The vulva refers to the visible or outer parts of the female genitalia. The appearance, shape and size of the vulva can vary from woman to woman. Most of these variations are normal. It is also normal to have one side of the vulva look slightly different than the other side of the vulva.

The vulva includes the pubic mound, the outer lips, the inner lips and the entrance to the openings of the bladder and vagina. The vagina (or birth canal) is the inner part of the female genitalia and is not visible from the outside.

Starting from the top down is the pubic mound or mons pubis. This is a pad of soft fatty tissue above the pubic bone. The skin in this area is covered with pubic hair. Below the mons pubis are the outer lips and inner lips of the vulva.

The outer lips (or skin folds) are large and have pubic hair. These lips are called the labia majora.

The inner lips are smaller and hairless. These lips are called the labia minora. The small lips join together, below the pubic mound to form a hood (or prepuce) above the glans (or tip) of the clitoris. The clitoris is very sensitive. The tip is visible on the outside but a larger portion (the shaft) is not visible.

Between the inner lips of the vulva is the vestibule. The urethra (a tube leading to the bladder) is located in the vestibule above the opening to the vagina. There are a number of glands that open into the vestibule – minor vestibular glands, Skene’s glands and the Bartholin’s glands. These glands produce secretions that make the vestibule moist.

Below the vestibule is the perineum. This skin lies between the opening to the vagina and the opening to the rectum (anus).  Many skin conditions that affect the vulva will also affect the skin around the anus or even in between the buttocks.

There are a broad range of medical conditions that can involve the vulva. These conditions can be divided into benign, pre-cancer and or cancer.

Inflammatory conditions (infectious)

Vaginitis: candidiasis, trichomoniasis, bacterial vaginosis

Vulvitis: tinea cruri, herpes simplex, genital warts and other sexually transmitted diseases

Inflammatory conditions (non-infectious)

Irritant/contact, allergic dermatitis

Eczema, psoriasis

Lichen simplex chronicus

Atrophic vulvovaginitis (postmenopausal)

Apthous ulcers

Folliculitis, cellulitis

Chronic vulvar purpura

Dermatological conditions

Lichenoid conditions: lichen sclerosus, lichen planus

Plasma cell vulvitis

Systemic disorders with vulvar manifestations

Lupus, Crohn’s Disease, hidradenitis suppurativa

Autoimmune disorders

Reiter’s Disease, Bechet’s Disease, blistering disorders (e.g. pemphigoid)

Lymphatic disorders lymphedema, lymphangitis circumscriptum

Benign cysts, and benign tumors of the vulva

Sebaceous cysts, epidermal inclusion cysts, vestibular cysts, bartholin’s duct cysts, Skene duct cysts, lipomas, fibromas, leiomyoma, endometriomas, acrochordons, seborrheic keratosis, pyogenic granuloma

Pre-Cancer Lesions

High grade squamous dysplasia/ vulvar intraepithelial neoplasia (usual type, differentiated type)

Cancers

Angiomyxoma

Melanoma in situ/melanoma

Verrucous carcinoma, basal cell carcinoma

Invasive squamous cell carcinoma of the vulva

Paget’s disease (adenocarcinoma)

Chronic pain

Vulvodynia: generalized or localized, provoked or unprovoked, vestibulodynia, clitorodynia

Pudendal neuralgia

Many women with chronic vulvar disorders report that the vulvar condition affects their overall sense of well-being, body image and sexual self-esteem.

A healthy vulva is critical for comfortable daily living activities such as: sitting, walking, and wearing clothes. If the vulvar skin is unhealthy it can make urination, menstruation, and or defecation uncomfortable. A healthy vulva is necessary for pain free and enjoyable sex. Vulvar disorders can interfere with a woman’s ability to get pregnant, be comfortable during pregnancy and have a safe vaginal delivery.

We understand that women who have vulvar symptoms or notice changes to their vulvas are often too embarrassed to seek help from a health care provider. However, it is often difficult to ignore these conditions. Women will often try numerous home remedies or over the counter treatments before seeking medical help.

First Step – Good Skin Care

We strongly discourage self-treatment with over-the-counter medications and vaginal preparations. While many women will find that applying any type of cream on the skin seems to help initially, over time they find the skin seems to get more and more sensitive and the creams are in fact making the discomfort worse. Women should be aware that they cannot “wash their symptoms away” and that the symptoms are NOT due to being “unclean” or having an “infection”.

Please follow our skin care recommendations

Be gentle with the vulvar skin. Do not over wash. This can dry out the skin and make it more prone to irritation. Avoid prolonged exposure to hot water. Do not rub the skin excessively – do not use a face cloth to wash the skin. Do not use a hair dryer to dry the skin. It is best to rinse the skin with water and pat dry with a soft towel. Do moisturize and protect the skin.

