Vulvovaginitis

Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed and free.

My name is Ashlea Broomfield, And I'll be your host for this episode. For today's episode, we're talking with GP, Dr Cate Sheppard about vulvovaginitis. Welcome Cate.

Hi.

So Cate, you have written an article in Australian Prescriber on vulvovaginitis. Can you talk through for our listeners what this actually means?

Well, vulvovaginitis is a descriptive term for presentations affecting primarily the vulva is what people present with. But often the conditions may be arising from the vagina and spreading into the vulva, or they may be in both the vulva and the vagina at the same time. The type of symptoms that people present with can include itch, irritation, pain, burning, and vaginal discharge.

So what we're looking at here is an approach to the clinical diagnosis and therefore treatment. And perhaps we should start with an age group. For a post-menopausal woman, what is your typical approach to deciding the underlying aetiology?

Well, I'm a real stickler for getting a good history and if possible, having that history backed up by any investigations. So I think the onset of the symptoms, when did they start, what is the nature of them and inquiring in a little bit more depth about the nature of them rather than accepting itch.

And having a woman point to a genital area I usually want to pin that down a little bit more, is it mainly out on the labia majora, is it mainly around the introitus or is it both? Is there any perianal itch? If it's a pain symptom, when does that pain occur, what are associating factors?

So I think it's the old story, you can't go past a really well-taken history. I'd also include in that wanting to know what it is that they may have tried themselves, or if they've seen a doctor previously and what that doctor might have suggested for them. So that's even before an examination. I’d also want to know about any other skin disorders that they might have, which might indicate a prediction to certain things in the genital area.

Then in terms of an examination, it's obvious to say you need really good lighting. And I think a lot of doctors don't look at the vulva that much, they're often so focused on putting in a speculum and seeing what the cervix looks like and what's going on further inwards that they actually don't look at the vulval skin very carefully.

So I'm looking for any architectural changes, any skin colour changes, any changes that might suggest some fine crinkling or any plaque development. So really having a good look and then using a cotton bud to elicit where their symptoms actually are. So again, if they're saying itch, I'll be using the cotton bud on the labia majora and saying, is this the area you're mainly itching or is it further in and more midline and introital or vestibular? So that's my approach.

Now, we know that all that itches is not necessarily thrush. What kind of populations are we looking at where a fungal cause of vulvovaginitis is not as common?

So the fungal causes of vulvovaginitis are most common in women in the reproductive ages. So we don't see candidiasis, which is the predominant fungal element that's involved. We don't see that in pre-pubertal girls, unless there are other significant factors such as diabetes or being immunocompromised for whatever reason. And we don't tend to see much in the way of fungal vulvovaginitis in post-menopausal women, unless they are on hormone replacement therapy or diabetic or immunocompromised.

And can you describe for our audience the utility of why you use a cotton bud?

Well, I use a moistened cotton bud. You get a finer movement. You're able to move the genital tissue around. I think it's a bit more respectful in a way, it's a bit more clinical. They're very good devices for eliciting more specifically where there is pain. So for example, if you see an interlabial split or a split on the fourchette, you can pinpoint quite well with a cotton bud.

And also if people have got significant pain, you can be quite specific in where you're pressing to elicit pain. If I'm doing it in examination for pain, now I will usually press with the cotton button on their thigh and say, "I will be pushing about this hard. I want you to tell me what this feels like." So they then have an understanding of what the kind of baseline is like for that touch element and what they're comparing it to.

Could you clarify then how you would take a sample after testing the area for any particular symptom?

So when taking microbiological samples, I would use a fresh swab for taking a sample from the vulva, and I would use a separate swab for taking any samples of discharge within the vagina.

So we've spoken about an approach to vulvovaginitis that could be applicable for any aged woman. For the different populations, can you give us an idea of the most likely and the most most diagnoses and then the ones that are often missed?

So if we start with children, young girls presenting usually with vulval itch, irritation or pain, the approach is much the same, but I always want a chaperone or a parent present. And you have to really make the young girl feel at ease. The most common diagnoses would be either some form of contact irritant. And so whether that's soaps or bubble baths, or urine is not an uncommon contact irritant, wearing bathers for too long and getting some chafing. So that's probably number one.

Then I would be looking to see if there was the fairly classical appearance of really introital redness with a discharge that we often see with group A strep infections, the strep pyogenes, which can also cause tonsillitis and impetigo. And the other most common infection that I've encountered in this setting is pinworms, so the pinworms are both in the anus and also in the vagina. And then also other skin disorders. So persistent in a prepubescent girl could be a sign of eczema or seborrheic eczema or lichen sclerosis, which is one of the genital dermatoses which classically presents with itch in that age group. And you'd see white plaques or pallor, sometimes skin split some time.

And you've outlined a lot of these differentials in the articles so that if anybody would like to read about them in more detail further, they can as well.

So in the reproductive age group, I think that adage that not all that itches is thrush is really important because that's the go-to for most people. They'll think, "Oh, I must have thrush." And it's not uncommon to see women who come in and say, "I've had thrush for the last five years and I can't seem to get on top of it."

And it's also not uncommon that they haven't actually been examined throughout that time. So a lot of doctors make that mistake as well. So you must examine in case you're really missing one of the other conditions as seborrheic eczema, seborrheic dermatitis, where there's a lot of itching out in the hair-bearing areas of the vulva. That's really very common.

And a good examination and a good pinpointing of where the person is itching is really helpful in that instance. But still, most commonly it would be a candida infection that will cause symptoms in a lot of women, but you need to confirm that that is the case. And I would always swab even if I think there may be an eczema dermatitis condition, I'll take a swab to see whether or not there is coinciding candidiasis. Beyond candidiasis, bacterial vaginosis doesn't tend to cause much itch, it tends to cause a lot more discharge, odour and a little bit of irritation.

