Managing vulval and vaginal health - Nursing in Practice

A review of key aspects of vaginal and vulval health, including how to recognise the signs and symptoms of disease, what tests and treatments are appropriate and when to refer

Patients may complain of symptoms or changes to their vulva or vagina during a consultation, or you may notice something during an examination. Here are some of the key signs and symptoms to look out for and what to advise patients.

What are the main infections to recognise? How are they treated?

Thrush
Thrush (Candida albicans) is a common yeast infection that can cause a change in vaginal discharge, as well as soreness and itching. It is not considered a sexually transmitted infection (STI), but it can be triggered by sex and sometimes passed between partners. 

The patient may have a thick, lumpy discharge, which is usually white, and an itchy, sore, stinging or inflamed vulva. There may also be fissures (tiny cuts) around the vagina, vulva, labia, clitoris or anus. It may be painful passing urine or during sex.  

If thrush is very mild, it may go away on its own. However, untreated thrush can worsen, causing further infection and discomfort.

Treatment involves a vaginal pessary, used overnight, and a topical antifungal (clotrimazole 1% cream). The patient can take an oral tablet (fluconazole) as an alternative to a pessary.

These treatments can be accessed over the counter (OTC) from pharmacies. However, in some cases a prescription may be necessary – for example, if the patient is vulnerable, does not have the funds to pay for treatment (which can be expensive if needed regularly) or cannot access a pharmacy.

For recurring or chronic thrush, the GP or prescribing nurse should advise on alternative treatment strategies, in line with the BNF.¹ These patients should be tested for diabetes and may need referral to a specialist service.  

Bacterial vaginosis
Another common cause of unusual discharge is bacterial vaginosis (BV).  Again, this is not sexually transmitted, although it can be triggered by sex. A change in vaginal environment, due to a penis or sperm entering the vagina in unprotected sex, can cause BV. The patient may notice their discharge has become watery or greyish in colour and has a bad (fishy) odour.  

BV should be treated with antibiotics, such as metronidazole. If someone is prone to BV, however, they may use OTC lactic acid gels, particularly around or after their period, to prevent the infection. 

Sexually transmitted infections
If the vaginal discharge is yellow or green, or of unusual consistency, or if the patient is experiencing other symptoms such as pain or discomfort when urinating, this could indicate an STI. 

Common STIs include gonorrhoea and chlamydia (both bacterial infections), trichomoniasis (caused by the protozoan Trichomoniasis vaginalis) and genital herpes simplex (a viral STI that can cause genital ulcers). The patient will need to undergo testing to guide treatment.  

How are infections diagnosed?
GPs and practice nurses can often diagnose thrush or BV based on clinical assessment. If symptoms are atypical, recurrent or not responding to treatment, they may take a high vaginal swab to test for BV, thrush or trichomoniasis infections, or refer the patient to a sexual health or genitourinary medicine (GUM) clinic for further testing.

(HSVs may also be taken in primary care to test for other infections, such as those causing cervicitis, or to screen for group B streptococcus in pregnancy.)

Sexual health or GUM clinics will usually use microscopy to confirm thrush, BV or trichomoniasis, and 'NAAT' (nucleic acid amplification test) endocervical swabs to test for infections like gonorrhoea and chlamydia.²

When should patients access STI testing?
If a patient complains of a change in discharge or other symptoms described above, and they are sexually active or have been in the past – including contact such as touching and use of sex toys – it is important to check if they have been screened for STIs recently. 

If there is a high suspicion of an STI, a screen should be performed. A patient may still be at risk if they have been with the same partner for years or have not changed partners since their last test, or even if they have been recently tested.     

Many regions of the UK now offer online testing, which means your patient can order a postal kit from their local sexual health service to test for STIs including gonorrhoea and chlamydia at home. If a patient gets a negative result with an at-home test, but is still experiencing symptoms, they will need to go to a sexual health clinic or their GP for further tests. 

Why is it important to ask about washing?
Washing can often be the cause of thrush, BV or dry and itchy skin. Washing inside the vagina or washing with strong soaps, shower gels or intimate feminine hygiene products can all cause a change in the natural pH balance of the vagina and cause irritation, soreness, or other symptoms of thrush or BV. 

Using strong soaps or products can also cause dryness and soreness on the internal and external skin. The vagina is self-cleaning, and genitals should be washed with plain water or very mild soap. Patients should be advised never to wash or douche inside the vagina. 

Tight clothing such as tights or leggings and washing detergents that are perfumed or biological can also cause thrush or BV.  If external skin is dry or sore, using an emollient wash cream can help.

Why is antibiotic use relevant?
It is important to ask if the patient has taken a course of antibiotics recently. Antibiotics can trigger thrush, as they diminish levels of the 'good' bacteria that keep a natural, healthy balance of different microorganisms – enabling a yeast infection to develop. 

Why always ask about sex?
It's important to ask if a patient is sexually active. Sexual activity can cause tiny micro-abrasions inside the vagina, and sperm upsets the natural pH balance, leading to the development of thrush or BV. 

If infection is regularly occurring after sex, advice to help avoid reoccurring infection may include: making sure they are well lubricated before having penetrative sex; using a water-based lubricant; and using condoms. In addition, healthcare professionals should advise patients not to wash inside the vagina or douche after sex.

