The commonest causes of symptomatic vulvar disease: a dermatologist's perspective

2024 British Association for Sexual Health and HIV (BASHH) UK national guideline on the management of vulval conditions

BACKGROUND

The management of vulval disorders in Genitourinary Medicine (GUM) clinics requires targeted approaches due to the wide range of conditions affecting the vulva. Vulval diseases encompass various aetiologies, including dermatoses, pain syndromes, and pre-malignant conditions, necessitating specialized care often involving multidisciplinary collaboration.

PURPOSE

This guideline aims to provide evidence-based recommendations for the diagnosis and management of specific vulval conditions that may present in GUM clinics. The focus is on conditions commonly managed by Genitourinary Physicians, either independently or in partnership with other specialists, depending on available local expertise. Additionally, guidance on onward referral is included to ensure optimal patient care.

STUDY SAMPLE

The guideline primarily addresses the management of individuals aged 16 years and older presenting to GUM clinics with non-infective vulval conditions.

DATA COLLECTION

Recommendations within this guideline are derived from a review of existing literature, clinical expertise, and consensus among specialists. Emphasis is placed on diagnostic tests and treatment regimens tailored to the following conditions: Lichen sclerosus, Lichen planus, Eczema, Lichen simplex, Psoriasis, Vulval high-grade squamous intraepithelial lesions (previously vulval intraepithelial neoplasia), Vulval pain syndromes, and Non-sexually acquired acute genital ulceration (Ulcer of Lipschütz).

CONCLUSIONS

This guideline offers practical recommendations for the effective management of specific vulval disorders in GUM settings. It is not intended to be a comprehensive review of all vulval diseases but rather a focused resource to assist clinicians in providing high-quality, patient-centred care. Onward referral pathways are also outlined to support collaborative and multidisciplinary management of complex cases.

Vulvar Cancer: Histopathologic Considerations and Nuances to Management

Vulvar cancer, although rare, poses significant challenges in diagnosis and treatment because of its histopathologic complexities and nuances. This paper reviewed key aspects of the management of vulvar cancer, focusing on histopathologic diagnosis, margin status interpretation, lymph node involvement assessment, and ongoing clinical trials.

The Association between Cardiovascular Risk Factors and Lichen Sclerosus: A Systematic Review and Meta-Analysis

Background/Objective: Lichen sclerosus is a chronic inflammatory skin disease that affects people of all ages and sexes. Evidence of cardiovascular risk factors in lichen sclerosus has been continuously reported; however, the definitive association remains inconclusive. This meta-analysis aimed to summarize the association between cardiovascular risk factors and lichen sclerosus. Methods: Electronic databases, including MEDLINE and EMBASE, were systematically searched from inception to May 2024 to identify the literature reporting the association between cardiovascular risk factors and lichen sclerosus. A random-effects model was used for the meta-analysis. Results: We included 16 eligible studies: nine case-control studies, six retrospective cohort studies, and one cross-sectional study. A total of 432,457 participants were included. Lichen sclerosus was significantly associated with type 2 diabetes mellitus with an odds ratio of 2.07 (95% CI: 1.21-3.52). Although not statistically significant, a trend of increasing risk in hypertension, dyslipidemia, obesity, and metabolic syndrome was observed among lichen sclerosus patients, with odds ratios of 1.56 (95% CI: 0.90-2.70), 1.44 (95% CI: 0.94-2.23), 5.84 (95% CI: 0.37-92.27), and 1.36 (95% CI: 0.52-3.54), respectively. Conclusions: Lichen sclerosus was associated with diabetes mellitus and potentially correlated with hypertension, dyslipidemia, obesity, and metabolic syndrome. Population-based prospective observational studies are required to further elucidate these findings and assess the impact of these associations.

Prevalence and risk factors of vulvar dermatoses: A hospital-based study

Background:

The overall prevalence of vulvar diseases in the literature is low because of underreporting and is often neglected; thus, its impact on a female's life is often underestimated.

Objectives:

This study is aimed to determine the prevalence of vulvar diseases and their associated risk factors in patients attending a tertiary care hospital.

Materials and Methods:

This is a descriptive, cross-sectional, and case–controlled study wherein all female patients attending the dermatology outpatient department (OPD) were screened for the signs and symptoms of vulvar dermatoses and were enrolled after obtaining informed consent and institutional ethics committee approval for 21 months. Out of them, 200 patients who consented and had signs and symptoms of vulvar diseases were selected as cases, and the same number of age-matched females were enrolled as controls with no signs and symptoms of vulvar dermatoses.

