Pruritus Vulvae – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Pruritus vulvae is a symptom as well as a primary diagnosis.
    • The symptom may indicate an underlying pathological process.
    • Only when no underlying disease is identified may this be used as a primary diagnosis.
  • Pruritus vulvae as a primary diagnosis may also be more appropriately documented as vulvodynia (See chapter on Vulvodynia) and burning vulva syndrome.

Epidemiology

Symptoms may occur at any given age during a woman’s lifetime.

  • Young girls most commonly have infectious etiology
  • Primary diagnosis more commonly seen in post-menopausal women

Incidence

The exact incidence is unknown, however the majority of women complain of vulvar pruritus at some point in their lifetime.

Risk Factors

  • High-risk sexual behavior
  • Immunosuppression
  • Obesity

General Prevention

  • Attention should be paid to personal hygiene and avoidance of possible environmental factors.
  • Tight fitting clothing should be avoided.
  • Only cotton underwear should be worn.

Etiology

Local irritants:

  • Perfumes
  • Soaps
  • Laundry detergent
  • Douches
  • Toilet paper
  • Sanitary napkins

Commonly Associated Conditions

  • Infectious etiology
    • Vaginal or vulvar candida
    • Gardnerella vaginalis
    • Trichomonas
    • Human Papilloma Virus
    • Herpes Simplex Virus
  • Vulvar vestibulitis
  • Lichen sclerosis
  • Hyperkeratosis
  • Malignant or pre-malignant conditions
  • Psoriasis
  • Fecal or urinary incontinence
  • Excessive heat with sweat
  • Dietary: methylxanthines (e.g., coffee, cola), tomatoes, peanuts

Diagnosis

Pruritus vulvae is a diagnosis of exclusion.

History

  • Persistent itching
  • Persistent burning sensation over the vulva or perineum
  • Change in vaginal discharge
  • Post-coital bleeding
  • Dyspareunia

Physical Exam

  • Visual inspection of the vulva, vagina, perineum, and anus
  • Light touch identification of affected areas
  • Q-tip-applied pressure to vestibular glands

Diagnostic Tests & Interpretation

  • Sodium chloride: Gardnerella or Trichomonas
  • 10% potassium hydroxide: Candida
  • Tzanck smear: Herpes Simplex Virus
  • Directed biopsy: Human papilloma virus, lichen, malignancy

Lab

Follow-Up & Special Considerations

A patch test may be performed by a dermatologist to assist in identifying causative agent if contact dermatitis is suspected.

Imaging

Initial approach

Colposcopy with acetic acid of Lugol’s solution of vagina and vulva

Follow-Up & Special Considerations

Exam-directed biopsies are essential in the post-menopausal population to rule out malignancy (1).

Diagnostic Procedures/Surgery

Biopsies should be collected from any ulceration, discoloration, raised areas, macerated areas, and the area of most intense pruritus.

Pathological Findings

Only in the absence of pathological findings can the primary diagnosis of pruritus vulvae be made.

Treatment

Initial treatment is conservative (2)[C]

  • Treatment of etiology beyond the primary diagnosis of vulvae pruritus
  • Avoidance of environment and dietary irritants
  • Sitz baths
  • Cool compresses or ice packs (gel packs or frozen vegetables)

Medication

First Line

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  • Antihistamines
    • Hydroxyzine 10–50 mg 2 h before bedtime
    • Diphenhydramine 25–50 mg at bedtime
  • Topical steroids (3)[C]
    • Triamcinolone 0.1% applied daily for 2–4 wks then twice weekly
    • Hydrocortisone 1–2.5% cream applied 2–4 times daily (4)
    • Avoid long-term use due to risk of atrophy.
  • SSRIs (citalopram, fluoxetine, or sertraline)
    • Citalopram 20–40 mg daily

Second Line

Topical pimecrolimus 1% cream applied twice daily for 3 weeks (5)[B]

Additional Treatment

  • Subcutaneous triamcinolone injections (6)[B]
  • Alcohol nerve block (7)[B]
  • Laser therapy (8)[B]

Issues for Referral

  • Persistent symptoms should prompt additional investigation and referral to a gynecologist or gynecologist oncologist.
  • Gynecology oncology referral for proven or suspected malignancy
  • Dermatology referral for patch testing to evaluate for contact dermatitis

Ongoing Care

  • Frequent evaluation, repeat cultures, and biopsies are necessary for cases resistant to treatment.
  • Refractory cases may require referral to gynecologist or gynecology oncology for further management.

Diet

Dietary alterations include avoidance of:

  • Coffee and other caffeine-containing beverages
  • Tomatoes
  • Peanuts

Patient Education

  • American Congress of Obstetricians and Gynecologists at www.acog.org
  • National Vulvodynia Foundation at http://www.nva.org/

Prognosis

Conservative measures and short-term topical steroids control most patient’s symptoms.

Complications

Malignancy

References

1. Sener AB, Kuscu E, Seckin NC et al. Postmenopausal vulvar pruritus–colposcopic diagnosis and treatment. J Pak Med Assoc. 1995;45:315–7.

2. Boardman LA, Botte J, Kennedy CM. Recurrent Vulvar Itching. Obstetrics and Gynecology, 2005;100(6):1451–55.

3. Weichert GE et al. An approach to the treatment of anogenital pruritus. Dermatol Ther. 2004;17:129–33.

4. Pincus. Vulvar Dermatoses and Pruritus Vulvae. Dermatologic Clinics. 1992;10(2):297–308.

5. Sarifakioglu E, Gumus II. Efficacy of topical pimecrolimus in the treatment of chronic vulvar pruritus: a prospective case series – a non-controlled, open-label study. J Dermatolog Treat. 2006;17(5):276–8.

6. Kelly RA, Foster DC, Woodruff JD. Subcutaneous injection of triamcinolone acetonide in the treatment of chronic vulvar pruritus. Am J Obstet Gynecol.1993;169(3):568–70.

7. Woodruff JD, Babaknia A et al. Local alcohol injection of the vulva: discussion of 35 cases. Obstet Gynecol. 1979;54:512–4.

8. Ovadia J, Levavi H, Edelstein T et al. Treatment of pruritus vulvae by means of CO2 laser. Acta Obstet Gynecol Scand. 1984;63:265–7.

Additional Reading

Bohl TG et al. Overview of vulvar pruritus through the life cycle. Clin Obstet Gynecol. 2005;48:786–807.

Farage MA, Miller KW, Ledger WJ et al. Determining the cause of vulvovaginal symptoms. Obstet Gynecol Surv. 2008;63:445–64.

Foster DC et al. Vulvar disease. Obstet Gynecol. 2002;100:145–63.

Petersen CD, Lundvall L, Kristensen E et al. Vulvodynia. Definition, diagnosis and treatment. Acta Obstet Gynecol Scand. 2008;87:893–901.

Codes

ICD9

698.1 Pruritus of genital organs

Snomed

67882000 pruritus of vulva (disorder)

Clinical Pearls

  • The majority of women complain of vulvar pruritus at some point in their lifetime.
  • Pruritus vulvae is a diagnosis of exclusion once other causes of itching have been ruled out.
  • Exam-directed biopsies from any ulceration, discoloration, raised areas, macerated areas, and the area of most intense pruritus are essential to rule out malignancy.
  • Initial treatment is conservative.

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