Introduction
Vulval disorders are common in women of all age groups and can have a number of different pathologies. History and examination form a major part of diagnosis, often a simple thorough examination of the vulval area is enough to diagnose most conditions at the first visit. There are a multitude of skin conditions which can affect the vulva. The purpose of this section is to discuss the most common vulval conditions seen in Dr Friebe’s practice.
Symptoms
Most vulval disorders will manifest as pain or itching. Occasionally a lesion or area of concern may be seen by the GP when taking a routine smear which has not been noticed by the woman, but usually there are symptoms present.
Conditions
Contact Dermatitis
This is very common. The vulval skin is sensitive and is easily irritated by soaps, perfumes, washing powder, sweat, even toilet paper! Dermatitis is easily settled with some steroid ointment and a review of possible irritants to the skin with some changes made at home if a culprit is discovered.
Lichen Sclerosis
This is a more serious condition that leads to itchy or painful whitish areas of change on the vulval skin. It is not certain what causes lichen sclerosis, but it is thought to most likely be auto immune in origin. Lichen sclerosis is not curable, but can be well managed with steroid ointment and observation by the gynaecologist. Left alone and not treated, lichen sclerosis has a risk of progressing to skin cancer.
Lichen sclerosis is diagnosed by biopsy of an affected patch of skin.
Recurrent thrush
Recurrent thrush is defined as 4 or more thrush attacks in a year. Thrush attacks will usually be characterised by vulval and vaginal itch or burning symptoms. A thick cheesy discharge may or may not be present. Recurrent thrush is a difficult, distressing problem that affects about 8% of women of reproductive age. Management usually requires a prolonged course (6 months) of oral treatment with Diflucan, as prolonged treatment with vaginal creams or pessaries can lead to a contact dermatitis, introducing a new problem.
Once again, history and examination forms the main basis for diagnosis, and while a tricky problem to treat, recurrent thrush can be settled down with the correct treatment.
Vulvar Intraepithelial Neoplasia (VIN)
This is a skin disease of the vulva, when Human Papilloma Virus (HPV) affects the skin cells of the vulva, causing progressively more abnormal cells to develop over time within the skin layer. The process is similar to Cervical Intraepithelial Neoplasia (CIN), when HPV affects the cervix and leads to progressively more abnormal cells to develop. This is checked for all women by regular HPV screening, Pap Smears and colposcopy if needed.
VIN generally presents as intense itching of the vulval skin area. It is more common in women after the menopause. Diagnosis is via vulvoscopy, when some watery vinegar solution is applied to the vulval skin and the area is then examined under magnification by the colposcope, similar to a colposcopy (see section). A biopsy is then taken of any suspicious areas for diagnosis.
If the VIN is severe enough, it will need to be excised in theatre under a general anaesthetic, as severe VIN can progress to skin cancer. Milder VIN can be monitored with check-ups with the gynaecologist, similar to mild CIN on the cervix.
Vulvar Vestibular Syndrome
Vulvar vestibular syndrome (VVS), is a pain syndrome localised to the vulva region. Most commonly it is characterised by severe pain, described as a cutting or burning type pain on attempted penetration of the vaginal orifice (sexual intercourse, tampon insertion).
Many women put up with this problem for a long time before mentioning it to their GP. It can also be a distressing problem, causing relationship tensions and self-esteem issues. Up to 10% of women are thought to be affected by this condition.
It isn’t exactly clear why VVS occurs. Some believe it is due to nerve endings at the vaginal opening being hypersensitive, others believe it can be brought on by recurrent thrush, or recurrent vaginal infections like Bacterial Vaginosis. Unfortunately, VVS can set off other issues in the body, including chronic tightening up of the vaginal muscles, leading to vaginismus and difficulty with intercourse. Psychological issues can also be a problem.
Once again, with all vulval disorders, a good history and thorough examination will often be all that is required to diagnose VVS. Sometimes swabs will need to be taken to rule out thrush or other vaginal infections.
While VVS can also be tricky to entirely settle down, there are good treatments available, and most women will get good relief. Often in association with some pelvic floor physiotherapy and relaxation techniques, many women can return to regular, pleasant sexual intercourse with their partner and be able to use tampons without an issue if required.