And one of the really common things that I've noticed in clinical practice is a very subtle presentation of genital herpes.

Yes, genital herpes can present with itch and it is the milder degree of recurrent herpes. So questions about is the itch always in the same place and asking the woman to point to where the itch is and often then what you'll see is a subtle skin split. And that may be it, usually not an ulcer or often just a split, so worthwhile swabbing. If the rest of the genitals look normal and there's just that one split and they say that's where it keeps coming back, certainly worth swabbing for herpes.

Anything that's often missed in this population?

I think lichen sclerosis is one that is often missed. And I think when we are doing examinations for... because not everybody with lichen sclerosis will present with symptoms with an itch. But when we're doing a genital examination, for example, for a cervical screening test, we should take the opportunity to examine the vulva and see if the skin actually looks normal. I have seen plenty of women who really don't present with much in the way of symptoms and have been having regular cervical screening tests. And they've got quite advanced lichen sclerosis and they haven't been aware of it.

I think it's a really important diagnosis to be aware of and consider because of the potential long-term complications that have been associated with it in regards to disfiguration and risk of vulva neoplasia in the future. Could you talk about some of the key findings to look for?

So in lichen sclerosis, the things that one should be looking for is a change in the architecture, which will often be manifesting as a loss of the labia minora, which either through resorption of the labia minora or adhering, where they adhere down to the labia majora. And the other significant loss of architecture is a sort of a burying of the clitoris where the clitoral hood effectively gets sort of scarred over and the clitoris is buried significantly down into the tissues.

You can also get introital stenosis as well. So looking for architectural change and then looking for colour change. So if you're seeing either a widespread pallor or areas of pallor, so-called plaques of pallor, and thickening up of the actual skin so that it has a much more, perhaps almost a rubbery texture, it's a harder texture and there's loss of mobility of the tissue.

The other sign that we commonly look for is skin crinkling, so-called cigarette papers crinkling. So these are very fine, fine crinkles and the skin will not look its normal, robust, shiny self either. It will often have a very dull appearance to it with these fine crinkles, pallor and maybe plaques.

And the other thing that I've noticed is the classic figure eight of the inflammation.

Certainly, yes, you can get the figure-of-eight inflammation, where people have changes down around the... so through the perineum and around the perianal skin, and that can extend quite high up the natal cleft. So when people are presenting with recurrent perianal itch, which we know is an incredibly common problem, it does behove us to actually have a look and see if the perianal skin looks normal or not. And sometimes people will present with only perianal symptoms as the first presentation of their lichen sclerosis.

And this particular diagnosis is more common in that post-menopausal age. What are the other really common diagnoses in this age group?

The most common diagnosis would be atrophic vaginitis and vulvitis where the loss of estrogen causes thinning out of the genital tissues and a loss of elasticity, a loss of lubrication and a loss of the sort of underlying fatty tissues. So everything is,well, vulnerable, really. And women who present with these symptoms may present with a pervasive feeling of dryness, or they may present with pain with intercourse, with dryness with intercourse, and sometimes with frequent urinary tract infections as well, and, or urinary urgency.

In this population, apart from lichen sclerosis as a common misdiagnosis, what are some other diagnoses that you've noticed are often missed or are less likely and things that need to be actively thought about?

Well, we certainly see less candidiasis, as I said, unless they're diabetic or immunocompromised. I have also seen strep pyogenes, so a group A strep. Staph aureus is not an uncommon cause of irritation. So again, you do need to be thinking about those broader microbiological infections. One also needs to consider the possibility of the less common genital dermatosis such as lichen planus, and also eczema, I suppose, which is a fairly common condition.

Just before we finish, we've talked a little bit about taking microbiological samples. Are there any other investigations that you might want to consider such as a vulval biopsy?

Certainly. So in the case where one is considering the possibility of lichen sclerosis or lichen planus. With the exception of children, I would do a vulval biopsy to be certain of the diagnosis. And I do that as a 3 mm punch biopsy. They're fairly straightforward to do, you do need to watch out for vessels and so on.

But I usually put on a bit of Emla for 20 minutes, half an hour or so beforehand just to be a little nicer in terms of putting in local anaesthetic. And most women find they recover from vulva biopsies very readily and I just advise them of genital skincare for the next few days.

When I first started out as a general practice registrar, I was very nervous about doing vulval biopsies, but you are correct. They are quite easy and fairly limited in terms of complications, even though they're very close to an environment that could easily increase the risk of infections so close to the anal area.

Yeah, definitely. I agree. I haven’t seen an infection as the result of a vulva biopsy. One thing that I often do is give take-home swabs. So particularly for those women where we're considering is this recurrent candidiasis, either to prove that it is or disprove it. Women will say, "Oh, I keep getting these itch and I'm sure it's thrush." And I send them home with a couple of swabs and a couple of path forms to home collect swabs when they've got the symptoms, because they may not be able to get in and see me.

I guess the only other thing I would add is that when women present with recurrent itch, they've often tried a lot of different creams, over-the-counter creams and alternative therapies, tea tree oil is a classic for causing genital burns. So-

Ointment as well.

Yes, yes. So you need to know what it is that they have already tried in the genital area.

And there's a really good website that's done by the Australian New Zealand Vulvovaginal Society, anzvs.org where you can find out a lot more information about vulvovaginal conditions and treatment in handouts.

Indeed.

Well, that's all that we have time for today. Thank you for joining us.

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The views of the guests and the hosts of this episode are their own and do not reflect Australian Prescriber or NPS MedicineWise. My name is Ashlea Broomfield and thank you for joining us.