Reasoning GP · Algorithm · 1-page summary
Vaginal mass
For: women and girls with a vaginal lump, bulge or mass in primary care. Not for: vulval lesions and Bartholin disease (vulvar disorders protocol) or long-term prolapse care (prolapse protocol). Pregnancy and prepubertal children go straight to blocks 0 and 2.
Core rule: first decide what the “mass” is. Most are prolapse or benign cysts, but an irregular, friable or bleeding lesion, postmenopausal bleeding, or any vaginal mass in a child needs the cancer route. Manage prolapse by symptoms, not stage.
0Stop — call 999 now — before any further examination
- Rapidly enlarging pelvic mass with severe pain, peritonism, instability or collapse in a woman of reproductive age (torsion, ruptured ectopic) → 999 IV access; hCG in any reproductive-age woman.
- Prolapsed mass that will not reduce, with haemorrhage, vascular congestion or necrosis (incarcerated prolapse, prolapsed fibroid with torsion) → 999 Do not reduce a necrotic, bleeding, severely painful or suspicious mass.
- Swelling with fever, spreading erythema or crepitus (necrotising fasciitis) → 999
- Pregnant, antepartum haemorrhage, friable cervix → Same-day obstetric; 999 if heavy bleeding or unstable. No digital vaginal examination until placenta praevia is excluded.
1Triage — what is the mass?
| Finding | Likely → route |
|---|---|
| Irregular, friable, bleeds | Cancer until proven otherwise → block 2 |
| Child, prepubertal | Sarcoma or abuse → block 2 |
| Bulge, worse standing | Prolapse: document compartment, leading edge vs hymen, reducible |
| Smooth cyst or polyp | Benign if clearly typical → block 4 |
| Posterolateral, 4 or 8 o'clock | Bartholin (vulval) → vulvar disorders protocol |
2Screen — one row is enough
- Suspicious cervix (irregular, friable, bleeding), suspicious vaginal lesion or mass, suspected VAIN → Suspected cancer pathway for colposcopy and biopsy. No smear from it.
- Postmenopausal bleeding, not attributable to HRT: aged 55 and over → Suspected cancer pathway; under 55 consider it (NG12).
- New unexplained discharge at 55 or over → check the NG12 direct-access ultrasound criterion.
- Prepubertal child: vaginal mass, bleeding or persistent discharge → Urgent paediatric gynaecology via the local sarcoma pathway + safeguarding. No biopsy in primary care.
- New Bartholin mass at 40 or over → Urgent gynaecology. Bartholin abscess → Same-day gynaecology
- Acute urinary retention with prolapse → Same-day bladder decompression; urgent gynaecology or urology advice.
3Assess — face to face
☐ Inspect vulva and introitus ☐ Speculum where appropriate and consented; see the cervix if bleeding or discharge ☐ Prolapse on cough and strain; urinary, bowel and sexual symptoms ☐ Pregnancy test where relevant; urine if urinary symptoms; swabs only if infection suspected
Transvaginal ultrasound for uterine or adnexal pathology or an unclear mass; none for obvious uncomplicated prolapse. Not in primary care: urodynamics; CA125 just because of a vaginal mass.
4Classify — only if the screen is negative
- Prolapse (cystocele, rectocele, uterine, vault) — dragging, worse standing, eased lying. Simplified stages are not POP-Q.
- Gartner duct cyst — smooth, non-tender, anterolateral. Observe only if small, typical and asymptomatic.
- Cervical polyp — smooth, red, pedunculated. Remove only if trained, clearly benign and locally supported; histology always.
- Nabothian cyst, cervical ectopy — benign; reassure.
- Pyometra — older woman, offensive discharge, fever → ultrasound + Urgent gynaecology (exclude endometrial cancer).
- Uncertain — say so and refer to gynaecology; do not label it a cyst.
5Treat today — prolapse
- Asymptomatic: reassure, advise, safety-net. Weight loss if BMI over 30; treat constipation and cough; stop smoking; limit heavy lifting.
- Symptomatic stage 1–2: consider supervised pelvic-floor muscle training for at least 16 weeks (NG123).
- Pessary: consider for symptomatic prolapse at any stage. Removed and vagina inspected at least every 6 months, by trained clinicians.
- Vaginal oestrogen: consider for genitourinary symptoms, atrophy or pessary mucosal problems; specialist advice after hormone-sensitive breast cancer. Doses: NICE/SPC, BNF, local formulary.
6Refer routinely
- Prolapse affecting quality of life, bladder or bowel dysfunction, failed conservative care, or wishes pessary or surgery → urogynaecology (not stage alone).
- Atypical, enlarging or uncertain vaginal-wall cyst; large or atypical polyp; symptomatic vault prolapse → gynaecology.
- Persistent postcoital bleeding with a normal cervix → local colposcopy or gynaecology pathway. Mesh symptoms → NHS mesh centre.
7Never reassure by
- A normal smear or HPV result — not a test for a symptomatic cervix.
- Calling a vaginal-wall mass a Gartner cyst when features are not clearly typical.
- Labelling postmenopausal discharge as BV, atrophy or prolapse without assessment.
- A low prolapse stage — symptoms rarely match stage.
- A normal-looking cervix when postcoital bleeding persists.
8Safety-net — say it, then document it
999 “Call 999 for sudden severe pelvic pain, fainting or collapse, or a lump that is stuck out, very painful, bleeding heavily or turning dark.” Same day: “Contact us today if you cannot pass urine, have fever with a painful swelling, or bleed in pregnancy.”
Remote or OOH: a vaginal mass needs a face-to-face examination; any block 0 feature → 999. Pessary users: clear instructions and access to review for bleeding, pain, discharge, retention or expulsion.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Examined; compartment and leading edge recorded
Cause named, or uncertainty stated and referred
Pregnancy and PMB status checked; NG12 route followed
Safety-net given; pessary review date set
Summary of the full Reasoning GP vaginal mass algorithm, which holds the detail, examination, staging and evidence. Sources: NICE NG123, NG12 (updated April 2026), NG126, NG246; RCOG/BSUG Green-top Guideline No. 46; NHS England Mesh Complication Centres. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.