Vulvar Disorders

INTRODUCTION

Clinical manifestations of vulvar disorders include itching, pain or discomfort, irritation, white mucosal patches, lichenification, erosions and intertrigo. The dermatoses, notably dermatitis, psoriasis, lichen planus and lichen sclerosus, are the main cause of vulvar problems. Pruritus vulvae is presented on 411.

LICHEN SCLEROSUS

This chronic inflammatory dermatosis of unknown aetiology presents as well-defined, white, finely wrinkled plaques that almost exclusively affect the anogenital skin but spare the vagina. The differential diagnosis is atrophic vaginitis.

Features

• Genital pruritus (main symptom) + soreness + white wrinkled plaques

• Bimodal peak: prepubertal girls, perimenopause

• Purpuric and ulcerated areas

• Lifetime risk SCC 2–6%

Management

• Best to consult with dermatologist.

• Use potent topical steroids for 6 mths, then hydrocortisone 1% long term.

CHRONIC VULVOVAGINAL CANDIDIASIS

This is different from acute candidiasis and may represent a localised hypersensitivity to C. albicans. Aim for symptom remission with continuous antifungal treatment up to 6 mths. Relieve itching with hydrocortisone 1%.

VULVOVAGINITIS IN PREPUBERTAL GIRLS

Usually presents with discomfort or soreness, often with dysuria. Avoid causal factors, e.g. wet bathers, synthetic underwear, bubble baths. Use barrier cream or, if persistent, 1% hydrocortisone ointment.

VULVODYNIA

This describes the symptom of pain (burning, rawness or stinging) and discomfort where no obvious cause can be found. Conditions include vestibular hypersensitivity (vulvar vestibular syndrome) and dysaesthetic vulvodynia (neuropathic pain in middle-aged to elderly women).

Provoked vestibulodynia (vulvar vestibular syndrome)

Features

• Severe pain with vestibular touch, incl. vaginal entry, e.g. intercourse, tampons

• Superficial entry dyspareunia

• Sexual dysfunction

Diagnosis Marked tenderness to light touch of the inner vestibule with a cotton bud.

Management Patient education, counselling and support. May benefit from pelvic floor physiotherapy or anti-neuropathic pain agents.

Dysaesthetic vulvodynia

The typical patient with this neuropathic pain problem is a middle-aged to elderly woman who presents with a constant burning pain of the labia. Examination is usually normal. The underlying cause may be pudendal neuralgia, referred spinal pain or idiopathic. Treatment options include antidepressants and ...