Results:

During the study period, 9431 females attended the dermatology OPD, of which the prevalence was 2.12% (200 patients). The most common infection was genital infection without sexually transmitted infection (57%) (tinea cruris [33.5%]), followed by inflammatory dermatoses (21%) (lichen sclerosus et atrophicus [6%]). The most common risk factor found statistically significant (P ≤ 0.005) were homemakers (49%) and the use of undergarments of mixed fabric (70.68%), followed by nonmenopausal females (63.15%).

Conclusion:

Our study findings indicated that the prevalence was low, which reflects the tip of an iceberg. Further clinical and population-based studies, a multidisciplinary approach including gynecological consult for diagnostic and therapeutic approach is needed for the optimal management of vulvar diseases.

Meet the expert: Topical management of vulvar dermatoses

Vulvar dermatoses are often debilitating chronic skin conditions associated with pain and pruritus. In oncologic patients, cancer treatments can precipitate and exacerbate vulvar dermatoses. Cytotoxic chemotherapy, hormonal therapies, and local pelvic radiation therapy can lead to vulvar symptoms, and cancer treatment-induced vulvar conditions include graft-versus-host-disease and radiation dermatitis. There have also been reports of lichen sclerosus development or exacerbation secondary to hormonal therapy and immune checkpoint inhibitors, attributed to proposed hormonal and immunologic pathogenesis of lichen sclerosus. Early recognition and treatment of these conditions can significantly improve quality of life. In this review, we summarize the clinical features and management characteristics of six types of common vulvar dermatoses that may present in the oncologic patient.

Role of partner support in psychosexual aspects of vulvar dermatoses

Women with vulvar dermatoses report a psychosexual effect due to the chronicity of symptoms and long-term treatment as the disabling nature of the condition impacts their sexual relationship. Partner role and support in the management of psychosexual impact are poorly understood and are not part of the routine care for increasing number of women with vulvar dermatoses. This paper provides an aide-mémoire for identifying patient concerns and supporting the partner. Holistic care of the affected women comprises assessment and management of the psychosexual impact of the disease on them and their partners through a dyadic or paired perspective. Limitations regarding the impact of increased virtual consultations, secondary to the recent global pandemic, and issues related to gender identity with sexual orientation are recognized.

Vulval lichen sclerosus: An Australasian management consensus

BACKGROUND/OBJECTIVES

Vulval lichen sclerosus (VLS) is a chronic inflammatory skin condition predominantly affecting the anogenital region in women and children. To date, there is lack of agreement amongst experts on a severity scale to aid assessment, research and treatment stratification on VLS. Furthermore, literature on best practice for long-term management of VLS is lacking. The aim of this consensus is to provide broad guidelines on the short and long-term management of VLS.

METHODS

An initial focus group of Australasian experts in vulval dermatology developed a draft consensus statement for the management of VLS. Based on the results of the draft statement, a consensus panel of 22 Australasian experts, comprised of the initial and additional members, participated in an anonymous four-stage eDelphi process. Round 1 involved generation and voting on statements from the draft consensus statement developed by the focus group. In Rounds 2, 3 & 4, panel members were presented formal feedback from previous rounds and asked to indicate their level of agreement. Consensus was reached if there was ≥70% agreement on the importance of an item in the 4 (agree) to 5 (strongly agree) range.

RESULTS

The expert panel, with a total of 504 collective years of experience in the field of VLS, reached consensus on a core set of 51 management statements related to diagnosis, severity, initial and long-term management, follow-up, and complications of VLS.

CONCLUSIONS

This study has identified a set of management statements for VLS that may be useful in clinical practice in the Australasian population.

Vulvar Pruritus: A Review of Clinical Associations, Pathophysiology and Therapeutic Management

Vulvar pruritus is an unpleasant sensation and frequent symptom associated with many dermatologic conditions, including infectious, inflammatory and neoplastic dermatoses affecting the female genitalia. It can lead to serious impairment of quality of life, impacting sexual function, relationships, sleep and self-esteem. In this review, common conditions associated with vulvar itch are discussed including atopic and contact dermatitis, lichen sclerosus, psoriasis and infectious vulvovaginitis. We review the potential physiologic, environmental and infectious factors that contribute to the development of vulvar itch and emphasize the importance of addressing their complex interplay when managing this disruptive and challenging symptom.

