Vulval Irritation

Vulval irritation encompasses soreness and itch and is a very common presentation in primary care. Embarrassment may mean a ‘calling card’ symptom has first to be presented. Sometimes it is a ‘calling card’ itself, being easier to talk about than a psychosexual problem. With sensitivity, the real issues should emerge during the consultation.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Thrush: Candida Infection
  • Trichomonas Vaginalis
  • Chemical: Bubble Baths, Detergents, ‘Feminine Hygiene’ Douches
  • Trauma: Insufficient Lubrication During Intercourse
  • Atrophic Vaginitis

Occasional Diagnoses

  • Ammoniacal Vulvitis from Incontinence
  • Skin Disorders (e.g. Eczema, Psoriasis, Lichen Planus)
  • Infestations: Threadworms, Pubic Lice
  • Psychosexual Problems
  • Other Infections (e.g. Genital Warts or Herpes)

Rare Diagnoses

  • Diabetes (without Candida Infection)
  • Vulval Dysplasia (Various other Terms For This Include Lichen Sclerosus et Atrophicus, Leukoplakia)
  • Vulval Carcinoma
  • General Disorder Causing Pruritus (e.g. Jaundice, Leukaemia, Chronic Renal Failure, Lymphoma)
  • Psychogenic (No organic or Psychosexual Problem)

Ready reckoner

Key distinguishing features of the most common diagnoses

ThrushTrichomonasChemicalTraumaAtrophic Vaginitis
Itching ProminentYesPossibleYesPossibleNo
Soreness ProminentPossibleYesYesYesYes
White DischargeYesNoNoNoNo
Fishy, Smelly DischargeNoYesNoNoNo
Thin, Dry, Red MucosaNoNoNoNoYes

Possible investigations

Likely: HVS (if discharge present).

Possible: Urinalysis.

Small Print: FBC, LFT, U&E, fasting sugar or HbA1c, vulval biopsy.

  • Urinalysis for sugar: Diabetes predisposes to thrush and glycosuria in itself can cause vulvitis.
  • FBC, LFT, U&E: If vulvitis is part of a generalised pruritus, or if the patient is generally unwell, these blood tests may reveal blood dyscrasias or renal or hepatic dysfunction.
  • Fasting sugar or HbA1c to diagnose or rule out underlying diabetes.
  • HVS: Identifying the pathogen if discharge is present will help management in puzzling or recurrent cases.
  • Vulval biopsy (secondary care): Multiple biopsies are required if vulval dysplasia or carcinoma is suspected.

Top Tips

  • It is easy to make an erroneous diagnosis of UTI in a patient with vulvitis – external dysuria and contamination of urine with pus cells and blood (especially if there is an associated discharge) may mislead the unwary. Helpful pointers are the presence of external vulval irritation and the absence of frequency or urgency.
  • In obscure cases, check the skin elsewhere. Vulval irritation may be a manifestation of a primary skin disorder, such as eczema or psoriasis.
  • The aetiology may be multifactorial with, for example, some primary cause leading to secondary chemical irritation from over-washing or the use of douches. A careful history is needed to unravel the underlying cause and exacerbating factors.
  • Recurrent candidal infection is a particular problem. Various therapeutic strategies are available, but it is important to take time to explore the woman’s perception of the cause, explain the diagnosis and resolve any exacerbating factors.

Red Flags

  • Post-menopausal atrophic vaginitis causes soreness rather than itch. Dysplasias and some carcinomas produce intense irritation. Examine these patients and, if in doubt, refer for biopsy.
  • Consider diabetes in florid or refractory cases of Candida infection.
  • Significant psychosexual problems may present with vulval irritation. Adopt a sympathetic, open approach. Take particular note of any comments made during the physical examination as this sometimes prompts the patient to reveal the true problem.
  • Persistent vulval irritation may rarely be a symptom of significant systemic disease. Consider this if the patient has generalised pruritus elsewhere and seems unwell in herself.
  • If the cause is sexually transmitted (e.g. genital herpes or warts), exclude other infections by referring to a GUM clinic.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.