Pruritus vulvae

Pruritus vulvae

OVERVIEW:

Pruritus vulvae is both a symptom and a pathologic process affecting the vulva. It is a symptom of underlying disease in the vast majority of the patients. As a primary diagnosis, it consists of irritation and vulvar itching without an underlying pathologic etiology.

System(s) affected: Skin/Exocrine
Genetics: Unknown
Incidence/Prevalence in USA: The exact incidence is unknown, although most women will complain of vulvar pruritus at some time during their life
Predominant age:
• Any age can be affected
• In young girls, it is usually caused by an infection
• Frequent in postmenopausal women
Predominant sex: Female only

SIGNS AND SYMPTOMS:

• Constant itching of the vulva
• Constant burning of the vulva

CAUSES:

• Infectious causes - vaginal yeast infections, Gardnerella, other vaginal infections, and yeast dermatitis of the vulva itself
• Urinary tract infections will produce vulvar burning on occasion
• Vulvar vestibulitis (inflammation of the vestibular glands) produces a constant burning with pruritus and dyspareunia
• Human papillomavirus (HPV) has been associated with burning and itching of the vulva
• Vulvar tissues are estrogen sensitive. Estrogen deprivation can produce burning and itching.
• A search for underlying malignancy should be paramount. Carcinoma in situ (Bowen's disease) and invasive malignancy will often be associated with pruritus.
• Changes in the epidermis, such as lichen sclerosis et atrophicus (LSA) (thinning of the vulvar tissues and homogenization at the basement membrane) or hyperkeratosis of the vulva produce pruritus
• Anal incontinence with fecal soilage produces pruritus
• Excessive heat produces symptoms from sweat and irritation
• Environmental and dietary irritants such as nylon, soaps, perfumes, and over-zealous cleansing can produce symptoms
• Dietary irritants include methylxanthines (coffee, cola), tomatoes, peanuts

RISK FACTORS:

N/A

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS:

• The diagnosis of primary idiopathic vulvar pruritus must be made by exclusion
• A search for infectious causes should be undertaken with treatment of yeast and other vaginitis
• Biopsy of any abnormal-appearing epithelium on the vulva to insure that malignant changes are not present
• Only when all other factors have been ruled out can the diagnosis primary idiopathic vulvar pruritus be established

LABORATORY:

• Vaginal secretions can be evaluated by wet mount (NaCl for trichomonas or Gardnerella, and KOH for yeast). Cultures seldom required.
• Gram stain of the vagina is non-diagnostic as multiple organisms are present in the normal flora

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS:

These are related to the underlying etiology. In primary vulvar pruritus, no changes will be noted. If HPV is present, these changes will be seen in the cornified layer of the squamous epithelium.

SPECIAL TESTS:

Whenever necessary, biopsy of the vulva should be used to establish the primary diagnosis

IMAGING:

N/A

DIAGNOSTIC PROCEDURES:

Biopsy when needed

TREATMENT

APPROPRIATE HEALTH CARE:

Outpatient

GENERAL MEASURES:

• Treatment of any underlying cause must be undertaken
• In cases of idiopathic primary vulvar pruritus, conservative measures include sitz baths, topical steroid creams, avoidance of chemical irritants and dietary changes
• When conservative measures fail, advanced cases can be treated with alcohol block or laser

SURGICAL MEASURES:

Bowen's disease and premalignant changes are treated with excision or laser vaporization

ACTIVITY:

Unlimited

DIET:

A trial of dietary alteration should be attempted for idiopathic pruritus. Coffee and caffeine-containing beverages should be avoided. Other foods to avoid include tomatoes, peanuts.

PATIENT EDUCATION:

See Prevention/Avoidance

MEDICATIONS

DRUG(S) OF CHOICE:

• Infectious sources should be treated with appropriate antimicrobials or antifungals
• Lichen sclerosis is treated with 2% testosterone in petrolatum
• Hyperkeratotic lesions are treated with topical steroid
• Idiopathic primary vulvar pruritus can be treated with topical steroids such as triamcinolone (Kenalog) or desoximetasone (Topicort) cream

Contraindications: N/A
Precautions: N/A
Significant possible interactions: N/A

ALTERNATIVE DRUGS:

N/A

FOLLOW UP

PATIENT MONITORING:

These women should be followed closely for the development of premalignant or malignant changes within the area of pruritus

PREVENTION/AVOIDANCE:

• Irritants to the vulva such as perfumes, soaps (use non-allergenic) or perfume douches must be avoided
• Only cotton underwear should be worn
• No tight fitting clothes or nylon pantyhose

POSSIBLE COMPLICATIONS:

Chronic course

EXPECTED COURSE AND PROGNOSIS:

• Vulvar pruritus can be kept under control with conservative measures and topical steroids
• When it advances to uncontrollable symptoms, alcohol block or laser may be necessary

MISCELLANEOUS

ASSOCIATED CONDITIONS:

N/A

AGE-RELATED FACTORS:

Pediatric: N/A
Geriatric: More frequent
Others: N/A

PREGNANCY:

N/A

SYNONYMS:

• Vulvar pruritus
• Vulvodynia
• Burning vulva syndrome

ICD-9-CM:

698.1 Pruritus of genital organs

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Medical Diagnosis » P » Pruritus vulvae