Differential Diagnosis of Rare Vulvar Diseases

The case presented highlights the challenges of clinically and instrumentally differentiating between clitoral hypertrophy and vulvar varicose veins (VVV) in a 47-year-old female patient. The patient reported perineal and clitoral pain, significant clitoral enlargement when in an upright position, and discomfort during intercourse. Following an initial clinical assessment by both a gynecologist and a vascular surgeon, VVV was suspected. Further examinations were conducted, including duplex ultrasound (DUS) of the pelvic and perineal veins, as well as computed tomography venography (CTV) of the pelvis. These investigations revealed no abnormalities in the pelvic and perineal veins; however, a hypodense, non-contrast-enhanced lesion was identified in the clitoral area, leading to a diagnosis of clitoral hypertrophy. A surgical procedure was subsequently performed, which revealed not only clitoral enlargement but also localized vein dilation measuring up to 1 cm in the clitoral region. A clitoral resection was carried out, along with the resection of the dilated vein. Postoperative recovery was smooth, with no complications reported. During follow-up examinations, the patient exhibited no symptoms, and clitoral size returned to normal. This clinical case illustrates the discordance between clinical findings, imaging results, and intraoperative observations, suggesting a likely interplay of organ-related and venous factors contributing to clitoral enlargement and perineal pain. The phlebological awareness of the gynecologist during the procedure facilitated the identification of the localized vein dilation in the clitoral area, allowing for a simultaneous clitoral vein resection alongside the clitoral resection.