Treatment for vulvar cancer

Surgery is the main treatment for vulvar cancer. Your gynaecological oncologist will talk to you about the most suitable type of surgery, as well as the risks and any possible complications.

The type of operation recommended depends on how far the cancer has spread. The box on the opposite page provides more information about the main types of surgery.

All tissue removed during surgery is checked for cancer cells by a pathologist. The results will help confirm the type of vulvar cancer you have and how far it has spread throughout the body.

Types of vulvar surgery

You may have one of the following types of surgery. A small border (1 cm) of healthy tissue (called a margin) is usually removed around the cancer.

Local excision – Recommended for precancerous changes only. The precancerous area is cut out with little need for margins.

Wide local excision – Recommended for small cancers. The surgeon cuts out the cancer and a margin. May also have a lymph node dissection.

Partial radical vulvectomy – Recommended for cancers that are confined to either side of the vulva, or the front or back only. This may mean that a large part of the vulva is removed. Usually, nearby lymph nodes are also removed.

Complete radical vulvectomy – Recommended for cancers that cover a large area of the vulva. The surgeon removes the entire vulva, which may
include the clitoris, and removes deep tissue around the vulva. Usually, nearby lymph nodes are also removed (lymph node dissection).

Click on image to enlarge

Treatment of lymph nodes

Cancer cells can spread from the vulva to the lymph nodes in the groin. You may have one of the following procedures:

Lymph node dissection – The gynaecological oncologist will remove a number of lymph nodes from one or both sides of the groin. This is called an inguinal lymph node dissection or lymphadenectomy.

Sentinel lymph node biopsy – Instead of a full lymph node dissection, the surgeon may perform a sentinel lymph node biopsy. This test helps to identify which lymph node the cancer is most likely to spread to first (known as the sentinel lymph node).

The sentinel node can be identified with a blue dye and/or a radioactive tracer. You will usually have a local anaesthetic injected into the tumour, then a small amount of radioactive dye  injected near the site of the cancer. This procedure is called a lymphoscintigraphy and it normally happens in a radiology department either the day before or the morning of your surgery. During the surgery, blue dye may also be injected to help identify the sentinel node. The dye will flow to the sentinel lymph node and the surgeon will remove it for testing.

If a pathologist finds cancer cells in the sentinel lymph node, the remaining nodes in the area may need to be removed in another operation or treated with radiation therapy. If the sentinel node does not contain cancer cells, a full lymph node dissection is not required. A sentinel lymph node biopsy can help the doctor avoid removing more lymph nodes than necessary and minimise side effects such as lymphoedema.

Sometimes, the removal of lymph nodes in the groin can stop or slow the natural flow of lymphatic fluid. When this happens, it can cause one or both legs to swell. This is known as lymphoedema. See the ‘Managing side effects of treatment’ page for more information and some tips on managing this side effect.

Reconstructive surgery

The surgeon will aim to remove all of the vulvar cancer while preserving as much normal tissue as possible. However, a margin of healthy tissue around the cancer must also be removed to reduce the risk of the cancer coming back (recurring) in the same area.

Most people will be able to have the remaining skin drawn together with stitches, but if a large area of skin is removed, you may need a skin graft or skin flap. In this case, flaps of skin in the vulvar area are moved to cover the wound.

The graft or flap will be done as part of the first operation, sometimes with the assistance of a reconstructive (plastic) surgeon. Rarely, the surgeon may take a thin piece of skin from another part of your body (usually your abdomen or thigh) and stitch it onto the operation site.

What to expect after surgery

After surgery, you will be monitored closely. You will need to take care while you recover. Your doctor will tell you when you can start regular activities again.

Recovery time – Your recovery time will depend on your age, the type of surgery you had and your general health. If only a small amount of skin is removed, the wound will heal quickly and you can go home in a day or two. If your lymph nodes are removed or the surgery is more extensive, recovery will take longer. You may spend up to a week in hospital.

Having pain relief – After an operation it is common to feel some pain, but this can be controlled. You will be given pain medicine as a tablet, through a drip into a vein (intravenously), through a drip into a space around the spinal cord (epidural), or through a button you press to give yourself a measured dose of pain relief (patient-controlled analgesia or PCA). After you go home, you can continue taking pain-relieving tablets as needed.

