18 The two most common vulval infections not transmitted via a sexual route are candidiasis and bacterial vaginosis. In both cases, the normal balance of the flora of the vulva and vagina is upset, causing overgrowth of organisms leading to symptoms. However, there are several less common infections that occur on the vulva that are not transmitted via sexual contact. Many of these are rare in the developed world but are listed in Table 18.1. Advice should be sought from experts in tropical medicine regarding diagnosis and management where relevant. Table 18.1 Nonsexually transmitted vulval infections. Note: aAsk for expert advice on investigation and management. Bacterial vaginosis (BV) is the commonest cause of a vaginal discharge in women during the reproductive years and is due to an imbalance in the normal flora causing overgrowth of Gardnerella vaginalis. It has been associated with pre‐term birth and endometritis. The classic feature is of an offensive profuse vaginal discharge. Inflammation is not generally associated, but the discharge can cause an irritant vulval dermatitis in some women. The Amsel diagnostic criteria include a white discharge, vaginal pH .4.5, clue cells on direct microscopy and a fishy odour with the addition of 10% potassium hydroxide. Metronidazole or clindamycin are recommended. BASHH patient information: CDC guidance: UK National Guideline for the Management of Bacterial Vaginosis 2012: Erythrasma is an infection caused by Corynebacterium minutissimum, a Gram‐positive aerobic bacterium It is found on normal skin but particularly favours moist environments, therefore vulval involvement is common. Predisposing factors include immunosuppression, diabetes and obesity. The areas are well demarcated (Figure 18.1) with superficial scaling at the edge (Figure 18.2). There may be a red / brown discoloration to the plaques with lesions at other sites, including the axillae and under the breasts. Figure 18.1 Erythrasma. Figure 18.2 Scaly edge to the plaques. Tinea cruris is the major differential diagnosis and the two infections can sometimes occur together. Microscopy of skin scrapings (see Chapter 5) can identify the organism. The diagnosis can also be made by using a Wood’s lamp as affected areas will show a coral‐pink fluorescence due to the presence of a porphyrin. Topical treatment with fusidic acid cream or topical erythromycin may be effective. Oral erythromycin 250 mg four times a day for 2 weeks is used in more severe infections. DermNet: These two common pathogenic bacteria cause a range of clinical patterns of infection (see Table 18.2). Table 18.2 Staphylococcal and streptococcal infections. Staphyloccous aureus is the usual agent responsible for folliculitis, a pustular infection around hair follicles, boils and abscesses. The increasingly recognized variant of S. aureus, PVL (Panton Leucocidin Valentine) can cause infection in the vulval area.
Vulval Infection – Nonsexually Transmitted
Clinical features
Diagnosis
Treatment
Nematode infection
Threadworm infection
(Enterobius vermicularis)
Common infection in children; anal and vulval pruritus
Identification of the threadworms or eggs on perianal skin – can be seen by applying adhesive tape to the skin and examining microscopically
Piperazine or mebendazole
Filariasisa
Lymphoedema and elephantiasis
Histology
Diethylcarbazine in increasing doses. Surgery may be required
Trematode (fluke) infection
Schistosomiasisa
Usually occurs before puberty with granulomatous nodules; swelling and scarring can occur
Ova are seen in the urine. ELISA tests available
Praziquantel
Protozoa
Leishmaniasisa
Large ulcers that can be similar to those seen in syphilis or donovanosis
Histology or specialized culture
Sodium stilbogluconate or antimony preparations
Amoebiasisa caused by Entamoeba histolytica
Abscesses on vulva, perineum or cervix with lymphadenopathy
Amoebae may be seen in the ulcers or on scrapings from cervix
Metronidazole
Mycobacterial infection
Tuberculosisa
Vulval involvement less common than upper genital tract; nodules, ulcers and scars occur; more common in immunosuppressed patients
Histology
Antituberculous treatment
Leprosya
Can be direct inoculation of the vulva or involvement by haematogenous spread
Expert advice
Other bacterial infections
Actinomycosis
Actinomycosis species can infect intrauterine devices
Culture and histology
Penicillin is first line, but Tetracyclines, clindamycin and erythromycin are alternative treatments.
Mycoplasma
Ureaplasma and mycoplasma species may be found in the vagina in asymptomatic patients; Bartholin’s abscesses may occur
Culture and histology
As for actinomycosis
Bacterial Infections
Bacterial Vaginosis
Clinical features
Diagnosis
Treatment
Further reading
Useful Web Sites for Patient Information
Erythrasma
Clinical features
Differential diagnosis
Diagnosis
Basic Management
Useful Web Site for Patient Information
Staphylococcal and Streptococcal Infections
Staphylococcus
Streptococcus
Either
Folliculitis
Streptococcal perianal dermatitis
Cellulitis
Bartholin’s gland abscess
Necrotizing fasciitis
Toxic shock syndrome
Staphylococcal scalded skin syndrome
Folliculitis
Pathophysiology
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