Vulval/vaginal disorders 

Cervical polyp

Valval Dermatoses

Vulval irritants

Lichen sclerosis 

Vaginal prolapse

Atrophic vaginitis 

Urethral caruncles

Vulval candida

Vulval Itch

Vuvlodynia

Bartholin cyst 

Valval Dermatoses

Vulval irritants

Lichen sclerosis 

• 3% post menopausal women
• Usually genital area  
• Associated with
  • Hashimoto’s thyroiditis
  • rheumatoid arthritis
  •  pernicious anemia
  • type I diabetes mellitus
  • alopecia areata
  • vitiligo
  • morphea
  • immuno-bullous mucocutaneous diseases
• Risk of developing vuvlva cancer

• Clinical
  • White, thickened plaques, which later change to atrophic scarring
  • itching sensation/pruritis
  • structural alteration in the vulva
  • affected skin sites including the head, neck, scalp, palms and soles, periorbital area, tongue, lip, and peristoma skin

• Complications
  • Can cause scarring of vulva, loss of labia minora, fusion
  • Painful fissuring, blisters, bleeding
  • If untreated 5% vuvlal carcinoma

• Investigations
  • Confirm with 3-mm punch biopsy of a white area under local

• Treatment
  • The lifelong and potentially progressive nature of LS; appropriate treatment can stop the condition from worsening.
  • Potent topic steroid
    • Betamethasone diproprionate 0.05%  
    • Twice daily until itching ceased, then once daily until skin normalises
    • Can take several months, monitor 6 -12 weekly
    • Won’t reverse scarring
  • When improved – ongoing use of a lower potency steroid
  • Also consider managing post-menopausal dryness with estrogen
  • Consider pelvic floor physiotherapist/counselling
  • Dermatologist ongoing management
  • Surveillance 6-12 monthly
  • Avoid vaingal irritants
  • Regular emollients

Vaginal prolapse 

• Anterior/cystocelePosterior/rectocele   
• Uterine prolapse

• Risk factors
  • Increasing age
  • Number pregnancyes
  • Vaginal delivery with instrumental
  • Young age at first pregnancy
  • Obesity
  • Smoking/chronic cough
  • Genetic
  • Chronic constipation
  • High infant birth weight
  • Pelvic surgery

• Treatment
• Non-parm
  • Lifestyle Modifications:
    • Weight Management: Achieving and maintaining a healthy weight to reduce pressure on the pelvic floor.
    • Dietary Adjustments: Increasing fiber intake to prevent constipation and reduce straining during bowel movements.
    • Avoiding Heavy Lifting: Minimizing activities that increase intra-abdominal pressure.
  • Pelvic Floor Muscle Training (PFMT):
    • Kegel Exercises: Regularly performing pelvic floor exercises to strengthen the pelvic muscles.
      • Contract and hold the pelvic floor muscles for a count of 5-10 seconds.
      • Relax for the same duration.
      • Repeat 10-15 times per session, three times a day.
    • Biofeedback: Using devices to provide feedback on muscle contraction, helping ensure proper exercise technique.
  • Physical Therapy:
    • Pelvic Floor Rehabilitation: Working with a physical therapist specializing in pelvic floor disorders to develop a personalized exercise regimen.
    • Manual Therapy: Techniques to improve pelvic alignment and muscle function.
• Pharmacological
  • Vaginal Pessary: A removable device inserted into the vagina to support areas of prolapse.
    • Different types (e.g., ring pessary, Gellhorn pessary) can be fitted based on the specific type of prolapse.
    • Regular follow-ups are necessary to ensure proper fit and monitor for potential complications like vaginal irritation or infection.
  • Vaginal Rings:
    • Usage: Inserted into the vagina and left in place for 3 months.
    • Examples: Estring™.
    • Dosage: Releases a consistent dose of estrogen over time.
  • Anterior Colporrhaphy:
    • Purpose: Repair of cystocele (bladder prolapse).
    • Procedure: Tightening the front (anterior) vaginal wall by suturing the supporting tissues.
    • Advantages: Effective for anterior vaginal wall prolapse.
  • Posterior Colporrhaphy:
    • Purpose: Repair of rectocele (rectal prolapse).
    • Procedure: Tightening the back (posterior) vaginal wall by suturing the supporting tissues.
    • Advantages: Effective for posterior vaginal wall prolapse.
  • Vaginal Vault Suspension:
    • Purpose: Support of the vaginal vault (top of the vagina) after a hysterectomy.
    • Types:
      • Sacrospinous Ligament Fixation (SSLF):
        • Procedure: The vaginal vault is attached to the sacrospinous ligament.
      • Uterosacral Ligament Suspension:
        • Procedure: The vaginal vault is attached to the uterosacral ligaments.
      • Sacrocolpopexy:
        • Procedure: The vaginal vault is attached to the sacrum using a mesh graft.
        • Approach: Can be done through abdominal surgery or minimally invasive techniques (laparoscopic or robotic).
  • Hysterectomy:
    • Purpose: Removal of the uterus, often combined with other prolapse repairs.
    • Types:
      • Vaginal Hysterectomy: Removal of the uterus through the vagina.
      • Laparoscopic or Robotic Hysterectomy: Minimally invasive removal of the uterus.
      • Abdominal Hysterectomy: Removal of the uterus through an abdominal incision.
  • Mesh Augmentation:
    • Purpose: Provide additional support to weakened vaginal tissues.
    • Procedure: Placement of a synthetic mesh to reinforce the vaginal walls.
    • Types:
      • Anterior Mesh: For cystocele repair.
      • Posterior Mesh: For rectocele repair.
      • Apical Mesh: For vaginal vault prolapse.