Bowel issues – Strong pain medicines and long periods in bed can make bowel motions difficult to pass (constipation). Avoid straining when having a bowel movement. Talk to your treatment team about taking laxatives if needed.

Stitches – Your doctor will tell you how soon you can sit up and walk after surgery and how to avoid the stitches coming apart. Stitches usually dissolve and disappear as the wound heals. Some surgeons use surgical glue instead of stitches. The glue falls off when the wound has healed.

Wound care – Infection is a risk after vulvar surgery, so keep the area clean and dry. While you are in hospital, the nurses will wash and dry the vulva for you a few times a day. They may also apply a cream to help prevent infection.

The nurses will show you how to look after the wound at home. You will need to wash it 2–3 times a day using a handheld shower or shallow basin (sitz bath). Use a soft, squeezable plastic water bottle to rinse the area with water after urinating or having a bowel movement. Dry the vulva well. If the area is numb, be careful patting it dry. Report any redness, pain, swelling, wound discharge or unusual smell to your doctor or nurse.

Tubes and drains – You may have a tube called a catheter to drain urine from your bladder. This helps keep your wound clean and dry. It will be removed before you leave hospital. There may also be a surgical drain to draw fluid away from the wound. You may go home with the drain in place if there is still fluid coming out. Community nurses can help you manage the care of the drain at home until it is removed.

What to wear – While you are in bed, you may need to wear compression stockings and have blood-thinning injections to prevent blood clots forming in your legs. Wear loose-fitting clothing and avoid underwear so your wound can air.

Do not put anything into your vagina after surgery until your doctor says the area is healed (usually 6–8 weeks). This includes using tampons and having sex. 

Taking care of yourself at home after surgery

Rest – You will need to take things easy and get plenty of rest in the first week. Avoid sitting for long periods of time if it is uncomfortable, or try sitting on a pillow or doughnut cushion.

Exercise – Check with your gynaecological oncologist or nurse about when you can start doing your regular activities. You may not be able to lift anything heavy, but gentle exercise such as walking can help speed up recovery. Because of the risk of infection, avoid swimming until your doctor says you can.

Emotions – If you have lost part of your genital area, you may feel a sense of loss and grief. It may help to talk about how you are feeling with someone you trust.

Sex – Sexual intercourse needs to be avoided for about 6–8 weeks after surgery. Ask your doctor when you can have sexual intercourse again, and explore other ways you and your partner can be intimate. You may feel concerned about the impact on your sex life after surgery.

Using the toilet – If the opening to your urethra is affected, you may find that going to the toilet is different. The urine stream might spray in different directions or go to one side.

Driving – You will need to avoid driving after the surgery until your wounds have healed and you are no longer in pain. Discuss this issue with your doctor.

Download our booklet ‘Understanding Surgery’

Also known as radiotherapy, radiation therapy uses a controlled dose of radiation, such as x-rays, to kill or damage cancer cells. Whether you have radiation therapy will depend on the stage of the cancer, its size, whether it has spread to the lymph nodes and, if so, how many nodes are affected. You can have radiation therapy:

• after surgery to get rid of any remaining cancer cells and reduce the risk of the cancer coming back (adjuvant treatment)
• before surgery to shrink the cancer and make it easier to remove (neoadjuvant treatment)
• instead of surgery
• to control symptoms of advanced cancer (palliative treatment).

External beam radiation therapy (EBRT) – This is the most common type of radiation therapy for vulvar cancer. You will lie on a treatment table while a machine, called a linear accelerator, directs radiation towards the affected areas of the pelvis. EBRT is given daily, Monday to Friday, over 5–6 weeks. The exact number of sessions you have will depend on the type and size of the cancer. Each session takes about 20 minutes.

Radiation therapy to the vulva and groin doesn’t hurt, but it can cause side effects. EBRT will not make you radioactive. It is safe for you to be with other people, including children, after your treatment.

