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Diagnosing and Treating
Vulvar Conditions: Tricks
of the Trade
Michael S. Policar, MD, MPH
UCSF School of Medicine
www.PolicarLectures.com
Objectives
 Explain 3 differences between lichen sclerosus
and lichen simplex chronicus.
 List the 3 major presentations of Bartholin duct
conditions and the preferred treatment for each.
 List the 3 main causes of vulvar pain and 2
treatment options for each.
 List the 3 possible conditions in the differential
diagnosis of a tender cystic mass of the vulva.
Presentations of Vulvar Conditions
Vulvar itching
Vulvar papules and
nodules
Chronic vulvar pain
Acute vulvar pain
– Dermatoses
– Vulvovaginitis
– Genital warts
– VIN, SC cancer
– Pigmented lesions
– Vestibulodynia
– Vulvodynia
– Abcess, cellulitis
– Vulvar ulcers
– Trauma
The “Itchy Vulva”
 The Lichens: LS, LSC, LS+LSC
 Systemic: psoriasis, lichen planus
 Eczemas: atopic dermatitis, contact
dermatitis (irritant, allergic)
 Fungal vulvitis: candidal, tinea
 Recurrent genital herpes
 VIN (Vulvar Intraepithelial Neoplasia)
Vulvar Skin Complaints: History

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Nature and duration of symptoms
Previous treatment and response
Personal, family history: eczema, psoriasis
Other sites involved: mouth, eyes, elbows, scalp
All medications applied to vulva
– Antibiotics, hormones, steroids, etc
 Skin care: soaps, baby wipes, menstrual pads,
new clothing, scrubbing, etc
 New sexual partner(s); barrier contraceptives
Vulvar Dermatoses
New Terminology
 Lichen sclerosus
 Squamous cell
hyperplasia
 Other dermatoses
 VIN
Old Terminology
- Lichen sclerosus et atrophicus
- Kraurosis vulvae
- Hyperplastic dystrophy
- Neurodermatitis
- Lichen simplex chronicus
- Lichen planus, psoriasis
- Hyperplasic dystrophy/atypia
- Bowenoid papulosis
- Vulvar CIS
Lichen Sclerosus: Natural History







Most common vulvar dystrophy
Bimodal ages: children, older women
Cause: unknown; probably autoimmune
Chronic, progressive, lifelong condition
Most common in Caucasian women
Can affect non-vulvar areas
Squamous cell carcinoma
– 3-5% lifetime risk
– 30-40% SCCA develops with LS
Lichen Sclerosus: Findings
 Symptoms
– Itching, burning, dyspareunia, dysuria
 Signs
– Thin white “parchment paper” epithelium
– Fissures, ulcers, bruises, or hemorrhage
– Submucosal hemorrhage
– Depigmentation (white) or hyperpigmentation in
“keyhole” distribution: vulva and anus
– Introital stenosis and loss of vulvar architecture
– Reduced skin elasticity
Lichen Sclerosus: Treatment
 Preferred treatment
– Clobetasol (Temovate) 0.05% BID x 2-3 wk, to QD
– Taper to med potency steroid 2-4x/month for life
 Testosterone ointment is time honored, but little
evidence to support
 Adjunctive therapy: anti-pruritic therapy
– Atarax or Benedryl PO, especially at night
– Doxypin, QHS or topically
– If not effective: amitriptyline PO
 Perineoplasty may help dyspareunia, fissuring
Lichen Simplex Chronicus =
Squamous Cell Hyperplasia
 Irritant initiates “scratch-itch” cycle
– Candida
– Chemical irritant, allergen
– Lichen sclerosus
 Presentation: always itching; burning, pain, and
tenderness
 Thickened leathery red (white if moisture) raised
lesion
 In absence of atypia, no malignant potential
– If atypia present , classified as VIN
L. Simplex Chronicus: Treatment
 Removal of irritants or allergens
 Treatment
– Triamcinolone acetonide (TAC) 0.1% ointment
BID x4-6 weeks, then QD
– Other moderate strength steroid ointments
– Intralesional TAC once every 3-6 months
 Anti-pruritics
– Hydroxyzine (Atarax) 25-75 mg QHS
– Doxepin 25-75 mg PO QHS
– Doxepin (Zonalon) 5% cream; start QD, work up
Lichen Sclerosus + LSC
 “Mixed dystrophy” deleted in 1987 ISSVD
System
 15% all vulvar dystrophies
 LS is irritant; scratching causes LSC
 DDX: LS with plaque, candida, VIN
 Treatment
– Clobetasol x12 weeks, then steroid
maintenance
– Stop the itch!!
