Vulvitis
Introduction
Vulvitis is defined as the inflammation of the vulva, the outer part of the female genitalia. It
is not a disease itself but a symptom of various underlying conditions ranging from
infections and allergies to autoimmune and idiopathic causes. The condition may be acute
or chronic and affects females across all age groups, with a higher prevalence in
prepubertal girls and postmenopausal women. In medical practice, Vulvitis is often
underdiagnosed due to overlapping symptoms with other genitourinary disorders.
1. Anatomy and Physiology of the Vulva
The vulva encompasses several important external structures of the female reproductive
tract:
Labia Majora: Outer fatty folds providing protection.
Labia Minora: Inner delicate folds enclosing the vestibule.
Clitoris: Highly innervated erectile tissue responsible for sexual arousal.
Vestibule: The space enclosed by labia minora containing the urethral and vaginal
openings.
Bartholin’s glands: Located on either side of the vaginal opening, they secrete mucus for
lubrication.
- The vulvar tissue is thin, moist, and vascularized. Estrogen maintains the trophic
integrity of the vulva by promoting epithelial maturation, vascularity, and
maintaining acidic pH through glycogen-rich secretions metabolized by lactobacilli.
- In estrogen-deficient states (e.g., menopause or childhood), the epithelium
becomes thinner, drier, and more susceptible to trauma and infection, predisposing
to vulvitis.
2. Classification of Vulvitis
Vulvitis can be categorized based on clinical duration and etiology:
Acute Vulvitis: Characterized by sudden onset symptoms such as redness, itching, and
pain. Often due to infections or irritants.
Chronic Vulvitis: Lasts more than three months. May be due to autoimmune conditions,
chronic allergic reactions, or idiopathic factors.
Vulvovaginitis: Involves both the vulva and vagina, common in pediatric and geriatric
populations.
Idiopathic Vulvitis: Chronic condition with no identifiable infectious or allergic cause.
Diagnosis of exclusion.
3. Etiology of Vulvitis
Infectious Causes
Fungal: Most commonly Candida albicans. Presents with intense pruritus, thick white
discharge, and erythematous vulva.
Bacterial: Gardnerella vaginalis (associated with BV), Streptococcus, Staphylococcus
aureus.
Viral: HSV causes painful vesicles and ulcers; HPV may cause warts
Parasitic: Scabies, pubic lice, and Trichomonas vaginalis
Non-Infectious Causes
Allergens: Latex, detergents, sanitary pads, deodorants.
Irritants: Harsh soaps, tight synthetic clothing, prolonged wetness.
Mechanical Trauma: Cycling, horse riding, excessive washing.
Hormonal Deficiency: Menopause or post-lactation periods.
Idiopathic Causes
These are chronic, non-specific inflammatory changes of the vulva without known
pathogens, allergens, or trauma. Often associated with chronic pain syndromes and
difficult to treat.
4. Pathology of Vulvitis
Histologically, vulvitis shows nonspecific inflammatory changes. The key pathological
features include:
Epithelial changes: Spongiosis (intercellular edema), acanthosis (epidermal thickening),
and parakeratosis may be present. In chronic cases, epithelial thinning is also observed.
Inflammatory infiltrate: Lymphocytic infiltration in the dermis, along with plasma cells
and histiocytes, is commonly noted. In acute cases, neutrophilic infiltrates predominate.
Vascular changes: Capillary dilation and increased vascular permeability may cause
erythema and edema seen clinically.
Ulceration or erosions: In severe or persistent vulvitis, erosions with underlying
granulation tissue may occur.
Special conditions: Lichen sclerosus may show thinning of the epidermis with
homogenization of collagen in the upper dermis. Lichen planus shows sawtooth
acanthosis and basal cell degeneration.
Histopathological examination is essential in chronic, unresponsive, or atypical
presentations to rule out premalignant or malignant changes.
5. Clinical Features
Symptoms vary based on cause but generally include:
Itching (pruritus): Most common complaint, worse at night.
Burning or pain: Aggravated by urination or intercourse.
Redness and swelling: Localized or diffuse.
Discharge: White (Candida), grey/fishy (BV), yellow-green (Trichomonas).
Cracked or thickened skin: In chronic cases.
Dyspareunia: Pain during sexual intercourse.
Lichenification: Thickening of skin from chronic scratching.
6. Diagnostic Evaluation
Step 1: Detailed History
Hygiene products
Sexual history
Past infections or STI exposure
Menstrual status or menopausal symptoms
Clothing and personal care habits
Step 2: Physical Examination
Use lithotomy position.
Look for redness, lichenification, ulcers, fissures.
Check for inguinal lymphadenopathy.
Perform speculum exam if vaginal discharge or bleeding is present.
7. Investigations
1. Vaginal pH Test
Normal vaginal pH is < 4.5.
BV and Trichomonas infections increase pH.
2. Microscopic Wet Mount & KOH Prep
Wet mount detects Trichomonas, clue cells (BV).
KOH prep helps identify yeast cells.
3. Whiff Test
Add 10% KOH to sample: Fishy smell indicates BV.
4. Culture & STI Screening
Swabs for Candida, Chlamydia, Gonorrhea, HSV PCR.
5. Skin Biopsy
In chronic/refractory cases or suspected malignancy.
6. Allergy Testing
Patch testing in idiopathic/chronic recurrent vulvitis.
8. Chronic Inflammatory Idiopathic Vulvitis
This condition presents as chronic itching, soreness, and thin, easily tearing vulvar skin.