Etiology, Clinical Features, and Diagnosis of Vulvar Lichen Sclerosus: A Scoping Review

Objective. Vulvar lichen sclerosus (VLS) is a chronic inflammatory disorder, which affects women of all ages. With numerous controversies as regards to the nomenclature, diagnosis and its association with neoplastic conditions, we decided to conduct a scoping review on this subject. Data Source. A review protocol was developed, and the Knowledge Resource Services website was used to do a search of articles pertaining to VLS with keywords "Vulvar," "Vulval," "diagnosis," "lichen sclerosus et atrophicus," "kraurosis," "vulvar dystrophy," and "Lichen Sclerosus". Study Selection. The search was limited to published data from the last ten years, i.e., from July 2009 onwards and in the English language. A total of 338 articles pertaining to VLS were obtained. Older data were accessed if particular information was sought for. Results & Conclusion. The presentation is bimodal, i.e., one in prepubertal girls (average age: 7.6 years) and the other in peri- and postmenopausal women (average age: 52.6 years). However, many cases also present during reproductive years. Studies suggest a multifactorial origin as far as etiology is concerned, including a genetic, autoimmune, hormonal, and local infectious background. It affects the genital labial, perineal, and perianal areas and manifests as a patchy, thin, glistening, ivory-white area. Diagnosis is mainly based on clinical features. Biopsy is seldom required. It has been well established as a precursor lesion of dVIN and vulvar carcinoma.

Genomic Profiling of Vulvar Lichen Sclerosus Patients Shows Possible Pathogenetic Disease Mechanisms

OBJECTIVE

Vulvar lichen sclerosus (LS) is known to occur in families, suggesting a genetic link. Genomic profiling of patients with vulvar LS was investigated to find underlying pathogenetic mechanisms, with the hope that targeted therapies and future clinical research will arise.

METHODS

Two unrelated families with vulvar LS were investigated using whole-exome sequencing. Five affected sisters from 1 family were compared with their unaffected paternal aunt (unaffected control). A mother-daughter pair from a second affected family was compared with the first family. The results of the sequencing were compared with population-specific allele frequency databases to prioritize potential variants contributing to vulvar LS development.

RESULTS

Recurrent germ-line variants in 4 genes were identified as likely to be deleterious to proper protein function in all of the 7 affected patients, but not in the unaffected control. The genes with variants included CD177 (neutrophil activation), CD200 (inhibitory signal to macrophages), ANKRD18A (ankyrin repeat protein, epigenetic regulation), and LATS2 (co-repressor of androgen signaling).

CONCLUSIONS

Although many providers may see a mother and daughter with vulvar LS, this condition is rarely seen in multiple family members who are available for genetic testing. This is the first report to detail genomic profiling related to a familial association of vulvar LS.

Diagnosis and Treatment of Vulvar Lichen Sclerosus: An Update for Dermatologists

Vulvar lichen sclerosus is an important skin disease that is common in women in their 50 s and beyond; however, it can also affect females of any age, including children. If not treated, it has the potential to cause significant and permanent scarring and deformity of the vulvar structure. In addition, if untreated, it is associated with a 2-6% lifetime risk of malignant squamous neoplasia of the vulva. Lichen sclerosus has been considered a difficult to manage condition; however, both serious complications can potentially be prevented with early intervention with topical corticosteroid, suggesting that the course of the disease can be treatment modified.

History of Abuse in Women With Vulvar Pruritus, Vulvodynia, and Asymptomatic Controls

OBJECTIVE

Chronic vulvar pruritus and vulvodynia are common vulvar diseases. The aim of this study was to compare gynecologic and sexual and physical abuse histories from patients with these diagnoses and from healthy controls.

MATERIALS AND METHODS

Questionnaires were self-completed by patients diagnosed with vulvar itch-scratch (n = 93), patients diagnosed with vulvodynia (n = 232), and patients presenting for annual gynecologic examinations (n = 104) at the University of Michigan Hospitals, Ann Arbor, MI.

