Vulva Conditions

Vulval Anatomy

It is important for a woman to be familiar with the anatomy of the vulva, to help identify any problems that may arise relating to that area. It is surprising how few people are actually familiar with the vulval anatomy, and who can successfully identify the different elements that compose it.

Found at the top of the vulva is the clitoral glans and the clitoral hood. These elements are involved primarily in sexual stimulation. The clitoris actually extends a lot further than most people would think. The small part of it that is visible is called the clitoral glans, but the majority of the clitoris is hidden from sight. It forms an upside-down ‘Y’ shape inside the body, reaching down to just below the vaginal entrance. The entire clitoris actually functions similarly to a penis.

When a woman is sexually aroused, the entire clitoris fills with blood and becomes harder and erect. Most of this activity is not visible, as it occurs inside the body. The head of the clitoris may become noticeably engorged. The head itself is extremely sensitive, containing more nerve endings than the head of the penis. Stimulation of the clitoral glans creates sexual excitement. The clitoral hood exists to protect the clitoral glans. The head is so sensitive that it can easily become uncomfortable if touched a lot. The clitoral hood shields it from rubbing against clothes for example.

The ‘lips’ of the vulva are called the labia, and there are two sets of them. The outer labia are called the labia majora. They run from above and beside the clitoris to the perineum, and protect the vaginal opening. They have layers of fat, giving them a thick appearance. The inner labia are called the labia minora. They run from just below the clitoral glans to the bottom of the labia majora. They cover the vaginal opening, protecting it.

Finally, the vaginal opening is an integral part of the vulval anatomy. It is the entrance to the vagina, and is protected by the labia minora and the labia majora. This entrance is where blood passes during menstruation, where a baby passes during childbirth and where the penis is entered during intercourse. Many women use a vaginal douche to clean inside the vagina, but this is often frowned upon by clinicians as the vagina effectively cleans itself. In many cases, douching can serve to remove helpful bacteria that fight vaginal infections.

In summary, ‘Vulva’ is the general name given to the external parts of the female genitals. It includes: the mons pubis(the pad of fatty tissue covered with pubic hair); the clitoris; labia majora (the outer lips); labia minora (the inner lips); the vestibule (area immediately surrounding the vaginal opening); the urinary opening; vaginal opening; and the perineum (area of skin between the anus and vagina). The appearance of the vulva can vary greatly between women.

Vulval Skin Conditions

Common skin conditions that occur on the rest of the body can also occur on the vulva.

Vulval Dermatitis

Dermatitis is the most common cause of chronic vulval symptoms. In some cases, vulval dermatitis can be caused by a genetic predisposition to allergies and hypersensitivity. These women will have conditions like asthma, hay fever or dermatitis in other areas of the body. Vulval dermatitis can also be caused by contact with an irritant or allergen such as:

  • laundry detergents, toilet paper, deodorants, dusting powders/talc
  • lubricants and spermicides
  • sanitary pads and panty liners
  • bath products, soap and shower gels
  • depilatory products
  • underwear (lace, G-strings)
  • latex in condoms or a diaphragm
  • over-the-counter medication (thrush treatments)

The main initial symptom of dermatitis is itching. Scratching the area can result in broken skin, burning or stinging, and pain during sex. Treatment for dermatitis usually involves the use of a topical corticosteroid cream. Cool compresses and antihistamines may be used to bring relief from symptoms. If the dermatitis is thought to be due to an allergy or irritant, it is important that attempts are made to identify and avoid the substance. It can take some time for symptoms to resolve as the skin of the vulva generally takes longer to heal than in other areas of the body. If a woman’s symptoms persist she should return to her doctor as women with vulval dermatitis may develop secondary infections such as thrush.Some general tips for vulval care are:

  • Switch to hypoallergenic versions of products like toilet paper and laundry detergent as these products have no or limited perfume and colourings known to cause irritation.
  • Avoid soap or use a soap substitute.
  • Take showers instead of baths and do not use douches or talc.
  • Wear cotton underwear and avoid tight-fitting trousers, pantyhose and G-strings.
  • When showering avoid getting shampoo or conditioner residue on the vulval area. Alternatively, wash hair in the basin.

Vulval Itching (Pruritus Vulvae) & Vulval Soreness

A wide number of conditions are included under the umbrella of this term, as follows. Most of these present as vulvitis, vulval itching and or vulval soreness.

Infection

  • Candida, trichomoniasis, bacterial vaginosis.
  • Pubic lice, threadworm, scabies.
  • Herpes simplex, urinary tract infection (UTI), vulval vestibulitis.
  • Group A beta-haemolytic streptococcal (GAS) infection has been reported in prepubertal girls and, on rare occasions, in adult women.

Dermatological conditions

Neoplasia

Atrophic

Miscellaneous

  • Poor hygiene.
  • Pregnancy.
  • Generalised pruritus.
  • Psychological problems.
  • Idiopathic - uncommon, and only diagnosed when all other causes have been excluded.
  • Vulvitis circumscripta plasmacellularis (Zoon's vulvitis). This is a distinct entity, presenting as shiny, atrophic, erythematous plaque of the vulva.