Atrophic vaginitis 

Causes:

• Associated with estrogen deficiency due to:
  • Menopause
  • Lactation
  • Hyperprolactinaemia
  • High-dose progesterone medicines
  • Breast cancer medication (e.g., tamoxifen, aromatase inhibitors)

Symptoms:

• Vaginal or vulval dryness
• Vaginal or vulval itching (pruritus vulvae)
• Vaginal burning
• Painful sex (dyspareunia)
• Skin splitting (fissuring) at the vaginal entrance (posterior fourchette)
• Vaginal spotting (bleeding)
• Dysuria (burning sensation when urinating), urinary urgency, frequency, incontinence (genitourinary syndrome of menopause)

Bacteria in the Vagina:

• Estrogen deficiency leads to changes in vaginal flora:
  • Lactobacilli disappear, replaced by gram-negative organisms (e.g., Escherichia coli) or those associated with bacterial vaginosis.
  • Increased risk of urinary or bladder infections in postmenopausal women.

Physical Appearance:

• Vulva appears paler
• Labia are thinner and smaller
• Less obvious clitoral hood
• Red membrane or polyp visible at urethral opening (urethral caruncle)
• Vaginal skin looks thin, dry, with visible tiny blood vessels and patchy redness
• Skin splitting at the bottom of the vagina or elsewhere when vulva is stretched

Diagnostic Tests:

• Skin Swab/Wet Mount Examination: To identify epithelial cells typical of postmenopausal vagina and detect infection.
• Biopsy: To rule out inflammatory skin disease or neoplastic conditions.
• Cystoscopy: To investigate bladder and urinary symptoms.
• Colposcopy: To examine vagina and cervix for gynecological symptoms.

General Measures:

• Use non-soap cleanser or wash with warm water alone, no more than once or twice daily.
• Apply emollient cream suitable for sensitive skin or petroleum jelly for dryness or itching.
• Use lubricants for sexual intercourse; if stings, try different products or oils.
• Trial of a vaginal moisturizer.
• Consider stopping anticholinergic, antihistamine, decongestant, or antidepressant medications that may contribute to dryness.
• Short-term use of topical steroid for dermatitis caused by irritants (e.g., urine, panty liners, tight clothing).

Estrogen Treatment:

• Topical Estrogen: Prescription treatments such as vaginal cream, pessaries, or vaginal ring (e.g., Ovestin™, Vagifem™).
  • Dose: Ovestin™ 0.5 mg/day for 1-2 weeks, then once or twice weekly.
• Benefits:
  • Normalizes vaginal wall cells
  • Improves vaginal blood flow
  • Decreases vaginal pH
  • Re-colonizes with lactobacilli
  • Improves vaginal thickness and elasticity
  • Reduces vulvovaginal symptoms
  • Enhances sexual function
  • Reduces urinary infections
• Safety: Topical estrogen is safe with minimal systemic absorption but not recommended for women with severe liver disease, estrogen-dependent cancers, or thromboembolic disease.
• Systemic Estrogen: Tablets, patches, gels, sprays, and emulsions (usually mixed with progestogens) are available but have significant risks and side effects, so not typically used solely for atrophic vaginitis.

Side Effects and Risks of Vaginal Estrogen Therapy:

• Vaginal itching and burning
• Increased risk of vaginal Candida albicans infection (thrush)
• Breast discomfort (uncommon)
• Vaginal bleeding (rare)
• Side effects are minimal when used once or twice weekly.

Other Treatments:

• Experimental Options for symptomatic women intolerant of estrogen therapy:
  • Platelet-rich plasma injections
  • Hyaluronic acid or fat implants (lipofilling of labia majora)
  • Fractional carbon dioxide laser, nonablative erbiumlaser, diode laser, and monopolar radiofrequency devices
  • Vaginal surgery (vaginoplasty)
• Note: Optimal regimens, effectiveness, and safety of these procedures are not yet well-established.

