by genital ulcers known as chancres; granuloma inguinale showing as inflammatory granulomas often described as nodules; syphilis –the primary stage classically presents with a single chancre, a firm, painless, non-itchy ulcer, but there may be multiple sores; and gonorrhea that very often presents no symptoms but can result in discharge. viral infections include human papillomavirus infection (hpv) – this is the most common sti and has many types. genital hpv can cause genital warts. there have been links made between hpv and vulvar cancer, though hpv most often causes cervical cancer. genital herpes is mostly asymptomatic but can present with small blisters that break open into ulcers. hiv/aids is mostly transmitted through sexual activity, and the vulva in some cases can be affected by sores. a highly contagious viral infection is molluscum contagiosum which is transmissible on close contact and causes water warts. parasitic infections include trichomoniasis, pediculosis pubis, and scabies. trichomoniasis is transmitted by a parasitic protozoan and is the most common non-viral sti. most cases are asymptomatic but may present symptoms of irritation and a discharge of unusual odor. pediculosis pubis commonly called crabs, is a disease caused by the crab louse an ectoparasite. when the pubic hair is infested the irritation produced can be intense. scabies, also known as the "seven year itch", is caused by another ectoparasite, the mite sarcoptes scabiei, giving intense irritation. cancer main article: vulvar cancer malignancies can develop in the glabrous and hair-bearing parts of the vulva. based on the cellular origin and histology, vulvar cancers are classified into squamous cell carcinomas, melanomas, basal cell carcinomas, adenocarcinomas, sarcomas and invasive extramammary paget's disease. squamous cell carcinomas represent the most common variant of vulvar cancers and account for approximately 75%. these are usually found in the labia particularly the labia majora. the second most common vulvar cancer is basal cell carcinoma, which rarely spreads to regional lymph nodes or distant organs. the third most common subtype is vulvar melanoma. studies have shown that vulvar melanomas appear to have a different tumor biology and mutational characteristics compared to skin melanomas, which has a direct impact on the medical treatment of vulvar melanomas. signs and symptoms of vulvar cancer can include: itching, or bleeding; skin changes including rashes, sores, lumps or ulcers, and changes in vulvar skin coloration. pelvic pain might also occur especially during urinating and sex. however, a significant proportion remains asymptomatic in early disease stages, often delaying its diagnosis. as such, 32% of women with vulvar melanoma already have regional involvement or distant metastases at the time of diagnosis, which significantly impacts prognosis. surgery (with or without removal of regional lymph nodes) is usually the primary treatment modality. typically, a wide-local excision is performed, in which the tumor is excised including a safety-margin of healthy tissue to ensure its entire removal, which is confirmed by a pathologist. in more advanced disease, a (partial) vulvectomy may need to be performed in order to remove some or all of the vulva. advanced-stage melanomas can be treated with checkpoint inhibitors. other labial fusion, also called labial adhesion, is the fusion of the labia minora. this affects a number of young girls and is not considered unduly problematic. the condition can usually be treated using creams, or it may right itself with the release of hormones at the onset of puberty. vulvodynia is chronic pain in the vulvar region. there is no single identifiable cause. a subtype of this is vulvar vestibulitis but since this is not thought to be an inflammatory condition it is more usually referred to as vestibulodynia. vulvar vestibulitis usually affects pre-menopausal women. a number of skin disorders such as lichen sclerosus, and lichen simplex chronicus can affect the vulva. crohn's disease of the vulva is an uncommon form of metastatic crohn's disease which manifests as a skin condition showing as hypertrophic lesions or vulvar abscesses. papillary hidradenomas are nodules that can ulcerate and are mostly found on the skin of the labia or of the interlabial folds. another more complex ulcerative condition is hidradenitis suppurativa which is characterised by painful cysts that can ulcerate, and recur, and can become chronic lasting for many years. chronic cases can develop into squamous cell carcinomas. an asymptomatic skin disorder of the vulval vestibule is vestibular papillomatosis which is characterised by fine, pink projections from either the epithelium of the vulva or from the labia minora. dermatoscopy can distinguish this condition from genital warts. a subtype of psoriasis, an autoimmune disease, is inverse psoriasis in which red patches can appear in the skin folds of the labia. childbirth the vulvar region is at risk for trauma during childbirth. during childbirth, the vagina and vulva must stretch to accommodate the baby's head (approximately 9.5 cm (3.7 in)). this can result in tears known as perineal tears in the vaginal opening, and other structures within the perineum. an episiotomy (a pre-emptive surgical cutting of the perineum) is sometimes performed to facilitate delivery and limit tearing. a tear takes longer to heal than an incision. tears and incisions may be repaired using sutures that may be layered. among the methods of hair removal evaluated for pre-surgeries, pubic hair shaving known as prepping, was seen to increase the risk of surgical site infections. no advantages have been demonstrated in the routine shaving of pubic hair prior to childbirth. surgery main articles: genitoplasty and cosmetic surgery genitoplasties are plastic surgeries that can be carried out to repair, restore or alter vulvar tissues, particularly following damage caused by injury or cancer treatment. these procedures include vaginoplasty which can also be performed as a cosmetic surgery. other cosmetic surgeries to change the appearance of external structures include labiaplasties. some of these procedures, vaginoplasties and labiaplasties, are also carried out as sex reassignment surgeries. the use of cosmetic surgeries has been criticized by clinicians. the american college of obstetricians and gynecologists recommends that women be informed of the risks of these surgeries. they refer to the lack of data relevant to their safety and effectiveness and to the potential associated risks such as infection, altered sensation, dyspareunia, adhesions, and scarring. there is also a percentage of people seeking cosmetic surgery who may be suffering from body dysmorphic disorder and surgery in these cases can be counterproductive. society and culture