Vulval Disorders

A clinical approach to a tricky area

Just what exactly has you been sitting on?
It is good to remember that common things occur commonly but also that any skin condition can occur on the vulva.

Symptoms of something wrong include itching, burning, stinging pain and bleeding.
Below is a guide for doctors and patients.

Patient Symptoms

Itching

Always think thrush, it may look red, white or normal. If unsure, take a swab. Itching occurs with any dermatitis: eczema, contact.

Burning

Common with infections. Red burning areas occur in diabetics and may be extensive.

Stinging

Often caused by a split or ulcerated area. Splits can occur at any age but are common after menopause.

Pain

The site of the pain will help get a diagnosis. Pain may be hard to localise if it due to muscle spasm. It can be caused by scars which can gradually shorten in time.

If unsure, which with vulvar pathology is common, either take a swab and/or biopsy or refer on. It is best to do the biopsy before instituting treatment, especially with steroids.

While you are waiting for the laboratory results, Kenacombe ointment will often reduce the discomfort of many conditions.

Appearances

Red vulvas

Especially if post-menopausal, this is common in diabetics. If burning is present it is most commonly infective, usually a Strep. Take a swab first for bacteriology and possibly viruses such as herpes. Also, think of causes of a contact dermatitis.

White patches

If post menopausal, Lichen sclerosis is the most common cause. But it may be any Lichen, simplex or planus or something else. Take a biopsy before treatment. You may be surprised by the histology result.

Splits

Can occur at any age including pre-menarche and cause pain. Post menopause, low hormone atrophy frequently causes splits. These respond to frequent local oestriol cream or the MonaLisa laser. They also occur with Lichen sclerosis and other conditions. Splits in women before menopause are less common. If no other dermatological cause is present, the MonaLisa laser helps.

Lumps

Warty lumps are usually common warts but may represent intraepithelial dysplasia or invasive cancer. Common warts have a typical vascular pattern seen with magnification. If any doubt, biopsy or refer. Other lumps may need a biopsy.

Ulcers

These have many causes including acute bacterial and viral infections. Before you treat, take swabs for infections. Swabs may give a false negative result due to covering exudate. If treatment does not work as you expect, biopsy or refer. Always be suspicious of a localised asymptomatic change.

Cysts

Small sebaceous cysts are common and usually do not require excision. A deep infected sebaceous cyst may need excision as without it, recurrence often continues. A cyst may be something more sinister.

Bartholins cysts are asymptomatic unless infected. They lie laterally opposite the midpoint of the vagina. If infected which is usually very painful, urgent marsupialisation is indicated. If the cyst ruptures spontaneously or is lanced, it will usually recur.

Urethral pouting

Some degree is common after menopause and usually asymptomatic. If acutely painful and at the posterior edge of the meatus it will usually be a urethral caruncle. It may look like (or be) a tumour. Most respond to frequent oestriol cream. Uncommonly the whole circumference protrudes which will be a urethral prolapse needing surgical treatment if symptomatic. A urethral opening partially or completely in the vagina can be a cause of frequent UTIs. The opening can be transplanted anteriorly with good results.

Vulval trauma

This may be due to a fall or “clumsy sex activity” but remember to consider sexual abuse and self abuse.

Vulval fusion

This could be midline and obstruct voiding with the vagina filling with urine which then dribbles out. It may simulate incontinence. It could be between the labia minora and majora which is usually asymptomatic. However in the presence of nearby Lichen sclerosis or dysplasia, it could hide significant pathology. Always be suspicious of a localised, perhaps asymptomatic, change in lumps, ulcers or red areas.