Symptoms in Vulval Disease

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Symptoms in Vulval Disease

A symptom is defined as the subjective evidence of disease or physical disturbance experienced by patients. They then seek medical advice about the cause and its treatment. However, some patients will present without symptoms, but they have become concerned after noticing a change in appearance of the vulva or the presence of a lesion. As outlined in Chapter 2, it is vital to define the reason for presentation and to obtain a clear history of the symptoms and their evolution. Some patients will present with disorders of sexual function, which may, or may not, be associated with a vulval disorder. After assessment to exclude any infection or dermatosis and so forth, the patient will then benefit from referral to an expert in sexual medicine.

Patients who present with a vulval problem generally do so for the following reasons:

pruritus/itch;
soreness or discomfort;
pain;
dyspareunia;
discharge;
change in appearance;
presence of a lump/lesion.

This chapter will define these symptoms and give the common diseases that give rise to them. Further information can then be found on the specific disorders in subsequent chapters. The lists are not exhaustive as some patients may describe a combination of symptoms and symptoms are subjective. One patient may describe a disease in terms of discomfort and another one could report pain for the same condition. It is helpful when trying to think through a differential diagnosis to group the potential causes into infection (sexually transmitted and nonsexually transmitted), inflammatory, neoplastic and others.

Pruritis (Itch)

Pruritus or itch is one of the most common presenting symptoms in any dermatological condition, but is also frequent in vulval disease. Itch is generally defined as an unpleasant sensation that gives the desire to scratch. Many patients use the term ‘irritation’ but this is not always synonymous with itch and they may be describing burning, discomfort or pain. It is therefore helpful to ask patients if they want to scratch to bring relief. If they say yes, then the problem is itch. However, if they say no, further exploration of the history is needed to try to define the true symptom.

Itch can be exacerbated via central mechanisms or environmental factors. Emotional stress is well known to worsen itch, as will warmth. Patients with vulval disease often report an exacerbation of symptoms in the evening, after a hot bath or in bed. This may be related to increased temperature of the affected area.

The pathophysiology of pruritus is not well understood and no specific skin receptors for itch have been identified. Physical and chemical stimuli can evoke itch and several pharmacological mediators in the skin are likely to be important, such as histamine, prostaglandins and proteases. Scratching can relieve itching for a short time after scratching the skin has stopped, but again the mechanisms are unclear.

Itching may often be replaced with soreness if scratching continues and leads to skin breakdown (excoriation) or fissuring, which is common in vulval disease.

Generalized itching can be related to systemic illness such as renal or hepatic disease or internal malignancy. However, isolated vulval itch is unlikely to be linked to these but may be involved as part of a generalized problem. In this case, the patient should be referred to a dermatologist for appropriate investigation.

Causes of vulval pruritis

The term ‘pruritus vulvae’ is still seen in some older texts but should never be regarded as a diagnosis but as a symptom. The cause of the itching (see Table 7.1) should be established and treated appropriately.