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 (which may include the hymen – a thin piece of skin at the entrance to the vagina (1); and the perineum (area of skin between the anus and vagina). The vulva also includes a number of glands, which produce fluids to cleanse and moisturise the vagina.

The three main purposes of the vulva are protection, sex and childbirth. Your vulva protects your sex organs, urinary opening, vestibule and vagina. During sex, the cushiony layer of fat on the mons pubis makes intercourse more comfortable. During sexual activity, the labia and clitoris engorge with blood to enhance sexual pleasure. While in childbirth, the connective tissue in the vulva and perineum (area between the vaginal opening and anus) soften as it prepares for childbirth (2).  

Appearance

The size, shape and colour 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. It is also not uncommon for the labia to be asymmetrical (uneven), with one being larger/longer than the other. The Labia Library shows that what is ‘normal’ varies, www.labialibrary.org.au.

The popularity of Brazilian waxing, removing the vast majority of pubic hair, may have made women more aware of the appearance of their genitals. Increased exposure may have led women to feel more self-conscious about their genitals and worried about whether they are ‘normal’ (3).

Medicare statistics reveal a three-fold increase in demand for labiaplasty, the surgical reduction of the labia minora, in Australia over a decade. Other forms of genital cosmetic surgery (GCS), including vulvoplasty, have also increased reflecting increased awareness of the range of available procedures (4).

SKIN CHANGES

Like other parts of the body, lumps, cysts, rashes and pimples can be present on the vulva. The care tips below may assist in managing these conditions. Embarrassment may lead to excessive washing of the area and use of over-the-counter preparations that may further irritate the condition. If symptoms persist, consider speaking with a health professional to obtain accurate diagnosis and treatment.

Ingrown hairs can develop in the vulva, particularly following waxing or shaving. An ingrown hair can result in the development of a pimple or a 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.

Care tips   

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.

  • Avoid soap or use a soap substitute or water.

  • Take showers instead of baths and do not use douches or talc.

  • Gently pat area dry after bathing rather than rubbing.

  • Wear cotton underwear and avoid tight-fitting trousers, pantyhose and G-strings.

  • Avoid wearing wet swimming suits and tight-fitting exercise wear for long periods (5).

  • 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. Consult your doctor if symptoms of thrush continue after initial treatment.

  • Ensure that you use adequate lubrication during intercourse.

  • Apply cool gel packs to relieve discomfort.

  • Examine your vulva on a regular basis so that you are aware of any changes that occur.

 

vulval-illustration

Skin conditions

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

DERMATITIS
Dermatitis, also known as eczema, is an inflammatory skin condition and the most common cause of chronic vulval symptoms. There are different types of dermatitis with different causes. 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 (6). Vulval dermatitis can also be caused by contact with an irritant or allergen such as:

  • laundry detergents

  • toilet paper and moist toilet wipes

  • deodorants/dusting powders/talc

  • lubricants, spermicides and depilatory products

  • sanitary pads and panty liners

  • bath products, soap and shower gels

  • underwear (lace, G-strings)

  • latex in condoms or a diaphragm

  • over-the-counter medication (thrush treatments) (7).

The main initial symptom of vulval dermatitis is itching. Scratching the area can result in broken and thickened skin, burning or stinging, and pain during sex. Treatment for dermatitis usually involves the use of a topical corticosteroid cream and changes to skin care. 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 it.

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. Dermatitis will often persist or reoccur and women with vulval dermatitis may develop secondary infections such as thrush. Ongoing professional care is suggested and swabs of the area may be taken to assist in diagnosis.

LICHEN SCLEROSUS (LS)
LS is a long-term skin condition that can affect the vulva (8). The main symptom of LS is severe itching, which can lead to sleep disturbances. Scratching can result in broken skin, burning or stinging and pain during sex and/or urination. The cause is unknown, although in some people LS is associated with autoimmune disorders, such as thyroid conditions (9). It affects women of all ages but is primarily found in post-menopausal women. It occurs less often in men and children. LS is not an infection and is not contagious (10). LS can be misdiagnosed as thrush, however, on inspection; the skin is dry, shiny, finely wrinkled and may have white patches (11). If left untreated, LS can cause severe scarring of the vulva (including the shrinking of the labia and narrowing of the vaginal entrance). In some cases, this inflammation can cause the normal anatomy of the vulva to change (12). It is also associated with a small increased risk of vulval cancer (13).