Psoriasis
 30% have family history
 Triggered by stress, drugs, infections, alcohol, cold
 Usually involves extensor skin beyond the vulva
elbows, knees, scalp, nails
– Genital involvement: mons, vulva, crural folds
– Pruritis, soreness
 Red epithelial patches with elevated silver scales
 Rx: Dovonex, topical steroids
Lichen Planus
 Probable autoimmune disease
 May present as purple, well-demarcated, flat
topped papules on oral, genital tissues
 Erythematous erosive lesions on vestibule or in
vagina
 Vulvar burning or pruritus
 50% of women with classic LP will have genitalia
involved
 DDX: LS, syphilis, herpes, chancroid, Behcet’s
 DX: biopsy essential
Lichen Planus: Treatment
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No one satisfactory treatment exists
Emollients, vulvar care; treat superinfection
Vulva: clobetasol ointment with taper
Vagina: Anusol HC 25 mg supp; ½-1 supp PV
BID x4 weeks, then taper
 Short course of oral steroids if necessary
 Vaginal dilators to prevent scarring
 Other Rx: Tacrolimus 0.1% (Protopic) BID,
Acitretin, methotrexate, Dapsone
Vulvar “Eczema”
 Atopic dermatitis
–“Endogenous eczema”
 Contact dermatitis: “Exogenous eczema”
–Irritant contact dermatitis (ICD)
–Allergic contact dermatitis ACD)
 Lichen Simplex Chronicus
–“End stage” eczema
Atopic Dermatitis
 Prevalence: 10-15% of population
 If 2 parents with eczema, 80% risk to children
 Criteria for diagnosis
– Itching/ scratch cycle
– Exacerbations and remissions
– Eczematoid lesions on vulva and elsewhere
(crural folds, scalp, umbilicus, extremities)
– Personal or family of hay fever, asthma, rhinitis,
or other allergies
– Clinical course longer than 6 weeks
Atopic Dermatitis: Treatments
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Avoid scratching; stress management
Emollients (bland, petrolatum based)
Topical steroids (moderate potency)
Intralesional triamcinolone
Tacrolimus (Protopic) 0.03% to 0.1% BID
Oral antihistamines or doxypin 5% cream
– Intended mainly to relieve itching
– Sedation in 20%
– May cause contact dermatitis
Contact Dermatitis
 Irritant contact dermatitis (ICD)
– Elicited in most people with a high enough dose
» Potent irritant: chemical burn
» Weaker irritant: applied repeatedly before sxs
– Rapid onset vulvar itching (hours-days)
 Allergic contact dermatitis (ACD)
– Delayed hypersensitivity
– 10-14d after first exposure; 1-7d after repeat exposure
 Atopy, ICD, ACD can all present with
– Itching, burning, swelling, redness
– Small vesicles or bullae more likely with ACD
Contact Dermatitis
 Common contact irritants
– Urine, feces, excessive sweating
– Saliva (receptive oral sex)
– Repetitive scratching, overwashing
– Detergents, fabric softeners
– Topical corticosteroids
– Toilet paper dyes and perfumes
– Hygiene pads (and liners), sprays, douches
– Lubricants, including condoms
Contact Dermatitis
 Common contact allergens
– Poison oak, poison ivy
– Topical antibiotics, esp neomycin, bacitracin
– Spermicides
– Latex (condoms, diaphragms)
– Vehicles of topical meds: propylene glycol
– Lidocaine, benzocaine
– Fragrances
Contact Dermatitis: Treatment
 Exclude contact with possible irritants
 Restore skin barrier with sitz baths, compresses
 After hydration, apply a bland emollient
– White petrolatum, mineral oil, olive oil
 Short term mild-moderate potency steroids
– TAC 0.1% BID x10-14 days (or clobetasol 0.05%)
– Fluconazole 150 mg PO weekly
 Cold packs: gel packs, peas in a “zip-lock” bag
 Doxypin or hydroxyzine (10-75 mg PO) at 6 pm
 Replace local estrogen, if necessary
 If recurrent, refer for patch testing
General Vulvar Care Measures
 Wear loose fitting clothing
 100% cotton underwear
– Rinse underwear twice
– Low irritant soap; no use of fabric softeners
 100% cotton menstrual pads
– www.gladrags.com
 Mild bathing soaps: Cetaphil, Kiss-My-Face, Basis
 Vulvar water rinse (or very soft toilet paper)
 Use vaginal lubricants: Replens, KY, Olive Oil
Measures for Vulvar Itching
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Aveeno Oatmeal compresses or tub soaks
Tea bags (compress, sitz, or tub)
Cold pack, especially before bed
Sedating antihistamines at bedtime
