Vulval problems
  • Vulval problems include itch, pain, swelling, bleeding, ulcers, lumps, change in skin colour or texture (eg skin cracking)
  • Some women do not have any symptoms or do not report them. The appearance of the vulva should be noted when the woman is examined for any another reason (eg cervical screening)
  • Any woman with persistent lump, ulcer, vulval skin colour change or vulval bleeding needs referring for a gynaecology consult to exclude vulval cancer
Vulval itch (vulvodynia)

Can be caused by many conditions

  • Candida (thrush)
  • Tinea cruris (jock itch)
  • Dermatitis, psoriasis
  • Lichen planus, lichen sclerosis — 3–5% risk of progressing to cancer
  • Vulvar intraepithelial neoplasia (VIN), vulval cancer
Vulval lumps
  • Bartholin's cyst, Bartholin’s abscess
  • Vulval abscesses (boils) — common in remote context
  • Syphilis sores or lesions 
  • Sebaceous cyst
  • Haematoma (collection of blood)
  • Varicose veins
  • Vulval cancer 
Vulval pain
  • Candidiasis (chronic thrush) or dermatitis with skin cracking 
  • Vulvodynia (can occur without visible lesion) 
  • STI related ulcers or lumps (usually but not always painless)
  • Trauma — laceration or abrasion

Figure 6.18   

 

Persistent changes
  • Skin changes include
    • Shiny appearance
    • Cracks
    • Colour — pale, red, pink, grey, brown
    • Raised areas, bleeding
  • Shrinking of labia minora
  • May be caused by
    • Lichen planus, lichen sclerosis — skin often paler
    • VIN, vulval cancer

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • U/A, pregnancy test
  • Vulva and perianal area — look for changes as above

Do

  • Full STI check
  • Lesion swab — viral swab for genital herpes (HSV), MC&S
  • If persistent itch, pain, lump, ulcer or skin changes — medical consult
    • Most women need gynaecology review and may need biopsy to make diagnosis

Follow-up

  • If lichen sclerosis, VIN or vulval cancer — woman needs regular gynaecology reviews
  • If vulval biopsy — woman needs gynaecology review to follow-up results
  • If topical corticosteroid prescribed for dermatitis or lichen sclerosis — check woman is using

Bartholin's cyst or abscess

  • Bartholin's cyst — lump or swelling either side of vagina opening — Figure 6.19
  • Bartholin’s abscess — infected Bartholin's cyst. Infection can be due to STI or many other organisms
    • Presents as red, hot, swollen, tender — can be very painful
    • May discharge spontaneously (without squeezing or pressing)

Figure 6.19   

 

Do

  • Swab and request MC&S and NAAT for chlamydia and gonorrhoea

Do — if painful cyst

  • If no infection — medical consult to consider referral to gynaecologist for possible surgery

Do — if abscess

  • Medical consult
  • If abscess hasn't discharged — send to hospital
    • Needs operation to drain abscess, stop it recurring
    • While waiting — keep comfortable, regular pain relief. May need opioids if severe pain
  • If advised by doctor 
    • Give  amoxicillin-clavulanic acid oral —  adult 875+125mg, twice a day (bd) for 5 days
    • AND doxycycline oral — adult 100mg, twice a day (bd) for 7 days
    • If pregnant — medical consult 
    • If allergy to penicillin or vomits after taking medicine — medical consult about different antibiotic

Follow-up

  • If abscess discharges — complete antibiotics
  • If recurrent abscesses — refer to gynaecologist. May need operation