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Vulvitis

Vulvitides

Vulvitis describes an inflammation of the outer female genitals, that includes labia, clitoris and the openings of the vagina and urethra. The terms vulvovaginitis and vaginitis are often utilized to refer to that same pathological condition.


Presentation

The most commonly reported symptoms are irritation, pruritus and pain. Some women claim sensations of soreness, rawness and burning, whereby the latter may aggravate when urinating. In general, symptoms are often experienced as more severe during the night.

Acute forms of vulvitis are characterized by a sudden onset of erythema, edema and pain and may be accompanied by mucoid discharge. There are also subacute forms of vulvitis that may be recognized on the basis of erythematous patches and plaques [7].

Clinical examination of the vulvar area, pubis and perineum should reveal signs of inflammation such as erythema and edema. Labia majora and minora as well as the vulvar vestibule are most severely affected in cases of vulvitis, but erythema may extend to adjacent regions.

Cheilitis
  • We hereby report, the association of granulomatous cheilitis with granulomatous vulvitis in a 30-year-old female.[ncbi.nlm.nih.gov]
  • Merkersson-Rosenthal syndrome (MRS) is characterized by cheilitis or pareitis granulomatosa, facial palsy, and fissured tongue. Sometimes the forehead, eyelids and chin are involved, and occasionally genital lesions are present.[ncbi.nlm.nih.gov]
  • The differential diagnosis of granulomatous vulvitis and cheilitis, as well as the symptomatology and treatment of vulvar and oral Crohn's disease are further discussed.[ncbi.nlm.nih.gov]
  • We present the case of a 77-year-old female with a rare genital and anoperineal granulomatous cutaneous manifestation resembling cheilitis granulomatosa Miescher.[ncbi.nlm.nih.gov]
  • The pathology reports of both regions were compatible with a diagnosis of granulomatous cheilitis and vulvitis.[ncbi.nlm.nih.gov]
Buccal Ulceration
  • In a case of acute Reiter's syndrome with severe vulvitis the diagnosis was based on the presence of a vaginal discharge and dysuria, arthritis, conjunctivitis, buccal ulceration, keratodermia blenorrhagica, and HLA B27 tissue-typing antigen.[ncbi.nlm.nih.gov]
Fissured Tongue
  • Merkersson-Rosenthal syndrome (MRS) is characterized by cheilitis or pareitis granulomatosa, facial palsy, and fissured tongue. Sometimes the forehead, eyelids and chin are involved, and occasionally genital lesions are present.[ncbi.nlm.nih.gov]
Skin Atrophy
  • Symptoms of a mild case include skin fissures, loss of skin pigment ( hypopigmentation ), skin atrophy, a parchment-like texture to the skin, dysuria, itching, discomfort, and excoriation.[en.wikipedia.org]
  • For short term uses, low-dose cortisone creams are advised; while in some conditions, fluorinated ones are far more effective although they cause skin atrophy and thinning if used for too long.[newhealthguide.org]
Blepharitis
  • Tranilast has been described as an effective treatment for cases of MRS, granulomatous cheilitis, and granulomatous blepharitis. Herein we report a successful treatment with tranilast of an adult female patient with vulvitis granulomatosa.[ncbi.nlm.nih.gov]
Dyspareunia
  • While promising, operation should be reserved for patients who have experienced unremitting dyspareunia associated with the characteristic focal inflammatory lesions for at least 6 months.[ncbi.nlm.nih.gov]
  • The presenting symptoms were pruritus, tenderness, superficial dyspareunia and vulvar dysuria.[ncbi.nlm.nih.gov]
  • Thirty patients (83.3%) complained of symptoms: burning was the most frequent (80.6%) while dyspareunia was the severest. Of the symptomatic patients, 73.3% experienced severe symptoms.[ncbi.nlm.nih.gov]
  • A 50-year-old female with longstanding complaints of spotting, vulvar dryness, irritation, and dyspareunia presented with circumscribed, purpuric, erythematous vulvar patches. Past estrogen cream treatment evoked symptoms of discomfort.[ncbi.nlm.nih.gov]
  • In the last decade focal vulvitis has been identified as a distinct syndrome, characterized by unexplained burning vulvar pain and superficial dyspareunia. A 'Woodruff perineoplasty' has been recommended as a treatment method.[ncbi.nlm.nih.gov]
Vulvar Rash
  • Candida infections cause a red raised vulvar rash with satellite lesions and clear borders, and are diagnosed by microscopically examining a sample treated with potassium hydroxide for hyphae.[en.wikipedia.org]

Workup

If the initial report supports diagnosis of vulvitis, a detailed medical history should be obtained to identify possible sources of infection as well as potential allergens. In this line, routine regarding personal hygiene, cleansers and underwear should be evaluated. It is important to know if the patient is currently treating any pathological condition and if so, which formulations are used.