How does contraception affect vaginal and vulval health?
Hormonal contraception can change vaginal discharge, and both hormonal and non-hormonal intrauterine devices can also cause BV in some people. If a patient who has a coil fitted is regularly getting BV, their threads will need to be checked. A thread that gets too long can trigger BV and will need to be cut shorter. If the threads have been checked and all other causes have been ruled out, a change of contraception method may be required.

What if symptoms persist despite treatment?
If the patient has received treatment for thrush or BV but is still complaining of symptoms, check how long ago they took the medication. Symptoms can often take one to two weeks to clear up. If they experience recurrent thrush or BV and treatment is not working, they will need to speak to their GP or local sexual health clinic. 

Similarly, if a patient is complaining of unusual discharge but thrush and BV have been ruled out, they are washing correctly and their STI screens come back negative, they will need to be seen in a sexual health clinic where they will be fully assessed.

Why is it important to ask about bleeding or pain?
If the patient has experienced changes to their bleeding pattern, bleeding during or after sex, pain during or after sex or pain in their lower abdomen, the causes need to be investigated. Sex should not be painful, and abnormal bleeding should not be ignored. 

They should be seen by their GP or a clinician at their sexual health clinic, who may examine their cervix and carry out further tests. You can advise them to check they are up to date with STI screens, as infections can often cause unusual bleeding or pain during sex. For over-25s, also check they are up to date with their smear tests. 

If they are having sex, it is important to ask about possible pregnancy and do a pregnancy test if necessary, even if they are on contraception or have taken emergency contraception after the last pregnancy risk. 

Also be aware that hormonal contraception can change discharge and bleeding patterns and cause cramps, especially in the first few months of taking it, or if doses are missed or taken late.

What skin changes might be relevant?
Vulval skin may appear dry or flaky; the patient may also tell you they have noticed changes to their skin, or lumps or sores, or you may notice these yourself. With dry skin, ensure they are washing correctly and advise an emollient cream to moisturise the area and also to replace soap for washing the area. 

If they have lumps or bumps, or sores, ask how long the skin has been like this, whether the patient shaves and if any lesion has grown recently. It can be normal to have some lumps or bumps due to in-grown hairs, a shaving rash, blocked hair follicles or skin tags that do not require treatment. However, if they tell you symptoms have changed, something is painful, ulcers or sores have developed or they are experiencing discomfort, or you notice something you are unsure of, then they will need to get this checked out by their GP or referred to a sexual health service.    

Potential skin conditions
Vulval dystrophy
Commonly caused by lichen sclerosus, this is a condition characterised by itchy patches of skin on the genitals, particularly the vulva or anus. The patches appear white and can be crinkled or smooth. They may be sore, and the skin may appear thinner and be easily damaged and bleed if scratched or rubbed. In severe cases, labia can fuse together and bury the clitoris. 

Atrophic vaginitis
This is more common in people with vaginas who are over 50 years old. It can occur when there is a reduction in oestrogen levels (due to pre, peri and post menopause) and can cause thinning of the vaginal walls, as well as a shortening and tightening of the vaginal canal. Vaginal atrophy can cause chronic vaginal infection, urinary problems, inflammation (which can involve symptoms of burning or pain), vaginal dryness, pain during sex and urinary problems. 

Vulval cancer
A very rare cancer that usually affects those over the age of 65 and those who are postmenopausal. It can cause symptoms such as: pain or tenderness in the vulva, a continuous itch on the vulva, open sores, skin cracks or ulcers, a growth or lump that changes shape or colour, changes to thickness or colour on patches of skin, unusual bleeding or burning pain when urinating. 

What is pelvic organ prolapse and what are the signs? 
Pelvic organ prolapse is where organs in the pelvis (the uterus, bladder or top of the vagina) slip down from their usual position and bulge into the vagina. Patients may complain of feeling like there is something inside their vagina; it may be an uncomfortable dragging sensation or feeling of heaviness in the genitals or abdomen. They may have issues with passing urine: feeling like they are not emptying their bladder, or the urge to go is more frequent, or leaking when they laugh, cough or sneeze. 

However, some patients have no idea they have a prolapse as they have no symptoms, with the condition only picked up during a cervical examination. 

Pelvic organ prolapse may occur as a result of pregnancy, childbirth (particularly from long and difficult labours), giving birth to a large baby, and as a result of multiple births. It may also be due to menopause: the reduction in oestrogen during menopause causes thinning of the tissue and support structure causing the pelvic organs to be less supported and subsequently to fall out of place. 

Being overweight, having a job or lifestyle that involves heavy lifting, having long-term constipation or a health condition that causes coughing or straining and having a hysterectomy can all cause pelvic organ prolapse.³

Helen Burkitt is a senior sexual health nurse at the non-profit online sexual health services SH:24 and Fettle

References

1. BNF. Vaginal and vulval infections: Recurrent vulvovaginal candidiasis. Link
2. RCGP Sex, Drugs, HIV and Viral Hepatitis Group and British Association for Sexual Health and HIV (BASHH) guideline: Sexually transmitted infections in primary care, 2013. Link
3. NHS. Overview: pelvic organ prolapse. Link