Vulval Conditions

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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 smaller, 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 skin of the vulva is extremely delicate, making it susceptible to a wide range of conditions. Women can experience difficulty in obtaining a correct diagnosis and may be told their symptoms are psychosomatic. While vulval conditions are not "all in the mind", their sometimes chronic nature can lead to mental and emotional health issues (1). By providing a brief overview of some of the more common conditions, this factsheet aims to assist women in obtaining an appropriate diagnosis and treatment.

Conditions of the vulva are loosely grouped into: dermatological; sexually transmitted infections and thrush; vulvodynia (vulval pain); and pre-cancerous and cancerous conditions.

Dermatological

There are a number of different dermatological conditions associated with the vulva.

Dermatitis
Dermatitis is the most common cause of chronic vulval symptom. 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 (2). Vulval dermatitis can also be caused by contact with an irritant or allergen. Irritants or allergens can include laundry detergents, toilet paper, deodorants, dusting powders, lubricants and spermicides, sanitary pads and panty liners, bath products, soap and shower gels, depilatory products, underwear (lace, G-strings), latex (condoms, diaphragm), over-the-counter medication (thrush treatments) or bodily fluids (3).

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 weak, 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 the source.

Some general tips 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, feminine hygiene products and talc in the genital area.
  
• 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 cotton tampons rather than sanitary pads, where possible. If pads are preferred, consider using washable cloth sanitary pads (available from some health food stores). Avoid the use of panty liners between periods.
  
• Avoid the 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.

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 exact cause of this condition is unknown, although an overactive immune system or genetic predisposition may play a role. The main symptom of lichen sclerosus is severe itching. Scratching can result in broken skin, burning or stinging, pain during sex and/or urination. 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 (4). 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, 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. Lichen planus may be associated with a small increased risk of vulval cancer (5).

Psoriasis
Women with psoriasis of the vulva often have the skin condition elsewhere on their body. 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 (6). 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 with ingrown hairs. Sebaceous cysts are caused by a blocked sebaceous gland (oil gland in the skin). They occur quite commonly in the vulva and appear as a small, hard lump which is generally painless. Sebaceous cysts require no treatment unless they cause discomfort.

Thrush and sexually transmitted infections

Candidiasis (thrush)
Thrush is caused by an overgrowth of yeast-like fungi called Candida. It is not considered to be a sexually transmitted infection. Symptoms include: itchiness or redness of the vagina and vulva; a thick white, creamy vaginal discharge; and 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 (eg. 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 factsheet.

Genital herpes
Genital herpes is a sexually transmitted infection caused by the herpes simplex virus. It is transmitted through vaginal, anal or oral sex. Symptoms include flu-like symptoms and painful blisters in the genital area, within 2-14 days of exposure. For some people this will be their only outbreak, while others may have several more. 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 of symptoms 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 present.

Genital warts
Genital warts are caused by particular types of the human papillomavirus (genital HPV). Genital HPV is transmitted through 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. For more information on genital warts see our Genital HPV factsheet.

Vulvodynia

The term vulvodynia, literally means pain of the vulva. The International Society for the Study of Vulvovaginal Disease (ISSVD) provides a more precise definition: vulval discomfort, most often descried as burning pain in the absence of visible or neurological findings (7). Numerous factors have been suggested as causing vulvodynia, however, no single factor has been proven to be the cause.

The pain experienced by women with vulvodynia varies in intensity from mild to severe and may be constant or intermittent (8). 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 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 the 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 under the dermatitis section. Women should also avoid constipation or a full bladder and activities like bike riding or sitting for long periods of time as these all place pressure on the vulva.

Biofeedback and physical therapy appear to be effective conservative treatments for vulvodynia (9). 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 overly negative pain-related thoughts (10).

Another conservative measure 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 (11).

Some women find a mild 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.

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 (12). It is important that a woman consults a surgeon who is experienced in this area.

Pre-cancerous and cancerous conditions

Vulval intraepithelial neoplasia (VIN)
Like a woman's cervix, the tissue of the vulva can undergo abnormal cell changes. These changes are referred to as vulval intraepithelial neoplasia (VIN). Some cases of VIN are associated with the human papillomavirus (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 monitoring the areas as VIN can disappear on its own. In some cases removing the abnormal tissue by surgery or laser may be required. Other treatments are being trialled and a vaccine against some types of HPV will hopefully 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 (13). 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 (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 (14).

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.

A vaccine for some types of HPV (which are linked to VIN and, therefore, vulval cancer) will hopefully reduce the risk of vulval cancer in the future.

Other vulval conditions

Vulval varices
While varicose veins are usually thought of as occurring in the legs, they can also affect the vulva. Vulval varicose veins or vulval varices, as they are often known, most commonly arise during pregnancy but can also affect non-pregnant women. Symptoms may include itching, pain in the vulva and the sensation of prolapse (feeling as though something has fallen down). Vulval varices during pregnancy usually improve once the baby is born, 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 consists of sclerotherapy, which involves injecting the vein with a saline solution. The saline solution irritates the lining of the vein causing it to collapse and be reabsorbed. A compression garment needs to be worn following sclerotherapy. If sclerotherapy is unsuccessful surgery may be required.