For optimal skin care use a moisturizer on the vulvar skin on a daily basis. After a bath or shower use a moisturizer for sensitive skin on the outside lips, inside lips and perineum. It is common that women will involuntarily leak urine or stool as they get older. If this is the case, use a protective barrier such as vaseline or a zinc based product. The barrier cream will sit on top of the skin, seal in the moisture and protect against contact with irritating substances.

Avoid all contact with chemicals that can irritate the vulvar skin. Do not use bar soap, feminine “wipes”, douches, perfumes, or feminine hygiene spray. Do not add fabric softener to clothes or towels. Do not treat “suspected” infections. Many over the counter medications that treat yeast and/or bacterial infections have ingredients in them that are irritating to the vulvar skin. Check with your doctor to see if you have an infection and then choose a medication that you can take by mouth. If you must use soap, consider a soap substitute and or gentle skin cleansers. Look for products designed for sensitive skin and labelled hypoallergenic.

Avoid contact with synthetic materials that rub against the vulvar skin. Avoid underwear that is tight fitting or rubs the skin (eg. thong underwear). Instead of synthetic menstrual pads and or liners consider using: a menstrual cup (these are good for the environment and come in a range of sizes and materials) or a reusable menstrual cloth pad. While these pads may cost more initially they will last for years. Wear loose clothing that encourages the air to circulate around the vulva. If you exercise on a regular basis try alternating exercise outfits from workout to workout so that you do not have the same area of the vulva being rubbed while exercising. Avoid wearing tight fitting synthetic stretch pants and underwear for every workout.

Unfortunately, when women do seek help they are often treated over and over again for a suspected vaginal infection. However, vulvar symptoms such as burning, itch or soreness may be due to a skin condition, NOT an infection. In this case, these treatments may in fact make the symptoms worse over time. If you are a woman with chronic vulvar symptoms it is important to get an accurate diagnosis. Do not give up. You are not alone.

The second step towards better vulvar health is to see a health care provider with experience and expertise in vulvovaginal disorders. The BCCVH works collaboratively with primary care physicians and the experts embedded within the Centre to quickly confirm, diagnose and treat vulvar conditions.

Third Step – Holistic Health

Many women who suffer from vulvar disorders have concerns about their Sexual Health.

Some vulvar conditions change the appearance of the vulva and that can make women feel uncomfortable or embarrassed in a sexual setting.

Vulvar diseases can cause significant discomfort when the genitalia are touched. Women report significant pain with sexual intercourse, reduced sexual frequency and decreased sexual desire. Women avoid sexual activity because of pain, and often choose to be sexually inactive. The avoidance of sex creates interpersonal conflict within relationships, which further compounds the stress of their condition.

Some vulvar conditions (and the treatment of these conditions), can make it physically difficult for a woman to have penetrative sex.  For example, Lichen Planus can cause scarring inside the vagina.

A sexual health expert can help women to address these sexual concerns and return to having a fulfilling sexual life.

Women with vulvar conditions may experience changes to their Mental Health.

Women may experience embarrassment, fear, anxiety, negative body image, and depression. Some vulvar conditions are associated with a small increased risk of vulvar cancer and thus require long term treatment and follow-up. Women may have difficulty coping with the need for chronic treatment and surveillance of a condition that affects the genitals.

The stress generated by these conditions can, in fact, intensify any discomfort or pain the woman experiences. This is because the increased stress increases the number of excitatory signals from the brain to the spinal cord. It has been shown that psychological techniques focused on stress reduction, anxiety control and relaxation have a positive benefit on vulvar pain.

When a woman experiences vulvar discomfort for months and years this can affect her underlying pelvic floor muscles. These muscles can tense up over time. This tension may not disappear when the vulvar condition is treated. Thus, addressing Pelvic Floor Health is an integral part of any treatment plan through the BCCVH.

Thorough physical therapy assessment and treatment addresses all aspects of interdependent pelvic floor function including bladder, bowel, lumbar and pelvic back support, as well as vulvar pain and spasm. It is important to consider all aspects of pelvic floor function as unaddressed pelvic floor dysfunction in one of these areas may limit improvement in another area.

Physical therapy interventions include techniques that help women learn to control both the contraction and relaxation of the pelvic floor, education on the changes that occur in the pain signaling system in chronic vulvar conditions, and instruction in the use of graduated vaginal inserts. Women find using the inserts helpful for learning how to keep their pelvic floor muscle relaxed during vaginal penetration.

Sexual counsellors and pelvic floor physiotherapists often work together to guide this treatment. Helpful tools physiotherapists commonly use are biofeedback and TENS (transcutaneous electrical nerve stimulation). Many women notice that when their ability to voluntarily relax their pelvic floor muscle improves, the discomfort associated with daily living activities and sexual activity decreases significantly.