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Vulval conditions fact sheet

 

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'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. For example, although the labia minora are referred to as the 'inner lips', it is quite normal for them to extend outside the labia majora.

 

vulval-illustration

 

 

 

 

 

 

 

          Diagram of a vulva

 

The skin in the vulval region is extremely delicate, making it susceptible to a wide range of conditions.

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.
  • Use tampons rather than sanitary pads where possible—they are less irritating to the vulva. If pads are preferred, consider using washable cloth sanitary pads. Avoid the use of panty-liners between periods.
  • Avoid repeated use of over the counter anti-fungal preparations for thrush. If symptoms of thrush continue after an initial treatment women should consult their doctor as these preparations are a common cause of irritation.
  • Examine your vulva on a regular basis so that you are aware of any changes that occur.

 

Skin conditions

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

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 (1).

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) (2).

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.

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 (3). It affects women of all ages but is primarily found in post-menopausal women (4).

Lichen sclerosus can be misdiagnosed as thrush (5) 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 (6).

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 (7).

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 (8).

Treatment includes the use of topical steroids and a low dose coal tar cream.

Ingrown hairs/sebaceous cysts

Ingrown hairs can develop in the vulva, particularly following waxing or shaving. The trend towards Brazilian waxing (where all hair in the vulval region is removed) has made this problem more common.

An ingrown hair can result in the development of a pimple or cyst on the skin's surface. Gentle exfoliation of the skin can help get rid of ingrown hairs.

Sebaceous cysts are caused by a blocked sebaceous gland (oil gland in the skin). They commonly occur in the vulva and appear as a small, hard lump which is generally painless.

Sebaceous cysts do not require treatment unless they cause discomfort.

Bartholin's glands cyst

The Bartholin's glands are tiny glands located on each labia minora, near the vaginal opening. These glands produce fluid that lubricates the entrance to the vagina and can become blocked, causing a cyst to develop. The cyst can become tender and, if large, can cause discomfort when walking/sitting.

If the cyst is small and is asymptomatic it can just be monitored. Sometimes the cyst can become infected and develop an abscess. In these cases, the cyst or abscess can be drained by a doctor.


Thrush and sexually transmissible infections (STIs)

Candidiasis (thrush)

Thrush is caused by an overgrowth of yeast-like fungi called Candida. It is not considered to be a sexually transmissible infection.

Symptoms include:

  • itchiness or redness of the vagina and vulva
  • a thick white, creamy vaginal discharge
  • discomfort and/or pain during sex.

A simple thrush infection is treated with an anti-fungal cream. Sometimes if the thrush has been longstanding (months to years) it can be associated with chronic vulval pain, and longer term thrush suppression treatment may be required.

It is important to note that other vulval conditions (e.g. dermatitis) are often initially mistaken for thrush. Therefore, if symptoms persist following treatment for thrush, women should see their doctor.

For more information on thrush see our Thrush and other vaginal infections fact sheet.

Genital herpes

Genital herpes is caused by the herpes simplex virus (HSV). It is transmissible through vaginal, anal or oral sex. Symptoms appear within 2-14 days of exposure and include flu-like symptoms and painful blisters in the genital area. Some people only experience one outbreak while others will have several. A minority of those infected experience frequent recurrences.

There is no cure for genital herpes but antiviral medications can help reduce the duration and severity of an outbreak and prevent frequent recurrences. Keeping the area clean and dry and bathing with a saline solution will help relieve discomfort and assist healing. It is important to remember that genital herpes can be transmitted to a partner even when there are no blisters or ulcers present.

Genital warts

Genital warts are caused by particular types of the human papilloma virus (genital HPV). Genital HPV is transmissible through vaginal, anal or oral sex. Warts can be found on the vulva, clitoris, and cervix, inside the vagina or urethra and in or around the anus. They can be flesh coloured or pink and come in a variety of sizes and shapes, occurring singularly or in clusters. The warts do not usually cause pain. Warts can be treated with chemical applications, ablation (freezing, burning or use of laser to remove warts) or a cream that enhances the body's immune response to the viral infection. For more information on genital warts see our Genital HPV fact sheet.

 

Vulvodynia

The term vulvodynia literally means pain of the vulva. The International Society for the Study of Vulvovaginal Disease (ISSVD) describes vulvodynia as vulval 'discomfort, pain, irritation, burning or rawness in the absence of visible or neurological findings' (9). While numerous factors have been suggested as causing vulvodynia, no single causal factor has been proven to date.

The pain experienced by women with vulvodynia varies in intensity from mild to severe and be consistent or intermittent (10). Certain activities can exacerbate pain with the most common being penetrative sex. Wearing tight clothing, riding a bicycle, inserting a tampon, having a pelvic examination or sitting for long periods of time can also cause pain.

