Q 31. 1 What skin conditions may affect the vulva?

Many generalised skin conditions that affect other parts of the body, including eczema and psoriasis, may be encountered on the vulva but some conditions, sometimes called vulval dystrophies, only affect the vulva.

Infections such as thrush have been discussed elsewhere (Q22.6). Infections of hair follicles (folliculitis – boils) can lead to abscess formation. Seborrhoeic eczema of the vulva is usually seen in combination with dandruff of the scalp. Eczema can be aggravated by chemicals added to bath water including oils and perfumes. Aqueous cream or another soap substitute may provide relief. Mild local corticosteroid creams, which may contain antifungal agents, are frequently used to suppress symptoms.

Q 31. 2 Which viral infections can affect the genitalia?

Herpes simplex and human papilloma virus, which is associated with warts, commonly affect the vulva. Viruses are minute living organisms that are much smaller even than bacteria and can only function within the cells of the host. Viruses may lie dormant within cells for many years before they enter an active phase.

Whilst they can be treated in these active phases, it is not possible to detect or destroy the dormant viruses. Many women with recurrent vulval herpes live in fear of the next attack and may feel unclean and helpless once the diagnosis has been made; libido may suffer.

They may avoid intermittent relationships or fear sexual activity. Depression is a common sequel. Whilst premenstrual syndrome, period problems and hormone replacement therapy may be fashionable subjects for discussion, herpes and warts are subjects that are avoided as sufferers may feel ashamed.

Q 31. 3 What problems can occur to people with herpes simplex?

Genital herpes is usually caused by herpes simplex type II virus but can be due to herpes simplex type I virus which is more commonly associated with “cold sores” around the mouth. The first attack of genital herpes, called primary infection, is associated with generalised illness which can be severe. The external genital skin becomes red and painful and there are typical blisters called vesicles.

When the blisters open they become painful ulcers. Blood and viral culture tests are usually undertaken to confirm the diagnosis which is usually apparent to the doctor who will often commence treatment with an antiviral agent (e.g. acyclovir – Zovirax – Glaxo) before awaiting laboratory confirmation. At times the infection may be so painful, the illness so weakening or bladder emptying so difficult that admission to hospital is required.

Repeat attacks, called secondary herpes, are less severe than primary infections. They last for between five and ten days if left untreated. There may be symptoms of impending problems 12-72 hours before vesicle eruption, with tingling or burning sensations. Attacks are thought to be more common at times of stress. Treatment with an antiviral agent at the onset of warning symptoms will lessen or prevent attacks. Sufferers should abstain from sexual intercourse during attacks to save the partner from infection. Whilst individual attacks can be thwarted, there is no long-term cure. When attacks occur more frequently than six times in a year, there may be understandable depression. For the minority with such frequent attacks there is a place for regular twice daily acyclovir tablets.

If there is active genital herpes around the time of childbirth, the baby can be infected with severe consequences. It is believed that this is more dangerous with the primary infection. If there is evidence of genital herpes around the time of delivery, Caesarean section reduces the risks.

Q 31. 4 What are genital warts?

Genital warts account for about a fifth of attendances at genitourinary clinics. Warts are caused by the human papillomavirus (HPV) which is transmitted by skin contact. Whilst this can occur from hand contact the usual cause is sexual transmission.

There are many strains of wart virus. The most common types of HPV associated with genital warts are 6 and 11; these can be associated with minor degrees of cervical smear abnormality. Types 16 and 18 are associated with more severe degrees of cervical smear abnormality and cervical cancer (Q32.16). Many women developing genital warts have understandable anxieties about cervical cancer. The majority of these warts will not be due to types 16 or 18.

Women with warts should have regular smear tests and use condoms to reduce the chance of infection. When there are just a few warts, they can be treated either at home or by the local doctor or practice nurse with applications of podophyllin. The home application is 0.15% podophyllotoxin (Warticon – Perstorp). The area should be washed and dried before application. Warticon is applied twice daily for three days each week for four weeks. Pregnancy should be excluded before treatment commences.