Urethral caruncles

• Benign fleshy outgrowths at the urethral meatusv  
• Post menopausal women
• Often asympatomica
• Sometimes – light bleeding, dysuria, pain or obstruction to urine flow
• Diagnosis – characteristic findings
• Treatment
  • Not required
  • Trial topical estrogen
  • Can excise if bothersome

Vulval Itch

Pruritus vulvae refers to itching in the vulval area without a known skin condition. It is different from vulval pain or vulvodynia (chronic burning sensation without clinical signs). Itching, pain, and burning can coexist.

Who Gets an Itchy Vulva?

Itchy vulva can affect girls and women of all ages and races, with varying severity and frequency. Some may have an associated skin condition, while others may not.

Causes of Vulval Itching

1. Infections

• Candida albicans (Vulvovaginal Thrush): Common in postpubertal women; rare in postmenopausal women unless diabetic or on estrogen/antibiotics.
• Bacterial Vaginosis: Causes a frothy, malodorous discharge; less commonly causes itch.
• Genital Viral Warts: Often itchy.
• Pinworms: Can cause nocturnal itching.
• Other Rare Infections: Cytolytic vaginosis, trichomoniasis.

2. Inflammatory Skin Conditions

• Irritant Contact Dermatitis: Common due to:
  • Lack of estrogen (prepubertal or postmenopausal)
  • Atopic dermatitis tendency
  • Scratching, rubbing, friction
  • Moisture from occlusive underwear, urine, feces
  • Soaps, cleansers, chemicals, medications
  • Vaginal secretions (normal, excessive, or infected).
• Severe Itch Conditions:
  • Lichen simplex
  • Lichen sclerosus
  • Lichen planus.
• Other Skin Disorders:
  • Psoriasis
  • Seborrhoeic dermatitis
  • Allergic contact dermatitis
  • Urticaria
  • Dermographism
  • Folliculitis.

3. Neoplasia

• Squamous Intraepithelial Lesions (VIN):
  • Benign and malignant neoplasms can cause itching, often asymptomatic in early stages.

4. Neuropathy

• Considered if no signs of infection or skin disease, may be due to injury, surgery, or disease (e.g., pudendal entrapment).

Clinical Features

The location and appearance of the rash help determine the cause. Specific areas affected might include:

• Convex areas/thighs: Irritant contact dermatitis or allergic dermatitis.
• Flexures: Seborrhoeic dermatitis or candida intertrigo.
• Mons pubis: Seborrhoeic dermatitis or folliculitis.
• Labia majora: Psoriasis, atopic dermatitis, lichen simplex.
• Labia minora: Lichen sclerosus, lichen planus.
• Vaginal introitus: Erosive lichen planus, atrophic vulvovaginitis.
• Perineum: Dermatitis, lichen sclerosus.
• Any site: Neoplasia.

Complications

An itchy vulva can lead to psychological distress, sleeplessness, and secondary bacterial infections due to scratching.

Diagnosis

Diagnosis involves a thorough history and examination, including:

• Full skin examination.
• Microbiological swabs.
• Skin biopsy.
• Patch tests for contact allergies.

Treatment

Treatments are condition-specific and may include:

• Antifungals/antibiotics for infections.
• Topical steroids/calcineurin inhibitors for inflammatory diseases.
• Oral antihistamines for urticaria.
• Surgery for neoplasia.
• Neuropathic treatments: Tricyclic antidepressants, serotonin reuptake inhibitors, anticonvulsants.

Nonspecific Treatments:

• Minimize scratching.
• Wear loose-fitting, absorbent clothing.
• Use emollients and barrier preparations.
• Avoid irritants and excessive washing.

Prevention

While prevention depends on the cause, maintaining vulval health through the above nonspecific measures can help reduce the risk of itchiness.

Vulval candida

• Treatment
  • Clotrimazole cream intravaginally 1% 6 night, 2% 3 nights, 10% 1 night
  • Clotrimazole pessary 100mg 6 nights, 500mg 1 night
  • Miconazole 2% vaginal cream 7 nights
  • Nystatin 100,000u/5g vaginal cream 14 nights
  • Fluconazole 150mg PO stat
  • Non soap cleanser
  • Avoid douches, tight clothing, saunas, incontinence, wear loose cotton underwear
  • Avoid vulva irritations/steroid creams

Vuvlodynia

• Can be localised/provoked or generalised
• Often tender to touch/pressure, provide by tampons, intercourse, tight clothing
• Primary or secondary — depending if arose before or after first intercourse
• No specific tests

