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Itching and pain … is not always yeast!
Nov 14, 2019, By: Julianna Briglio

Takeaway messages

  • Vulvar itching is easily diagnosed as yeast on exam. It is important to examine the patient and not just assume it is yeast.
  • If you are unsure what the diagnosis is, do a swab for STI’s, bacterial vaginosis and yeast. Refer for unresolved symptoms.
  • If you don’t ask patients about vulvar itching, vulvar pain, or dyspareunia they often will not tell you.

The vulva is that private area that, when you are young, you dare not talk about. As you age and are exposed to the many risks that exist once you become sexually active, you are forced to talk a little about it. Then you have children, and don’t care who looks down there. In your fifties, for whatever reason, you dare not to talk about it. Unfortunately, this is the time when we must talk about it.

As women age, our risk of vulvar disease and vulvar cancer increases. We develop leaking bladders that irritate the skin of our vulvar area and can swirl into a mess of an itchy pain cycle “down there,” in the land of the abyss, where no one dares to look or ask.

Case 1

A woman in her mid-70s had a 5-year history of vulvar itching. She’d had a hysterectomy in her 40s for benign reasons and did not require Pap smears. She self-treated for what she thought was yeast for a number of years. She would have improvement from time to time, but then the treatment would no longer work, and she finally went to her family practitioner. He too thought it was yeast from her history, and tried another regime of treatment. The treatment helped for a bit, but symptoms returned—and she also noticed “something down there.” Completely embarrassed and painfully shy, she sought the care of a female practitioner who specialized in women’s health. With a quick look, it was obvious to her that it was vulvar cancer.

Case 2

A practitioner referred a woman aged 70 for vulvar pain and itching not resolved with antifungals. On examination, the vulva looked entirely normal. The vulvar architecture was intact; there was no discharge, only slight redness. However, the patient could not sit for prolonged periods. The pain was so awful that she would use ice packs to numb the skin so that she could sleep. In her case, antifungals would not work, because this woman had vulvodynia—a condition in which the patient experiences chronic pain or discomfort around the opening of the vagina that persists for at least 3 months. With a proper diagnosis and treatment, she is 90% improved.

Case 3

A 50 year old woman presented to clinic with chronic yeast infection for a number of years. The use of antifungals was somewhat helpful, although the itching was more intense at night. On examination, there was significant loss of architecture of the labia majora; the colour of the vulva was white with some slight redness at the bottom of the vulvar introitus. She responded to high-potency steroids at night and antifungal cream in the morning. This patient has lichen sclerosus (a chronic condition with no cure) with co-existing yeast.

Implications for practice

Registered Nurses and Licensed/Registered Practical Nurses are the gatekeepers to office and non-emergent care. You are in the unique position to ready the patient for an exam, if you think necessary, based on the clinical history taken. If the patient is undressed before the health care provider enters the room, this is the nudge often needed to prompt an examination of what is most often assumed but not necessarily correct.

Nurse Practitioners need to know that vulvar itch is not always yeast. Look, see, and if you are not sure, or the response to treatment is not what is expected, refer.

Additional resources

Improving Women's Health - What is Vulvodynia?

Rare Disease Database - Lichen Sclerosus

Vulvar Cancer: Types, Symptoms, and More

Julianna Briglio, NP, has been involved in nursing for more than 32 years, working in a variety of positions in a number of different health care facilities. She has practised as a Nurse Practitioner in family practice for a number of years and for the last 20 years she works in Obstetrics/Gynecology and Dermatology.


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