Emollient during activities
– Aquaphor, SBR Lipocream, A&D ointment,
petrolatum
 Doxypin 5% cream (20% will become drowsy)
Rules for Topical Steroid Use
 Topical steroids are not a cure
– Use potency that will control condition quickly,
then stop, use PRN, or maintain with low potency
 Limit the amount prescribed to 15 grams
 Ointments are stronger, last longer, less irritating
 Show the patient exactly how to use it: thin film
 L. minora are steroid resistant
 L. majora, crural fold, thighs thin easily; get striae
 At any suggestion of 2o candidal infection, use steroid
along with topical antifungal drug
Evaluation: Recurrent VV Itching
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Symptom diary
Detailed search for anatomic causes (e.g., fistula)
Saline, KOH slides during symptomatic period
Vaginal pH, amine test
Candidal culture and speciation, or PCR
If at risk for glucose intolerance, check FBS
If vaginitis is chronic, severe, recalcitrant, or if oral
thrush or lymphadenopathy, consider HIV
CDC Classification of VVC
 Uncomplicated VVC (80-90%)
– Sporadic or infrequent VVC, or AND
– Mild-to-moderate VVC, or AND
– Likely to be Candida albicans, or AND
– Non-immunecompromised women
 Complicated VVC (10-20%)
– Recurrent VVC, or
– Severe VVC, or
– Non-albicans candidiasis, or
– Uncontrolled DM, immunosuppression, pregnancy
VC: SEVEN DAY Therapy
Miconazole
Terconazole
Clotrimazole
Monistat-7
2% cream,
100 mg sup
Terazol-7
0.4% cream
Gynelotrimin 7
1% cream,
Mycelex
100 mg tab
–Rx: 1 application at bedtime for 7 days
OTC drugs in italics
VC: THREE DAY Therapy
 Butoconazole
 Miconazole
 Terconazole
Femstat 3
Monistat-3
Terazol-3
2% cream
200 mg supp
80 mg supp,
0.8% cream
 Rx: 1 application at bedtime for 3 days
 Alternative:
– Miconazole 2% cream
BID x 3 days
– Clotrimazole 1% cream
– Clotrimazole 100 mg tab
2 QHS x 3 days
OTC drugs in italics
VC: ONE DAY Therapy
 Clotrimazole
 Tioconazole
 Miconazole
 Butoconazole
Rx:
Mycelex G-500
500 mg suppository
Vagistat-1 6.5% ointment
Monistat 1 1.2 gm suppository
Gynazole-1 2% bioadh cream*
1 app at bedtime (*anytime)
 Fluconazole
Rx:
Diflucan 150 mg
1 tablet PO
OTC drugs in italics
Uncomplicated VVC: Treatments
 Non-pregnant
– 3, 7 day topicals equal efficacy and price
– Recommend: 3 day topical or fluconazole PO
 Mild or early case: any 1 or 3 day regimen
 If first course fails
– Reconfirm microscopic diagnosis
– Treat with alternate antifungal Rx
– Candidal culture to speciate
 No role for nystatin, candicidin
CDC 2002: Complicated VVC
Severe VVC
 Advanced findings: erythema, excoriation,
fissures
 Treat for 7-14 days of topical therapy or
fluconazole 150 mg PO repeat in 3 days
Compromised host
 Conventional antimycotic tx for 7-14 days
Pregnancy
 Topical azoles for 7 days
Candidia glabrata Vaginitis
 Main symptom is intense vulvo-vaginal burning,
rather than itching
 KOH : yeast spores and buds, not hyphae
 Treatments
– Best coverage (lowest MIC) with butoconazole
– Imidazoles for 7-14 days
– Boric acid 600 mg QD x 14 days
– Topical gentian violet
– Fluconazole not recommended (by CDC)
CDC 2002: Complicated VVC
Recurrent VVC (RVVC)
 > 4 episodes of symptomatic VVC per year
 Most women have no predisposing condition
– Partners are rarely source of infection
 Confirm with candidal culture, since often due to
non-albicans species
 Early treatment regimen: self-medication 3 days
with onset of symptoms
CDC 2002: Complicated VVC
 RVVC: Treatment
– Treat for 7-14 days of topical therapy or
fluconazole 150 mg PO q 72o x3 doses, then
– Maintenance therapy x 6 months
»Fluconazole 100-200 mg PO 1-2 per week
»Itraconazole 100 mg/wk or 400 mg/month
»Clotrimazole 500 mg suppos 1 per week
»Boric acid 600 mg suppos QD x14, then BIW
»Gentian violet: Q week x2, Q month X 3-6 mo
Vaginal Candidiasis Tips
 2/3 of women who believe that the have chronic or
recurrent Candida don’t
– Verify diagnosis with PCR, fungal culture
 Consider Candida glabrata
– Different presentation, different treatments
 Oral or vaginal yoghurt doesn’t work because
– Lactobacillus strains don’t adhere to vaginal cells
– Predominant normal flora is L. crispatus, not L.