RESULTS

Patients who came for annual examinations were less likely to report past gynecologic infections (p < .05) and indicated higher interest in and more frequent sexual activity than the other 2 groups (p = .003). Vulvodynia patients had the highest scores on the McGill Pain Questionnaire (p < .001). Subjects with either vulvar disorder were more likely to self-report a history of gynecologic infections than annual examination controls. Rates of sexual (p = .78) and physical abuse (p = .12) were similar for all 3 groups.

CONCLUSIONS

Patients with vulvar pruritus and vulvodynia report similar rates of sexual and physical abuse.

Lower Urinary Tract and Functional Bowel Symptoms in Women With Vulvar Diseases and Controls

OBJECTIVES

This study aims to compare the prevalences of lower urinary tract symptoms (LUTS), irritable bowel syndrome (IBS) and constipation in women with vulvar diseases to those from the general population.

METHODS

Three groups of women were recruited from the University of Michigan Gynecology Clinics, women with: (1) biopsy proven lichen sclerosus (LS), (2) non-LS vulvar diseases (vulvar controls, VC), and (3) presenting for annual examinations (AE). All patients completed self-administered surveys and validated pelvic floor symptom questionnaires.

RESULTS

317 subjects were enrolled: 101 with LS, 86 VCs, and 130 AEs. Compared to women in the VC and AE groups, LS subjects were older and of higher parity, and also had a higher prevalence of overactive bladder and urinary incontinence. The IBS was more common in the LS and VC groups compared to the AE group but no difference in constipation was seen. Similar results were found when all women with vulvar disease (LS and VC) were compared to the AEs. Age (adjusted odds ratio [OR], 1.28; P = 0.003) and IBS (adjusted OR, 3.05; P < 0.001) were the 2 variables predictive of overactive bladder. Urinary incontinence was predicted by age (adjusted OR, 1.35; P = 0.002), vulvar disease categorization (adjusted OR, 2.31; P = 0.004) and IBS (adjusted OR, 4.51; P < 0.001).

CONCLUSIONS

We find a significantly greater prevalence of LUTS and IBS in women with vulvar disease compared to women presenting for annual gynecologic exams, but no difference in constipation. Similar rates of LUTS, IBS, and constipation were seen in women with LS and non-LS vulvar disease.

Vulval pruritus: the experience of gynaecologists revealed by biopsy

Pruritus of the vulva is a common symptom among patients attending to outpatient clinics. In the present study, we aimed to assess pathologies causing vulval pruritus in the reliability of biopsy in a tertiary referral centre. A total of 137 patients undergoing vulval colposcopy because of vulval pruritus were reviewed from the hospital records retrospectively. The mean age of the patients was 47.61 ± 11.88 years and 36.5% of the patients were postmenopausal. In 101 (73.7%) of the patients, macroscopic lesions were present. In 88 (64.2%) of the patients, tolidine-positive stained areas were determined under colposcopy. In total, 68 (49.6%) of the lesions were plain, whereas 51 (37.2%) of them were depigmented. Lichen simplex chronicus, lichen sclerosis and chronic inflammation were the major pathologies associated with vulval pruritus (25.5%, n = 35; 20.4%, n = 28; 14.6%, n = 20). In conclusion, several pathologies out of vulvovaginal candidiasis may lead to vulval pruritus and clinicians should be aware of the importance of biopsy in determining the underlying pathology.

Chronic Pain of the Vulva without Dermatologic Manifestations: Distinguishing among a Spectrum of clinical Disorders

The causes of chronic vulvar pain are many and when not accompanied by obvious physical signs they are difficult to unravel. Many common vulvar dermatoses can manifest without obvious erythema or mucocutaneous lesions, as can some less common disorders of both infectious and allergic origin. In addition localized and generalized vulvar dysesthesia, recently defined chronic pain syndromes of neurogenic origin, can also occur in the vulvar area.

Chronic vulvovaginal symptoms in early stages are often presumptuously labeled as vulvovaginal candidiasis (VVC) by patients and clinicians alike, which can delay accurate diagnosis. When presented with chronic vulvar pain unaccompanied by verifiable signs, the clinician must effect a sensitive integration of a detailed medical history, including temporal associations of all potential exposures, with more definitive diagnostic tools. Effective use of those available tools can improve initial diagnosis, thus allowing prompt initiation of effective therapy. Optimal therapy will recognize the significant psychological distress that accompanies any chronic pain syndrome.