Bartholin's glands cyst
The Bartholin's glands are tiny glands located on each labia minora, near the vaginal opening. These glands are responsible for producing a small amount of fluid to lubricate the entrance to the vagina. The glands 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 an abscess develops. In these cases, the cysts or abscess can be drained by a doctor.

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 (ie. do they change according to different phases of the menstrual cycle)
  
• Factors that exacerbate symptoms (eg. sex, tampon use)
  
• If the symptoms began around a particular time (ie. 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 transmitted infections like genital HPV, genital herpes and the treatment received
  
• Family history of 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. If appropriate, they will arrange for tests to exclude sexually transmitted infections and fungal infections like thrush. In the case of vulvodynia, the doctor will try and ascertain the areas which are painful. The doctor may also provide a referral to a specialist.

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

It is hoped that improved awareness of the conditions which can affect the vulva will encourage women to consult a doctor about vulval symptoms. In addition, better knowledge and understanding of vulval conditions amongst medical professionals will assist women in getting a correct diagnosis and receiving appropriate treatment.

References

1. Muto, M G. The vulva. In Ryan, K J et al. Kistner's Gynecology and Women's Health St Louis Mosby 1999 p58
   
2. Wines, N. Strategies required to improve the management of chronic vulvar discomfort in Australia Australian and New Zealand Journal of Obstetrics & Gynaecology 2002 Vol 42 No 1 p75-78
   
3. Fischer, G & Bradford, J. Vulval disease- Part 2: Patients with a symptomatic rash Medicine Today 2000 Vol 1 No 7 p58-70
   
4. Fischer, G & Bradford, J. Ibid p59
   
5. Fischer, G & Bradford, J. Ibid p59
   
6. Klemperer, E. Vulvar dermatoses: Recognition, differential diagnosis, and treatment The Female Patient 1999 Supplement August p14-19
   
7. Muto, M G. Ibid p69
   
8. Mazza, D. Lichen planus: Information for women Australian Family Physician 1999 Vol 28 No 4 p371
   
9. Lewis, F M. Vulval lichen planus British Journal of Dermatology 1998 Vol 138 No 4 p569-575
   
10. Fischer, G & Bradford, J. Ibid p61
    
11. Lynch, P. Vulvodynia: a syndrome of unexplained vulvar pain, psychological disability and sexual dysfunction Journal of Reproductive Medicine 1986 Vol 31 No 9 p773-80
    
12. Wines, N & Dayan, L. Vulvodynia: Assessment and treatment Current Therapeutics 2001 Vol 42 No 3 p17-23
    
13. Thomason, J L. Vulvodynia: Update on a cryptic condition The Female Patient 1999 Supplement August p20-24
    
14. Wines, N. Ibid p 76
    
15. Thomason, J L. Ibid p21
    
16. Paavonen J. Vulvodynia - a complex syndrome of vulvar pain Acta Obstetricia et Gynaecologica Scandinavica 1995 Vol 74 No 4 p243-7
    
17. Jantos M & White G. The vestibulitis syndrome. Medical and psychosexual assessment of a cohort of patients Journal of Reproductive Medicine 1997 Vol 42 No 3 p145-52
    
18. University of Michigan Health System, Department of Obstetrics & Gynecology Vulvodynia and Vulvar Vestibulitis University of Michigan Health System http://www.med.umich.edu/obgyn/vulva/
    vulvodyn.htm [website] date accessed: 14th March 2002.
    
19. White, G et al. Establishing the diagnosis of vulvar vestibulitis Journal of Reproductive Medicine 1997 Vol 42 No 3 p157-60
    
20. University of Michigan Health System, Department of Obstetrics & Gynecology Vulvodynia and Vulvar Vestibulitis Ibid
    
21. McKay, M. Dysesthetic ("essential") vulvodynia. Treatment with amitriptyline Journal of Reproductive Medicine 1993 Vol 38 No 1 p9-13
    
22. Wines, N & Dayan, L. Ibid p23
    
23. Keefe, F J. Cognitive behavioural therapy for managing pain The Clinical Psychologist 1996 Vol 49 No 3 p4-5
    
24. Wines, N & Dayan, L. Ibid p22
    
25. Muto, M G. Ibid p73
    
26. University of Michigan Health System, Department of Obstetrics & Gynecology Vulvar Intraepithelial Neoplasia University of Michigan Health System
    http://www.med.umich.edu/obgyn/vulva/intraep.htm
    [website] date accessed: 14th March 2002
    
27. Fischer, G & Bradford, J. Ibid p62
    
28. Fry, R. Vulval cancer Radio National: The Health Report ABC http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/
    s104268.htm [website] date accessed: 14th March 2002
    
29. Gynaecological Cancer Society. Cancer of the Vulva: General Information Gynaecological Cancer Society http://www.gcsq.org.au/patient/vulva_gen.asp
    [website] dateaccessed: 21 March 2002
    
30. American Academy of Family Physicians. Bartholin's Gland Cyst American Academy of Family Physicians
    http://familydoctor.org/handouts/235.htm [website]
    date accessed: 28th March 2002

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Further reading

See our

• Thrush and other vaginal infections factsheet            
• Genital HPV factsheet   
• Gynaecological health library booklist     

This factsheet was originally published by Women's Health Queensland Wide (Women's Health) in June 2002. it was revised by Kirsten Braun and the Editorial Committee at Women's Health in July 2006.

Last Modified: July 1, 2006