Benign vulval disease

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Chapter 24 Benign vulval disease

Neroli Ngenda

Infections

Fungal

Candida albicans

• predisposed groups: newborns, females between puberty and menopause, postmenopausal women on hormone replacement therapy (HRT), women with diabetes mellitus
• symptoms: vulval pruritus, cheesy discharge, dyspareunia
• premenstrual and postcoital exacerbation can occur
• diagnosis: on vaginal swab
• treatment: vaginal imidazoles (e.g. clotrimazole) and, if required, single-dose oral therapy fluconazole; vaginal boric acid may be used
• apply imidazoles and boric acid intravaginally only, not to the vulva
• longer term oral therapy may be required for recurrent candidiasis (e.g. ketoconazole, fluconazole)

Non-albicans yeast infection

• Candida glabrata, C. krusei, C. parapsilosis, C. guillermondii
• relatively resistant to imidazoles
• boric acid is used for treatment

Tinea cruris

• It produces a well-demarcated erythematous lesion extending from the labia to the inner aspect of the thigh.
• Diagnosis is via microscopy of scrapings.
• Topical treatment with imidazoles may help; however, oral antifungal treatment is required for cure (e.g. griseofulvin).

Pityriasis versicolor (tinea versicolor)

• caused by Malassezia furfur
• may be asymptomatic or cause vulval pruritus
• treatment: topical or oral azoles

Viral

• herpes simplex virus 1 and 2
• human papillomavirus
• molluscum contagiosum

Bacterial

• pyogenic vulval infection (impetigo, folliculitis, abscess, carbuncle, cellulitis), Bartholin’s gland infection, chancroid, donovanosis, syphilis, lymphogranuloma venereum

Parasitic

• pediculosis pubis (pubic lice), scabies, worms, trichomoniasis, schistosomiasis, filariasis, hydatid disease

Non-infectious dermatoses

Contact/allergic dermatitis

• may be triggered by local irritants (e.g. perfumes, soaps, fabric softeners, detergents, feminine sprays, urine, pads and panty liners, toilet paper); drugs; topical creams; latex in condoms
• causes vulval pruritus
• examination may reveal vulval erythema and/or swelling; fissuring in the interlabial sulci may occur
• lichenification can occur from scratching
• important to exclude the presence of candidiasis
• important to avoid the trigger and other irritants such as perfumes, soaps, fabric softener, nylon underwear, tight clothing, excessive pad/panty liner use, toilet paper with fragrance
• use aqueous cream or sorbelene to wash the vulva
• zinc, castor oil cream or Vaseline may be useful to protect the skin in cases of urinary incontinence
• topical steroids can assist in resolution

Lichen sclerosus

• can occur at any age, but is most common in postmenopausal women in whom it is a chronic condition
• also can occur in childhood (usually regresses at puberty)
• autoimmune condition
• causes vulval pruritus and eventually decreased clitoral sensation
• in advanced stages can result in dyspareunia due to introital stenosis
• sites of occurrence include the vulva, perineum and perianal area (spares the labia majora and vagina)
• examination includes the vulva and review of the perineum and perianal area
• the skin develops a white appearance; ecchymoses can develop
• the condition alters the vulval architecture resulting in atrophy (resorption of labia minora, phimosis of clitoral hood, introital stenosis, fissuring of the fourchette and/or vestibule during intercourse)
• malignant potential: 1%–4% risk of vulval squamous cell carcinoma (if adequately managed risk is reduced)
• biopsy is used to confirm the diagnosis
• histology reveals homogenised collagen in the upper dermis; basal layer vacuolar degeneration and lymphocytic inflammatory infiltrate; acanthosis of the epidermis
• in established lesions, histology reveals hyperkeratosis, dermal hyalinisation and fibrosis