Treatment involves the use of topical steroids (applied directly to the affected skin) and is often life-long. Once a woman is diagnosed with LS she should undergo regular reviews, even if asymptomatic, to ensure the condition is under control and no changes have occurred.

LICHEN PLANUS (LP)
This skin condition affects a number of areas of the body including the vagina and vulva. As with LS, 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, itching, burning associated with raw areas of skin, as well as bleeding and/or painful sex. These symptoms may also be present on areas of the mouth, scalp, nails and other areas of skin (14). Vaginal discharge may also be heavier, sticky, and/or yellow. If left untreated, LP can cause scarring of the vagina and vulva. Treatment involves topical and oral steroids and pain relief gels, oral pain relief and antidepressants (used for pain relief). LP may be associated with a small increased risk of vulval cancer (15).

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). The typical silvery scale seen on other parts of the body with psoriasis is usually absent with vulval psoriasis because of the moist environment (16). Other signs that may point to psoriasis include nail pitting, scalp scaling and a family history of the condition (17). Treatment may include the use of topical steroids and a low dose coal tar cream. There is some evidence to suggest frequent use of steroid creams in the vulva can thin the skin and cause stretch marks. Over the counter preparations should be used with caution as some may irritate genital skin (18).

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 into 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. It is a very common condition with 70-75 per cent of women having at least one attack in their life (19).

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. Recurrent infection (four to six episodes a year) (20) may require longer term thrush suppression treatment. In some cases longstanding thrush (months to years) can be associated with chronic vulval pain. 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.

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.

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 papillomavirus (HPV). Genital HPV is transmissible through skin-to-skin contact during vaginal, anal or oral sex. Warts can be found on the vulva, clitoris, 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. HPV may persist on the skin even when no warts are visible. For more information on thrush and STIs, read our fact sheets.

Vulvodynia (vulval pain)

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”. Classification is based further on whether the pain is generalised or localised and whether it is provoked, unprovoked, or both. Research suggests that vulvodynia occurs more frequently than reported with some women reluctant to seek treatment (21). 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 can be consistent or intermittent. Pain symptoms may include burning, aching, stinging, soreness, rawness/irritation and itching (22). 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 or standing 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. Diagnosis may not be made until other conditions are ruled out and a full pain history taken (23). The chronic pain coupled with difficulty in obtaining an accurate diagnosis can lead some women to suffer mental and emotional health problems such as depression. Women may also experience sexual and relationship difficulties (24). Resources are available to assist with these difficulties and options can be discussed with health professionals.

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. Pain and specialised vulval clinics operate in several centres throughout Queensland; referrals to both public and private facilities are available.

Biofeedback and physical therapy appear to be effective conservative treatments for vulvodynia (25). Biofeedback involves the use of sensors that provide feedback to the woman so she can learn to control and relax the pelvic floor muscles. Physical therapy involves 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), hypnotherapy or acupuncture to help manage pain (26).

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. Combining a range of treatment options simultaneously to address the different components of vulvodynia may increase effectiveness (27).

A diet low in oxalate salts has been suggested as a treatment for women who experience vulvodynia. There appears to be limited clinical evidence to support this diet though it may benefit some women with vulval pain (28).

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 that causes the pain. Only a minority of women will be suitable for surgery. If surgery is offered, physical, psychological and sexual counselling and support should be provided before and after surgery (29,30).

Pre-cancerous and cancerous conditions
 

VULVAL INTRAEPITHELIAL NEOPLASIS (VIN)
Like a woman’s cervix, the vulva can undergo abnormal cell changes. VIN is the term used to refer to pre-cancerous cells in the skin of the vulva. Some cases of VIN are associated with HPV, while others are thought to be due to irritation and infection. There are suggestions that smoking may increase persistence of the condition for some women (31). If VIN persists for many years cancer of the vulva can develop.

Symptoms vary but may include itching, burning or pain in a specific area of the vulva; or one or more raised lesions that may be pink, red, brown and/or white in colour (32).