acidophilus or L. bulgaricus
HPV Infection: Overview
 Pendulum has swung widely over four decades
– Controversies persist regarding HPV transmission,
treatment, and prevention
 PH model: STD protection  cancer prevention
– Primary prevention with HPV vaccine
 Once infected with HPV
– Most HPV infections are transient
»Women < 30 yo; LR types; immunocompetent
– Persistent HPV infection causes HG lesions
»Women > 30 yo; HR types; immunosuppressed
HPV Infection: Overview
 Therapeutic eradication of HPV is not possible
– Goal is the control of existing and new lesions
 Treatment should be limited to
– High grade pre-invasive disease
»CIN (cervix), VaIN (vagina), VIN (vulva)
»Anal IN, Penile IN
– Genital warts that cause
»Irritative symptoms of vulva, anus, or penis
»Cosmetically objectionable lesions
 Treatment must not be worse than disease
EGW Treatment: General Principles
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Advise patient to stop cigarette smoking
Evaluate for trichomoniasis; treat if present
No one treatment is ideal for all patients or all warts
More than one modality may be necessary
– Should be used sequentially; not simultaneously
 Treatment must be individualized
–
–
–
–
–
Size of the warts; extent, location of the outbreak
Personal preferences, medical status of patient
Experience of clinician
Available treatment resources
Cost considerations
Vulvar Papules: Differential Diagnosis
 VIN or vulvar carcinoma
–
–
–
–
Usually multifocal in premenopausal women
Raised with irregular edges but not exuberant
Red, white, or hyperpigmented
Opaque white with vinegar application
 Condyloma latum
– Diagnostic of secondary syphilis
– Not as exuberant as condyloma accuminata
– Circular flat papules, usually in clusters
– If suspected, order syphilis serology (RPR or VDRL)
 Other lesions: molluscum contagiosum, skin tags, nevi, scars
Vulvar Papules: Evaluation
 Exam of vulva, perineum, and anus
– If questionable, use vinegar for acetowhitening
 Biopsy
– Typical condys do not require biopsy
– Biopsy atypical condys, VIN, or vulvar carcinoma
 Cervical Pap smear for multicentric disease
 If perianal warts, evaluate anus by Pap + anoscopy
 Test for other infectious conditions
– GC, chlamydia, syphilis, HIV
– NaCl suspension for vaginal trichomoniasis
EGW: No Treatment
 Small asymptomatic vulvar and vaginal
genital warts
 Non-specific acetowhitening of laba majora,
labia minora, or introitus (non-HPV)
 Vestibilar papillomatosis (non-HPV)
 In placebo-control groups of women with
genital warts, 10-30% of cases resolve
spontaneously within 3 months
EGW: Clinician Applied Treatments
 TCA or BCA 85-90%
– Moderate vulvar, vaginal GW; not cervical GW
 Podophyllin 10-25%
– Resin is less effective, more irritating than TCA
 Cryotherapy (liquid N2, cryoprobe)
– Used for isolated vulvar, vaginal, cervical lesions
 Office excision
– Simple surgical excision: scissors or scalpel
– Electrocautery (coagulation), electrodessication
Self-Applied: Condylox 0.5%Gel
 Purified podophylotoxin; derived from podophyllin
– Mechanism: mitotic spindle poison; blocks cell
division
 Use: Apply BID for 3 days, then four days off
 Expect response by 4 wks; if so, use up to 8 wks
 Response rate (8 weeks): 80% of women
 Pregnancy category C
 Cost (AWP) is $57 per 4 week cycle
R
Condylox 0.5% Gel
 Advantages
– Good short term wart resolution rates
– Fewer adverse effects than podophyllin resin
– Shorter course, less expensive than Aldara
 Disadvantages
– Must apply correctly, consistently for optimal
effect
– Mild-moderate pain, local irritation may occur
– Safety in pregnancy has not been established
Self-Applied: Aldara 5% Cream
 Immune response modifier
– Stimulates natural killer cell, T-cell activity
– Induces a-interferon production from local tissues
– No antiviral effect or direct tissue destruction
 Apply to EGW every other day x3, then 2 days off
– Use Mon, Wed, Fri, then Sat, Sun off
– Wash off in morning using mild soap and water
– Expect response by 4 wks; if so, use up to 12 wks
 Pregnancy category B
 PHS price is $60 per 4 week cycle
Aldara 5% Cream
 Advantages
– Good short term wart resolution rates
– Little toxicity; mainly erythema and irritation
– Pain or irritiation; discontination in < 2%
– Drug of choice in large vulvar EGW “blooms” in
women and for immunosuppressed patients
 Disadvantages
– Must apply correctly and consistently
– May take longer for response than podofilox
Anal and Perianal Warts
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
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25% women with vulvar warts have perianal warts
Vaginal-to-anal self-inoculation + microtrauma
Intra-anal warts often 2o to anoreceptive sex
If perianal warts, examine for intra-anal warts
– Anal Pap; anoscopy if lesion extends upward
 Treatment
– Imiquimod (Aldara) cream
– Cryotherapy
– TCA/BCA
Genital Warts: Complex Treatments
 CO2 Laser
– Extensive or refractory vulvar warts or VIN
 Topical 5-FU (Efudex):
– Extensive intravaginal condylomata accuminata
– Primary or recurrent VAIN
 Extensive surgical excision or electrocautery
– Extensive refractory lower genital tract lesions
 Interferon injections:
– Refractory vulvar lesions
PPFA Visit and Cost Distribution
VISITS
COSTS
Visit
Number
Number
Pts.
Pct.
Distrib.
1
115
23.0%
23.0%
11.2%
11.2%
2
170
34.0%
57.0%
24.7%
35.8%
3
87
17.4%
74.4%
17.8%
53.7%
4
5
52
28
10.4%
5.6%
84.8%
90.4%
13.6%
9.2%
67.2%
76.4%
>5
48
9.6%
100.0%
23.6%
100.0%
25.6%
Cumulative
Pct.
Cumulative
Distrib.
Distrib.
Distrib.
46.4%
PPFA First Line Treatment Analysis
MAXIMUM
First Line
Therapy
No.
Patients
Avg.
Visits
Avg. Cost
Visits
Costs
TCA
330
3.1
$262.93
17
$ 1,074.95
Cryotherapy
91
3.0
$440.79
17
$ 2,443.30
Aldara
TCA + Aldara
Cryo + Aldara
42
27
7
2.4
1.5
1.4
$234.78
$241.12
$270.03
9
4
2
$705.35
$408.40
$409.80
TCA + Condylox
Condylox
2
1
3.5
6.0
$305.16
$457.86
6
6
$457.86
$457.86
EGW Treatment Algorithm
Patient Presents
with EGW
Recurrent
EGW Patient
First-time
EGW Patient
Single location
of lesions ?
