Clinical practice guideline to identify women requiring testing and referral for vulvar disorders.
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Anticipated outcomes
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Women's health nurse practitioners will provide primary assessment of vulvar disorders, management of results and referral to the medical service specialising in management of vulvar disorders.
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Optimal care in the management of vulvar disorders.
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Definition of terms
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Eligible women are women who are:
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- self reporting as asymptomatic but demonstrate signs of vulvar disorders on examination
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- symptomatic for vulval disorders
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History
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The women's health nurse practitioner should document:
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- the patient's description of the presenting issue or problem
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- signs and symptoms, .e.g. discharge, odour, itchiness, pain, scratching
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- duration of problem, timing of problem, i.e. post coital, cyclic
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- dermatological history, including personal or family history of eczema or psoriasis, other skin or oral diseases
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- relevant medical and drug history, including history of vaginal or vulvar candidiasis, genital human papilloma virus, urinary incontinence, dysuria, diabetes, drug sensitivities, medications including ointments used, e.g. antibiotics, lubricants, use of oral and barrier contraceptives and spermicides, age of menarche, menopausal status
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- lifestyle factors, e.g. tampon usage, panty liner usage, dyspareunia, sexual practices, use of tight fitting clothing, relevant sporting activities such as prolonged bike riding, jogging, use of soaps, detergents and disinfectants or any other substance used on the vulvar area, diet or suspected vitamin deficiencies, weight control issues, smoking
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Examination
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The women's health nurse practitioner should perform a speculum examination of the vaginal walls and cervix, including diagrammatic representation and patient's indication of the affected area:
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- redness, oedema, excoriation, ulceration, thickening, discrete lesions,pigmentation, fissures, erosions, ulcers, labial fusion, white skin
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- description of any vaginal discharge
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- abnormalities including lice, visible warts, skin tags
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- the presence of female genital mutilation
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- urethral tenderness or swelling of Bartholin's glands
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- any other dermatological abnormalities appearing on other parts of the body, including trunk, neck, axillae, wrist, mouth and hands
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Testing
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Eligible women requiring testing for vulvar disorders should have the following swabs:
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External Genitalia
| from the interlabial sulcus, vestibule, additional scaly areas and fissures
|  | - Candidiasis including speciation
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| from moist crusted areas
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- Staphlococcus
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| from vesicles, erosions or ulcers
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Vagina and Cervix
| for Genital Tract Infections:
| | - Candidiasis including speciation
- Bacterial vaginosis
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| for Sexually Transmissible Infections as indicated by risk assessment
| | - Trichomonas vaginalis
- Neisseria Gonorrhoeae
- Chlamydia trachomatis
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As indicated by history and presentation, eligible women may also be offered serology for diabetes mellitus.
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General advice for all vulval conditions
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- avoid soap, shampoo and bubble bath. Use aqueous cream or emulsifying ointment as a soap substitute
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- avoid tight fitting garments
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- use cotton underwear and avoid synthetic material
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- avoid use of spermicidal cream / impregnated condoms
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- use bland, non-irritating moisturiser such as aqueous cream or petroleum jelly
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- seek investigation for infections, sexually transmissible infections or urinary incontinence
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Referral and follow up
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Following primary assessment, the nurse practitioner should refer all eligible women to a medical service specialising in management of vulvar disorders.
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A letter of referral including the medical practitioner's provider number is necessary for private referrals to:
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- The Women's Vulvar Clinic
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A letter of referral is necessary for referral to the following public clinics:
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- Mercy Hospital for Women Vulva Clinic
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- Melbourne Sexual Health Centre Vulval Clinic
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Where appropriate, referrals to other services such as sexual counselling may also be offered.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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