Vulvovaginal Ulceration

What is Vulvovaginal Ulceration?

Vulvovaginal ulceration refers to the presence of an open sore or breakdown of the skin and mucous membranes on the vulva (the external female genitalia) and/or the vagina. The ulcer may appear as a single lesion or multiple patches, and can range from a tiny pinpoint ulcer to a larger, painful crater. Ulcers are a symptom, not a disease themselves, and they signal that the underlying tissue has been damaged by infection, inflammation, trauma, or systemic disease.

Because the vulva and vagina are highly vascular and innervated, ulcers in this region often cause significant discomfort, burning, itching, or bleeding. Prompt recognition and evaluation are essential to determine the cause and to prevent complications such as secondary infection or scarring.

Common Causes

There are many conditions that can lead to vulvovaginal ulceration. The most frequent causes are:

• Sexually transmitted infections (STIs) – herpes simplex virus (HSV), syphilis, chancroid, and lymphogranuloma venereum.
• Non‑sexually transmitted infections – Candida spp., bacterial vaginosis complications, and tuberculosis.
• Autoimmune / inflammatory disorders – Behçet’s disease, lichen planus, lichen sclerosus, and granuloma inguinale.
• Dermatologic conditions – Pemphigus vulgaris, epidermolysis bullosa, and contact dermatitis from soaps, lubricants, or condoms.
• Trauma – Sexual intercourse (especially rough or painful), insertion of foreign objects, vigorous hygiene practices, or childbirth lacerations.
• Cancers – Squamous cell carcinoma of the vulva, vaginal melanoma, or metastatic lesions.
• Hormonal changes – Atrophic vaginitis in post‑menopausal women can cause fragile mucosa that ulcerates with minor irritation.
• Systemic infections – Human immunodeficiency virus (HIV)–related ulcerations, cytomegalovirus (CMV) in immunocompromised patients.
• Drug reactions – Stevens‑Johnson syndrome, toxic epidermal necrolysis, and fixed drug eruptions.
• Rare conditions – Crohn’s disease with perianal or vulvar involvement, sarcoidosis, and vasculitis (e.g., Wegener’s granulomatosis).

Associated Symptoms

Vulvovaginal ulcers rarely occur in isolation. Patients often notice other signs that can help pinpoint the cause:

• Painful urination (dysuria) or urgency.
• Vaginal discharge – may be watery, purulent, or blood‑stained.
• Bleeding or spotting, especially after intercourse.
• Itching or burning sensation.
• Fever, chills, or malaise (suggesting infection).
• Swollen or tender lymph nodes in the groin (inguinal adenopathy).
• Systemic symptoms such as joint pain, oral ulcers, or skin rashes (pointing toward autoimmune disease).

When to See a Doctor

Most vulvovaginal ulcers require professional evaluation. Seek medical care promptly if you notice any of the following:

• Ulcers that do not begin to heal within 5–7 days.
• Severe or worsening pain that interferes with walking, sitting, or sexual activity.
• Heavy bleeding or a sudden increase in size of the ulcer.
• Fever (≥38 °C / 100.4 °F) or chills.
• Multiple ulcers or a pattern suggestive of an STI.
• Recent unprotected sexual contact, especially with a partner who has symptoms.
• Pregnancy – ulceration can increase the risk of preterm labor or infection.
• Any suspicion of cancer (persistent ulcer with irregular edges, a mass, or non‑healing ulcer).

Diagnosis

Evaluation typically follows a stepwise approach:

1. Detailed History

• Onset, duration, and progression of the ulcer.
• Sexual history, recent partners, and condom use.
• Previous STIs, autoimmune disease, or malignancy.
• Recent medication changes, hygiene products, or trauma.
• Systemic symptoms (fever, joint pain, oral lesions).

2. Physical Examination

• Inspection of the vulva, vagina, perineum, and inguinal lymph nodes.
• Assessment of ulcer size, depth, base (clean, necrotic, exudative), and margins.
• Speculum examination to view the vaginal walls.

