Transcript of VPS Podcast 5 - Vulvodynia: a podcast lecture by David Nunns

Slide 6 (04:26) Management

The management of vulval eczema is to essentially look for a potential irritant on the skin: an over the counter product, a topical treatment, or it may be something like urine or even sanitary pads. This should be withdrawn. A moisturiser is essential, and the moisturiser of choice would be something such as Cetraben. This can be used regularly and liberally. Sometimes patients itch with their vulval eczema at night time, and therefore an antihistamine can be helpful, and the treatment for eczema, the mainstay of treatment is going to be a steroid ointment in a reducing regime for around three months. It’s very important to give the patient written information.

Slide 7 (05:18) Lichen planus

I wanted to mention lichen planus because this can also present with vulval pain, and these patients often have an overlap with lichen sclerosus, which is another itchy, inflammatory skin condition, but in lichen planus soreness is the main presenting complaint rather than itch. Sometimes there’s a profuse vaginal discharge and the appearance can be very subtle. So it’s very important to look at not only the vulva but also the vagina in all patients who present with pain to not overlook some subtle lichen planus. When this is involving the vagina, it’s called erosive lichen planus.

Slide 8 (06:06) Management

When managing lichen planus, the treatment is going to be similar to our treatment for lichen sclerosus: a very potent topical corticosteroid such as Dermovate on a reducing regime. Scarring and narrowing of the vagina can happen, particularly with vaginal involvement, and sometimes for vaginal disease we use intravaginal steroids such as the Predfoam enemas that we use for inflammatory bowel disease. These patients do need long term follow-up, and occasionally systemic treatment under a specialist dermatologist interested in lichen planus.

Slide 9 (06:51) Vulval fissures

Vulval fissures are the final skin disease I wanted to mention before moving on to vulvodynia, because these very small fine paper cuts in the skin can be a cause of vulval pain. They can occur as a part of another skin problem such as eczema or even lichen sclerosus, but they can just develop in isolation. The treatment of this problem is difficult, but the general approaches are to treat the underlying skin problem if there is one with the steroids and the emollients mentioned before, massage the area, or any other desensitisation technique is helpful, and surgery, really as a last resort, to cut out the area of the fissure.

Slide 10 (07:43) Picture

This picture shows a patient who’s got a posterior fourchette fissure. These patients are often quite phobic about touch, and quite apprehensive about intercourse, so it’s important to ask about any psychosexual problems - in particular vaginismus.