Vulvitis

What is vulvitis?

Vulvitis specifically refers to inflammation of the vulval area. However, the terms vulvitis, vulvovaginitis and vaginitis are used by gynaecologists more or less interchangeably. There is a wide number of conditions included under the umbrella of this term.

Vulvitis causes

Infection

• Candida, trichomoniasis, bacterial vaginosis.

• Pubic lice, threadworm, scabies.

• Herpes simplex, urinary tract infection (UTI), vulval vestibulitis.

• In prepubertal girls a group A beta haemolytic streptococcus, Escherichia coli or Haemophilus influenzae are the most common pathogens causing vulvitis¹ . Group A beta haemolytic streptococcal infection can also cause a vulvovaginitis in adult women² .

Dermatological conditions³

• Allergic dermatitis. The most common vulval dermatosis in both adults and children is dermatitis. The majority of these patients are atopic⁴ .

• Psoriasis, lichen simplex/planus/sclerosus.

Neoplasia

• Squamous cell carcinoma (90% of cases have vulvitis).

Atrophic

• Atrophic vaginitis - it has been estimated that 4-5 years after the menopause, around 25-50% of women experience symptoms due to atrophic vaginitis⁵ .

• Breastfeeding can also result in lowered oestrogen levels and consequent vulval symptoms.

Miscellaneous

• Poor hygiene.

• Pregnancy.

• Generalised pruritus.

• Psychological problems.

• Hormonal pH changes associated with the menstrual cycle can lead to pruritus vulvae as increasing pH is known to activate the proteinase-activated receptor-2, which is an itch mediator⁶ .

• Idiopathic - uncommon, and only diagnosed when all other causes have been excluded.

• Vulvitis circumscripta plasmacellularis (Zoon's vulvitis). This is a is a rare, benign vulval disorder that presents with erythematous patches and erosions⁷ .

Miscellaneous pain syndromes

• Vulvodynia - causes chronic vulval and pelvic pain, of unknown aetiology⁸ . Vulvodynia is a complex disorder reported by up to 16% of women in the general population⁹ .

• Vulvar vestibulitis syndrome - this is often considered to be a subset of vulvodynia that is characterised by severe pain during attempted vaginal entry (intercourse or tampons insertion), tenderness to pressure localised to the vulvar vestibule and redness of the vulvar vestibule¹⁰ .

Conditions causing the vulva to become excessively moist, such as vaginal discharge and urinary incontinence, lower the defences against commensal organisms and make the area vulnerable to infection.

Epidemiology

Exact figures are not available because the term covers so many different conditions and many women self-treat and do not consult a health professional. Females of all ages are affected, from prepubertal girls to the elderly. Vulval diseases are still underdiagnosed and undertreated⁴ .

Vulvitis symptoms

History

The presenting symptoms are usually itch, irritation, soreness, rawness or burning.

• Dermatitis may cause intermittent itching, with flares associated with exposure to irritants.

• Vaginal discharge may be a pointer to infection.

• A personal or family history of skin disease (eg, atopy, psoriasis, eczema) or autoimmune disease (associated with lichen sclerosus) may be significant.

• Enquiry should be made about general health and any stress factors.

Other information of importance includes current medication, previous treatment (prescribed or purchased), obstetric and gynaecological history (including genital warts) and any potential allergens or sensitiser, such as sanitary wear, soap or detergent.

Examination

The examination should be performed in good lighting to assess subtle changes in the skin. A chaperone should be offered.

• As a minimum, the vulva, pubis and perianal area should be examined. The cervix and vagina should be included if genital infection is suspected.

• Other areas of skin should be examined if there are rashes elsewhere. For example, there may be evidence of facial, hand or flexural dermatitis.

• If the presenting complaint is mainly dyspareunia, pelvic muscle tone may need to be assessed.

• If the appearance is essentially normal it may be worth proceeding to see whether the pain is localised and provoked by light touch (suggestive of vulvar vestibular disorder) or is more generalised and not provoked by touch (suggestive of vulvodynia).

Investigations

• The clinical diagnosis may be apparent from the history and examination. However, investigations are often required to support the clinician's suspicions. Blood tests may include fasting glucose, FBC and serum ferritin.

• If an infection is suspected, appropriate swabs or cultures should be taken to look for conditions such as candida or bacterial vaginosis.

• If a sexually transmitted infection is suspected, appropriate swabs and/or blood tests should be undertaken.

• Skin biopsy is usually required in cases of diagnostic difficulty (or for any skin lesion not responding to a six-week course of treatment). This is usually performed in secondary care or by a GP with special interest.

Associated diseases

Depending on cause this could include:

• Diabetes.

• Immune deficiency states.

• Urinary incontinence.

• Perimenopause, and postmenopausal oestrogen deficiency.

• Faecal incontinence.

• Any cause of generalised pruritus - eg, liver disease, lymphoma.

• Psychological problems.

Vulvitis treatment

• Most cases will have an identifiable cause, so accurate diagnosis is an important precursor to management.

• Potential malignant change in an area of pruritus is always a possibility, so patients with unresolved symptoms should be reviewed regularly.

• Suspected vulval carcinoma (ie women with an unexplained vulval lump, ulceration or bleeding) needs urgent referral for an appointment within two weeks as per local and national guidelines¹¹ .

• Consider referring patients with non-suspicious skin changes and negative microbiology for patch testing, as these cases are often allergic in nature.

