Vulvar Conditions: Answers to FAQs

Frederick R. Jelovsek MD

Growth on vulvar lips that swells up

I am too embarrassed to tell my mom or anyone and I don't go to a gynecologist but I have a problem that I really need help with. I wasn't quite sure where to go until I found this page. Okay, inside like the lips to my vulva, where the flaps of skin are, there's like a growth. It's attached by a thin piece of skin and it just hangs off. I have had it for at least a year. It usually doesn't bother me and I don't pay any attention to it but every once in a while it swells up really bad into this huge hard ball, usually its a few days before and after my period. It's really noticeable. It hurts me to walk, to move, sometimes to sit or even lie down. Does it sound like a simple infection? Its usually not hard most of the time it is just like limp and like excess skin. Is there something over-the-counter I could get to help it? Cream? Please tell me there is! I'm scared. If it helps, I'm under 18, I am sexually active. Please. Reply soon, as I am writing this it hurts me to sit down. I'd appreciate any help I could get.

Can't tell without actually seeing it but it sounds like a polyp of the vagina, a skin tag or gland infection of the hymen or labia minora or maybe even a condyloma accuminata.

The periodic swelling may represent a gland in the skin tag in which the duct gets periodically blocked. If you see a gynecologist, that should be easily removed if it is on a stalk. I don't think there is any cream you can use or anything you can do yourself to get rid of it.

Try not to be embarrassed. This isn't something you caused. It's probably just the way your skin and anatomy is and it could get irritated by just tampon or pad use. I don't think your mother would think badly of you and would probably be more supportive than you think.

I have a couple more questions... Okay, is this normal??

No. Most women do not have this problem.

If it goes untreated for a while will it hurt anything?

Probably not if you don't get worsening symptoms and it doesn't start swelling and hurting more and more frequently.

Does sex irritate it?

Since it is at the entrance to the vagina I suspect sex will irritate it and make it swell more. You would be the one to answer that. Try to get it looked at so you will know and not worry.

Enlarging tissue below the urethral opening

During the past couple of months I have noticed an enlarging of tissue around the vagina area. There has always been a small bulb-like amount of tissue at the top of the opening of the vagina, below the urethral opening but it has never been a problem. Lately it has enlarged and has stayed that way and causes pain during intercourse.

Is this a normal part of the female anatomy?

Without seeing it, making a diagnosis is difficult. However, several possibilities exist which include NORMAL hymen, urethral diverticulum or blocked/infected Skene's gland. The Skene's gland cyst is the most likely from your description and will need to be opened or excised if it keeps swelling up.

Why is it swollen suddenly?

Infection or possibly irritation with intercourse

I am hesitant about going to my gynecologist about this because I do not know if it is normal or not. Please give advice if possible.

If you are concerned, see your doctor so he/she can obtain a history (which would include things like how long "the tissue" has been present, the presence of any discharge, fever, redness, painful urination etc) and do a physical exam.

Tear or cut near clitoris

Recently my clitoris has been quite sore, almost like it has been cut, and after intercourse my whole vagina became incredibly swollen. I have noticed that there is a small amount of discharge from the clitoris, and at times I am quite itchy. I have a faithful relationship with my partner and do not know what is wrong with me. Please help, I have lost all of my sex drive as well!

It sounds as if there was some direct mechanical irritation of the clitoral area or possibly even a contact dermatitis. Did you use any lubricants, deodorants, creams etc., on the area? Treatment usually is to abstain from relations for about 5-7 days, use petrolatum as a coating to prevent further contact irritation (use about twice per day apply thin coat) and avoid other creams or soaps directly. Tub bath with just soap in water but not directly on affected area is ok.

Fear of pain can decrease libido. Was desire a problem before this came up? Are you on any meds? Need some more info.

I'm on medication for my asthma, although it has never been a problem with my libido before. After another examination, I have found that I have what may be a cut or a tear on the clitoris hood. What can I do to heal this? I have felt as though there has been a cut or scratch there before, so it seems to either not heal or it may be something else.

I would just treat it as a tear for right now and see if it clears up with a week of using Neosporin® ointment on it twice a day. If it doesn't clear up with that, then you need to have it checked out.

Morning vulvar irritation and burning urination

I have been experiencing what I call recurrent cystitis. It starts upon arising in the morning. After I first urinate, I feel the constant urge to go again. It becomes very frequent and painful--sometimes accompanied by a tinge of blood. I also notice at the same time that I have what I call a "full" feeling in my vaginal area. I take OTC pyridium, which relieves the feeling of having to urinate so much and the pain, then I apply Vagisil® to the vaginal area. After a few hours, all of these symptoms disappear. I find it difficult to see my gynecologist, as I have an HMO that makes me see the primary care doctor first. All he does is prescribe Bactrim® for a bladder infection. My question is this: do I actually have bladder infection, or is the vulvitis (inflammation of the vagina) causing the symptoms of cystitis, and what can I do to avoid this?