Clinical examination should not be limited to the vulvar region. Patients suffering from vulvitis may also present vaginitis or dermatitis in other areas of their skin. Thus, cervix and vagina should be examined as well as face, hands and other parts of the body if skin alterations are present.

If an infection is suspected, swabs and possibly tissue samples should be obtained and prepared for microbiological culture. Bacterial culture may also help to identify effective antibiotics.

General analysis of blood samples is particularly indicated in patients with relapses. Here, a weakened immune system may account for predisposition for infection. Hemogram and blood chemistry may reveal valuable hints at anemia, diabetes mellitus or other comorbidities.

Tissue biopsies may be required in cases of resistance to therapy.

HLA-B27
  • The diagnosis was based on the presence of increased vaginal and cervical discharge containing excess leucocytes, arthritis, conjunctivitis, and HLA B27 tissue-typing antigen.[ncbi.nlm.nih.gov]
  • In a case of acute Reiter's syndrome with severe vulvitis the diagnosis was based on the presence of a vaginal discharge and dysuria, arthritis, conjunctivitis, buccal ulceration, keratodermia blenorrhagica, and HLA B27 tissue-typing antigen.[ncbi.nlm.nih.gov]

Treatment

Treatment is mainly based on topical use of medication and adjustments in personal hygiene and behavior.

In order to decrease pruritus and subsequent scratching, which only aggravates irritation and inflammation, corticosteroids are usually administered. There are distinct schedules regarding corticosteroid application. Some experts suggest to start with weaker compounds and to reserve potent steroids for isolated, severe cases [6]. Elsewhere it has been proposed to start treatment with potent drugs in order to rapidly gain control over pruritus and to switch to a low-potency steroid afterwards [11].

Corticosteroid treatment is symptomatic and also immunosuppressive. Therefore, it is of utmost importance to identify the cause of vulvitis. Patients suffering from allergic vulvitis will most likely benefit from immunosuppression, those women who present with infectious vulvitis will not. Anti-fungal medication is required in cases of Candida infection. While antibiotics reduce the pathogenic load in bacterial vulvitis, anti-viral drugs should be applied in cases of herpes simplex virus infections.

Postmenopausal women depicting diminished estrogen levels may use minimally absorbed local estrogen products to avoid progress of atrophic vaginitis [12].

With regards to personal hygiene and behavior, women should be advised to reduce skin contact with perfumed soaps, shampoos, hygiene sprays, toilet paper and wet wipes. Loose cotton underwear is recommended and should be washed with sensitive washing liquid and without conditioner. Use of spermicidal lubricated condoms should be avoided.

Prognosis

Prognosis depends on the underlying cause. Most cases of infectious and allergic vulvitis have a good prognosis if the causative agent can be identified and is adequately treated.

Etiology

Vulvitis may result from infection with distinct types of pathogens, from direct contact to irritating substances and allergens as well as from neoplasms.

Infectious vulvitis is by far the most common form of vulvitis. Many women suffer from Candida infection. Bacteria, particularly Chlamydia and Gardnerella, may cause vulvitis. In young girls and adult women, infections with group A β-hemolytic Streptococcus strains have recently been associated with vulvitis [5]. Herpes simplex virus and other viruses, but also parasites like Trichomonas vaginalis, the pinworm Strongyloides stercoralis, the pubic louse Pthirus pubis and different species of mite may also lead to infectious vulvitis.

Allergic dermatitis is another frequent cause of vulvitis. Soap and other cleanser, creams, feminine hygiene sprays, medications and other products that enter in direct contact with the vulvar area may cause contact dermatitis and allergic vulvitis [6]. The majority of patients who present with allergic dermatitis of the vulvar area is atopic [7].

It has to be taken into account that vulvar tissues previously damaged by irritation or allergy are more susceptible to secondary infection. Thus, single triggers may not be distinguishable when women present with advanced vulvitis.

In rare cases, vulvitis may be developed as a symptom of squamous cell carcinoma. The vast majority of patients suffering from this type of cancer have vulvitis.