Diagnosis is by skin biopsy and treatment depends on the stage of the condition but may involve monitoring the area as VIN can disappear on its own. Other treatments include use of topical creams; surgery or laser application.

Use of the HPV vaccine has been shown to decrease the risk of VIN (33).

VULVAL CANCER
Vulval cancer is relatively uncommon, with less than 300 cases diagnosed in Australia each year (34). The majority of these cancers occur in women aged 50 and over. There are two main types of vulval cancer, those associated with LS and those related to VIN. Symptoms of vulval cancer include: itching, soreness, burning or pain in the vulva; vulval skin that looks white, feels rough or has a lump; bleeding or discharge not related to menstruation (35).

Treatment for vulval cancer depends on how advanced the cancer is when diagnosed, the person’s age and their overall medical condition. It may be embarrassing to discuss concerns with a health professional; however, 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. They can occur alone or with varicose veins of the legs. Symptoms may include pain in the vulva and a ‘dragging’, ‘heavy’ or full 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, wear support garments, ensure periods of rest lying down and avoid constipation. Treatment for vulval varices may involve embolisation; where a coil is inserted in the vein to block it, ligation; (cutting of the vein), sclerotherapy; injecting the vein with a saline solution to collapse it, or surgery (36).

When to seek help

Many women find it difficult to discuss intimate details about this part of their body with others. It is important to visit a doctor for a thorough initial consultation. 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 and length of symptoms (burning, itching)

  • Severity and type of pain

  • 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 LP)

  • Allergies (including to previous medications)

  • Urinary or faecal incontinence (these can cause skin irritation)

  • History of thrush or STIs and treatment received

  • Family history of skin or genital cancers

  • Medications taken

  • History of gynaecological surgery

  • Medical conditions like diabetes or immunosuppressive illnesses such as thyroid disease (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 STIs and fungal infections like thrush. In the case of vulvodynia, the doctor will try and determine the areas that 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.

References

  1. Royal Women’s Hospital Melbourne. (2014). Vulva & Vagina Health. .What’s Normal. Retrieved November 20, 2014. From www.thewomens.org.au/health-information/vulva-vagina/your-vulva-vagina/w...

  2. Stewart, E.G. (2002).  The V Book. New York: Bantam Books, p. 102-106

  3.  Braun, K. (2013) Genital cosmetic surgery. Health Journey. Issue 3

  4. ABC Radio, ‘Demand for genital barbie-plasty surgery triples in a decade’, The World Today, 10 October 2014 (Deborah Cornwall) http://www.abc.net.au/worldtoday/content/2014/s4104368.htm

  5. Stewart, E.G. (2002). The V Book. New York:Bantam Book, p. 262

  6. Fischer, G. Bradford, J. Vulval disease – Part 2: Patients with a symptomatic rash: Medicine Today 2000 Vol: 1 No:7 p58-70

  7. Welsh, B., Howard, A., Cook, K., Vulval itch. Australian Family Physician 2004; 33:7:5050-10

  8. 2010. International Society for the study of vulvovaginal disease (ISSVD) Patient Education Committee fact sheet. Vulvar Lichen Sclerosus

  9. Pangano, R. Common vulvar disorders. Medical Observer 17 November 2006 pp.25-8

  10. 2010. International Society for the study of vulvovaginal disease (ISSVD) Patient Education Committee factsheet. Vulvar Lichen Sclerosus

  11. Pangano, R., Common vulvar disorder. Medical Observer 17 November 2006 pp.25-8

  12. Drummond, C., (2013, June 28) Update 27: Diagnosing and managing Vulval Rashes. Medical Observer, p27—29

  13. Fistarol, S. Itin, P. (2013) Diagnosis and treatment of Linchen Sclerosus: An Update. American Journal Clinical Dermatology 14:27-47

  14.  Lambert, J. (2014). Pruritus in Female Patients. BioMed Research International. March 10, 2014, dio:10.1155/2014/541867

  15. Fistarol, S. Itin, P. (2013) Diagnosis and treatment of Linchen Sclerosus: An Update. American Journal Clinical Dermatology 14:27-47

  16. Drummond, C. (2013, June 28) Update 27: Diagnosing and managing Vulval Rashes. Medical Observer, p27—29

  17.  Fischer, G., Bradford, J., Vulval disease – Part 2: Patients with a symptomatic rash. Medicine Today 2000 Vole 1 No 7 p58-70

  18.  National Psoriasis Foundation. (n.d.). Genital Psoriasis: How to treat it, how to manage it. Retrieved December 2, 2014 from www.psoriasis.org/advance/genital-psoriasis-how-to-treat-it-how-to-manage-it

  19.  Fischer, G., (2012). Chronic vulvovaginal candidiasis: What we know and what we have yet to learn. Australasian Journal of Dermatology (2012)55:247-254.