A retrospective study of the referral patterns to a vulval clinic: highlighting educational needs in this subspecialty

A retrospective study of the referral patterns to a specialist vulval clinic was performed. A total of 200 clinical records were reviewed of new patients seen between January 2004 and June 2005. A provisional diagnosis was stated in 45.5% of referrals, of which 27.5% had the diagnosis changed at the clinic. The majority of referrals were from general practitioners (GPs) (77%) and smaller proportions from gynaecologists (11%), dermatologists (9%) and others (3%). The most common conditions seen were lichen sclerosus (39%), eczema/lichen simplex (30.5%), lichen planus (11.5%), pain syndromes (10.5%) and others (8.5%). Lichen sclerosus was accurately diagnosed in 54.5% of referrals but for eczema/lichen simplex it was only recognised in 11.5% of referrals. Nine cases of lichen sclerosus had been referred by gynaecologists after histological confirmation, for advice on management. Education of vulval diseases to non-specialists should focus on conditions that they are most likely to encounter and find difficult to manage. This study illustrates an effective method to define what the local teaching requirements are.

Do panty liners promote vulvovaginal candidiasis or urinary tract infections? A review of the scientific evidence

Panty liners are used to absorb light menstrual flow, vaginal discharge, or urine leakage, or to maintain a clean, dry feeling. Allegations that panty liners may trap heat and moisture to promote vulvovaginal candidiasis (VVC) or promote colonization by microbes that contribute to urinary tract infections appear to be unfounded. As reviewed herein, measurements of the impact of panty liners on skin temperature and skin surface moisture had no clinically meaningful effect on cell densities of genital microflora. Epidemiological investigations of a potential link to VVC were either negative or were inconclusive because of confounding factors. Although enteric microbes reside on the vulva and perineum, no evidence exists that panty liner use promotes urethral colonization by enteric microbes. Moreover, a series of 13 randomized prospective trials of panty liners or ultra-thin pads demonstrated no clinically significant adverse effects either on the skin or on isolation frequencies or cell densities of representative genital microflora. Post-market surveillance systems suggest a low incidence of complaints. Evidence from vulvar clinic patients reveals no significant contribution of these products to persistent vulvar symptoms. Taken together, the scientific evidence supports the conclusion that panty liners are safe when used as intended and do not promote VVC or urinary tract infections.

Features of patients with vulvar dermatoses in dermatologic and gynecologic practice in Turkey: is there a need for an interdisciplinary approach?

AIM

Vulvar dermatoses are very common problems in women and they are associated with significant morbidity. The aims of the present study were to evaluate the features of patients with vulvar diseases in gynecology and dermatology out-patient clinics in Turkey, and to determine the need for a multidisciplinary vulvar clinic in this country.

METHODS

A total of 310 patients with vulvar problems as their primary complaints were included in the study. There were 144 women from a dermatology clinic and 166 women from a gynecology clinic. The following factors were recorded for all patients: physical examination findings, menarche age, age at first intercourse, education level, marital status, clinical diagnoses and associated gynecologic problems.

RESULTS

There were no significant differences between the two groups when the mean age, menarche age and age at first intercourse were compared (P > 0.05). The number of unmarried women was statistically significantly higher in the dermatology group than in the gynecology group (P < 0.0001). The number of women who graduated from high school and university was also statistically significantly higher in the dermatology group than in the gynecology group (P < 0.01). The frequency of gynecologic problems was statistically significantly higher in the gynecology group than in the dermatology group (P < 0.001); however, dermatologic conditions were the most frequent diagnosis overall (33.54%). Forty patients in the gynecology group were referred to the dermatology clinic.

CONCLUSIONS

The approach to patients with vulvar disorders varies from country to country. However, multidisciplinary clinics seem to improve the understanding of vulvar diseases, to make correct diagnoses and to raise patients' quality of life. The need for a multidisciplinary vulvar clinic should not be ignored by the physicians in Turkey.

Inflammatory dermatoses of the vulva

Inflammatory, non-neoplastic epidermal alterations of the vulva can be correctly diagnosed using classification schemes applied to skin elsewhere on the body. A wide range of inflammatory disorders may occur on the vulva, and they may have a similar clinical presentation to HPV lesions. However, HPV is incurable and often is treated surgically. Accordingly, as inflammatory dermatoses commonly occur on the vulva and are often curable with topical therapy, an awareness of these entities and an ability to distinguish them from HPV are imperative.