Q 31. 5 What is lichen sclerosus?

The vulval skin appears white and there may be some cracks. The resulting scarring leads to destruction of the normal vulval anatomy with a tendency for the labia minorae to shrink and the clitoris may become hidden. The diameter of the introitus (vaginal entrance) may be reduced so that intercourse becomes painful or impossible.

The exact cause of this condition is not known. There have been many names applied to chronic vulval skin conditions. These have included leucoplakia, kraurosis vulvae, Bowen’s disease and Paget’s disease. At one time they were all grouped as vulval dystrophies. With lichen sclerosus, there are inflammatory cells below the skin. Biopsy of the affected vulval skin is sometimes undertaken to confirm the diagnosis although it is now considered reasonable to confine biopsy to patients who do not respond to local medication.

Although patients presenting with cancer of the vulva often have associated lichen sclerosus, most patients with lichen sclerosus will never develop vulval cancer. To provide reassurance, however, gynaecologists tend to keep patients with lichen sclerosus under review.

Q 31. 6 How is lichen sclerosus treated?

Lichen sclerosus is treated by local application of glucocorticoid steroids. There are many steroid ointments and creams for topical application grouped into four strengths – very potent, potent, moderate and mild. The tendency was previously to use the weakest ointments and increase in strength until symptoms resolved. Nowadays the recommendation is to use one of the more potent ointments such as Dermovate (Glaxo) for three months and then intermittently as required. These creams should be applied sparingly. As a guide it may be suggested that you squeeze about a half inch length on to the tip of your index finger and this is all that is needed for one application.

Q 31. 7 What could be causing my vulval irritation (pruritis vulvae)?

Vulval irritation is a distressing symptom, which may arise from a number of causes including:-

• undergarments that have been washed in irritating chemicals such as detergents and fabric softeners and inadequately rinsed out.

• perfumed soaps and panty liners.

• detergents used to clean the bath.

• vaginal discharge with infection, particularly thrush (Q22.6) and trichomonas (Q22.6).

• diabetes – the vulval area appears red either due to sugar from the urine irritating the skin or from candida which enjoys the sugary environment. Sugar in the urine or a blood sugar test will confirm the diagnosis.

• warts (Q31.4)

• malignant change.

• psychosomatic (Q23.2).

Q 31. 8 How could my vulval irritation be treated?

This will depend on the cause. The irritation will usually vanish quickly if an irritating chemical, such as bath detergent or washing powder, can be identified and avoided. When the vulval skin disorder is part of a generalised skin problem, the advice of a dermatologist may be required. Diabetic vulvitis responds to control of sugar levels. Infections such as trichomonas, thrush and warts respond to the appropriate specific treatments.

Q 31. 9 What is a Bartholin’s cyst / abscess?

There is a Bartholin’s gland on either side of the vaginal introitus (Figure 2.2), which produce a little of the lubricating fluid that facilitates intercourse. The fluid passes through a fine duct (tube) and is released from the 5 and 7 o’clock areas of the vestibule just outside the hymen. Infection of the duct may cause blockage and the fluid accumulates in a cyst (like a tiny balloon filled with fluid) arising from the duct. This Bartholin’s cyst does not usually cause problems unless it becomes infected (Bartholin’s abscess). The abscess may cause severe pain.

Q 31. 10 How is a Bartholin’s cyst / abscess treated?

In the earliest stage of infection, antibiotics may be effective. Once an abscess has formed, surgical drainage is required. The operation of choice is called marsupialisation. Usually under general anaesthesia, the skin and cyst are opened. A small area of the skin and cyst wall are removed and the cyst wall is stitched to the skin edges leaving a channel from the gland. Marsupialisation generally provides a permanent solution although, on occasion, repeat marsupialisation may be required. Rarely, repeated marsupialisation fails and the cyst and gland may have to be removed.

Q 31. 11 What is vulvodynia?