  20. Ooi, C., (2012, September 4) Five Things to know about vulvovaginal candidiasis. Medical Observer.www.medicalobserver.com.au/news/five-things-to-know-about-vulvovaginal-candidiasis

  21. Harlow, B.L., Kunitz, C., Nguyen,R., et al. (2014) Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions. American Journal of Obstetrics & Gynecology 2014;210;40.e1-8

  22. Stewart, E.G. (2002).  The V Book. New York: Bantam Books, p. 321-330

  23. Mandal,D., Nunns,D., Byrne, M., McLelland,J., Rani,R.,Cullimore,J.,..and British Society for the Study of Vulval Disease (BSSVD) Guideline Group (2010), Guidelines for the management of vulvodynia. British Journal of Dermatology, 162:1180-1185. DOI:10.1111/j.1365

  24. Ibid.

  25. Reed BD. Vulvodynia: Diagnosis and management. American Family Physician 2006;73:7:1231-1235

  26.  Powell J, Wojnarowska  F. Acupuncture for Vulvodynia. Journal of the Society for Medicine November 1999, PMID: 10703496 accessed 28 April 2011

  27. Mandal,D., Nunns,D., Byrne, M., McLelland,J., Rani,R.,Cullimore,J.,..and British Society for the Study of Vulval Disease (BSSVD) Guideline Group (2010), Guidelines for the management of vulvodynia. British Journal of Dermatology, 162:1180-1185. DOI:10.1111/j.1365

  28. Vulval Pain Society (n.d.) the low-oxalate diet. Retrieved December 2, 2014, from www.vulvalpainsociety.org/vps/index.php/treatments/the-low-oxalate-diet

  29. Mandal,D., Nunns,D., Byrne, M., McLelland,J., Rani,R.,Cullimore,J.,..and British Society for the Study of Vulval Disease (BSSVD) Guideline Group (2010), Guidelines for the management of vulvodynia. British Journal of Dermatology, 162:1180-1185. DOI:10.1111/j.1365

  30. Nguyen, R.H. (2012) When good isn’t good enough – treatment for vulvodynia. Nature Review- Urology 9:482-483 DOI:10.1038/nrurol.2012:145

  31. The American Congress of Obstetricians and Gynaecologists (ACOG), 2011 (Reaffirmed 2014), Management of Vulvar Intraepithelial Neoplasia – Committee Opinion. Retrieved  January 21, 2015, from http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Vulvar-Intraepithelial-Neoplasia

  32. DermNet New Zealand Trust (2015) Vulval intraepithelial neoplasia. Retrieved  January 6, 2015 from http://www.dermnetnz.org/site-age-specific/vulvar-intraepithelial-neoplasia.html

  33. Couto, E.M, Saeterdal, I., Juver L, et al. (2014) HPV catch-up vaccination of young women: a systematic review and meta- analysis. BMC Public Health.14:867. Dio:10.1186/1471-2458-1

  34. Australian Institute of Health and Welfare (AIHW) 2012 Gynaecological cancers in Australia: an overview. Cancer series no.70 AIHW: Canberra 2012

  35. Bailey, C., Luesley.D. (2013) Squamous vulval cancer – an update. The Obstetrician & Gynaecologist (Review). 2013;15:227-31   DOI:10.1111/tog.12059

  36. Liddle, A., Davies, A., (2007) Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology, 22(3) 100-104.

For help understanding this fact sheet or further information on vulval conditions, call the Health Information Line on 3216 0376 or 1800 017 676 (toll free outside Brisbane).

This is one of a series of women’s health information fact sheets.

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