Introduction

Vulvitis is a familiar and prevalent disease in gynaecological clinics. Although it is not an emergency, the discomfort it causes is hard to ignore.

• Intermittent itching attacks make it feel as though insects are crawling around the affected area, causing restlessness, sleep disturbances, and an inability to concentrate at work
• The recurrent nature of the disease is elusive and discouraging, and maybe anxiety-inducing and causes low mood 

Despite being a minor inflammation, vulvitis can significantly disrupt the lives of those affected, especially when it frequently recurs. Continuous medication without improvement can lead to doubts about more serious underlying illnesses.

So today, let's discuss how vulvitis is diagnosed and the available treatment options.

What is vulvitis?

Vulvitis is the inflammation of a woman's external genitalia. The contamination affects the mons pubis, clitoris, the labia majora and labia minora (the outer and inner "lips"), and the glands near the vaginal opening. Vulvitis is characterised by swelling, redness, itching, burning, pain during sexual intercourse, and pain when urinating. Vulvovaginitis is vulvitis combined with vaginitis.

If vulvitis isn’t treated promptly, it can lead to further health issues such as:

• Vaginitis: Often caused by the same pathogens as vulvitis
• Urinary tract infections: the occurrence of urogenital infections, which are accompanied by frequent urination and pain
• Other reproductive system infections: Such as cervicitis and adnexitis
• Infertility: Pathogen infections disrupt the microbial environment in the vagina of women of reproductive age, which can negatively affect sperm life

Causes of vulvitis

Depending on the origin, vulvitis can be divided into several common types:

• Non-specific vulvitis: This is caused by non-infectious factors such as long-term irritation from urine, faeces, or menstrual blood, or by poor ventilation in the genital area due to factors like sitting for long periods or frequent use of panty liners
• Infectious vulvitis: This type is when germs like bacteria or fungus start an infection in the genital area
• Allergic vulvitis: Allergic reactions to substances like scented soaps, synthetic fibres, or cleaning agents can cause an acute allergic response, leading to vulvitis

But most of the time, vulvovaginitis doesn't come from one specific thing. The most common causes of nonspecific vulvitis are poor hygiene, excess cleaning around the area, and chemical irritants.¹

Young girls yet to go through puberty experience vulvovaginitis more often.² This is because their private parts haven't fully developed yet, such as the outer and inner lips, and there's no protective hair or enough fat tissue.³ This means the vagina is more exposed and can easily get infected by germs from the area around the anus (like from soap, bubble baths, and wipes). 

Also, the vagina's natural environment is more neutral (the opposite of acidic), which can let harmful germs overgrow. Normally, good bacteria are present there and help stop too many bad germs from growing, but when there are not enough of these good bacteria, it can lead to vulvovaginitis.

How to diagnose vulvitis?

The differential diagnosis of vulvitis includes a range of conditions such as urinary tract infections (UTIs), psoriasis, eczema, contact dermatitis, scabies, vesicovaginal reflux, congenital conditions (conditions present from birth) like ectopic ureter, certain fistulas, and systemic diseases like Kawasaki disease, Crohn's disease, and scarlet fever. However, the focus generally remains on the following two types of examinations:

• Gynaecological examination: The doctor will observe the vulva to identify any signs of swelling, scratches, erosion, lichen-like changes, eczema-like changes, or tenderness. This physical inspection helps in assessing the visual and physical symptoms that might indicate vulvitis
• Pathological examination: A sample of vaginal discharge is collected to identify the pathogens responsible for the infection. This test helps pinpoint the exact type of pathogen present. Additionally, an antimicrobial susceptibility test can be performed to guide future medication choices

These diagnostic steps are essential in confirming the presence of vulvitis and determining the most effective treatment plan.

Treatment options and prevention tips

Teaching proper genital hygiene to girls

• Observing hygiene: Pre-pubescent girls need to maintain good hygiene. Poor hygiene behaviours such as incorrect wiping or urinating with legs closed can worsen conditions by promoting bacterial growth. This creates an environment where urine is trapped and faecal bacteria can be transferred to the vaginal entrance⁴
• Correct wiping technique: The mothers or caregivers should teach the girls to wipe from the front to back to avoid transferring bacteria from the anal region to the vaginal parts
• Bathing and wiping: Lukewarm water should be used to clean the genital region and the body should be dried with a towel. Irritants like paper tissues, scented papers, and bubble baths should be avoided whereas plain tissue paper and toilet paper should be used

Clothing recommendations

Cotton and loose clothing: Girls should wear cotton underwear and loose clothing to ensure proper air circulation around the genital area. During hot weather, it's advisable to wear loose pyjamas or shorts at night instead of tight underwear.

Probiotics for non-specific vulvitis

Probiotics, defined as live microorganisms which, when administered in adequate amounts, confer a health benefit on the host, have shown effectiveness in treating vulvovaginitis, particularly as a supplementary treatment to conventional drug therapies.⁵ A 2020 scientific review supported their use in the short-term treatment of common vaginal infections in non-pregnant adult women.⁶

Symptom relief through warm baths

Sitting in a tub full of warm water or using a sitz bath can be helpful. The region should be gently dried completely using a gentle, dry, fresh towel or a cool blow dryer after bathing. Applying barrier cream or emollient to the dry area can then help secure the skin and relieve dryness.⁴

Pathogen-specific  treatments

• Antibiotics: If a specific pathogen is identified, the use of topical or systemic antibiotics is usually effective
• Antifungal creams: These are generally effective for treating candida infections.
• Treatment for parasites: Medications such as mebendazole are effective for treating pinworm infections
• Further investigations: Isolation of sexually transmitted pathogens requires further investigation. Physicians should also be aware of the increased incidence of vulvovaginitis in girls who have been sexually abused
• Checking for foreign bodies: For persistent diseases, the possibility of foreign bodies should be examined

FAQs

What is the difference between vulvitis and vaginitis?

Vulvitis and vaginitis are terms used to describe inflammation in the lower genital tract. While vulvitis specifically refers to inflammation of the external parts of the female genitalia, known as the vulva, vaginitis is the inflammation of the vaginal canal itself. When both the vulva and vagina are inflamed, the condition is known as vulvovaginitis. Untreated, these conditions can lead to complications such as ascending infections that spread to the upper genital tract, potentially causing pelvic inflammatory disease (PID), damage to the fallopian tubes, chronic pelvic pain, and infertility.⁷

Is vulvitis contagious?

Vulvitis itself is not contagious, but some of the causes can be. A variety of bacterial, viral, fungal, and parasitic organisms can infect the vulva. Vulvitis caused by allergies or skin irritations is not contagious.

Can vulvitis lead to cancer?

It is possible. Chronic inflammation, such as that seen in vulvitis, can be one of the risk factors for vulvar cancer. However, having risk factors for cancer does not mean cancer will occur. Proper and standardised treatment can reduce the risk of such complications.

Summary 

Vulvitis is an inflammatory condition of women's external genitalia. It can be caused by conditions which include non-specific causes like irritation or poor hygiene, infections, allergies etc. A detailed physical examination by a gynaecologist and certain diagnostic tests to identify the exact cause can help diagnose this condition.

While vulvitis can be a distressing condition, proper diagnosis, hygiene education, and targeted treatment can effectively manage and prevent it.