Assessment

As with any diagnosis, taking a careful and focused history and performing a detailed physical examination are essential. Women can present with symptoms, such as vulvar burning, itching, pain with day-to-day activities, coital discomfort, and/or discharge/bleeding, or any combination of these symptoms as their chief complaint. Patients may also describe a sore, ulcer, or lump. The assessment should seek information about the onset of symptom and duration as well as information regarding aggravating factors (e.g., contact irritants and activities) and the response to any prior treatment. It is useful to obtain subjective and objective information when assessing symptoms. Clinicians can use a simple subjective symptom scale such as, "Are your symptoms better, unchanged, or worse?" An objective scale, such as a Likert 0 to 10 scale (with 0 being absence of symptoms and 10 being the most severe symptom) is also useful. In addition, it is important to identify any correlation of symptom change with the menstrual cycle (e.g., whether the symptoms improve or worsen before, during, or after menses). Identifying any correlation with the circadian cycle can help in disease identification; some symptoms can be less severe upon awakening and worsen as the day progresses. With some conditions, symptoms worsen at nighttime, disrupting sleep and leading to problems associated with sleep deprivation. Coital discomfort can be assessed by determining if the symptom occurs with insertion, thrusting, and/or irritation after coital activity. Evaluating the partner's symptoms with regard to coital activity can provide additional useful information as well.

Vulvar hygiene practices also can contribute to symptoms. Thus, clinicians must identify any chemical, mechanical, and moisture irritant(s) to which the vulva is exposed. Chemical irritant exposures include laundry detergents, fabric softeners, body soaps and washes, perfumes, depilatory creams, various hygiene wipes and douches, lubricants/spermicides with sexual activity, topical prescription and nonprescription medications, and activities such as swimming in a chlorinated pool or using a hot tub. Mechanical exposures include tight-fitting clothing, such as exercise clothing, swim suits, and thong-type undergarments. Also, daily sanitary pad wear can cause mechanical irritation. The clinician should assess other forms of mechanical irritation, which include scrubbing the vulva with a wash cloth, shaving to remove pubic hair, piercing the labia or the clitoris, exercises such as bicycling, and sexual practices including the use of vibrators.

Moisture (e.g., urine, perspiration, or aquatic activities) can exacerbate symptoms. Endogenous moisture exposure can result from normal or abnormal vulvovaginal discharge, normal urination, and perspiration, or urinary and fecal incontinence; thus, the assessment of any associated bladder and bowel symptoms is also important (5). Exogenous excess moisture can result from prolonged bathing or swimming. A complete assessment requires that the clinician obtain the patient's medical history and any family history of dermatologic and immunologic conditions as well.

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