No
Multiple
locations
Yes
Treat with
TCA/Cryo
Patient cleared
in < 3 visits
No
Yes
Treatment
Completed
Aldara,
with
Education
Materials
Vulvar Intraepithelial Neoplasia (VIN)




Due to infection with HPV 18 or LSC (no HPV)
Graded I-III, based upon severity of atypia
Sxs: itching, burning, ulceration
4 P’s
– Papule formation: raised lesion
– Pruritic: itching is prominent
– “Patriotic”: red, white, or blue (hyperpigmented)
– Parakeratosis on microscopy
Vulvar Intraepithelial Neoplasia
 Location
– Multifocal: premenopause, im’compromised
– Unifocal in postmenopause
– May be multicentric
 Precursor to vulvar cancer; low “hit rate”
 Smoking cessation may improve outcome
 Tx: Wide local excision, laser ablation
 Recurrence is common (48% at 15 years)
Differential Diagnosis: Dark Lesions
 Hyperpigmentation due to scarring
 Lentigo, benign genital melanosis
 Benign nevi
 VIN
 Invasive squamous cell carcinoma
 Malignant melanoma
Vulvar Melanoma: ABCD Rule
 A: Asymmetry
 B: Border Irrigularities
 C: Color black or multicolored
 D: Diameter larger than 6 mm
 Any change in mole should arouse
suspicion
 Biopsy mandatory when melanoma is a
possibility
Fox-Fordyce Disease
 Disorder of apocrine glands
 Found on mons, labia majora, axilla
 Cyclic pruritis; improves with
menopause
 Treatments:
– OCs
– Retinoic acid
Hidradenoma
 “Milk
line” location (interlabial sulcus)
 Benign tumor
 0.5-2 cm diameter
 Solid consistency
 Often umbilicated center
 Non tender
 Treatment: shells out easily with excision
 Path mimics adenocarcinoma
Paget’s Disease
 Occurs in milk line
 Extramammary disease may invovle genital,
perianal and axillary areas
 Lesions are brick red, scaly, velvety eczematoid
plaque with sharp border
 S/S: itching, burning, bleeding
 Cellular origin unclear
 Treatment: excision with > 3 mm border from
visible margin
 Local recurrence rate is 31-43%
Tips for Vulvar Biopsies
 Where to biopsy
– Homogeneous : one biopsy in center of lesion
– Heterogeneous: biopsy each different lesions
 ELA-Max (10% lidocaine cream) applied 20-30
minutes pre-op may be sufficient for anesthesia
 Skin local anesthesia
– Use smallest, sharpest needle: insulin syringe
– Inject s-l-o-w-l-y
– Most lesions will require ½ cc. lidocaine or less
 Stretch skin; rotate 3 or 4 mm Keyes punch
Tips for Vulvar Biopsies
 Lift
circle with forceps or needle;
snip base
 Hemostasis with AgNO3 stick,
Monsels, Gelfoam, hemostatic mesh
 Separate pathology container for
each area biopsied
Chronic Vulvar Pain Syndromes
 Vestibulodynia (VBD): painful vestibule
– Vulvar vestibulitis syndrome
 Vulvodynia (VVD): painful vulva
– Dysesthetic (Essential) vulvodynia
– Pudendal neuralgia
 Vulvar pain of known cause
– Lichen sclerosis, L planus, Behcet dz, Crohn dz
– Dermatitis: allergic/ irritant/ eczema/ LSC
– Infections: Candida, Herpes, Bartholinitis
– Trauma, scarring
Vulvodynia: More Questions Than Answers
 Little agreement regarding definition, epidemiology,
diagnosis, management, etiology, and
 Pressing need for large-scale, controlled studies to
explore these issues in greater detail
 Defined as chronic vulvar pain in which other
pathologic etiologies have been ruled out, but
duration of pain is not agreed upon
–Pain lasting from 3 to 6 months is typically
considered to be “chronic”
Vulvodynia: Age-Specific Incidence
Percent of Women
10
8
6.8
6
5
4
3.6
3.4
3.9
2
0
<25
25-34
35-44
45-54
Age at First Onset (y)
Harlow BL, Stewart EG. J Am Med Womens Assoc. 2003;58:82-88.
55-64
Vulvodynia: Ethnicity
Percent of Women
25
22.7
19.5
20
16.2
14.4
15
11.1
10
5
0
Hispanic
African
American
White
Harlow BL, Stewart EG. J Am Med Womens Assoc. 2003;58:82-88.
Asian
Other
Nonwhite
Vulvodynia: Symptoms
 Pain – Knifelike; with genital area contact
 Itching – With or without pain
 Burning – Persistent
 Dyspareunia – Pain and discomfort on penetration
 Sexual response – Hypervigilance for coital pain
 Skin changes – Erythema, scaling, fissures
Sadownik LA. J Reprod Med. 2000;45:679-684; Hansen A, et al. J Reprod Med. 2002;47:854-860;
Welsh BM, et al. Med J Aust. 2003;178:391-395; Payne KA, et al. Eur J Pain. 2005;9:427-436.