Vulvar susceptibility to contact irritants and allergens: a review

Vulvar tissue differs from cutaneous epithelia in structure, morphology and biophysical characteristics. For example, the skin of the labia majora exhibits elevated hydration, occlusion and frictional properties, which may increase susceptibility to irritants and contact sensitizers. Furthermore, the nonkeratinized vulvar vestibule is likely to be more permeable than keratinized regions. These differences heighten vulvar susceptibility to topical agents. This reviews the structure and properties of vulvar tissue, emphasizing their impact on susceptibility contact irritants and allergens.

The joint vulval clinic: a review of the first three years

This aim of this study was to undertake a retrospective analysis of the notes of all new patients who attended the joint vulval clinic between 1994 and 1997. One hundred and forty-five patients were seen, and data analysed for 133 (92%). The study identified the range of diagnoses seen; treatment modalities undertaken; and enabled comparisons to be made between our findings and those of other workers.

Management of common vulval conditions

Community-based surveys indicate that about a fifth of women have significant vulval symptoms lasting over three months at some time in their lives. Common causes of itch or pain are dermatitis, recurrent candidiasis and the recently recognised pain syndromes--vulvar vestibular syndrome and dysaesthetic vulvodynia. Diagnosis is usually apparent after a thorough history and examination, although conditions commonly coexist and are complicated by prior treatment. Skin lesions not responding to treatment require biopsy. Treatment aims to control symptoms rather than to cure; avoiding soaps and other irritants is central to management. An early, accurate diagnosis should enhance management of vulval conditions, particularly pain syndromes.

Vulval disease in pre-pubertal girls

Children present with vulval complaints less frequently than do adults; although there are many similarities between paediatric and adult groups of patients with vulval disease, there are also important differences. In both groups, dermatitis, psoriasis and lichen sclerosus are the most frequently seen dermatoses. Birthmarks and congenital abnormalities presenting for the first time are more of an issue in children than in adults. Fusion of the labia and streptococcal vulvovaginitis are conditions seen only in the paediatric group. Sexually transmitted diseases such as genital warts and genital herpes are not common in this group and should always raise the possibility of child sexual abuse. Chronic vulvovaginal candidiasis, although a very common problem in adult patients, is not seen in the prepubertal group.

Menopause and the skin

Women live one-third of their lives in the post-menopausal state. Significant hormonal alterations occur at the time of menopause, leading to a range of physiological disorders affecting multiple organ systems in the body. The effects of menopause on the skin have been underresearched. Many skin changes occur at the time of menopause and the cutaneous effects of hormone replacement therapy are significant. Menopausal changes in hormones may alter the biomechanical properties of the skin and certain disorders are more common in menopausal women, such as lichen sclerosus, atrophic vulvovaginitis, flushing and dysaesthetic vulvodynia. Hair and oral changes may also be associated. As the average life expectancy increases, dermatologists need to be familiar with skin diseases affecting women in this age group.

Vulvar disease in children: a clinical audit of 130 cases

We evaluated 130 prepubertal girls presenting with a vulvar complaint to determine the spectrum and frequency of conditions seen in this age group. Of the patients, 41 (33%) had atopic or irritant dermatitis, 23 (18%) had lichen sclerosus, 21 (17%) had psoriasis, 15 (12%) had vulvar lesions, most often hemangiomas and nevi, and 13 (10%) had streptococcal vulvovaginitis. Diagnoses less frequently seen were staphylococcal folliculitis (four patients), labial fusion (three patients), genital warts (two patients), molluscum contagiosum of the vulva only (one patient), vulvar bullous pemphigoid (two patients), scabies nodules (one patient), erythema annulare centrifugum (one patient), tinea (two patients), and vitiligo (one patient). We also encountered vulvar presentations of systemic diseases (varicella, staphylococcal scalded skin syndrome, and Henoch-Schönlein purpura, all one patient each). We did not see candidal vulvovaginitis in this age group nor did we encounter bacterial infection with pathogens other than Staphylococcus aureus and S. pyogenes.

Understanding vulvodynia

Vulvodynia is a difficult management problem. In this review article, the clinical subsets of vulvodynia including recurrent vulvovaginal candidiasis, vulvar vestibulitis syndrome and dysaesthetic vulvodynia are described. Their aetiology is discussed and available therapies are presented.