A small share of vulvitis cases is deemed idiopathic because no cause can be identified.

Hormonal changes associated with menstrual cycle, pregnancy or menopause may render women more prone for vulvitis. They are related to changes in mucosal and skin pH values to a more basic range, which may either directly alter the physiological flora of these tissues or activate protease-activated receptor 2 [8]. This receptor mediates pruritus and itching prompts the urge to scratch. Of note, menopausal alterations regarding hormone levels also cause tissue degradation and may lead to atrophic vaginitis. Between one and two out of four women are estimated to suffer from atrophic vaginitis five years after their last menstrual cycle [9]. These women are more susceptible for the above mentioned forms of vulvitis.

In general, poor personal hygiene greatly facilitates development of vulvitis.

Epidemiology

The overall incidence of vulvitis is high. Presumably, more than 50% of all women will develop vulvitis at least once in their lives [1] [2]. The disease is likely to be underdiagnosed and undertreated [7].

Low estrogen levels apparently predispose for vulvitis. In this context, it is not surprising that girls who have not yet reached puberty and post-menopausal women frequently present with vulvitis. However, vulvitis is a pathological condition that may affect girls and women of all ages. Vulvitis and vulvovaginitis are the most common triggers of vulvar discomfort or pain [10].

Sex distribution
Age distribution

Pathophysiology

Microscopic lesions of the vulvar skin and vaginal mucosa may facilitate infection and can largely be prevented by adequate personal hygiene and choice of underwear. Reduction of estrogen levels, however, is considered part of the post-menopausal hormonal changes. It causes atrophy of the vulvar and vaginal epithelium, leaving it more susceptible to physical damage and infection. Similar conditions may be described in women with decreased ovarian estrogen production due to other pathological conditions, irradiation or chemotherapy. After bilateral oophorectomy, estrogen levels will also diminish.

Type IV hypersensitivity does account for vulvar allergic contact dermatitis. Here, allergen exposure is followed by sensitization and finally allergic reaction upon repeated exposure. The allergic reaction is mediated by immune cells. In contrast, certain substances may provoke irritant contact dermatitis by rapidly causing tissue damage. Potent irritants will trigger irritant contact dermatitis upon first use, weak irritants may provoke chronic dermatitis.

Prevention

Adequate personal hygiene largely contributes to prevention of vulvitis. Sensitive soaps should be used to clean the vulvar area, perfumed soaps, shampoos and feminine hygiene sprays should be avoided. After showering, bathing, swimming or similar activities, the genital area should be dried carefully.

With regards to underwear, loose cotton garments are recommended. Appropriate underwear helps to avoid excess heat and moisture and reduces constant rubbing of tissues against the skin. Underwear should be changed after exercise and sweating.

Summary

The vulvar area comprises labia, clitoris and the openings of the urethra and vagina. While vaginal mucosa as well as vulvar skin are colonized by distinct microorganisms that form their physiological flora, the vulvar area is warm and humid and therefore susceptible to infection with pathogens. The skin of the vulva is continuously in contact with underwear and different hygiene products that may not only cause skin irritation and small lesions that, in turn, facilitate infection, but they may also carry microorganisms that are not part of the normal flora. This sequence of events may lead to infection and inflammation of the vulva, a condition referred to as vulvitis. Because parts of the vagina are often affected by this condition, gynecologists usually diagnose vulvitis and vaginitis or vulvovaginitis. Some have estimated that half of all women will suffer from vulvitis at least once in their lives, others assume that the actual incidence of vulvitis is even higher [1] [2].

All types of microorganisms, i.e., bacteria, viruses and fungi as well as parasites, may trigger vulvitis [3] [4]. Whereas inadequate hygiene measures greatly facilitate vulva infection, hormonal changes associated with menstrual cycle and menopause may provoke altered pH values in the vulvar area and have similar consequences. Reduced estrogen levels have been repeatedly shown to cause drying and thinning of vaginal mucosa and vulvar skin and this condition renders women more susceptible to infectious vulvitis. However, infection with pathogenic agents does not account for all cases of vulvitis and many women suffer from vulvar contact dermatitis and allergy.

Pruritus and pain are the most commonly experienced symptoms. The urge to scratch is often worse at night, but any scratching contributes to irritation and inflammation, causes pain and delays recovery. Women may claim urine and vaginal secretions to irritate their vulvar area, but this can generally be ascribed to existing skin lesions.