Vulvodynia: Psychosocial Assessment
 Women reporting vulvar and nonvulvar pain are
twice as likely as asymptomatic women to report:
– History of depression (P<0.001)
– Chronic vaginal infections (P<0.001)
– Poorer quality of life (P<0.001)
– Greater stress
 Strongest correlates of chronic vulvar pain are selfreport of vaginal infections and stress
Bachmann GA, et al. J Reprod Med. 2006;51:3-9.
Work-up of Patient Presenting
with Pain Only
Pain Alone
Normal on examination
Pain localized and
provoked by
pressure
Vulvar vestibular
syndrome likely
(typically younger
age)*
Abnormalities on examination
Pain poorly
localized and
spontaneous
Dysesthetic
vulvodynia likely
(typically older
age)†
Welsh BM et al. Management of common vulval conditions. MJA 2003; 178: 391-395.
©Copyright 2003. The Medical Journal of Australia - reproduced with permission.
Diagnosis
depends on
examination
VVS: Epidemiology
 15% RA women: introitus painful to touch
– ½ “mild”; doesn’t affect activities
– ½ sig. dyspareunia; ½ asked for help
 VVS has two common times of onset
– 1o VVS: onset as teen; present in mother
– 2o VVS: onset post-partum; no family hx
 Many causes investigated, none proven
– Chronic candida, HPV not causes
– Connection with interstitial cystitis
VVS: Presentation
 Symptoms
–
–
–
–
Pain symptoms on touch or vaginal entry
Absence of symptoms during daily activities
Avoidance of pants with tight inseam
Avoidance of tampons due to insertional pain
 Signs
– Inflamed patches of skin or regions of vestibule
– Positive “swab test”:
» Intense pain during rolling of moistened cotton swab
over red areas on vestibule
» Skin beyond ½ cm of inflamed area non-tender
VVS: Diagnosis
 “Definitive test” for VVS (Goetsch)
– Perform swab test
– 4% lidocaine with cotton app, wait a few minutes
– Repeat test; if pain is sig. diminished, dx is VVS
 ISSVD diagnostic criteria
–
–
–
–
–
Severe pain on touch or attempted entry
Tenderness to pressure localized within vestibule
Only finding is vestibular erythema
Symptoms must have been present for > 6 months
No evidence of vaginitis or vulvar dermatoses
Vulvar Pain, Burning: Diagnosis
 Pain mapping
 KOH suspension for candida
– If negative, culture and speciate
 That’s it!!!...
 In the absence of lesions, no role for
– Vestibular or vulvar biopsy
– HPV screening (Hybrid Capture)
– HSV culture or antibody testing
VVS: Management
Ineffective Therapies
 Antifungals
 Topical or systemic antibiotics
 Antivirals (acyclovir)
 Dietary restriction of oxalates
 Interferon injections
 Laser therapy
VVS: Stepwise Approach to Treatment




Vulvar skin care measures
Topical steroids: estrogen, cortisone
Local anesthetics
Neuropathic pain medications
– Tricyclic antidepressants
– Anti-seizure drugs
 Physical therapy and biofeedback
 Surgery
– Vestibulectomy
Vulvar Pain Measures
 Acute pain: ice pack applied to vulva
 Episodic relief (30 minutes before intercourse)
– Lidocaine
»Xylocaine jelly 2%, Xylocaine ointment 5%
– EMLA cream (lidocaine 2.5% + prilocaine 2.5%)
– L-M-X 4 Cream (4% lidocaine)
– L-M-X 5 Anorectal Cream (5% lidocaine)
– Dispense 30 gm tube; limit to 2.5 gm/application
– Avoid oral contact of partner
 Avoid benzocaine, diphenhydramine additives
Vulvar Pain Measures
 Overnight topical anesthetics
– Apply ointment to introitus + vaginal cotton ball
 Topical sedatives for relief if itching
– Doxepin (Zonalon) 5% cream
– Start once a day, then work up
 Systemic
– Tricyclics: amitriptyline (10-25 mg) QHS
»Nortriptyline, desipramine fewer side effects
– Anticonvulsants
» Gabapentin (Neurontin), carbamazepine (Tegretol)
Tricyclics for Vulvar Pain




Must take daily, not “as needed”
May take weeks to “kick-in”
May have good days and bad days, even with tx
Start at low dose, then work up every week
– Start with 10 mg…progress to 100-150 mg.
 Because of sedation, dry mouth, take at bedtime
– If excessively tired in am, take after dinner
 Once pain is controlled, slowly taper
– If too fast, get bounce-back pain, nausea, fatigue
VVS: Surgical Therapy
 Woodruff”s vestibulectomy (perineoplasty)
– Surgical excision of vestibule, with undermining
of vagina and “pull through” to cover defect
– 60-89% cure rate
 Adverse effects
– Removal of glands necessary for sexual
lubrication
– 1 month recovery
– Scar tissue; May mildly disfigure vulva
– Potential recurrence of symptoms after 6 months
Vulvar Vestibulitis: Surgery
 At 6-month follow-up, 60% to 89% of patients show
improvement and approximately 10% have
deteriorated
 Higher SES, older age, and participation in
psychological evaluation/postoperative sex therapy
predict better outcomes
 Childlessness, deep dyspareunia, and diffuse genital
pain predict poor outcomes
Masheb RM, Nash JM, Brondolo E, Kerns RD. Pain. 2000;86:3-10.
