Vulval Problems - Spire Healthcare

Common Vulval Problems
Nitu Bajekal
MBBS, MD,DNB,FRCOG
Consultant Gynaecologist
Spire Bushey Hospital
Barnet & Chase Farm Hospitals NHS Trust
Website www.nitubajekal.co.uk
The Normal Vulva
Likely Diagnosis?
 A 2 month old baby is brought
to the surgery with a rash

40 year old female suddenly noticed
severe itching after using a new
perfumed toiletry.
A 45 year old woman gives a history
of recent onset of vulval itching,
burning and soreness
Questions you may wish to ask?
Examination findings?
Likely treatment suggestions?
Contact Vulval Dermatitis
Most common cause of chronic vulval symptoms
Accounts for 1/3 of consultations
 Irritant Dermatitis.
Irritants can include laundry
detergents, toilet paper,
deodorants, lubricants,
spermicides, sanitary pads,
bath products, urine.
 Allergic Dermatitis to
perfume in toilet paper,
latex, /lanolin
Contact Vulval Dermatitis –
Allergic or Irritant
 Remove irritant, use soap
substitute, steroids/emollients
 Vulval care/antihistamines
 Genetic predisposition
 Look for superimposed infection
General Vulval Care
Applicable to all benign vulval conditions
Ø Healthy diet, rich in fruit and vegetables.
Ø Use non-soap based washes/emollients, Epaderm, Oilatum
Ø Use an emollient (moisturiser) cream such as aqueous cream
to clean the genital area.
Ø Use Non- Biological washing powders.
Ø Avoid synthetic underclothes.
Ø Avoid perfumed toiletries.
Ø Avoid fabric conditioners.
Ø Avoid scratching, better to use a cold flannel
Ø Avoid tight clothes, which can make the area hot and itchy
A 50 year old woman complains of
dryness and painful intercourse –
Likely cause?
 Relevant questions?
 Examination
findings?
 Likely suggestions?
Atrophic Vulvo Vaginitis
(Menopause)
 ↓Barrier function/vulva
close to rectum
 ↓estrogen/lipid
production
 ↑in pH (less acidic)
 ↓cell mediated immunity
 Vulnerable to excess
cleaning/ammonia from
urine
 1/3 women- dyspareunia
dryness/irritation/itching/
 Pallor/loss of rugosity
/petechiae/loss of pubic hair
 General vulval care
 Vaginal estrogen safe, effective,
use as long as needed
 Oral HRT most effective, <5yrs
For treatment of vasomotor symptoms
26 year old accountant, burning vulval
pain & painful superficial intercourse
– recent onset
Vulvodynia
 Provoked pain (VVS)
 Unprovoked pain
 Generalised around vulva
 Localised
Pain:
 Spontaneous pain
 Pain is burning, soreness
 Itching not as common
 Pain with light touch eg
tampon use or sexual
intercourse
Aetiology
&Treatment
 May be alteration in neuro
pathway of vulva so that
sensations such as touch
and pressure are perceived
as pain and discomfort.
 Poorly understood condn
 History/exam – Cotton bud
test for pain, swabs
 General Vulval Care
 Difficult to treat
 Self Help groups
 Topical :Lidocaine ointment
 Oral medications first line
 Tricyclic antidepressants
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SSRIs
Anticonvulsants Gabapentin
Biofeedback (pelvic floor awareness)
Acupuncture
Low oxalate diet with calcium citrate
suppl
 Cognitive behaviour therapy
 Intralesional injections

Triamcinolone & bupivacaine
 Surgery - rare
52 year old lady with a 1 year
history of
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Vulval itching
Vulval soreness
No change in habits
Treated several times for
thrush
 Menopausal
 On Thyroxine
 History of childhood
eczema
What is the likely diagnosis?
 Chronic,relapsing inflammatory skin
disorder :commonly affects vulva,
perineal and perianal skin(85 -98%)
 Pruritus and Pain
 1 in 30 elderly women to 1 in 59
women in a general gynaecology
practice
 Prepubertal & postmenopausal peaks
 Can affect men and other areas
 Unknown etiology
Symptoms of Lichen Sclerosus
 Same in children/adults.
 Persisting
itching
or
soreness of the vulval area,
in spite of usual treatment
 Pain, fissuring, erosions
 Splitting of the vulval skin,
causing stinging and pain
 Small, subtle white spots
early on, are slightly shiny,
smooth, become confluent.
