Vulvar discomfort and irritation

Probability diagnosis

Atopic dermatitis/seborrhoeic dermatitis

Chronic vulvovaginal candidiasis

Irritant contact dermatitis (e.g. douches, bubble baths)

Allergic contact dermatitis (e.g. perfumes, topical antimicrobials)

Fissuring from the above dermatoses

Trauma: ‘dry’ coitus

Serious disorders not to be missed

Cancer:

• squamous cell carcinoma

• lymphomas, etc. → pruritus

• melanoma

Infection:

• streptococcal vulvovaginitis

• herpes simplex virus; herpes zoster

Other:

• vulval vestibular syndrome (provoked vestibulodynia)

Pitfalls (often missed)

Lichen sclerosus

Urinary incontinence → ammoniacal vulvitis

Faecal soiling

Tinea cruris

Trichomonal vaginitis

Atrophic vaginitis

Aphthous ulcers

Dysaesthetic vulvodynia

Psoriasis

Lichen planus

Infestations:

• threadworms

• pubic lice

• scabies

Masquerades checklist

Depression

Diabetes

Drugs (e.g. antibiotics)

Spinal dysfunction (?dysaesthesia)

UTI

Is the patient trying to tell me something?

Common: psychosexual problems.

Key history

• Appropriate history including atopic skin diseases.

• Gynae-urological history (e.g. oestrogen status, faecal or urinary incontinence, vaginal discharge, ‘thrush’)

• Check allergens and irritants (e.g. panty liners, soap, bubble bath, perfumes, condoms, douches)

• Sporting activity (e.g. bike riding and costumes)

• Check psychosexual history (e.g. dyspareunia, partnership issues, depression)

Key examination

• General health

• Inspection of vulva and rest of skin, scalp nails

• Vaginal examination

Key investigations

• Vaginal swab

• Pap smear

• Consider need for vulval biopsy and patch testing

Diagnostic tips

• The previously named vulvar vestibular syndrome or vestibulitis is now termed provoked vestibulodynia, whereby a vestibule tender to pinpoint pressure and variable erthythema is found, typically, in young nulliparous women.

• Always biopsy a focal lesion on the vulva.