Glazer HI, et al. J Reprod Med. 1995;40:283-290.
Essential Vulvodynia
 Pudendal neuralgia is likely cause
 Seen mainly in older women
 Presentation
– Poorly localized pain; diffuse and variable
hypersensitivity
– May cause constant, unremitting burning
– Altered perception to light touch
– Vulva and introitus appear normal
– No effect of topical lidocaine
 Treatment
– Low dose TCAD:desipramine, imipramine, amitriptylene
– Gabapentin, carbamazepine, venlafaxine
Posterior Fourchette Fissure
 Tender shallow ulcer or fissure at 6 o’clock
of introitus
 Causes severe dyspareunia (or apareunia)
– “Paper cut” acute pain
 Possible causes
– LS, apthosis, chronic candida, OB
laceration, ? atrophy
 Diagnosis: biopsy usually not helpful
Posterior Fourchette Fissure
 Management
– Emollients and moisturizers
– Elamax cream 30 min before intercourse
– Water or oil-based lubricant with intercourse
– High potency topical steroids; steroid injection
» Cox: add topical estrogen (Estrace) cream to
corticosteroid
– Local destruction (AgNO3 or electrocautery)
– Surgery: perineoplasty, Y-V flap
Resources
- National Vulvodynia
Associationn
www.nva.org
V Book chapters:
“It Hurts”
“Sexual Healing”
- www.thevbook.com
The Vulvodynia Guideline
 Haefner, HK, et al. Journal of Lower
Genital Tract Disease 2005; 9:40-51
 www.jlgtd.com
– Links and Resources
» ASCCP guidelines
» The Vulvodynia Guideline
 PolicarLectures.com
– Reproductive HC links
– Vulvar Skin Conditions and Colposcopy
Patient Resources
 International Society for the Study of
Vulvovaginal Disease: www.issvd.org
 National Vulvodynia Association:
www.nva.org
 Vulvar Pain Foundation:
www.vulvarpainfoundation.org
 Interstitial Cystitis Association:
www.ichelp.org
Bartholin Duct Conditions
 Bartholin duct and gland at 5, 7 o’clock cephalad
(deep) to hymeneal ring
 Makes serous secretion to “lubricate” introitus
 If BG duct is transected or blocked, fluid
accumulates
– Non-infected: BD cyst
– Infected: BD abcess or cellulitis
 All treatments are designed to drain and create a
new duct
Bartholin Duct: Infectious Conditions
 Bartholin duct cellulitis
–
–
–
–
–
Red induration of lat’l perinuem , no abcess
Most commonly due to skin streptococcus
Tx: PO cephalosporin, moist heat
Will either resolve or point as abcess
Treat immunecompromised women aggressively
 Bartholin duct abcess
–
–
–
–
Fluctulent abcess; pus with needle aspiration
Tx: I&D, insert Word catheter x 6 weeks
Culture pus for gonorrhea
Cephalosporin if cellulitis; metronidazole if anaerobic
Bartholin Duct: Non Infectious
 Bartholin duct cyst
– Nontender cystic mass
– Treat only if symptomatic or recurrent
– Tx: marsupialize or insert Word catheter x 6 weeks
 Bartholin duct carcinoma
–
–
–
–
Most common in women over 40
Can be adenoca, transitional cell, or squamous cell
Firm non-tender mass in region of Bartholin gland
Suspect if recurrent BD cyst or abcess with firm base
after drainage
Vulvar Ulcer: Differential Diagnosis






Genital Herpes
Syphilis
Chancroid
“Tropical STD”: granuloma inguinale, LGV
Behcet’s Disease: mouth, eye, genital ulcers
Crohn’s Disease:
– Knife-cut ulcers, GI-cutaneous fistulae
 Lichen planus, lichen sclerosus
Genital Ulcers: Management
 Syphilis
– VDRL or RPR
 Chancroid
– Test for H ducreyi (culture, PCR, DNA)
 Herpes simplex
– Early lesion: HSV culture, PCR, or DFA
– Late lesion: DFA or cytology
– Type-specific HSV serology
 Biopsy if Bechet’s or Crohn’s suspected
 Presumptively treat for “best guess” or syphilis + chancroid
Chancroid
 Due to Hemophilis ducreyi
 10% also have syphilis or herpes
– Co-factor for HIV infection
 Symptoms/ signs
– One or more painful genital ulcers
– Regional adenopathy; may suppurate (buboe)
 Lab: culture <80% sensitive; contact lab before sampling
 Treatment
– Azithromycin 1 gram PO
– Ceftriaxone 250 mg IM
 F/U in 7 days; treat partners within 10 days
Herpes Simplex Virus: Organism Tests
PCR
HSV culture
 ELVIS rapid
 ELVIS std
 Cytopathic
Herpes DFA
Cytology
Sensit Specif Cost Comment
+4
+4 $$$$ Not in most labs
+3
+3
+3
+2
+1
+4
+4
+3
+3
+3
$$$
$$$
$$
$$
$$
No typing
Reflex typing
Phasing out
Scrape; plate
Scrape; plate
Herpes Simplex Virus
Serologic Tests
 Use only “type-specific” tests for HSV-2 antibody
– Almost all HSV-2 is sexually acquired
– HSV-1 antibody orolabial or genitally acquired
 Envelope glycoprotein G (gG) HSV-type specific
assays
– HerpeSelect-1 ELISA or HerpeSelect-2 ELISA
– HerpeSelect-1 and 2 Immunoblot G
