She feels uncomfortable down below. She has this irresistible urge to scratch that itch every now and then. Every contact her undies makes with her vulva leaves her sore. And any time she pees, and it touches her vulval skin, it burns. Her colleagues couldn't help but notice the uneasy, and unsettled, look on her face the embarrassment of it. Pruritus vulvae!
WHAT IS PRURITUS VULVAE?
Pruritus vulvae is intense itching of the female genitalia which is usually accompanied by irritation, soreness, and abnormal vaginal discharge.
It usually arises due to inflammation of the genitals, which could be as a result of an infection, or not. If the inflammation is limited to the Vagina, it is termed Vaginitis, but if it extends to involve the vulva as well, it is termed Vulvovaginitis.
Whichever is the case, they are more or less the same, sharing the same symptom complex, the same causes, and responding to the same range of treatments.
THE DYNAMICS OF THE VAGINAL FLORA
The vagina has been likened to a garden, with flowers, and weeds alike, growing in it. The outcome of this natural garden depends on which of the two outgrows the other: if the flowers keeps growing, everything remains beautiful; but if the weeds outgrows the flowers, everything turns "ugly," constituting a nuisance.
The normal vaginal flora constitutes of naturally harmless organisms the bulk of which are the Lactobacilliary species. These group of organisms protect the vagina from harmful invaders, by competing with them for space -- by the mere means of their physical presence; and by making the vaginal pH acidic, which is unconducive for harmful organisms. In our analogy, above, this group of organisms would be the flowers.
In the vaginal garden, there are also weeds. These are organisms that are potentially harmful, but are usually in small amounts, as they are continuously being "weeded off" by the mechanism described above. These organisms include microbes from the gut, surrounding skin, and things like yeast [fungi]. If for any reason the flowers are plucked out, and/or there's a change in the vaginal acidity, these "weeds and thorns" will grow unchecked, constituting nuisance.
RISK FACTORS FOR VAGINITIS
The risk factors for vaginitis include lifestyles, and conditions, that alter the delicate balance of the vaginal flora predisposing to an overgrowth of the "weeds and thorns," leading to Vaginitis.
- Indiscriminate used of antibiotics
- Vaginal douching
- States of low immunity, like HIV, and Diabetes.
- Unprotected sex with multiple sexual partners
- Poor genital hygiene
- Wearing of heat-retaining undies
- Hormonal factors like menopause, and use of hormonal contraceptives
- Alkalinization of the vagina by the presence of semen, and menstrual flow [reason symptoms seems to worsen after a sexual encounter, and during, or after, one's menses]
CAUSES OF VULVAL ITCHING
The causes of vaginitis, and therefore vulval itching, includes both infective and non infective causes. The commonest causes, by far, are the infective causes which accounts for about 80% of cases. For this reason, this article will be dwelling more on these infective causes, which include bacterial vaginosis, candidiasis, and trichomoniasis.
- Bacterial Vaginosis
This is the commonest cause of vaginitis, especially in the reproductive age group, accounting for about 45 to 50% of cases.
It is NOT sexually transmitted, and is caused by organisms like Gardnerella vaginalis, Mobiluncus species, and Peptostreptococcus.
The characteristic features include a copious malodorous discharge, that is usually thin, grey-white in color, and has a fishy smell. It also comes with itching, and discomfort, but usually not with vulval soreness, or redness.
The major risk factors include douching, abuse of antibiotics, and pregnancy.
- Vaginal Candidiasis
This is the second commonest cause, accounting for about 20 to 25% of cases.
It is NOT sexually transmitted, and is a fungal infection caused by the yeast, Candida albicans.
The characteristic features include intense itching, irritation, vulval redness and soreness, and pain on urination, and during sex, especially on superficial penetration.
The discharge is usually whitish in color, thick and sticky, like cottage cheese, and usually non foul-smelling.
Major risk factors include abuse of antibiotics, pregnancy, diabetes, HIV, and wearing of heat-retaining undies.
This is the 3rd commonest cause, accounting for about 15% of cases.
It is SEXUALLY TRANSMITTED, and is caused by the protozoan, Trichomonas vaginalis.
The symptoms include intense itching, irritation, soreness, redness, and pain, both on urination, and during sex.
The discharge is usually foamy, greenish yellow, or greyish, and foul-smelling [fishy at times]. There could be incidences of slight bleeding after sex. And the cervix has a strawberry appearance due to punctate haemorrhages.
Major risk factor is unprotected sex.
- Other Causes
In children, commonest causes include poor genital hygiene [like wiping from back to front], retained tissue papers and tampons, use of irritant soaps and creams, and pin worm infestation.
In Post-menopausal women, the comments cause is atrophic vaginitis, a direct consequence of dwindling estrogen levels. Other causes include genital cancers.
In the reproductive age group, the infective causes are commonest. Other causes however include PID, retained tampons, use of IUDs, use of scented soaps and feminine washes, etc.
Miscellaneous causes include skin conditions like contact dermatitis, lichen sclerosus, etc.
This includes avoidance of the aforementioned risk factors. The major ones, worth mentioning again, include:
- Avoidance of indiscriminate use of antibiotics
- avoidance of douching, and use of genital perfumes, and scented soaps.
- Ensuring good genital hygiene.
- Allowing the vagina space to "breathe."
- Restoration of the normal vaginal flora with probiotics, especially after a course of antibiotic therapy. A readily accessible probiotic is Yoghurt which contains an enormous amount of Lactobacilliary species.
Good news is that vaginitides, despite their worrisome symptoms, are not just treatable, but CURABLE.
Treatment depends on the cause. Thus the first step is seeing a doctor and getting properly diagnosed with clinical evaluation and the RELEVANT laboratory tests.
However, generally speaking treatment could be divided into:
- Definitive Treatment
This targets the underlying cause. For the infective causes, antifungal drugs, and/or antiprotozoan-antibiotic medication, is usually used, depending on the aetiology.
- Symptomatic treatment
This is rarely indicated. However, if symptoms are intense, this may be necessary to relieve the associated discomfort. Here, antihistamines and steroid creams may come in handy.