Painful Intercourse Painful intercourse (dyspareunia) may be caused by many different vulvovaginal conditions, including common vaginal infections and vaginismus (see Chapters 11 and 18). A careful sexual history is essential, as is a careful examination of the vulvar area and vagina. Vulvodynia is the term used to describe unexplained vulvar pain, sexual dysfunction, and the resultant psychological disability (240,241). The term vulvar vestibulitis was previously used to describe a situation in which there is pain during intercourse or when attempting to insert an object into the vagina; pain on pressure to the vestibule on examination and vestibular erythema (known as Friedrich’s triad); this entity is now described as localized provoked vulvodynia in the International Society for the Study of Vulvovaginal Disease (ISSVD) (240–243) (see Chapter 16). A number of recent studies failed to demonstrate a consistent relationship with any genital infectious organism, including C. trachomatis, gonorrhea, Trichomonas, mycoplasma, Ureaplasma, Gardnerella, candida, or HPV, and the condition has been characterized as multifactorial, with both inﬂammatory, neuropathic, and functional components. Although the symptoms of dyspareunia with insertion can be disabling, no curative therapies were found. Both medical and behavioral therapies are of some benefit, and some authors encourage surgery, but the role of this treatment and newer therapies such as the injection of botulinum toxin A is not well established (241).
Vulvar Ulcers A number of STDs can cause vulvar ulcers, including herpes simplex virus, syphilis, lymphogranuloma venereum, and granuloma inguinale (see Chapter 18). Crohn’s disease can include vulvar involvement with abscesses, fistulae, sinus tracts, fenestrations, and other scarring. Although medical treatment, with systemic steroids and other systemic agents, is the standard therapy, surgical therapy for both intestinal and vulvar disease may be required.
Behcet’s Disease This systemic condition is characterized by genital and oral ulcerations with ocular inﬂammation and many other manifestations (244). The cause and the most effective therapy are not well established, although anti-inﬂammatory and immunosuppressive therapies may be effective (245).
Lichen Planus This condition causes oral and genital ulcerations. Typically, there is desquamative vaginitis with erosion of the vestibule. Treatment is based on the use of both topical and systemic steroids. Plasma cell mucositis appears as erosions in the vulvar area, particularly the vestibule. Biopsy is essential in establishing the diagnosis.
Vaginal discharge is one of the most common vaginal symptoms. Conditions ranging from vaginal candidiasis to chlamydia cervicitis to bacterial vaginosis to cervical carcinoma may cause vaginal discharge. Infectious vaginal conditions are addressed more completely in Chapter 18. Vaginal lesions may occasionally be palpable to a woman. More commonly, vaginal lesions are discovered on examination by a clinician. They may contribute to symptoms (such as bleeding or discharge) or they may be entirely asymptomatic. Vaginitis, cervicitis, and vaginal or cervical lesions (including malignancies) can be causes of vaginal discharge. Other noninfectious causes of discharge are as follows: 1.
Retained foreign body—tampon, pessary 2.
Ulcerations—tampon-induced, lichen planus, herpes simplex infection 3.
Malignancy—cervical, vaginal