Miscellaneous Vulval Pain syndromes

  • Vulvar vestibulitis syndrome - thought to be due to nonspecific inflammation of the minor vestibular glands.
  • Vulvodynia - causes chronic vulval and pelvic pain, of unknown aetiology.

Conditions causing the vulva to become excessively moist, such as vaginal discharge and urinary incontinence, lower the defences against commensal organisms and make the area vulnerable to infection and inflammation – vulvitis.

Vulvitis

What is vulvitis?

Vulvitis is an inflammation of the vulva (the visible external genitalia). Vulvitis is not a condition or disease; it is a symptom that results from a number of different causes including allergies, infections, injuries, and other external irritants. Other vaginal infections such as vaginitis or genital herpes often accompany vulvitis. Women who experience excessive stress, whose nutrition is poor, or who have poor hygiene may be more susceptible to vulvitis. Pruritus Vulvae is when vulvitis is accompanied by vulval itching.

What causes vulvitis and vulval itching?

Several factors may contribute to the development of vulvitis:

  • Oral sex.
  • Scented or colored toilet tissue.
  • Bacterial or fungal infection.
  • Hot tubs and swimming pools.
  • Horseback riding.
  • Sexually transmitted infections
  • Leaving a wet swimming suit on for a long period.
  • Bicycle riding.
  • Allergic reactions to products such as: soaps, shampoos, bubble baths, powders, deodorants, sanitary napkins, non-cotton underwear, pantyhose, vaginal douches, topical medications.

Risk Factors / Associations for Vulvitis?

  • Diabetic women face increased risk of developing vulvitis because the high sugar content of their cells increases susceptibility to infections. As oestrogen levels drop during perimenopause, vulvar tissues become thinner, drier, and less elastic increasing a woman's chance of developing vulvitis, or other infections such as vaginitis. Young girls who have not yet reached puberty are also at possible risk due to the fact that adequate hormone levels have not yet been reached. Any woman who is allergy-prone, has sensitive skin, or who has other infections or diseases can develop vulvitis.
  • Other associations or risk factors include immune deficiency states, Urinary incontinence. Faecal incontinence , Any cause of generalised pruritus, e.g. liver disease, lymphoma, Psychological problems.

Symptoms of vulvitis?

While each woman may experience vulvitis symptoms differently, some of the most common symptoms are:

  • Itching. Redness. Swelling. Fluid-filled, clear blisters that break open, and form a crust (sometimes mistaken for herpes). Irritation. Burning sensation.
  • Soreness. Scaly appearance. Thickened or whitish patches. Possible vaginal discharge.

It's important for women with these symptoms to remember not to scratch as this can lead to further irritation and/or infection. Although it may seem like a good idea to wash repeatedly over the day, the fact is that over washing the affected area can lead to further irritation. It's best to wash just once a day with warm water only when symptoms of vulvitis are present.

How is vulvitis diagnosed?

Several diagnostic tools such as blood tests, urinalysis, testing for sexually transmitted diseases (STDs), and Pap smears help your doctor diagnose vulvitis. A personal or family history of skin disease (e.g. atopy, psoriasis, eczema) or autoimmune disease (associated with lichen sclerosus) may be significant.

Investigations to aid diagnosis may include the following:

  • Blood tests – which may include fasting glucose, FBC, serum ferritin and TFTs..
  • If an infection is suspected, appropriate swabs or cultures should be taken to look for conditions such as candida or bacterial vaginosis.
  • If a sexually transmitted disease is suspected, appropriate swabs and/or blood tests should be arranged.
  • Skin biopsy may be required in cases of diagnostic difficulty (as a rule of thumb, any skin lesion not responding to a six-week course of treatment).

What is the treatment for vulvitis?

The treatment for vulvitis varies according to cause. Your clinician will consider several factors before determining which treatment is the right one. Some factors your clinician will consider include:

  • Your age, general health, and medical history.
  • The cause of your symptoms.
  • The specific symptoms you are experiencing.
  • The severity of your symptoms.
  • How well you tolerate certain medications, procedures, or therapies.

Once these factors are considered, several methods of treatment are available including both self-help measures, and prescribed medications. Low-dose hydrocortisone creams may be prescribed for short periods. Anti-fungal creams are sometimes helpful for treatment of vulvitis. Post menopausal women may find topical oestrogen relieves their symptoms. Self-help treatments include:

  • Baths containing soothing compounds such as Aveeno baths or comfrey tea baths.
  • Stopping the use of any products that may be a contributing factor.
  • The vulva should be kept clean, dry, and cool. Do remember to wipe from front to back.
  • Hot boric acid compresses.
  • Cold compresses filled with plain yogurt or cottage cheese help ease itching and irritation.
  • Calamine lotion.
  • Using sterile, non-irritating personal lubricants such as K-Y Jelly, or Sylk during sexual activity.
  • Learning to reduce stress.
  • Eating an adequate and nutritious diet.
  • Making sure you get enough sleep at night.

