These pathways were developed to guide clinicians when managing vulval irritation
The pathways are not provider specific and so the guidance and forms apply to all providers.
Care of Vulval Skin – British Association of Dermatologists leaflet - http://www.bad.org.uk/shared/get-file.ashx?id=74&itemtype=document
- Vulval skin conditions can present with itching, pain or discomfort and superficial dyspareunia
- Ask about discharge and bleeding
- Take a sexual history
- Note the age – atrophic vaginitis can occur in peri and post-menopausal women. Vaginal dryness can result in irritation and superficial dyspareunia
- Take a skin history, asking about eczema, dermatitis and psoriasis
- Ask about showering, douching, use of soaps and use of lubricants during intercourse
- Look for inflammation, scarring, discrete skin lesions, ulceration, infestation.
- Document areas of tenderness.
- Perform a speculum to check the vaginal walls and cervix – observe any discharge.
Eczema/dermatitis – can be atopic, irritant or friction mediated
Mx – try potent steroid if simple measures are not helping.
- Young women – consider STI (HSV, chancroid, granuloma inguinale, lymphogranuloma venereum, syphilis) – refer GUM or treat – as appropriate
- Older women – consider VIN and malignancy – refer 2 week wait
- In all, consider rarer skin conditions including behcets, SLE, pemphigus and pemphigoid – refer vulval clinic / dermatology
- Referral Criteria
- Diagnosis uncertainty – refer to LTHT gynaecology single point of access
Consider vulvodynia in the absence of physical findings
Definition - International Society for the Study of Vulvovaginal Disease (ISSVD) defines vulvodynia as a chronic discomfort involving the vulva in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder.
Symptoms – burning or soreness of the vulva that can be provoked or unprovoked, localised or generalised.
- The British Society for the Study of Vulval Disease (BSSVD) guidelines recommend a multidisciplinary approach and advise that combining treatments can be helpful in dealing with different aspects of vulval pain. Specialities which may be involved include psychosexual medicine, physiotherapy, clinical psychology and pain management teams.
- Care of the vulval skin leaflet - http://www.bad.org.uk/shared/get-file.ashx?id=74&itemtype=document
- Try topical local anaesthetic – e.g. 5% lidocaine ointment or 2% lidocaine gel 20 minutes before intercourse (wash off before penetration as may also cause penile numbness)
- SSRIs can be tried
- Physiotherapy may help
- Psychological therapies e.g. cognitive behavioural therapy – can be helpful.
More information for patients - http://www.vulvalpainsociety.org/vps/
- Non hormonal vaginal moisturisers can be helpful for vaginal dryness – regularly or prn – e.g. Replens
- Use of lubrication during sex.
- Lichen sclerosus – cigarette paper skin – pale and scarred – introitus may be narrowed – changes may extend perianally
- Mx – care of vulval skin and trial of potent steroid – e.g. dermovate ointment bd for month, od for 1 month then twice a week
- Lichen planus – purple tinged or hyperpigmented papules, can be scaly and may have reticulated white network
- Mx – refer if in doubt of diagnosis. Try potent steroids ointment
- Lichen simplex – follows repetitive scratching and rubbing – see confluent thickened papules, signs of excoritation
- Mx – refer if in doubt of the diagnosis. Try potent topical steroids ointment until the lesion has resolved – usually 4-6 weeks
- Genital warts – refer to GUM (or in house treatment if available)
- Skin tags – refer to minor surgery or gynae if appropriate, for excision.
- Advice on use of adequate over the counter or prescription lubrication – water, silicone or oil based (although beware condom use and oil based lubricants.)
- Lidocaine ointment or gel can be helpful
- Vaginal moisturisers used regularly or prn can be helpful – e.g. Replens
- Dilators can be prescribed or bought if symptoms persist after the underlying condition has been treated – e.g. prescribe Amielle comfort dilators. Advise to start with the smallest most comfortable dilator, insert for approx. 10 mins every day and move up to the next size when ready.
- Psychosexual counselling may be needed – refer as appropriate
Peri or Post-Menopausal Women
Consider atrophic vaginitis and a trial of vaginal oestrogens even if on systemic HRT, e.g. estradiol (Vagifem) 10mcg every night for 2 weeks, then twice a week. Vagifem has a license for long term use. If a cream is preferred, try estriol 0.1% (e.g. ovestin) or estriol 0.01% (e.g. gynest), 1 applicatorful every night for 2 weeks and then twice a week. See NICE Menopause Guidelines (Menopause: diagnosis and management. Vaginal oestrogen use in women who have had breast cancer may be possible – refer to a healthcare professional with expertise in menopause management. NICE guideline [NG23] Published date: November 2015.)