 Skin parchment paper,
figure of 8 distribution in
perianal skin
Symptoms of Lichen Sclerosus
 Scarring may cause labia
minora to shrink and
disappear, the opening of
the vagina to narrow,
causing urinary difficulties/
sexual problems
 Loss of vulval features,
labia, clitoris
 Does not affect vagina
cervix/uterus etc
Advanced LS
Lichen Sclerosus
Aetiology & Prognosis
 Cause ? ? Genetic
 Connection between LS and
thyroid disease, vitiligo/autoimmune disease (1 in 4).
 History of eczema or psoriasis
 Risk of cancer– Squamous cell
cancer -3%, over many years
 Early diagnosis allows the
correct support/treatment to start
 The condition is chronic
 No permanent cure.
Diagnosis of Lichen Sclerosus
 Can take several years and several visits to various health
professionals before the diagnosis is considered.
 This can be very frustrating for the woman considered.
 Refer to a dermatologist or a gynaecologist with a special
interest in vulval conditions.
Vulval Symptom Sheet
Welcome to the Vulval Clinic.
Please complete this form to aid us in your care
Vulval Hygiene
Do you use soaps/shower gel/detergents to
clean the vulva? Yes
No
Do you shampoo hair in the bath or
shower?
Yes
No
Do you use bubble bath?
Yes
No
Do you wear tights/synthetic material
trousers?
Yes
No
Do you wear panty liners?
Yes
No
Do you use wet ones/feminine wipes?
Yes
No
Do you suffer from urinary incontinence?
Yes
No
Do you have pain/difficulty with sexual
intercourse
Yes No
N/A
Symptoms
Do you get vulval itching?
Yes
No
Do you get vulval soreness/pain/Burning?
Yes
No
What creams/medication (if any) have you used?
Name and for how long, if possible
Associated Medical conditions
Do you have Diabetes?
Yes
No
Do you have a Thyroid problem?
Yes
No
Do you suffer from any skin conditions?
Yes
No
If Yes, what
Other
Do you suffer from any medical or
gynaecological conditions or had any
operations?
What medications are you taking?
Are you allergic to anything?
Vulval History Sheet
Gynaecological History
Presenting Complaint:
Itching
LMP:
Menopause:
Periods: HRT:
IMB/PCB:
Smears (past & present):
Sexual History/STIs
night-time itching
bleeding
Vulval soreness/pain/burning
provoked
unprovoked
Generalised
Localised



Onset/Duration of symptoms:
Exacerbating/relieving factors:
Topical treatments/medication tried (and period
of use):
History of:
 Diabetes/Thyroid disease
 Eczema/Psoriasis/other skin conditions
 Autoimmune disease (eg.Lupus)
 Smoking/Alcohol
Obstetric History:
Medical/Surgical History:
Drug History:
Allergies:
Family History:
Examination:General:
Local:Vulva/Vagina/Pelvic:
Management Plan:
Information Leaflet:
Follow Up:
Diagnosis of Lichen Sclerosus
 A vulval biopsy, under a local anaesthetic is needed, only
if in doubt of diagnosis or malignancy suspected
 Vulvoscopy, which involves looking at the affected areas
with a colposcope and 5% acetic acid to allow proper
examination and to help in selecting the right area for
biopsy.
 Skin swab if infection suspected
 Test for diabetes and thyroid dysfunction
Vulvoscopy Set Up
Vulval Biopsy
(Local anaesthetic, Keyes 4mm punch)
Difficulty in Sexual Intercourse
 Vaginal Dilators may
be recommended,
where vagina is
narrowed in LP or
the introitus is tight
from scarring in LS
 Lubricants may be
useful during sex if
this is painful.
Treatment of LS
 Topical steroids:
A strong steroid ointment is the main treatment. Steroids
reduce inflammation and reduce cytokine production.
 Irritation tends to ease after two weeks or so, but the skin
may take about three months of treatment to look and feel
better.
 The skin may return to normal if lichen sclerosus is
diagnosed and treated in its early stages.
Treatment of LS
Dermovate ointment (high potency clobetasol 0.5%) –
 Once daily for 2 -4 weeks
 Alternate nights at bedtime for 2-4 weeks
 1-2/ weekly for 3 months and review
 77% sig improvement
After the initial regular treatment, ointment may need to
be used once or twice every 1-2 weeks to keep symptoms
away.