Management

• Topical steroid therapy can be used for symptoms and to slow the progression of anatomical distortion.
• Treatment starts with potent topical steroids (e.g. betamethasone dipropionate; mometasone furoate 0.1%) and may move to mid-strength topical steroids for maintenance (e.g. betamethasone valerate 0.02%; triamcinolone acetonide).
• Use of topical pimecrolimus may be necessary in cases resistant to topical steroids.
• Vulval care is important: gentle drying of the vulva after washing; cease use of perfumes, deodorants, douches, soaps, fabric softeners, nylon underwear, tight clothing, excessive pad/panty liner use.
• The condition will recur after surgical excision; therefore, vulvectomy has no place.
• Surgery, however, may be necessary to exclude malignancy or to treat introital stenosis.
• Regular follow-up is required due to malignant potential; biopsy any suspicious lesions.

Lichen planus

• Aetiology is uncertain.
• Most cases affect the mucosa of the mouth and gums; 25% of cases have vulval involvement.
• Symptoms include pain, soreness, dyspareunia, discharge and bleeding from lesions.
• It causes epithelial erosions, usually on the medial aspect of the labia minora, extending to a variable degree into the vagina.
• In severe cases, adhesions can cause partial obliteration of the vagina.
• Treatment is with intravaginal steroids or pimecrolimus.
• Oral steroids may be required.
• Lignocaine gel applied prior to intercourse may be helpful.
• Vaginal dilators may be required to help decrease vaginal scarring.

Lichen simplex chronicus (LSC)

• refers to lichenified skin where no other pathology is diagnosed
• causes vulval pruritus especially at night
• skin thickening occurs in response to scratching
• the skin may appear white if moist; fissuring and excoriation may be present
• the condition may have commenced due to a pruritic process (e.g. allergic reactions, fungal infection)
• need to exclude other causes of vulval pruritus to make the diagnosis
• check for iron deficiency, which may be present in LSC
• treatment: topical steroids; behaviour modification (breaking the itch–scratch cycle); eliminate exposure to any irritants
• usually a good resolution if the itch–scratch cycle can be broken

Psoriasis

• autoimmune disease
• causes vulval pruritus
• lesions are erythematous and well demarcated
• no scale is present on vulval lesions
• spares the labia minora, clitoris and vestibule
• can extend to the natal cleft
• look for extragenital lesions to help establish the diagnosis (knees, elbows, scalp)
• treatment: topical steroids

Vulvodynia

• genital dyaesthesia described as pain, burning, stinging and irritation in the absence of visible findings or identified disease of the vulva or vagina
• neuropathic pain: increased concentration of nerve endings in the vestibule have been demonstrated
• can be provoked, unprovoked or mixed/generalised or localised
• may be triggered by: infection (recurrent candidiasis, herpes simplex virus, human papillomavirus), vulval laser or diathermy, trauma, vaginal surgery
• often no apparent trigger
• on examination with a Q-tip swab, one can find tenderness over the vestibular glands and vestibule (which may be erythematous)
• exclusion of candidiasis is imperative; if candidiasis is present, treat with long-term oral antifungals
• a biopsy is only indicated if there is suspicion of other vulval pathology (e.g. lichen sclerosus, vulval intraepithelial neoplasia)
• management involves a multidisciplinary approach: physiotherapy, psychologist (biofeedback), psychosexual counselling, pain management, support groups
• medication for treatment: low-dose amitriptyline or nortriptyline for 3–6 months; explain to patient that not being used as an antidepressant; antiepileptics (e.g. carbamazepine; gabapentin)
• lignocaine gel may be helpful for intercourse
• surgery: rarely indicated, but vestibulectomy may be required for refractory cases

Further reading

Dennerstein G., Scurry J., Brenan J., Allen D. The vulva and vagina manual. Melbourne: Gynederm Publishing; 2005.

Farage M., Galask R. Vulvar vestibulitis syndrome: a review. National Vulvodynia Association News, USA. 2006. Winter

Goldstein A. Dermatological diseases of the vulval. USA: National Vulvodynia Association News; 2006. Summer

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