• Psychological factors can be a cause and a complication of vulvitis - an holistic approach should be taken.
  

General advice

• All women should be advised to avoid contact of the vulval skin with soap, bubble bath, shampoo, perfumes, personal deodorants, wet wipes, detergents, textile dyes, fabric conditioners and sanitary wear.

• In addition, they should use a non-soap cleanser and wear loose cotton clothing.

• Partners should avoid use of spermicidally lubricated condoms.

• Patients should be given accurate and clear written information to reinforce these measures.

Pruritus vulvae of unknown cause

In the absence of a specific diagnosis, or whilst waiting for results, the following treatments can be tried. Most are based on the empirical experience of experts, as there is little published evidence:

• Emollients can be used as an adjunct to other treatments and are suitable for easing itching in almost all types of vulval disease; they can be used in addition to most other therapies. They can also be used as a soap substitute or moisturiser. There is wide patient variability and lack of comparative evidence, so the choice of preparation can be left to individual preference. If topical steroids are used as well, the emollient should be used first and the steroid 10-20 minutes later. This ensures the skin is moisturised and avoids spread of the steroid to normal skin.

• Sedating oral antihistamines appear to work by promoting sedation rather than blocking the action of histamine. Sedative antidepressants have been used with similar benefit.

• Low-potency topical corticosteroids (eg, hydrocortisone 1% ointment) can be considered as a short trial (1-2 weeks). Potent steroids should be avoided, as they can affect surface features and confuse the diagnosis should subsequent specialist referral be required. Specialist referral is indicated if there is no response to steroids.

Specific management of vulvitis (known cause)

This will depend on the underlying condition and the results of investigations. Topical corticosteroids are the mainstay of treatment for inflammatory vulval disorders. Ointments are better tolerated than creams, as they are less likely to cause stinging¹² .

Potent steroids should only be used if the prescriber is confident in the diagnosis. This is usually after confirmation by a specialist, often on the basis of biopsy results.

Infection

Vulval and vaginal infections should be treated with the appropriate antibiotic, antifungal, antiviral or other antimicrobial agent.

Steroids are often also given to improve the associated inflammation. A potent corticosteroid provides more rapid and effective control, so this is often given first, then tapering to a weaker steroid¹² . Women should be reassured that atrophy is rare with short-term use of potent corticosteroids.

Dermatological conditions

• Contact dermatitis - this is mainly centred on irritant avoidance, with topical corticosteroid treatment as a secondary measure to relieve itching.

• Seborrhoeic dermatitis and psoriasis - these are usually treated with judicious use of topical corticosteroids (sometimes combined with an antibacterial or anticandidal agent). Ketoconazole shampoo can be used as body wash for seborrhoeic dermatitis.

• Lichen simplex can be treated with topical betamethasone for 1-2 weeks to break the itch-scratch cycle.

• Lichen sclerosus and lichen planus usually respond to short-term regular potent or superpotent topical corticosteroids. Women with lichen sclerosus and lichen planus have a small risk (2-5%) of developing carcinoma, so long-term follow-up is often recommended¹³ . It is not known if the treatment of vulval lichen sclerosus and vulval lichen planus prevents the development of squamous cell carcinoma¹⁴ .

Atrophic vaginitis

Management of atrophic vaginitis is usually the use of minimally absorbed local vaginal oestrogens, along with non-hormonal lubricants or moisturisers, coupled with maintenance of sexual activity if possible¹⁵ .

Zoon's vulvitis

This normally responds to high-potency topical steroids¹⁶ . Successful treatment with platelet-rich plasma has been reported¹⁷ .

Other conditions

In both the conditions below, examination and investigations are usually normal:

• Vulvodynia - the predominant symptom is chronic, poorly localised vulval burning or pain. The exact aetiology is unclear but the condition shares some features with neuropathic pain syndromes. An approach to the diagnosis and management of a woman presenting with vulvodynia should address the biological, psychological and social/interpersonal factors that contribute to this condition¹⁸ .

• Vulvar vestibular syndrome - this is also known as vestibulitis, vestibular pain syndrome, vestibulodynia and localised vulval dysaesthesia. Altered pain perception is the major feature of this syndrome. Management is often challenging. A number of treatments have been tried, including Xylocaine® gel, pelvic floor retraining with biofeedback, low-dose tricyclic antidepressants, newer neuropathic pain agents and cognitive behavioural therapy. Surgery for this condition exists, with success rates of 60% to 90%. However, surgery is recommended only in cases that have failed to respond to traditional treatments¹⁹ .

When to refer

Referral is indicated if:

• There is an unexplained vulval lump or vulval bleeding due to ulceration.

• Sexually transmitted infection is suspected and there is no capacity for the clinician to do screening tests.

• A dermatological diagnosis is suspected but there is no response to treatment.

• Contact allergy is suspected and patch testing is required.

• An underlying cause has not been identified and symptoms do not respond to simple advice or a short trial of topical steroids.

Vulvitis complications

• Night-time pruritus can lead to sleep loss and reduce quality of life.

• If correctly diagnosed, most underlying causes can be successfully treated.

• Failure to diagnose serious underlying conditions, such as neoplasia, can be fatal.

• Anxiety states and neuroses can lead to psychosexual problems. Some women may find that pruritus is made worse rather than helped by topical products.

Prognosis

• Most cases of pruritus resolve once the correct diagnosis is made and appropriate treatment instituted.

• The prognosis will depend on the underlying condition causing the vulvitis.