A preliminary diagnosis can be based on medical history and clinical examination. In cases of infectious vulvitis, the causative agent needs to be identified in order to chose the correct treatment. Microbiological culture may be helpful here. In severe and resistant cases, histopathologic analysis of tissue samples is required.

In order to reduce pruritus, corticosteroids are topically applied. This treatment has to be combined with causative therapy to avoid stimulation of pathogen growth. Antibiotic and anti-fungal creams, e.g., metronidazole, doxycycline, clotrimazole, nystatin and miconazole, are most frequently prescribed. Affected women should be advised to wear loose, absorbent underwear and to maintain an adequate personal hygiene.

Patient Information

The vulvar area comprises the outer genitals of women, i.e., labia, clitoris and opening of the vagina. The inflammation of this area is called vulvitis. Because parts of the vagina are often involved in such inflammatory processes, gynecologists may also diagnose vulvitis and vaginitis or vulvovaginitis and refer to the same condition.

Causes

There are several causes for vulvitis. Most commonly, the inflammation of the vulvar area results from an infection with fungi, bacteria, viruses or parasites. Among the most frequently detected pathogens there are Candida albicans, a yeast fungus, Chlamydia, Gardnerella, herpes simplex virus and pubic lice. While some of these microorganisms are sexually transmitted, others are opportunistic pathogens that take advantage of a momentarily weakened immune system or poor personal hygiene.

Another share of vulvitis cases corresponds to irritant or allergic contact dermatitis. In this line, soap, shampoos, hygiene sprays, wet wipes, underwear and washing agents may cause vulvitis.

Low estrogen levels as usually detected in postmenopausal women facilitate development of vulvitis.

Symptoms

The most common symptoms are irritation, itching and pain. Symptoms are usually more severe at night and might aggravate when urinating. Discharge may be noted.

Vulvitis is accompanied by redness, swelling and soreness of the vulvar area, but these symptoms can also extend to adjacent regions, e.g. to pubis, thighs and perineum.

Diagnosis

Symptoms and clinical picture allow for diagnosis of vulvitis. However, additional diagnostic measures are required to distinguish between infectious and allergic vulvitis, and to identify the causative agent in case of the former. Therefor, the gynecologists will take swabs and prepare them for microbiological cultures.

Treatment

If the precise cause of vulvitis has been identified, causative treatment can be initiated. Most frequently it consists in topical application of anti-fungal medication, antibiotics or anti-viral drugs to eliminate pathogens. Corticosteroids will be prescribed to control the itching. Women suffering from contact dermatitis will also benefit from the immunosuppressive effects of corticosteroids.

Topical application of estrogen-containing creams may help to prevent disease progress in postmenopausal women.

References

Article

  1. Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Womens Assoc. 2003; 58(2):82-88.
  2. Reed BD. Vulvodynia: diagnosis and management. Am Fam Physician. 2006; 73(7):1231-1238.
  3. Mårdh PA, Rodrigues AG, Genc M, Novikova N, Martinez-de-Oliveira J, Guaschino S. Facts and myths on recurrent vulvovaginal candidosis--a review on epidemiology, clinical manifestations, diagnosis, pathogenesis and therapy. Int J STD AIDS. 2002; 13(8):522-539.
  4. Sobel JD. Vulvovaginitis. When Candida becomes a problem. Dermatol Clin. 1998; 16(4):763-768, xii.
  5. Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. Group A streptococcal vaginitis: an unrecognized cause of vaginal symptoms in adult women. Arch Gynecol Obstet. 2011; 284(1):95-98.
  6. Rietschel R, Fowler JM. Fisher’s contact dermatitis. Vol 6. Whitby, ON: McGraw-Hill; 2008.
  7. Lambert J. Pruritus in female patients. Biomed Res Int. 2014; 2014:541867.
  8. Rimoin LP, Kwatra SG, Yosipovitch G. Female-specific pruritus from childhood to postmenopause: clinical features, hormonal factors, and treatment considerations. Dermatol Ther. 2013; 26(2):157-167.
  9. Sturdee DW, Panay N. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010; 13(6):509-522.
  10. Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician. 2004; 70(11):2125-2132.
  11. Drummond C. Common vulval dermatoses. Aust Fam Physician. 2011; 40(7):490-496.
  12. Krychman ML. Vaginal estrogens for the treatment of dyspareunia. J Sex Med. 2011; 8(3):666-674.

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Last updated: 2017-08-09 18:06