The management of vaginal and vulval health

An overview of the critical elements of vaginal and vulval health and how to spot the symptoms and signs of illness, which procedures and tests are suitable, and when to seek a referral

Patients may experience signs or changes in their vagina or vulva during an appointment, or you might notice something unusual during an exam. Here are some most important signs and symptoms to watch out for and the best way to suggest to patients.

What are the most prevalent illnesses to look out for? What are the best ways to treat them?


Thrush (Candida albicans) is a widespread yeast infection that may cause an increase in vaginal discharge along with itching and soreness. It’s not considered an STI (STI); however, it could be generated through sexual contact and transmitted between partners.

The patient could suffer a thick, lumpy discharge, usually white and itchy, painful, stinging, or inflamed vagina. There are also fissures (tiny cuts) around the vagina, vulva labia, clitoris, or anus. It can be painful to pass urine or during sexual activity.

If the thrush is mild, it could disappear by itself. But if it is not treated, thrush could worsen, leading to further discomfort and infection.

Treatment includes a vaginal sexy, used overnight, and an antifungal topical (clotrimazole cream 1%). Patients can also use the tablet orally (fluconazole) in addition to the pessary.

The treatments are available on the market (OTC) at pharmacies. However, in certain instances, prescriptions may be required in certain circumstances, for example, if the patient needs or does not have enough money to cover the cost of treatment (which could be costly when frequently required) or cannot access an online pharmacy.

For chronic or repeated thrush If thrush is persistent or chronic, the GP or the nurse who prescribes can provide recommendations on alternative treatment options in line with the BNF.1 Patients with these conditions should be examined for diabetes and may require referral to a specialist.

Bacterial vaginosis

Another reason for unusual discharges is bacterial vaginosis (BV). It is also not sexually transmitted. However, it is triggered through sex. Changes in the vaginal surroundings caused by the entry of sperm or penis into the vagina during sex that is not protected could trigger BV. Patients may notice that the discharge is now dark grey or watery and has a foul (fishy) scent.

BV must be treated with antibiotics such as metronidazole. If you are prone to BV, you could take OTC lactic acid gels, particularly after or during their period, to avoid the infection.

Sexually transmitted infections

If the vaginal discharge appears either green or yellow or has a peculiar consistency, or if the patient is experiencing other symptoms, like discomfort or pain when the bowels are empty, this could mean the presence of an STI.

Common STIs include chlamydia and gonorrhea (both bacteria-related infections) as well as trichomoniasis (caused through this protozoan Trichomoniasis vaginalis) and genital herpes simplex (a viral STI which can lead to ulcers in the genital area). Patients will have to undergo tests to help determine the treatment.

What are the signs of infection?

Practice nurses and GPs will often be able to identify thrush and BV based on a clinical examination. Suppose the symptoms are abnormal or recurrent or do not respond to therapy. In that case, patients might perform a vaginal swab to determine if BV is present and trichomoniasis or thrush infections or recommend the patient to the sexual health or genitourinary medical (GUM) clinic to conduct further tests.

(HSVs are also taken as a primary treatment to check the presence of other diseases, like those that cause cervicitis, or to check for streptococcal group B in pregnancy.)

Sexual health clinics or GUM clinics usually employ microscopy to determine if thrush is present, BV, or trichomoniasis, and also ‘NAAT’ (nucleic acid amplification test) endocervical swabs are used to look for infections such as the gonorrhea virus and chlamydia.2

When should patients get STI tests?

Suppose a patient is complaining of discharge changes or has other symptoms described above and is sexually active or was in the past, including touching or using sex toys. In that case, it’s essential to determine if they’ve been tested to detect STIs recently.

If there is a high probability of developing an STI, screening should be conducted. Patients may be at risk if they’ve maintained the status of the exact person for a long time or haven’t changed partners since the last time they tested, or have recently been checked.

A lot of regions in the UK currently offer online testing. Patients can purchase an online kit from the local sexual health clinic to check for STIs such as chlamydia and gonorrhea at home. Suppose a patient receives negative results with the test at home. However, they are still experiencing symptoms, so they’ll need to visit the sexual health clinic or their physician for additional tests.

Why is it so important to inquire regarding washing?

The washing process can be the reason for thrush, the BV, or itchy and dry skin. Vaginal washing or cleaning with soaps that are strong shower gels or other private feminine products could result in a change to the pH balance in the vagina, causing irritation, soreness, or other signs of BV or thrush.

Using solid soaps and products may cause soreness and dryness on the exterior and internal skin. Vaginas are self-clean, and the genitals need to be cleaned with plain water or mild soap. Patients should not be advised to wash or shower inside the vagina.

Tight-fitting clothing like leggings or tights and washing detergents with perfume or biological could also trigger BV or thrush. If your skin appears too dry or irritable, emollient cream for washing may be helpful.

The reason why antibiotics are essential?

It is crucial to determine whether the patient took an antibiotic treatment recently. The effects of antibiotics can cause thrush because they reduce levels of the beneficial bacteria that maintain a natural balanced balance of various microorganisms, allowing the development of a yeast infection.

Why do we always have to ask about sexual relations?

It is essential to inquire whether the patient has been sexually active. Sexual activity can trigger tiny micro-abrasions in the vagina. Sperm can upset the balance of pH and can cause developing thrush, or BV.