– POCkit HSV-2, biokitHSV-2 (point of care)
 Sensitivity: 80-98%; specificity > 96%
HSV-2 Serologic Diagnostic Testing
 History suggestive of HSV but no lesions to test
– If seronegative, not due to genital herpes
– If seropositive, HSV lesion or prior infection
 Culture negative recurrent lesion
– If seronegative, not due to genital herpes
– If seropositive, HSV lesion or prior infection
 Suspected 1o herpes, if initial testing negative and
more than 6 weeks prior
– If seronegative, not due to genital herpes
– If seropositive, HSV infection confirmed
HSV-2 Serologic Screening
Screen general population
Should not be offered
Universal screening in
pregnancy
Screening in HIV-positive
patients
Screening in patients in
partnerships with HSV-2
infected people
Screening in patients at risk
for STD/HIV
Should not be offered
Should generally be offered
Should generally be offered
Should be offered to select
patients
Guidelines for the Use of HSV-2 Type-Specific Serologies, CA DHS 2003
HSV-2 Serologic Screening
 At risk for STD/HIV (current STD or HR behavior),
offer to select patients [C] if:
– Patient is motivated to reduce risky behavior
– Patient is willing to use condoms or Rx
consistently
– Risk reduction counseling will be provided
 Arguments against screening
– Limited evidence that counseling or Rx works
– Limited evidence that condoms will be used
– Little value if risk reduction counseling not given
Transmission of HSV-2 to Susceptible Partners
with Suppressive Therapy
Percent Transmission
RCT of 1,484 hetero couples
• Valacyclovir 500 mg QD or
placebo QD for 8 months
• Monthly HSV serology for
susceptible partners
The valacyclovir group showed
• 47% less HSV-2 transmission
• Lower frequency of shedding
• Fewer copies of HSV-2 DNA
when shedding occurred
4
3.6%
3.5
3
2.5
2
1.9%
1.5
1
0.5
0
Valacyclovir
Group
(N=743)
Control
Group
(N=741)
Corey et al, NEJM 2004; 350:11-20
Prevention of Genital Herpes
 Incident HSV infection reduced by 1.7% over 1 year
– 96.4% don’t seroconvert in absence of treatment
– 1.9% seroconvert with treatment
– Must treat 59 people to prevent one case/ year
 Indications may include
– Discordant couples (reassess annually)
– Infected persons with multiple partners
– MSM
– HIV-positive
 Counsel regarding condoms, disclosure, abstinence
* Discussed at the
2006 Guidelines Meeting
Genital Herpes and Antiviral Drugs
 Primary Herpes
– Shortens median duration of lesions by 3-5 days
» Therefore, initiate within 6 days of onset
– May decrease systemic symptoms
– No effect on subsequent risk, frequency, or severity of
recurrences
 Recurrent Herpes
– Shortens the mean duration by 1 day
– Initiate meds within 2 days of onset
» Best to start with onset of prodromal symptoms
» Patient should have supply of meds available
HSV: Adjunctive Therapy
 Frequent dosing of NSAID (ibuprofen) or aspirin
 Sitz baths (TID) in cool or warm water or use milk
compresses
 Burrows solution sitz baths (Domeboro) or Burrows
compresses
 To avoid towel drying, use the cool setting of a hand
dryer
 If urinary tract symptoms prominent, urinate in
warm sitz bath
 Topical local anesthetics may provide limited relief
HSV: Suppression Therapy
 Acyclovir given continuously to decrease frequency,
severity of outbreaks
– Studies have shown befeficial effect for up to five years
– Will not affect natural history of HSV infection
– Prior pattern of recurrences after discontinuation
 Used for those with >6 recurrences per year
 After 1 year, discontinue to allow assessment of
recurrent episodes
 Most widely used regimen is acyclovir 400 mg PO
BID; may be increased to 3-5 times per day
Management of Vulvar Hematoma
 Almost all are due to straddle injuries
 Initial management
– Pressure
– Ice packs
– Watchful waiting
 Complex management
– Use if extreme pain or failure of conservative mgt
– Incise inside hymeneal ring, evacuate clots
– Pack with strip gauze, sitzbaths
Additional References
 Marzano DA, The bartholin gland cyst: past, present, and
future. J Low Genit Tract Dis 2004 Jul;8(3):195-204
 Bauer A, Vulvar dermatoses--irritant and allergic contact
dermatitis of the vulva. Dermatology 2005;210(2):143-9.
 Smith YR, Vulvar lichen sclerosus : pathophysiology and
treatment. Am J Clin Dermatol. 2004;5(2):105-25.
 Fischer G, Management of vulvar pain. Dermatol Ther
2004;17(1):134-49.
 Edwards L, Vulvar fissures: causes and therapy. Dermatol
Ther 2004;17(1):111-6
 Foster DC, Vulvar disease. Obstet Gynecol 2002; 100(1):
145-63.