What are some symptoms of a vulval condition?
Vulval Pain and discomfort (also called vulvodynia) can be caused by a number of conditions. It can be experienced during intercourse, or it can be constant or intermittent pain. Very careful consultation is required when diagnosing and treatment and counseling around vulvodynia, as it can often be a symptom of a serious underlying condition which warrants immediate treatment. Any visible abnormalities – things such as a lesion or skin whitening, rash, ulceration, swelling or lumps, bleeding, itching or burning – are causes for investigation.
What is Lichen Sclerosus?
Lichen Sclerosus (LS) is a skin condition. It may involve any part of the skin, but most often it is found on the genital area. This information is about genital LS only.
LS is more common in women than in men. It can start at any age, most commonly around menopause, but also occurs in young children. Once LS starts, it usually continues for life. Although a specific cause of LS is yet to be identified, evidence supports the likelihood of a genetic component and autoimmune connection. It is not an internal disease and never extends into the vagina.
The typical appearance is of whitened skin around the vulva, perineum and anus. There may also be lesions that look like blisters and bruises. As a result, it often leads to a concern of sexual abuse in children.
LS may cause scarring, resulting in loss of the labia minora (inner lips of the vagina) and reduction in size of the vaginal opening if the condition has not been treated for a long time.
To diagnose Lichen Sclerosus, a vulvoscopy and a skin biopsy are required. Although it is not contagious and is therefore not communicable between the patient and their partner (or the patient and yourself), it needs appropriate treatment and continued monitoring as it is a precancerous condition.
Vulval Candida (Thrush)
Thrush (also known as ‘monilial’ or yeast infection) is a very common condition in menstruating women which causes an itchy and uncomfortable feeling which affects the vulva and vagina. It is caused by the fungus Candida, a type of yeast which occurs naturally on the body.
Common home remedies such as yoghurt and probiotics have not been shown to have any benefit. As the fungus thrives in a high sugar environment, patients with uncontrolled diabetes are prone to thrush and a low sugar diet is recommended to reduce the risk of infection.
Although thrush is very common, it is advisable to take a swab to confirm the infection before suggesting a treatment. Thrush is generally treated easily with over-the-counter antifungal pessaries or a single dose tablet provided the case is once-off and not ongoing.
Around 75% of women will contract thrush at some point during their lifetime, but chronic and ongoing thrush may a symptom or misdiagnosis of a more serious condition such as Lichen Sclerosus. As a result, it is best to monitor ongoing cases.
Sexual transmission of the Candida fungus to a partner is possible, though preventative treatment of the partner is not necessary or recommended.
Diagnosis of Vulval Conditions
A vulvoscopy is required for any patient requiring a diagnosis of any untreated and ongoing vulval conditions.
What is a Vulvoscopy?
A Colposcope is used to magnify the area (this is not inserted into the body) so any abnormal changes may be seen clearly by the doctor. A weak solution of Acetic Acid (vinegar) is applied on the vulva, which turns abnormal cells white compared to normal cells. The Acetic Acid may sting slightly when applied.
If abnormal cells are detected during the examination, a small biopsy (tissue sample) will be taken under local anaesthetic to be examined for abnormal cells. The biopsy is 3-4 mm in diameter and a dissolving suture may be placed to close it. The suture will dissolve and fall out in the next 5-7 days without the need for a follow-up appointment to remove it.
The vulvoscopy will show whether or not treatment is needed and will determine the nature of an abnormality. It is important to determine the diagnosis as some of the conditions affecting the area carry a malignant potential.
Preparation for a Vulvoscopy
A vulvoscopy takes approximately 20 minutes to complete. If a biopsy is taken, the area from which the sample was taken will be sore afterwards when the local anaesthetic wears off. It would be advisable for a patient to take 2 panadol tablets 1 hour before the procedure.
After the Vulvoscopy
It is advised not to have intercourse until the biopsy site has healed (at least a week). The patient will then need to return in 1-2 weeks time to discuss the vulvoscopy results and any further treatment required.
Vulval Skin Care
Using soap (particularly if this is done frequently), will make the skin more sensitive. Soap, abrasive washers, and wet wipes should all be avoided. A soap substitute such as QV wash, or simply soaking in the bath is the best way to clean vulval skin.
When having a bath, make sure it is not too hot. Avoid bubble bath, perfumed oils, medicated bath oils and antiseptics. A bath oil formulated for sensitive skin or just a handful of salt is the best bath additive.
Saline (can be made at home by a patient by adding two teaspoons of salt to a litre of water, or bought commercially) is useful for cleaning inflamed vulval skin It is best applied on a wad of cotton wool or used to soak in a bowl.
Vulval skin should be patted dry gently to avoid scratching with a towel. It also may be helpful to dry sensitive vulval skin with a hair dryer set to the coolest setting.
Avoiding irritating substances
Patients should avoid perfumed products, feminine sprays and antiseptics. Old medications from previous conditions should never be used. Methylated spirits, aloe vera and tea tree oil are popular remedies for vulval skin conditions, but they can be very irritating and can even make the afflictions worse. Tampons, rather than pads, are better for menstruation if possible: the plastic backing in pads is not breathable and can cause a build-up of fluids which promote bacteria growth. Pantiliners should not be used on a daily basis between, periods, as even “breathable” liners may increase irritation. Rather than advising the use of liners for patients with heavy discharge, it is better to advise that they change their underwear at lunchtime and put the used item in a snap-lock plastic bag to wash at home.
Similarly, nylon underwear should be avoided due to its lack of breathability, as well as tight pants, G-string underwear, and control panties. Swimming costumes worn in a chlorinated pool should be removed and washed immediately after swimming to minimise the chance of infection.
Many women have difficulty cleaning after a bowel motion which leads to irritation caused by excessive wiping. A simple solution is to put a thick layer of petroleum jelly also known as Vaseline over the anal skin before producing a motion. This protects the skin and makes cleaning much easier. It is also best to use hypoallergenic toilet paper (such as Sorbent) to clean with, as they are less likely to cause abrasion and irritation to the anus and vulva.
Things you could be allergic to
Many commonly used items can cause allergic reactions resulting in vulval discomfort. These include:
- Toilet paper
- Any medication, either prescribed or over-the-counter
- Perfumed products
- Antifungal creams and pessaries
- Nail polish
- Latex condoms
Patients should avoid contact with any items which they believe may be causing or worsening their conditions, and should be screened for possible allergies if the symptoms persist.
Most patients with a vulval problem have found that it has interfered with their sex life in some way. Sexual arousal may be less easy, leading to anxiety, dryness and sometimes painful vaginal spasm. It is normal for women to take longer to become aroused than men, and it is important to encourage patients not to attempt vaginal intercourse until aroused.
Patients should not attempt penetration if it is causing pain. Instead, they should wait until their issue has settled completely. It is possible to have a sex life without penetration, and it may be necessary to prompt the patient to have this discussion with their partner.
Lubricants can often assist in intercourse, but gels should be avoided. These usually sting and can contain antiseptics which may result in further complications.
Ongoing Vulval Care
Remember that this problem is one that needs ongoing care. Forgetting about treatment may lead to relapse, so it is important to make treatment part of a daily routine.
Vulval conditions often require ongoing care from specialists, such as the ones here at Northside Gynaecology. We are an all-female gynaecology clinic dedicated to providing professional care to women who suffer from all manners of related conditions, and we pride ourselves on providing the best treatments possible to help better the lives of women living with vulval conditions.
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