Patient with persistent vulval itching criticises former GP
Mrs Smith is 43 and new to the practice. She tells you she is at her wits' end because of vulval itching that has been going on for several months. 'My last doctor never examined me; he just kept giving me cream for thrush.' Dr Melanie
Wynne-Jones explores the problem.
How should you respond to this implied criticism of a colleague?
You should proceed very cautiously. You know very little about Mrs Smith and nothing about the doctor concerned, the nature of their doctor-patient relationship and the number of times she saw him about this problem. Mrs Smith may herself have asked for repeat prescriptions, declined examination or mentioned this problem at the end of a long list of other problems.
The doctor may not have had time or a chaperone available. Her records, when they arrive, and your gradual acquaintance with Mrs Smith may help you to draw your own conclusions. If subsequent events suggest her previous GP has truly been negligent, you will have to act, but for now, it is wiser not to comment.
What questions should you ask?
Does she mean true itching, soreness or actual pain? Is there a discharge or any other gynaecological symptom? Could she be menopausal? What sort of contraception does she use and is pruritus affecting or worsened by sexual activity?
Is there anything to see and does she have skin problems elsewhere? Does she have any urinary problems or systemic symptoms? What medication or topical substances is she using? Soap, bubble-bath, creams, panty-liners, vaginal deodorants, condoms and spermicides can all sensitise the skin.
Possible causes of pruritus vulvae include:
linfection candida, bacterial vaginosis, Trichomonas vaginalis, scabies, pubic lice or threadworms; genital herpes tends to be intermittent, and painful rather than itchy
lskin conditions eczema, psoriasis, lichen simplex or planus, contact dermatitis
lmalignancy any type of skin cancer; thickened white patches may indicate lichen sclerosus or leukoplakia; potentially malignant conditions
lurinary problems incontinence or pads can macerate skin; polyuria suggests diabetes
llow oestrogen levels during breast-feeding or after the menopause produce atrophic vaginitis
lsystemic causes diabetes, malignancy, iron deficiency anaemia, hepatic, renal or thyroid disease
lpsychogenic pruritus pruritus may also be a ticket for presenting sexual difficulties
lvulval vestibulitis localises to the introitus which is tender
lvulvodynia a distressing chronic dysaesthesia which may be neurogenic in origin.
Should you examine Mrs Smith now?
You should certainly suggest examining her and, even if it means her appointment will significantly overrun, there may be no time like the present (especially if she complains of skin abnormalities or a lump).
However, if you are already running late, cannot offer a chaperone or have missed the pathology van collection it may be better to suggest a separate appointment.
Mrs Smith herself may have assumed she would not be examined and might prefer to come prepared on another day.
You will need to inspect the vulva, vagina and perianal area, and the cervix if infection is suspected, taking swabs for thrush, bacterial vaginosis, T. vaginalis, chlamydia and possibly gonorrhoea.
Depending on other symptoms, you may need to perform a pelvic or abdominal examination and inspect the skin elsewhere. Urinalysis and blood tests for diabetes, the menopause and other systemic causes may also be indicated.
What simple measures are worth trying?
l'Letting the air circulate' cotton underwear, avoiding tights or tight jeans, no pants in bed, no panty-liners
· Avoiding sensitisers (see above list)
· Washing and drying thoroughly just once daily, using an emollient such as aqueous cream instead of soap, which is drying
· Keeping nails short and avoiding scratching, which releases histamine
· Using lubricants for intercourse.
What can you do?
What is appropriate will depend on the history and findings but may include:
lreassurance and advice
lantibiotics or antifungal treatment; possible referral to genitourinary medicine clinic
lprescription of emollients for symptom relief and use instead of soap
lshort-term prescription of low-potency steroid cream (or rarely, a high-potency steroid)
loestrogen (short-term topical or formal HRT)
lan 'old-fashioned' (sedating) antihistamine such as hydroxyzine, to prevent scratching when half-asleep
lmanagement of urinary incontinence
ltreatment for systemic disease such as diabetes
la review, if skin abnormalities are noted
lreferral to a dermatologist or gynaecologist (under the two-week rule if you suspect malignancy); many areas have one gynaecologist who specialises in vulval disorders; tricyclic antidepressants may be prescribed for vulvodynia
lreferral for psychosexual counselling.
· Patients' comments about other doctors are only one side of the story
· Pruritus vulvae does not automatically equal thrush; examine the patient
· Local, systemic and psychosexual causes should be considered
· Referral to a gynaecologist specialising in vulval disorders may be helpful for women with persistent/distressing symptoms
References and resources
http://www.prodigy.nhs.uk Clinical guidance on pruritis vulvae and female genital candidiasis; PILS (patient information leaflet)
British Society for Study of Vulval Diseases http://www.bssvd.fsnet.co.uk
Vulval Pain Society P O Box 514, Slough, Berkshire, SL1 2BP http://www.vul-pain.dircon.co.uk