Vulval Health

Question 1

Vulval health:

Chronic vulvovaginal candidiasis key tips?

Answer 1

Overgrowth of commensal candida yeast; typically candida albicans (90%) – the remainder caused mainly Candidia glabrata

Requires oestrogenised tissue ie. Menstruating or on oestrogen based therapy

Increased risk if associated pregnancy, antibiotics, diabetes (and SGLT2i) or immunosuppression
Women with diabetes have a higher risk of non-C. albicans species

Symptoms:
Acute: – vulval itch, cottage cheese-like discharge, tenderness, superficial dyspareunia, dysuria

Chronic/recurrent (4 or more episodes proven on MCS per year): - persistent non specific vulvovaginitis, soreness, cyclical change in intensity (eg. Worse prior to menses and improvement post menses), vulval swelling, thinner discharge

Treatment:

1) Intensive therapy – 7 days of PV antifungal cream OR Fluconazole 150mg for 4 – 9 days
2) Maintenance therapy – weekly antifungal pessary OR fluconazole 150mg for 6 months
* high rates of relapse (only 42.9% of patients are disease free after 12 months)

*If C. glabrata identified will need compounded boric acid 600mg pessary used nocte for 14 days (acute or chronic candidiasis) - Nystatin has some efficacy also but is not ideal

Question 2

Vulval health:

Vulvoldynia?

Answer 2

Vulvodynia is often described as a burning pain.

To fit the diagnosis there needs to be an absence of physical signs or identifiable neurological disorder.

Technically it fits in to the category of dysfunctional sensory functioning which is associated with IBS, fibromyalgia, interstitial cystitis and TMJ dysfunction.

Types:

1) Unprovoked/spontaneous
2) Provoked
a) primary - always been present
b) secondary - absent symptoms prior to a sensitising event
3) Mixed

Location descriptor also:

1) Generalised - all genitals possibly including thighs and perianal region
2) Local - specific site like introitus, labia, clitoris

Management:
-Provoked vulvodynia = lignocaine gel/ointment

Unprovoked vulvodynia:

• neuropathic agents (no evidence)
• if pelvic floor physiotherapist for biofeedback exercises (responds well)
• CBT

Question 3

Vulval health:

Herpes key points?

Answer 3

The characteristic vesicles are not always present and clinicians should always be suspicious when there are vulval non healing splits or ulcerations.

Recurrences can be triggered by:

• trauma or surgery to affected areas
• URTIs
• Sun exposure
• Hormonal changes (pre-menstrual can be common in some women)
• Emotional stress

Management:
1st episode = Valaciclovir 500gm BD 5 - 10 days
2nd episode = Valaciclovir 500mg BD 3 days
Recurrence = Valaciclovir 500mg daily for 6 months (then trial removal, if recurs then may need lifelong prophylaxis)

Question 4

Vulval health:

Lichen Sclerosis key points?

Answer 4

Chronic inflammatory change of vulval and perianal tissue.

Symptoms:

• itch
• introital pain with sex
• bleeding
• sensation of vulval change
• thickened/smooth skin

Classic figure of eight pattern around vulva and anus - but can present anyway.

Vitiligo has an association with lichen sclerosis.

Has a 5% lifetime risk of conversion to squamous cell carcinoma.

Management:

• high potency steroid daily for up to 10 weeks
• then 1 -2 times weekly as maintenance for life (risk of telangiectasis and skin thinning)

Resolution pattern as follows:

1) Itch resolves
2) thickened areas improve
* architectural changes will remain

Question 5

Vulval health:

General vulval skin care tips?

Answer 5

• soap free body washes
• emollient wash in shower and regular application to vulva
• avoid tight fitting clothing
• avoid scratching
• avoid using fragranced products (emollients, liners, detergents)

Question 6

Vulval health:

Is there any vulval lesions caused by HPV infection?

Answer 6

Yes
Vulval Intraepithelial Neoplasia (VIN) is a premalignant vulval lesion change that can develop into Squamous Cell Carcinoma

Question 7

Vulval health:

Lichen Planus key points?

Answer 7

T cell modulated autoimmune inflammatory condition

Occurs in many locations from cutaneous, mucosal, hair follicles and nails.

Vulval forms:
Presents with anogenital lesions in 3 forms
1) Erosive = most common
-onset in 50”s
-painful eroded mucosa
-treat early to prevent scarring
2) Classical
-often asymmetric papules on keratinised skin
3) Hypertrophic
-rare
-warty plaques that can ulcerate and get infected

Management:

1) Topical potent steroid
2) oral immunosuppressants (specialist input ideally)

Question 8

Vulval health:

Common types of normal anatomy that are misinterpreted as abnormal?

Answer 8

Fordyce spots (apocrine glands)
Hymenal remnants
Sebaceous glands
Papillomatosis
Angiokeratoma