Internal radiation therapy – Also called brachytherapy, this delivers radiation therapy directly to the tumour from inside your body. It is rarely used for vulvar cancer.

Short-term side effects of radiation therapy

The side effects you experience will vary depending on the dose of radiation and the areas treated. Many will be short-term side effects. These often get worse during treatment and just after the course of treatment has ended.

• skin reactions – The vulva may become sore and swollen, and feel like a bad sunburn. It may start by being pink or red and feeling itchy, and then peel, blister or weep. Your treatment team will recommend creams and pain relief to use until the skin heals. Wash the vulvar area with lukewarm, slightly salted water, and avoid perfumed products and talcum powder.
• fatigue – Your body uses a lot of energy to recover and travelling to treatment can also be tiring. The fatigue may last for weeks after treatment ends.
• bladder and bowel problems – Radiation therapy can irritate the bladder and bowel. You may pass urine more often or with a burning sensation. Bowel motions may be more frequent, urgent or loose (diarrhoea), and you may pass more wind. Less commonly, you may have some blood in your faeces (poo). Always tell your doctor about any bleeding.
• vaginal discharge – Radiation therapy may cause or increase vaginal discharge. Let your treatment team know if it smells bad or has blood in it. Do not wash inside the vagina with douches as this may cause infection.

Long-term or late effects of radiation therapy

Side effects can take several weeks to get better, though some may continue longer. Some side effects from radiation therapy may not show up until many months or years after treatment. These are called late effects.

• hair loss – You may lose your pubic hair. Sometimes, this can be permanent. Radiation therapy will not affect the hair on your head or other body areas.
• bladder, bowel and rectal changes – Bladder changes (e.g. frequent or painful urination) and bowel changes (e.g. diarrhoea or wind) can appear months or years after radiation therapy ends. In some cases, a bowel blockage can occur. In rare cases, you may experience some bleeding from the rectum. Let your doctor know if you have pain in the abdomen, have any bleeding or cannot open your bowels.
• lymphoedema – Like surgery, radiation therapy can increase the risk of lymphoedema. If the lymph nodes and vessels have been removed during surgery or scarred during radiation therapy, lymph fluid can’t drain properly. Lymph fluid can become trapped, causing the legs, vulva or mons pubis to swell.
• narrowing of the vagina – The vagina can become drier, shorter and narrower (vaginal stenosis), which may make having sex and follow-up pelvic examinations uncomfortable or difficult. Your treatment team will suggest ways to prevent this.
• menopause – If you are premenopausal, radiation therapy to the pelvis can stop the ovaries producing hormones, which causes early menopause. Talk to your radiation oncologist about menopause or any fertility issues before starting treatment.

Download our booklet ‘Understanding Radiation Therapy’

Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells. Chemotherapy for vulvar cancer may be given:

• during a course of radiation therapy, to make the radiation therapy treatment more effective (known as chemoradiation)
• to control cancer that has spread to other parts of the body
• as palliative treatment, to relieve the symptoms of the cancer.

The drugs are given by injection into a vein (intravenously). You will usually have several treatment sessions, with rest periods in between. Together, the session and rest period are called a cycle. Treatment is usually given during day visits to a hospital or clinic as an outpatient. Rarely, you may need to stay in hospital for a night or two.

Side effects of chemotherapy

There are many different types of chemotherapy drugs. The side effects will vary depending on the drugs you are given, the dosage and how you respond. Chemotherapy for vulvar cancer may also increase any skin soreness caused by radiation therapy. Your medical oncologist or nurse will discuss the likely side effects with you, including how they can be prevented or controlled with medicine.

Download our booklet ‘Understanding Chemotherapy’

Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care. Many people think that palliative treatment is only for people at the end of their life, but it may help at any stage of advanced vulvar cancer. It is about living for as long as possible in the most comfortable way you can.

As well as slowing the spread of cancer, palliative treatment can relieve symptoms such as pain or bleeding. Treatment may include radiation therapy, chemotherapy or other drug therapies.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, practical, cultural, social and spiritual needs.

Download our booklet ‘Understanding Palliative Care’

Download our booklet ‘Living with Advanced Cancer’