Often, women experience the pain for a number of years and consult a number of practitioners before being diagnosed. The chronic pain of vulvodynia coupled with difficulty in obtaining an accurate diagnosis can lead women to suffer mental and emotional health problems such as depression. Women may also experience sexual and relationship difficulties.

Treatment for vulvodynia is focused on relieving the discomfort experienced. Symptoms may be reduced by following the general vulval care tips listed at the beginning of this fact sheet. Women should also avoid constipation or a full bladder and activities that put pressure on the vulva such as bike riding or sitting for long periods.

Biofeedback and physical therapy appear to be effective conservative treatments for vulvodynia (11). They can assist women in strengthening and relaxing the pelvic floor muscles (pelvic floor muscles that are not relaxed can cause spasms and pain). Biofeedback involves the use of sensors which provide feedback to the woman so she can learn to control and relax the pelvic floor muscles. Physical therapy involves a number of techniques including therapeutic exercises, pelvic floor rehabilitation, trigger-point pressure/massage, electrical stimulation, ultrasound and manipulation.

Women may also benefit from cognitive behaviour therapy (CBT) to help manage chronic pain. CBT helps patients understand that their thoughts and behaviours may affect the way they experience pain. It also involves a variety of coping strategies including: progressive relaxation; pleasant activity scheduling; and distraction techniques to assist people to identify and challenge pain-related thoughts (12).

Hypnotherapy and acupuncture are two other pain relief treatments commonly used by women with vulvodynia. Hypnotherapy involves a practitioner making suggestions to a patient while they are in a deep state of relaxation. Acupuncture involves the insertion of very fine needles into specific points of the body. Although how acupuncture works to relieve pain is not known, some women report finding it beneficial (13).

Some women find a mild lignocaine (local anaesthetic) ointment applied to the area provides relief. Medications like antidepressants and anticonvulsant medications are also used. It is important that women understand that antidepressants are prescribed in the treatment of vulvodynia for their pain-relieving properties.

Another approach is a low oxalate diet combined with calcium citrate supplementation. It is thought that a high concentration of oxalate crystals in the urine may irritate the vulva. Calcium citrate, taken before meals, binds to the oxalates preventing their absorption. Foods high in oxalates include tea, coffee, spinach, celery, sweet potatoes, most berries, purple grapes, tangerines, nuts and chocolate. There is, however, limited evidence to support the effectiveness of this approach (14).

If other treatment options have been unsuccessful and a woman's symptoms are very severe and localised to the vestibule, surgery may be considered. Surgery involves removing the area which causes the pain. The use of surgery for vulvodynia is still controversial (15). It is important that a woman consults a surgeon who is experienced in the area.


Pre-cancerous and cancerous conditions

Vulval intraepithelial neoplasia (VIN)

Like a woman's cervix, the vulva can undergo abnormal cell changes. These are referred to as vulval intraepithelial neoplasia (VIN). Some cases of VIN are associated with the human papilloma virus (HPV), while others are thought to be due to irritation. If VIN persists for many years cancer of the vulva can develop.

Symptoms of VIN may include: itching and burning in a specific area of the vulva; raised brown, red, pink or white lesions; warty lesions or persistent erosions or ulcers. Treatment for VIN depends on the stage of the condition but may involve use of a topical cream (16) or monitoring the area as VIN can disappear on its own. In some cases removing the abnormal tissue by surgery or laser may be required (17). The Gardisal and Cervarix vaccines which prevent some strains of HPV are expected to decrease the incidence of HPV-related VIN in the future.

Vulval cancer

Vulval cancer is relatively uncommon, with just over 200 cases diagnosed in Australia each year (18). The majority of these cancers occur in women 50 and over. There are two main types of vulval cancer, those associated with lichen sclerosus (see lichen sclerosus section) and those related to VIN (see VIN section). Symptoms of vulval cancer include: itching, burning or pain in the vulva; vulval skin that looks white, feels rough or has a lump; bleeding or discharge not related to menstruation (19).

Treatment for vulval cancer depends on how advanced the cancer is when diagnosed, the person's age and their overall medical condition. Early detection of vulval cancer is important as it improves the chances of successful treatment.

Surgery is the most common treatment for vulval cancer. Radiation therapy and/or chemotherapy may also be used.

Vulval varices

Varicose veins affecting the vulva are called vulval varices. They most commonly occur during pregnancy but can also affect non-pregnant women. Symptoms may include pain in the vulva and a 'dragging' or 'heavy' feeling. Those that develop during pregnancy usually improve following birth, but if they are still symptomatic three months after childbirth, treatment should be considered. For symptom relief women can use ice packs on the area, ensure periods of rest lying down and avoid constipation. Treatment for vulval varices may involve embolisation (20), where a coil is inserted in the vein to block it, or sclerotherapy, which involves injecting the vein with a saline solution to collapse it. Surgery to remove the veins may also be performed.


