Disorders of the vulva and vagina are very common and cause considerable discomfort. Until recently, however, our understanding of vulvar conditions has been scant due to the lack of communication between gynecologists, dermatologists, pathologists, and sex therapists, each with his or her own ideas of the natural history, mode of diagnosis, and preferred therapy. An obvious consequence is the propagation of terms for the same disorders. The establishment in 1970 of the International Society for the Study of Vulvovaginal Disease (ISSVD) fostered exchange of ideas, collective discussion, and understanding of the natural history and modern treatment of vulvar diseases. Common terminology was established. The terminology of benign vulvar and vaginal disorders used in this chapter is based on the guidelines of the ISSVD. The morphologic and functional approach is accessible to the novice in vulvar and vaginal disease. At the same time it emphasizes breakthroughs in the understanding of the different vulvar pain syndromes, the influence of the vaccine against human papillomavirus (HPV) on vulvar diseases, and the modern treatment of the vulvar dermatoses. The premalignant and malignant vulvar and vaginal disorders are discussed in Chapter 47.
The anatomy of the vagina and vulva is described in Chapter 1. In recent years the vulvar vestibule, the site of origin of vestibulodynia, the “provoked” vulvar pain of dyspareunia, has been a focus of attention. Although the vulvar skin is devoid of estrogen receptors, the development of vaginal disorders is influenced by the presence or absence of endogenous or exogenous estrogen. Estrogen thickens the vaginal epithelium, which leads to the accumulation of glycogen in the epithelial cells. The intraepithelial glycogen metabolizes to lactic acid. The resultant vaginal pH of 3.5–4.0 promotes the growth of normal vaginal flora, chiefly lactobacilli and acidogenic corynebacteria. Asymptomatic Candida organisms may be present in small quantities.
Evaluation of a patient with vulvar and/or vaginal symptoms requires the following:
- A meticulous review of physiologic systems to reveal underlying medical conditions that may lead to vulvar symptoms.
- Diabetes mellitus may be associated with vulvar pruritus or pain as a consequence of vulvovaginal candidiasis or, in advanced cases, as a result of neuropathic pain.
- Elevated serum levels of biliary salts, such as in biliary stasis or primary biliary cirrhosis, may cause vulvar pruritus.
- Hematologic disorders such as polycythemia or lymphoma may be associated with systemic symptoms, including vulvar pruritus.
- A complete history of potential causes of vulvar irritation, including creams, powders, soaps, type of underwear, and cleansing techniques, should be reviewed.
- Assessment of compliance to previous prescriptions may help determine whether failure of past treatments is attributable to incorrect diagnosis or to inadequate treatment.
- Patients sometimes refrain from the use of common medications for vulvar disease due to their high potency or potential for side effects. Typical examples are systemic or potent topical steroids such as clobetasol propionate (Dermovate) and tricyclic antidepressants such as amitriptyline. • Information regarding ...