Vulvodynia is chronic discomfort of the vulva. The discomfort may vary with irritation, soreness, burning or pain. There may be obvious vulval disease or no visible abnormality.

Q 31. 12 How can my vulvodynia be treated?

If there is a specific disease the relevant treatment will be provided. Chemical irritants in bath water or in underclothes should be avoided. Topical steroid creams may prove helpful.

Sometimes mild antidepressants such as amitriptyline 25 mg at night may assist with sleep and this often seems to alleviate symptoms. Side-effects, including fatigue, dizziness, dry mouth and constipation, tend to resolve after a couple of weeks. Increasing your fluid intake and changing to a high fibre diet overcome some of these problems. When an antidepressant is prescribed as part of the treatment for pain it does not mean that your doctor is attributing your pain to a psychological problem. The dose of an antidepressant used for pain is much lower than in the treatment of depression.

References:

The vulval pain syndromes. (1999 – 2683)

Q 31. 13 What is vestibulitis?

Vestibulitis is characterised by inflammation of the vestibule (Figure 2.2) or pain in the vestibule with no abnormality that can be seen. There may be dyspareunia (pain with intercourse – Q.23.31). Usually the painful area tends to be at the back of the vestibule but it can sometimes be specifically located at the sites of the ducts from the Bartholin’s glands (Figure 2.2).

Frequently, no definitive cause can be determined although infections such as candida (Q22.6) may sometimes be found. Viruses, notably the wart virus (HPV) have been implicated but their role remains debatable.

References:

Vulvar vestibulitis syndrome: An often unrecognized cause of dyspareunia. (1999-3055a)

Vulvodynia caused by the vulvar vestibulitis syndrome. (1997 – 3055d)

Vulvar vestibulitis. Subgroup with Bartholin gland duct inflammation. (1989 – 3055b)

Q 31. 1 What skin conditions may affect the vulva?

Q 31. 2 Which viral infections can affect the genitalia?

Q 31. 3 What problems can occur to people with herpes simplex?

Q 31. 4 What are genital warts?

Q 31. 5 What is lichen sclerosus?

Q 31. 6 How is lichen sclerosus treated?

Q 31. 7 What could be causing my vulval irritation?

Q 31. 8 How could my vulval irritation be treated?

Q 31. 9 What is a Bartholin’s cyst / abscess?

Q 31. 10 How is a Bartholin’s cyst / abscess treated?

Q 31. 11 What is vulvodynia?

Q 31. 12 How can my vulvodynia be treated?

Q 31. 13 What is vestibulitis?

Q 31. 14 How can my

Q 31. 14 How can my vestibulitis be treated?

Your doctor will wish to examine you to see exactly where there is tenderness and to exclude obvious disease including infection. If the cause can be determined appropriate treatment can be provided. When no obvious cause is found empirical treatment including anti-fungal agents, antibiotics, topical steroids, analgesics (pain-killers) and amitriptyline (Q31.12) may be tried. Occasionally, the tender area of skin may be removed surgically (partial vestibulectomy).

References:

Treatment of vulvar vestibulitis with posterior excision. A series of 12 cases. (1997-3055c)

Q 31. 15 Where can I obtain further information?

https://2womenshealth.com/

Q 31. 16 Could I have some useful Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter:

Q 31. 1 What skin conditions may affect the vulva?

Q 31. 2 Which viral infections can affect the genitalia?

Q 31. 3 What problems can occur to people with herpes simplex?

Q 31. 4 What are genital warts?

Q 31. 5 What is lichen sclerosus?

Q 31. 6 How is lichen sclerosus treated?

Q 31. 7 What could be causing my vulval irritation?

Q 31. 8 How could my vulval irritation be treated?

Q 31. 9 What is a Bartholin’s cyst / abscess?

Q 31. 10 How is a Bartholin’s cyst / abscess treated?

Q 31. 11 What is vulvodynia?

Q 31. 12 How can my vulvodynia be treated?

Q 31. 13 What is vestibulitis?

Q 31. 14 How can my

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