genitourinary melanoma in the United States: 1992 through 2012. J Am Acad Dermatol. 2016;75:144-150.
- Misitzis A, Beatson M, Weinstock MA. Keratinocyte carcinoma mortality in the United States as reported in death certificates, 2011-2017. Dermatol Surg. 2020;46:1135-1140.
- Sullivan AK, Straughair GJ, Marwood RP, et al. A multidisciplinary vulva clinic: the role of genito-urinary medicine. J Eur Acad Dermatol Venereol. 1999;13:36-40.
- Goncalves DLM, Romero RL, Ferreira PL, et al. Clinical and epidemiological profile of patients attended in a vulvar clinic of the dermatology outpatient unit of a tertiary hospital during a 4-year period. Int J Dermatol. 2019;58:1311-1316.
- Bauer A, Greif C, Vollandt R, et al. Vulval diseases need an interdisciplinary approach. Dermatology. 1999;199:223-226.
- Nunns D, Mandal D. The chronically symptomatic vulva: prevalence in primary health care. Genitourin Med. 1996;72:343-344.
- Meeuwis KA, de Hullu JA, de Jager ME, et al. Genital psoriasis: a questionnaire-based survey on a concealed skin disease in the Netherlands. J Eur Acad Dermatol Venereol. 2010;24:1425-1430.
- Ryan C, Sadlier M, De Vol E, et al. Genital psoriasis is associated with significant impairment in quality of life and sexual functioning. J Am Acad Dermatol. 2015;72:978-983.
- Fouéré S, Adjadj L, Pawin H. How patients experience psoriasis: results from a European survey. J Eur Acad Dermatol Venereol. 2005;(19 suppl 3):2-6.
- Eisen D. The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88:431-436.
- Meeuwis KAP, Potts Bleakman A, van de Kerkhof PCM, et al. Prevalence of genital psoriasis in patients with psoriasis. J Dermatolog Treat. 2018;29:754-760.
- Larsabal M, Ly S, Sbidian E, et al. GENIPSO: a French prospective study assessing instantaneous prevalence, clinical features and impact on quality of life of genital psoriasis among patients consulting for psoriasis. Br J Dermatol. 2019;180:647-656.
- Rigel DS, Friedman RJ, Kopf AW, et al. Importance of complete cutaneous examination for the detection of malignant melanoma. J Am Acad Dermatol. 1986;14(5 pt 1):857-860.
- De Rooij MJ, Rampen FH, Schouten LJ, et al. Total skin examination during screening for malignant melanoma does not increase the detection rate. Br J Dermatol. 1996;135:42-45.
- Johansson M, Brodersen J, Gøtzsche PC, et al. Screening for reducing morbidity and mortality in malignant melanoma. Cochrane Database Syst Rev. 2019;6:CD012352.
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:429-435.
- Mauskar MM, Marathe K, Venkatesan A, et al. Vulvar diseases: approach to the patient. J Am Acad Dermatol. 2020;82:1277-1284.
- Chen C. How full is a full body skin exam? investigation into the practice of the full body skin exam as conducted by board-certified and board-eligibile dermatologists. Michigan State University. Published April 24, 2015. Accessed February 4, 2021. https://cdn.ymaws.com/www.aocd.org/resource/resmgr/2015SpringMeeting/ChenSpr15.pdf
- Zikry J, Chapman LW, Korta DZ, et al. Genital melanoma: are we adequately screening our patients? Dermatol Online J. 2017;23:13030/qt7zk476vn.
- Seehusen DA, Johnson DR, Earwood JS, et al. Improving women’s experience during speculum examinations at routine gynaecological visits: randomised clinical trial [published online June 27, 2006]. BMJ. 2006;333:171.
- Habeshian K, Fowler K, Gomez-Lobo V, et al. Guidelines for pediatric anogenital examination: insights from our vulvar dermatology clinic. Pediatr Dermatol. 2018;35:693-695.
- Leffell DJ, Berwick M, Bolognia J. The effect of pre-education on patient compliance with full-body examination in a public skin cancer screening. J Dermatol Surg Oncol. 1993;19:660-663.
- Hong J, Nguyen TV, Prose NS. Compassionate care: enhancing physician-patient communication and education in dermatology: part II: patient education. J Am Acad Dermatol. 2013;68:364.e361-310.
- Rosamilia LL. The naked truth about total body skin examination: a lesson from Goldilocks and the Three Bears. American Academy of Dermatology. Published November 13, 2019. Accessed February 4, 2021. https://www.aad.org/dw/dw-insights-and-inquiries/2019-archive/november/dwii-11-13-19-the-naked-truth-about-total-body-skin-examination-a-lesson-from-goldilocks-and-the-three-bears
Resident Pearls
- Dermatologists should offer a genital examination to all patients who present for a routine total-body skin examination.
- It is critical to educate patients about the importance of examining the genital skin by discussing that skin diseases can arise in all areas of the body including the genital area. Encouraging genital self-examination also is helpful.
- If a patient declines, the dermatologist should strive to ensure that another provider is examining the genital skin.