It is difficult to say for sure without examining the urine microscopically and examining you in the vulvar area when you are having symptoms. If this is happening primarily on the mornings after sexual relations, urethral syndrome comes to mind. This is a direct irritation of the urethra due to sexual relations (often referred to as "honeymoon cystitis" although it can happen long after the initial relations with a new partner). Usually the urine culture is negative but sometimes there are blood cells in the microscopic urinalysis.

If this is happening everyday regardless of sexual relations, it may represent an active urine infection that has not been well treated or just keeps coming back.

If you think it is just burning because the urine hits an irritated vulva, try to void when you get up in the morning by sitting in a bath tub and void in the water. If the burning is not present then, it is because of vulvar irritation and that is what needs to be checked out. If the burning is still present, it is urethral in origin and that should be the focus of diagnosis.

Another woman responds: I have in the past (first few years of marriage) gone through a similar situation that you described. Save yourself some time and pain--ask your doctor to do a "culture" of your urine. Sometimes the Bactrim® won't clear up certain infections and you need to custom prescribe for it. After they did this, my infection was quickly cleared up. Also, make sure they check your blood sugar. These are small, legitimate tests to ask for that are more than reasonable to justify asking your doctor to perform. The HMO should not object. I am not a doctor but sometimes you have to be your own advocate.

Clitoral pain - is surgery needed?

Since my daughter started puberty, she has had problems with clit-pain. Their doctor says that her clit-hood is too narrow and if her clitoris is erect the hood can not slide away. He says that her hood must be removed completely.

Can you tell me more about this op?

This is a female circumcision procedure. It is not recommended or necessary and there are world wide efforts being made to ban it's use.

Which risk has it?

Disfigurement mostly. Sometimes it just exposes sensitive tissue to more constant irritation especially if a woman wears pads during menstruation.

Will her sexuality be affected?

Yes it can. This often affects self-image and might make a women more self-conscious during sexual relations.

In the rare case of pthimosis (narrowing, stricture) of the clitoral hood, only a small incision needs to be made so the hood can retract. Then keep something like petrolatum gel or vegetable oil on the cut surfaces until it heals (about 7-10 days). The entire hood does not need to be removed.

Varicose veins of the vulva

I have varicose veins of the legs, vagina and vulva. I have 8 children. During my last three pregnancies, these veins were quite severe and the vaginal/vulvar ones were particularly swollen. After birth, the veins have receded remarkably well considering how bad they were. My baby is now 5 months old. I had a vaginal hysterectomy 5 1/2 weeks ago. Internal bleeding, abdominal incision to locate the source of bleeding, 6 units transfused. I was hoping that the hysterectomy would take some of the stress/pressure away from the vaginal/vulvar veins but now that I am on my feet and back too much of the time, I feel that these veins are just as painful if not more so. What's going on here? Did I do something wrong? Did something affect these veins during surgery? Do I just need to be more patient in my recovery?

5 1/2 weeks is too soon to tell about the varicosities. They may still improve as swelling in the pelvis subsides. It's difficult to say at this point how bad they will be. It won't be until about 3 months after surgery that you can tell their baseline rate. In your case it might be a month to 6 weeks longer because of the post operative complication you had.

This unlikely to be due to anything you have done. You can help though, by wearing good support hose during the recovery process.

The leg ones aren't too bad -- would the support hose help the vaginal/vulvar veins?

You have to get fitted panty hose to help the vulvar ones but any support of any of the veins makes less stretching of the veins.

Itching after sex using condoms

Each time my husband and I use a condom to prevent pregnancy, I end up with redness and itching (about 12 hours later). Could this be an allergic reaction to the condom? I am not allergic to latex gloves. The condom was free of spermicide but did have a lubricant. HELP !! I was going to the doctor next month to get a diaphragm, but aren't those latex?

Yes. You are probably having a contact allergy. Most often it is the lubricant and not the latex. You have to be your own detective to determine which brand is the problem. There are unlubricated condoms you can try and then add Replens as a lubricant. You may want to try the Replens first to make sure you don't react to it but it is one of the least reactive ones to try. Let us know.

Primary Vulvodynia, vestibulitis and HPV

I have been with my girlfriend for 6 months now. Before I met her, she never experienced sexual relations. And since the first sexual relation I've had with her, she feels burning during the penetration and also the day after. After 3 months, she went to the doctor and he said to her that it was probably a vestibulitis. Now after 6 months the problem remains, it still hurts. She went to pass a pap test lately and the the test was ABNORMAL. I have red a few articles on the internet that say that HPV might be a cause of vestibulitis.

In the past, I've had a few sexual partners, with 2 of them I had unprotected sex. I passed some tests for aids and stuff like but the results were negative. So I guess it's possible that I have HPV.