Pruritus vulvae of unknown cause

In the absence of a specific diagnosis, or whilst waiting for results, the following treatments can be tried. Most are based on the empirical experience of experts, as there is little published evidence:

  • Emollients can be used as an adjunct to other treatments and are suitable for easing itching in almost all types of vulval disease; they can be used in addition to most other therapies. They can also be used as a soap substitute or moisturiser. There is wide patient variability and lack of comparative evidence, so the choice of preparation can be left to individual preference. If topical steroids are used as well, the emollient should be used first and the steroid 10-20 minutes later. This ensures the skin is moisturised and avoids spread of the steroid to normal skin.
  • Sedating oral antihistamines appear to work by promoting sedation rather than blocking the action of histamine. Sedative antidepressants have been used with similar benefit
  • Low-potency topical corticosteroids, e.g. hydrocortisone 1% ointment, can be considered as a short trial (1-2 weeks). Potent steroids should be avoided as they can affect surface features and confuse the diagnosis should subsequent specialist referral be required. Specialist referral is indicated if there is no response to steroids.

Specific management (known cause)

This will depend on the underlying condition and the results of investigations. Potent steroids should only be used if the prescriber is confident in the diagnosis. This is usually after confirmation by a specialist, often on the basis of biopsy results.

Infection - Vulval and vaginal infections should be treated with the appropriate antibiotic, antifungal, antiviral or other antimicrobial agent. Consider investigating and treating the partners of women with recurrent Group A beta-haemolytic streptococcal (GAS) infection. Such men have been found to have a high incidence of GAS in the bowel which is passed on via contamination of bedding. Treating both partners sometimes results in resolution of the condition.

Dermatological conditions

  • Contact dermatitis - this is mainly centred on irritant avoidance, with topical corticosteroid treatment as a secondary measure to relieve itching.
  • Seborrhoeic dermatitis and psoriasis - these are usually treated with judicious use of topical corticosteroids (sometimes combined with an antibacterial or anticandidal agent). Ketoconazole shampoo can be used as body wash for seborrhoeic dermatitis.
  • Lichen simplex can be treated with topical betamethasone for 1-2 weeks to break the itch-scratch cycle.
  • Lichen sclerosus and lichen planus may respond to short-term regular potent or superpotent topical corticosteroids followed by maintenance application. Women with lichen sclerosus have a small risk (2-5%) of developing carcinoma, so long-term follow-up is recommended. Regular use of a simple moisturiser may lessen attacks and reduce the requirement for steroids.
  • Zoon's vulvitis - This normally responds to high-potency topical steroids.

Other Vulval Conditions

  • Vulvar vestibular syndrome - this is also known as vestibulitis, vestibular pain syndrome, vestibulodynia and localised vulval dysaesthesia. Altered pain perception is the major feature of this syndrome. Management is often difficult. A number of treatments have been tried, including Xylocaine® gel, pelvic floor retraining with biofeedback, low-dose tricyclic antidepressants, newer agents for neuropathic pain, and cognitive behavioural therapy. Rarely, vestibulectomy is offered as a last resort.
  • Dysaesthetic vulvodynia - this is also known as essential vulvodynia and generalised vulval dysaesthesia. The predominant symptom is chronic, poorly localised vulval burning or pain. The exact aetiology is unclear, but the condition shares some features with neuropathic pain syndromes. Low-dose tricyclic antidepressants are the standard treatment for dysaesthetic vulvodynia. Gabapentin, imipramine and venlafaxine have also been reported to be beneficial.
  • Lichen sclerosus - The main symptom of lichen sclerosus is severe itching. Scratching can result in broken skin, burning or stinging, pain during sex and/or urination. Lichen sclerosus is thought to be an autoimmune disorder. It affects women of all ages but is primarily found in post-menopausal women. Lichen sclerosus can be misdiagnosed as thrush however, on inspection, the skin is dry, shiny, finely wrinkled and may have white patches. If left untreated lichen sclerosus can cause severe scarring of the vulva (including the shrinking of the labia and narrowing of the vaginal entrance). It is also associated with a small increased risk of vulval cancer. Treatment involves the use of a topical steroid and is often life-long. Once a woman is diagnosed with lichen sclerosus she should undergo regular reviews, even if asymptomatic, to ensure the condition is under control and no cancerous changes have occurred.
  • Lichen planus This skin condition affects a number of areas of the body including the vagina and vulva. As with lichen sclerosus the exact cause is unknown, but an overactive immune system or genetic predisposition may play a role. Symptoms can include small lesions, a red-purplish colour to the skin, soreness and burning associated with raw areas of skin as well as bleeding and/or painful sex. Vaginal discharge may be heavier, sticky and/or yellow. If left untreated lichen planus can cause scarring of the vagina and vulva. Treatment involves topical or oral steroids and pain relief gels, oral pain relief and antidepressants (used for pain relief). Lichen planus may be associated with a small increased risk of vulval cancer
  • Psoriasis - Women with psoriasis of the vulva often have the skin condition elsewhere on their body. Psoriasis is an immune system disorder. Symptoms include scaly, red plaques (although on the vulva these are generally less well defined than on other areas of the body). Other signs which may point to psoriasis include nail pitting, scalp scaling and a family history of the condition. Treatment includes the use of topical steroids and a low dose coal tar cream.