Suppose you notice that infections are frequently occurring after sexual contact. In that case, recommendations to prevent the recurrence of disease might include: ensuring that they are lubricated before having sex that penetrates and using a water-based fluid and condoms. Additionally, healthcare experts should warn patients not to wash their vagina or shower after sexual activity.

How can contraceptives affect the health of vulval and vaginal health?

Contraceptives for hormonal reasons can affect vaginal discharge. Both hormone- and nonhormonal intrauterine devices can cause BV in certain people. If a person with the coil installed frequently have BV, their threads must be checked. If a line is too long could cause BV and need to be cut short. If the cables are limited and the other causes have been eliminated, the possibility of a change in contraception method could be necessary.

What happens if the symptoms persist regardless of treatment?

When a person has been given treatment for BV or thrush but still has symptoms, consider the time since they last were prescribed the medication. The symptoms can take anywhere from one or two weeks to resolve. If they have recurrent cases of symptoms of BV or thrush and the treatment isn’t practical, they should consult their GP or the local sexual health center.

In the same way, when patients complain of unusual discharge, BV and thrush have been eliminated, and they’re washing correctly. If their STI screenings are negative, They will have to see an STI clinic where they will be thoroughly evaluated.

Why is it necessary to inquire about bleeding or discomfort?

Suppose the patient has noticed changes in their bleeding pattern and bleeding in the course of or following sexual activity, pain or discomfort following or during sex, or discomfort in their lower abdomen. In that case, It is essential to determine the cause. Be examined. Sexual activities should not be painful, and bleeding abnormally is not something to be ignored.

It is recommended that they see their physician or a doctor in their sexual health clinic who can check their cervix and perform other tests. Ensuring they’re current on STI screenings is recommended since infections are often the cause of unusual bleeding or discomfort during sex. If you are over 25, ensure that they’re up-to-date in their smear testing.

Suppose they are experiencing sexual activity or sexual relations. In that case, it’s essential to inquire about the possibility of pregnancy and perform a pregnancy test is required, even if they’re using contraception or taking precautionary contraceptives following the last pregnancy chance.

Be mindful that contraceptives with hormonal ingredients could alter the flow of blood and bleeding patterns and trigger cramps, particularly within the first few weeks of use or if doses are not taken or missed later.

What could changes to the skin be significant?

Vulval skin can seem dry and flaky. The patient might also tell you that they’ve noticed changes in their skin, lumps, or sores or may be able to catch them yourself. If your skin is dry, make sure that they wash correctly and recommend an emollient cream to moisturize the skin and substitute for soap when cleaning the region.

If there are lumps, bumps, or sores, inquire how long it has been off, if the patient has shaved or shaved and if any lesions have been grorecently times. It is normal to experience bumps or lumps because of hair follicles that have grown or shaving rash, blocked hair follicles, or skin tags that don’t require treatment. However, suppose they inform you that symptoms have changed. In that case, there feel painful, ulcers or sores are developing, you feel discomfort, or you spot something you’re not sure of the cause, they should be examined by their GP or refer them to sexual healthcare service.

Skin conditions that could be a cause for concern.

Vulval dystrophy

Most often caused by lichen sclerosis, it is characterized by itchy patches of flesh on the female genitals and, in particular, the vulva and anus. These patches are white and could be smooth or crinkled. They can be painful, and the skin can appear thinner and easily damaged and bleed if scratched or rubbed. In extreme cases, the labia may encase and even bury the clitoris.

Atrophic vaginitis

It is more prevalent in women with vaginas that have reached the age of 50. It may occur in the event of a decrease in estrogen levels (due to menopausal symptoms, pre, and post-menopausal). It may cause thinning of the vaginal wall and shortening and tightening of the vaginal canal. Vaginal atrophy may cause persistent vaginal infections, urinary issues and inflammation (which may manifest as burning or discomfort), dryness of the vagina or pain when sexing, and urinary problems.

Vulval cancer

Rare cancer is usually found in people over 65 and women who are menopausal. It can trigger symptoms like tenderness or pain in the vulva, a perpetual itch on the vulva, open sores, skin ulcers or skin cracks, A lump or growth that alters form or color, or changes in size or the color of patches of abnormal skin bleeding or burning pain while urinating.

Prolapse of the pelvic organ? What are the indications?

Pelvic organ prolapse happens when organs of the pelvis (the bladder, uterus, or the top of the vagina) fall away from their normal position and expand to the side of the vagina. Patients may feel that there’s something in their vagina. This could be a numbing sensation or a feeling of heaviness in the abdomen, genitals, or. Patients may experience issues with urine flow, feeling as if they’re not emptying their bladders or that the desire to go out is more frequent, or leaks when they cough, laugh or even sneeze.

But, some are unaware that they have a prolapse because they don’t show any symptoms or signs, and it is only being detected when undergoing a cervical exam.

Prolapse of the pelvic organs can happen due to pregnancy and childbirth (mainly due to prolonged and labor-intensive labors) and when giving birth to an infant that is large or due to multiple births. It can also be caused by menopausal as the decrease in estrogen during menopausal changes causes the thinning of the tissues and support structures, which causes pelvic organs to become less well-supported and, consequently, shift out of position.

Being overweight, working an occupation or routine that demands the lifting of heavy objects, suffering from constipation that lasts for long periods, or a medical condition that results in straining or coughing and having a hysterectomy could cause pelvic organ damage prolapse.3

Helen Burkitt is a senior sexual health nurse for the non-profit online sexual health service SH:24 and Fettle.

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