Not caused by sexual activity or poor hygiene.
Frequently worsened by scratching or intercourse.
May not respond to typical antifungal/antibiotic treatment.
Histology shows nonspecific inflammation without neoplasia or infection. Diagnosis is
made by exclusion. Management focuses on symptomatic relief and quality of life.
9. Management
A. Allopathic Medicine
1. General Care Recommendations
These apply to all types of vulvitis:
Avoid irritants: Perfumed soaps, scented sanitary products, synthetic underwear, bubble
baths, and douches.
Use warm water and mild, unscented cleansers for vulvar hygiene.
Wear loose-fitting cotton underwear to allow ventilation.
Change wet clothing (e.g., after swimming or sweating) promptly.
Avoid scratching: Trim nails and consider using cold compresses or antihistamines to
reduce itching.
2. Pharmacologic Treatment Based on Cause
A. Infectious Vulvitis
1. Fungal (Candida albicans)
Topical antifungals:
Clotrimazole 1% cream (e.g., Canesten) – apply twice daily for 7–14 days.
Miconazole cream (e.g., Micatin, Daktarin) – effective against Candida and some bacteria.
Oral antifungals (for recurrent/severe):
Fluconazole 150 mg (e.g., Diflucan) – single oral dose or weekly for recurrence.
2. Bacterial (Bacterial Vaginosis, Streptococcus)
Metronidazole:
Oral: 500 mg twice daily for 7 days
Topical: 0.75% gel (e.g., MetroGel-Vaginal) applied once daily for 5 days
Clindamycin cream 2% (e.g., Cleocin) once daily for 7 days
3. Viral (Herpes Simplex Virus)
Antivirals:
Acyclovir 400 mg orally three times daily for 7–10 days
Valacyclovir 500–1000 mg orally twice daily
4. Parasitic
Scabies:
Permethrin 5% cream – apply from neck to toes, wash after 8–14 hours
Pubic lice:
Permethrin 1% cream rinse (e.g., Nix) or malathion 0.5% lotion
B. Non-Infectious Vulvitis
1. Irritant/Allergic Vulvitis
Topical corticosteroids:
Hydrocortisone 1% (e.g., Cortaid) – mild cases
Clobetasone butyrate 0.05% (e.g., Eumovate) – moderate cases
Betamethasone valerate 0.1% (e.g., Betnovate) – short-term use for severe inflammation
Clobetasol propionate 0.05% (e.g., Dermovate) – very potent; use for limited time only
Antihistamines:
Hydroxyzine, Loratadine, or Cetirizine – to relieve itching, especially at night
2. Atrophic Vulvitis (Postmenopausal)
Topical estrogen therapy:
Conjugated estrogen cream (e.g., Premarin) – apply a small amount daily for 2–3 weeks,
then reduce to 2–3 times/week
Estradiol vaginal tablets (e.g., Vagifem) – 10 mcg daily for 2 weeks, then twice weekly
C. Chronic or Idiopathic Vulvitis
Topical steroids (as above) to manage flare-ups
Topical testosterone 2% (custom compounded) – helps improve skin regeneration; applied
1–2 times/day
Topical anesthetics:
Lidocaine 2% gel (e.g., Xylocaine) – apply before sleep or sexual activity
Neuropathic pain treatment:
Amitriptyline 10–25 mg at night, titrate as needed – for chronic vulvar pain
Barrier ointments:
Zinc oxide or petroleum jelly (Vaseline) – for protection against irritants
3. Supportive Therapy
Sitz baths: Warm water soaks 1–2 times daily for 10–15 minutes
Cold compresses for temporary itching relief
Psychological support: Counseling for vulvodynia or sexual dysfunction if needed.
B. Unani Medicine
Unani describes this condition as "Waram-e-Farj" and relates it to su’-e-mizaj haar (hot
temperament).
Moallid (Anti-inflammatory): Roghan-e-Babchi, Sharbat-e-Unnab
Musakkin-e-Hararat (Cooling agents): Roghan-e-Kadu, Sharbat-e-Bazoori
Mushil (Purgatives): Safoof-e-Muqil to eliminate morbid humors
Topical: Zemad-e-Kafoor (camphor with rosewater)
Hammam (Sitz Bath): Decoction of Neem leaves and Sana Makki
Lifestyle modifications
It include avoiding hot/spicy food, increasing hydration, and using breathable clothing.
C. Complementary and Alternative Medicine (CAM)
1. Acupuncture
Points: SP6, CV4, LV3
Benefits: Pain relief, improves circulation
Duration: 20–30 minutes/session, 2–3 sessions/week
2. Herbal Applications
Calendula ointment: Anti-inflammatory, speeds healing
Aloe Vera gel: Hydrating and anti-pruritic
Chamomile Sitz Bath: Anti-inflammatory and relaxing
3. Psychosocial Support
CBT and counseling for patients with chronic vulvar pain
Addressing sexual dysfunction and distress
10. Complications
Vulvar skin atrophy
Dyspareunia
Vulvodynia (chronic pain syndrome)
Secondary infection
Psychological impact: anxiety, depression, sexual aversion
11. Prevention
Avoid scented soaps, douches, synthetic undergarments
Use hypoallergenic hygiene products
Maintain vulvar hygiene with water or mild cleansers
Early treatment of infections
Postmenopausal women: consider topical estrogen (e.g., Premarin Cream)