Diagnosis of vulval conditions

Women experiencing a vulval condition should visit their doctor. As some vulval conditions are not widely understood, women can experience delays in being correctly diagnosed and treated. It is, therefore, important that a woman's initial consultation is thorough. A detailed history taking and examination at this stage will assist in achieving a more accurate diagnosis.

History

It may be helpful for women to take along a list of the following information to their doctor's appointment to assist in their diagnosis.

About symptoms :

  • Type of symptoms (burning, itching)
  • Severity
  • How long the symptoms have been present
  • When the symptoms occur (e.g. do they change according to different phases of the menstrual cycle?)
  • Factors that exacerbate symptoms (e.g. sex, tampon use)
  • If the symptoms began around a particular time (i.e. following treatment for a vaginal infection or STI, surgery, new sexual partner, pregnancy)
  • Impact of symptoms on sexual activity
  • Treatments tried to alleviate the symptoms.

About other conditions:

  • Personal or family history of skin conditions, asthma or hay fever
  • Oral lesions (these can indicate lichen planus)
  • Allergies (including to previous medications)
  • Urinary or faecal incontinence (these can cause skin irritation)
  • History of thrush or sexually transmissible infections like genital HPV, genital herpes and the treatment received
  • Family history of skin or genital cancers
  • Medications taken
  • History of gynaecological surgery
  • Medical conditions like diabetes or immunosuppressive illnesses (these can cause a susceptibility to infection).

Other:

  • Recent use of new products like detergent, soap or sanitary products.

 

Examination

It is important that the doctor performs a close inspection of the entire vulval area. They may use a colposcope, a viewing instrument with a light that provides a magnified view of the area. If appropriate, they will arrange for tests to exclude sexually transmissible infections and fungal infections like thrush. In the case of vulvodynia, the doctor will try and determine the areas which are painful.

If there are any unusual looking changes a biopsy may be carried out. A biopsy involves removing a small piece of skin from the affected area on the vulva, after having a local anaesthetic.

 

Further information

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References

  1. Fischer G, Bradford J. Vulval disease- Part 2: Patients with a symptomatic rash. Medicine Today 2000 Vol 1 No 7 p58-70
  2. Welsh B, Howard A, Cook K. Vulval itch. Australian Family Physician 2004; 33:7:5050-10
  3. Pangano R. Common vulvar disorders. Medical Observer 17 November 2006 pp25-8
  4. ibid.
  5. ibid.
  6. Fischer G. Lichen sclerosus. Medical Observer 28 April 2006 p.35
  7. Lewis F M. Vulval lichen planus. British Journal of Dermatology 1998 Vol 138 No 4 p569-575
  8. Fischer G, Bradford, J, op. cit., p61
  9. Pagano R, ibid.
  10. Thomason JL. Vulvodynia: Update on a cryptic condition. The Female Patient 1999 Supplement August p20-24
  11. Reed BD. Vulvodynia: Diagnosis and management. American Family Physician 2006; 73:7:1231-1235
  12. Keefe FJ. Cognitive behavioural therapy for managing pain. The Clinical Psychologist 1996; 49:3:4-5
  13. Powell J, Wojnarowska F. Acupuncture for Vulvodynia. Journal of the Royal Society for Medicine November 1999, PMID: 10703496 accessed 28 April 2011
  14. Reed BD, ibid.
  15. Glazer H, Rodke G. The Vulvodynia Survival Guide: How to overcome painful vaginal symptoms and enjoy an active lifestyle. Oakland, New Harbinger, 2002, p91.
  16. Pagano, ibid.
  17. ibid.
  18. Australian Institute of Health and Welfare (AIHW) and Australasian Association of Cancer Registries (AACR). Cancer in Australia 2001 AIHW: Canberra 2004
  19. Gynaecological Cancer Society. Cancer of the Vulva: General Information Gynaecological Cancer Society http://www.gcsau.org/node/176 accessed 21 June 2011
  20. Ashour MA, Soliman HE & Khougeeer GA. Role of descending venography and endovenous embolization in treatment of females with lower extremity varicose veins, vulvar and posterior thigh varices. Saudi Med J. 2007 Feb;28(2):206-12. PMID: 17268690 accessed 13 May 2011

 

For help understanding this fact sheet or further information on vulval conditions women in Queensland can call the Health Information Line on 3839 9988 (within Brisbane) or 1800 017 676 (toll free outside Brisbane)

 

 

Last updated: September 2011

© Women's Health Queensland Wide Inc. This factsheet was revised by Lorraine Pacey and the Women's Health Queensland Wide (Women's Health) Editorial Committee in September 2011.

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