So here is my question, is it possible that I gave HPV to her and then she developed vestibulitis? Because if it did, it would have to have develop very fast because we never had a sexual relation where it did not hurt her.

And by the way, how is it possible for a male to know if he really has HPV?

While it has been suspected that HPV may play a role in vulvar vestibulitis, recent controlled studies are against HPV as an etiology. (R)

There is such a condition of primary vulvar vestibulitis that occurs from the time of the first intercourse. Not much is known about this but it responds the same as a secondary vulvar vestibulitis. (R)

I suspect that many times it is just a direct trauma to the skin at the vaginal opening due to several factors such as involuntary muscle spasm (vaginismus), lack of good lubrication at the opening and sometimes just the physical anatomy of tightness at the introitus. Women who never used tampons for menses (which seem to slowly dilate the vaginal tissues and make them more elastic) before starting intercourse seem to have more problems with this. On the other hand maybe using tampons was too painful from the start indicating anatomy tightness.

If a male does not have any visible venereal warts on the glands or shaft of the penis then it is very difficult to know if HPV is present. The virus can be in the skin cells inactive for a long time. Anyhow, I doubt HPV is playing a role here.

Categories of vulvodynia

I still get confused about vulvodynia versus vulvar vestibulitis. What is the difference?

Vulvodynia refers not to a specific disease, but rather to a symptom - vulvar pain. In this case the pain is chronic and either recurrent or almost constant. Vulvodynia can be primary, i.e., starting from the first episode of intercourse, or secondary, starting after a specific event.

There are 4 main categories of vulvodynia:

1. vulvar dermatoses
2. cyclic vulvovaginitis
3. vulvar vestibulitis syndrome
4. dysesthetic vulvodynia

Again, these four categories are not diseases themselves but rather clusters of different diseases or descriptive syndromes whose etiology is unknown.

Vulvar dermatoses often require a biopsy for diagnosis. Examples might include psoriasis, seborrheic dermatitis, tinea cruris, contact dermatitis, lichen simplex chronicus, lichen planus, lichen sclerosis, pemphigus, and erythema multiforme. Sometimes a dermatologist is the person to see for this rather than a gynecologist especially if the vulva seems to have a chronic redness or scaliness.

Cyclic vulvovaginitis is frequently due to a recurrent yeast infection but it can also be bacterial in origin commonly from E.Coli and Group D or B streptococcus. In this instance, secretions from the vagina are the skin irritants and if use of a tampon eases the burning, it is very likely that cyclic vulvovaginitis is the major factor.

The remaining two subcategories, vulvar vestibulitis and dysesthetic vulvodynia are totally unknown as to their etiology. Vulvar vestibulitis shows inflammation of the vestibular glands on biopsy but what causes the inflammation is unknown. It does not respond to antibiotics. HPV virus was postulated as a possible cause but current concepts are that HPV is not the cause.

Dysethetic vulvodynia tends to be found in postmenopausal women and is postulated to be an inflammation of the nerves similar to a herpetic vulvitis. There are no histological changes on biopsy so it is really just the existence of vulvar pain in the absence of inflammation on biopsy. Primary vulvodynia may also fall under this category. In this case it is young women who have the problem and vaginismus, involuntary contraction of the pelvic floor muscles plays a big role. Pelvic floor therapy with microelectrical stimulation may be helpful for this.

All categories of vulvodynia may be associated with a secondary vaginismus. If a woman fears pain with vaginal intercourse, there is almost always an involuntary muscle contraction that narrows the vaginal opening and continues to cause vulvar pain because of direct friction. thus the primary cause can be cured (the dermatosis, the vaginitis, the vestibulitis, the atrophic vulvitis) but the pain continues because of fear of pain and involuntary muscle spasms.

Irritant vulvitis or vulvodynia?

How can you differentiate between irritant vulvitis (caused by say a laundry detergent) and a secondary yeast infection (caused by lots of antibiotics) and vulvodynia? Does vulvitis that doesn't heal properly turn into vulvodynia?

With a recurrent or secondary yeast infection of the vagina, the yeast metabolizes glycogen (sugar) in the vaginal cells to alcohol. When alcohol gets on the vulvar skin, it burns and irritates it. If you wear tampons to prevent the discharge from getting on to the vulva and the pain lessens or goes away, then the main problem is a recurrent yeast infection. Also, vaginal yeast cultures will show heavy growth.

With an irritant vulvitis, vaginal yeast cultures are generally negative, and pain does not improve with tampon use. If the vulvitis is constant, it is by definition vulvodynia which merely means vulvar pain. Vulvodynia is a constant, chronic condition which has different etiologies such as chronic yeast infections, a contact dermatitis (irritant vulvitis) but a large category is unknown cause. Vulvar vestibulitis which is an inflammation or the glands of the vestibule skin is actually a very less common cause of vulvodynia but an important one because it is a persistant disease refractory to treatment.