• Management
  • Avoid irritants
  • Appropriate underwear
  • Skin care
  • Lubrication
  • Physiotherapy for pelvic muscle dysfunction
  • Topical lignocaine
  • Low dose TCA – amitriptyline
  • SNRIs- duloxetine, venlafaxine
• Causes vulval pain
  • Vuvlodynia – pain syndrome
  • Infection – candida, BV< herpes
  • Dermatoses – eczema, lichen simplex chronicus, contact dermatitis, psoriasis, lichen sclerosis
  • Vaginal atrophy
  • Neoplastic – VIN, Pagets, SCC
  • Trauma
  • Vaginismus – often with vulvodynia
  • Neurolgoical pudendal nerve neuralgia

Bartholin cyst 

• Bartholin’s glands^[
• Pea-sized glands located bilaterally at the 4 o’clock and 8 o’clock positions of the posterior introitus
• Provide lubrication to the vagina by secreting mucus via ducts into the introitus
• If normal, usually cannot be felt by simple palpation

• Epidemiology:
  • 2% of women have a lifetime incidence of a Bartholin’s cyst or abscess
  • Much more common in reproductive-age women  

• Pathogenesis:
  • When a Bartholin’s duct is obstructed, mucoid secretions cannot be released^[
  • Secretions build up inside the duct and eventually form a Bartholin’s cyst
  • If the cyst becomes infected, it develops into a Bartholin’s abscess
  • However, an abscess does not always need a cyst to precede it
  • Initially thought to be caused solely by STI organisms, but that is no longer the case

• Clinical Presentation:
  • Usually painful, unilateral, and located at the 4 o’clock or 8 o’clock position
  • A Bartholin’s cyst, while located in the same position, is usually not painful
  • Fluctuant mass with possible induration/erythema on overlying skin
  • May already be draining purulent fluid

• Differential Diagnosis:
  • Soft Lesion: Bartholin’s cyst, Bartholin’s abscess, Skene’s duct cyst, Epidermal inclusion cyst
  • Firm Lesion: Leiomyoma, Lipoma, Squamous cell carcinomA
• History:
  • How long have symptoms been occurring?
  • What is the extent of the patient’s pain? Is it occurring with simple movements such as walking or intercourse?
  • History of prior Bartholin’s cyst or abscess?
  • Obtain a thorough sexual history to differentiate various genital lesions

• Physical Exam:
  • Perform both an external and internal exam to determine extent of patient’s symptoms
  • Important points to consider during your exam:
    • Are there multiple lesions?
    • Is the lesion painful?
    • Are there any overlying skin changes?
    • Are there systemic symptoms?
    • If there is vaginal discharge or cervical motion tenderness, an STI etiology may be more likely

• Management:

• Rarely resolves on its own. 
• If a patient has pain, intervention will likely be needed
• Treatment begins with an incision and drainage.
•  Afterwards, a Word catheter or Jacobi ring must be used
• I&D: This step will be like any other I&D
  • Anesthetize the area with lidocaine
  • Using a #11 blade, make a vertical incision posterior to the labia minora. This location will prevent notable scarring
  • Break up loculations with a hemostat to allow proper drainage
  • Send off a culture after collecting purulent fluid on a culture swab
• Bartholin’s abscess I&D is not a definitive treatment
  • 13% of patients will have recurrent abscess
  • This is due to premature closure of the tract which prevents further drainage
  • To allow continued drainage and thereby prevent recurrence
    • a Word catheter
    • Jacobi ring should be placed
• Word catheter: Short, rubber catheter with a balloon tip^[8]

• Antibiotics
• Should cover Gram-positive organisms, including MRSA
  • Choices include Bactrim 800mg/160mg BID x7 days or
  •  Doxycycline 100mg BID x7 days
• Sitz baths
• refrain from intercourse
• Patient should follow up with an OB/GYN after discharge due to risk of recurrence

Cervical polyp 

• Cervical polyps are benign growths, usually protruding from the surface of the cervical canal. 
• They commonly occur during the reproductive years, especially after the age of 20.
• Although cervical polyps are commonly benign, malignant polyps can present in 0.2 to 1.5% of the cases. 
• Malignant polyps are more likely to be seen in postmenopausal patients. 
• categorized 
• The endocervical polyps are the most common type
  • occur in premenopausal women. 
  • arise from the cervical glands in the endocervix.
• The ectocervical polyps
  • more common in postmenopausal women 
  • arise from the outer surface layer cells of the cervix within the ectocervix
• Treatment
  • symptomatic polyps usually don’t need any intervention
  • Symptomatic, large, or atypical polyps usually warrant removal
  • polypectomy followed by cauterized to prevent bleeding and reduce the recurrence rate. However, if the base is very wide, it can be treated using electrosurgery or laser ablation

• Complications
  • infertility when they grow big enough to block the external os of the cervix.
  • can become inflamed or infected
  • polypectomy itself can be associated with a few complications, which include:
    • Infection
    • Hemorrhage
    • Uterine perforation