 Trimovate ointment(contains moderate potency
clobetasone butyrate 0.05% w/w, oxytetracycline 3.0% and
nystatin 100,000 units per gram)
Follow up of Lichen Sclerosus
 Initial follow up in 3 -4 months to check response and compliance
 Subsequent annual follow up for 1-2 years
 Educate woman to report persistent itching, non healing ulcers, any
uncontrolled symptoms, lumps, PMB.
 Surgery rarely needed. Sometimes if scarring is severe, this may
need to be released.
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Further help and information
National Lichen Sclerosus Support Group
2011 RCOG Guideline on vulval disease
www.lichensclerosus.org
Lichen Planus (LP)
 Half the women with
vulval \vaginal LP also
have oral LP.
 Signs of vulval LP include
sores, redness, vag d/c
 Multidisciplinary approach
Treatment may include
 Steroid Ointments
 Systemic steroids, rare
 General vulval care
Vulval Psoriasis
Vulval Eczema
 Usually have it elsewhere
 Symptoms may include
scaly, red plaques
 Other signs for psoriasis nail pitting, scalp scaling
 Family history.
 Biopsy
 Treatment includes topical
steroids/low dose coal tar
cream.
Vulval Infections
Candidiasis (Thrush)
 Itchiness or redness; cottage
cheese discharge
 Discomfort and/or painful
intercourse.
 Does not occur in children
 Rule out diabetes
 May have chronic vulval pain
 If symptoms persist, consider
other causes
Vulval infections
Refer to Local GU clinic for full screen
Genital Herpes
HSV
Condyloma acuminata
(venereal warts - HPV)
Vulval Disease in Childhood
 Atopic Dermatitis, psoriasis and
lichen sclerosus are the three most
common conditions.
 Poor hygiene is rarely responsible
for vulval symptoms
 Intravaginal foreign bodies rare.
 Diagnose on history/examination
and usually a bacterial swab is only
required.
 Sexual abuse is always an issue but
rare.
Vulval Disease in Childhood
 Thrush is not seen in the non-oestrogenised
vulva/vagina.
 Infective vulvovaginitis in girls is almost
always due Group A beta-haemolytic strep
 General vulval care measures
 Chlorinated water is a powerful irritant.
Apply vaseline or zinc cream before
swimming.
 Incontinence, either enuresis or
constipation with overflow, needs to be
dealt with.
 1% hydrocortisone safe in children
Vulval Intraepithelial Neoplasia
(VIN)
 80% of untreated VIN 3 will
progress to cancer.
 Differentiated (5%) – LS
 Usual (Multifocal) – 95%
 Look for global disease – CIN,
AIN, VAIN
 Smoking and HPV risk factors
 Wide excision and follow up
 Newer treatments – drugs such
as Imiquimod – topical immune
response modifier by ↑local
cytokine production
Vulval Cancer
 3-5% of all genital
cancers
 Incidence increasing
 Long standing Itching
 Lump or mass
 Treatment – excision
of tumour with
nodes/radiotherapy
Key Learning Points
Vulval Problems
 General vulval care with emollients applicable to all & is
first line treatment
 Contact irritant or allergic dermatitis most common
 Atrophic Vulvovaginitis – local estrogen safe & effective
 Vulvodynia: Detailed history and examination helpful.
Key Learning Points
Vulval Problems
 Lichen Sclerosus: Early diagnosis allows support
and treatment to commence early.
 It is a chronic inflammatory condition
 Cancer very rare.
 Educate woman to use steroid ointment
regularly, safe, effective. Report lumps,
uncontrolled symptoms, PMB
 Help and support is available with specialists
 Handle the prepubertal child with care
General Vulval Care
Give written information
DO NOT
DO USE
 use Soap,shower gel or
detergent to cleanse
 Soap substitute-aqueous
cream/Oilatum/Balneum
 wear synthetic
underwear/trousers
 Wear cotton knickers/Loose
garments
 Address urinary incontinence
 wear panty liners
 wet wipes/feminine wipes etc
 scratch, use a cold flannel and
press
 Plenty of emollients
 Steroid ointment regularly in
Lichen Sclerosus
 Do seek help if unusual
lumps/PMB/uncontolled Sx
www.nitubajekal.co.uk
Vulvodynia
Cancer/VIN
Warts/Thrush
Lichen Sclerosus
Lichen Planus
Dermatitis
Psoriasis
/Eczema