3. Laboratory Tests

• Swabs for viral PCR (HSV‑1/2), bacterial cultures, and syphilis serology (RPR/VDRL).
• Gram stain and culture for bacterial vaginosis or candidiasis.
• Blood tests: CBC, CRP/ESR, HIV screening, autoimmune panels (ANA, dsDNA, ANCA) if indicated.
• Biopsy of the ulcer edge or base when malignancy, lichen planus, or rare inflammatory disorders are suspected.

4. Imaging (if needed)

Pelvic ultrasound or MRI may be ordered for deep or extensive lesions, especially when malignancy or Crohn’s disease is a concern.

Treatment Options

Therapy is directed at the underlying cause and at relieving symptoms. It often combines medical and self‑care measures.

1. Antiviral Therapy

• Herpes simplex virus – Oral acyclovir 400 mg 5 times daily, valacyclovir 500 mg twice daily, or famciclovir 250 mg three times daily for 7–10 days (treatment) and suppressive dosing for recurrent outbreaks.

2. Antibiotic Therapy

• Syphilis – Single intramuscular dose of benzathine penicillin G 2.4 MU; alternative doxycycline 100 mg twice daily for 14 days if allergic.
• Chancroid, lymphogranuloma venereum – Single dose of azithromycin 1 g or ceftriaxone 250 mg IM.
• Empiric coverage for bacterial superinfection (e.g., clindamycin 300 mg q6h) when there is purulent discharge.

3. Anti‑inflammatory / Immunosuppressive Therapy

• Lichen planus or lichen sclerosus – High‑potency topical steroids (clobetasol 0.05% ointment) applied nightly for 2–4 weeks, then tapered.
• Behçet’s disease – Colchicine 0.5 mg twice daily, or systemic steroids (prednisone 0.5 mg/kg) for severe flares; biologics (anti‑TNF agents) for refractory cases.

4. Antifungal Therapy

• Topical azoles (clotrimazole 1% cream) for candidal ulcerations; oral fluconazole 150 mg single dose for extensive infection.

5. Cancer Management

• Surgical excision, radiation, or chemotherapy according to oncology guidelines for vulvar/vaginal malignancies.

6. Symptomatic & Home Care

• Warm sitz baths (10‑15 minutes, 2‑3 times daily) to reduce pain.
• Avoid irritants – scented soaps, douches, tight synthetic underwear.
• Use a water‑based lubricant during intercourse.
• Apply barrier ointments (e.g., zinc oxide) to protect surrounding skin.
• Take analgesics such as ibuprofen 400 mg q6‑8h for pain and inflammation.

Prevention Tips

While not all ulcerations are preventable, many can be minimized with simple habits:

• Practice safe sex – use condoms and discuss STI testing with partners.
• Maintain good genital hygiene: gentle washing with water, avoid harsh soaps or antiseptics.
• Limit use of scented feminine products, wipes, and bubble baths.
• Stay up‑to‑date with vaccinations (HPV, hepatitis B) and routine STI screenings.
• If you have a chronic skin condition (e.g., lichen sclerosus), follow prescribed topical therapy and routine follow‑up.
• Manage underlying systemic diseases (e.g., Crohn’s disease, HIV) with your specialist.
• During menopause, consider vaginal estrogen therapy (prescribed) to reduce atrophic changes.
• Wear breathable cotton underwear and avoid tight clothing that can trap moisture.

Emergency Warning Signs

References

• Mayo Clinic. “Genital sores (herpes, syphilis, and other STDs).” https://www.mayoclinic.org
• Centers for Disease Control and Prevention. “Sexually transmitted infections (STIs) Treatment Guidelines.” https://www.cdc.gov/std/treatment
• National Institutes of Health. “Behçet’s Disease.” https://www.nhlbi.nih.gov
• Cleveland Clinic. “Vulvar Lichen Sclerosus.” https://my.clevelandclinic.org
• World Health Organization. “Guidelines for the treatment of sexually transmitted infections (2016).” https://www.who.int
• British Association of Dermatologists. “Guidelines for the Management of Genital Lichen Planus.” https://www.bad.org.uk
• American College of Obstetricians and Gynecologists. “Management of Vulvar Cancer.” https://www.acog.org