Vulva: Structure, Functions, and Common Conditions

What is a vulva?

The vulva is the external part of the female genitalia, containing a variety of structures that play important roles in sexual function, protection, and sensation. It comprises the mons pubis, labia majora, labia minora, clitoris, vestibule, urethral opening, and vaginal opening. Each of these components serves a specific purpose and adds to the overall health and well-being of the female reproductive system. Understanding the anatomy and physiology of the vulva is critical for recognizing its role in sexual health, as well as diagnosing and treating related conditions.

Detailed Anatomy

The vulva consists of several distinct structures, each with its own anatomical features and functions. Here’s a detailed look at the different parts of the vulva:

Mons Pubis

The mons pubis is a rounded area of fatty tissue that covers the pubic bone. It has pubic hair and acts as a cushion during sexual intercourse.

• Structure: The mons pubis is made up of adipose tissue (fat) and covered in skin with sebaceous glands that secrete oils to lubricate and protect the area.
• Function: It serves as a protective cushion during sexual activities, shielding against potential trauma.

Labia Majora

The labia majora are two fleshy folds of skin that extend from the mons pubis to the perineum. They enclose and protect the remaining external genital structures.

• Structure: The labia majora consist of adipose tissue, sebaceous glands, and sweat glands. They have pubic hair on their outer surfaces.
• Function: They protect the internal genitalia from mechanical damage and infections while also maintaining the moisture balance of the vulvar area.

Labia Minora

The labia minora are two thinner skin folds that exist within the labia major. They surround the vaginal and urethral openings and meet at the clitoral hood.

• Structure: The labia minora are rich in blood vessels and nerve endings, making them extremely sensitive. They lack hair but do have sebaceous glands that help lubricate the area.
• Function: They protect the vaginal and urethral openings, increase sexual arousal due to their sensitivity, and direct urine flow.

Clitoris

The clitoris is a small, highly sensitive organ that sits at the top of the vulva, where the labia minora meet. It contributes significantly to female sexual pleasure.

• Structure: The clitoris is made up of the glans (visible part), the body (shaft), and two crura (roots) that extend internally. It contains erectile tissue similar to that found in the penis, which swells with blood during arousal.
• Function: The clitoris serves primarily to provide sexual pleasure. With its extensive nerve supply, it is the most sensitive part of the female genitalia.

Vestibular

The vestibule is the area enclosed by the labia minora and contains the urethral and vaginal openings, as well as the ducts of the Bartholin’s and Skene’s glands.

• Structure: The vestibule has a mucous membrane lining and numerous glands that secrete fluids to keep the area moist.
• Function: It helps urine pass through the urethra and serves as the entrance to the vagina. The glandular secretions help to lubricate the vaginal opening during sexual activity.

Urethral Opening

The urethral opening, also known as the meatus, is the urethra’s external opening, located below the clitoris and above the vaginal opening.

• Structure: It is a small, round, or slit-shaped opening surrounded by a delicate mucous membrane.
• Function: The urethral opening allows urine to leave the body via the bladder.

Vaginal Opening

The vaginal opening, also known as the introitus, is the external entrance to the vagina that is located below the urethral opening in the vestibule.

• Structure: The hymen, a thin membrane that may partially cover the opening in young women, surrounds it. The vaginal opening varies in size and shape.
• Function: It facilitates the passage of menstrual blood, sexual intercourse, and childbirth.

Bartholin’s Glands

The Bartholin’s glands are two small glands located on either side of the vaginal opening. They secrete lubricating fluid.

• Structure: Each gland is approximately the size of a pea and has a duct that leads into the vestibule.
• Function: They secrete a mucus-like fluid that lubricates the vaginal opening, particularly during sexual arousal.

Skene’s Glands

Skene’s glands, also known as paraurethral glands, are lubricating glands found near the urethral opening.

• Structure: These glands resemble the male prostate and open into the urethra and vestibule.
• Function: They secrete a fluid that lubricates the urethral opening and may aid in the female ejaculate during orgasm.

Perineum

The perineum is the region of tissue between the vaginal opening and the anus.

• Structure: It consists of skin, muscle, and connective tissue.
• Function: It supports the pelvic floor and helps with sexual sensation and childbirth. During childbirth, the perineum may stretch or tear, and an episiotomy (surgical cut) may be required to facilitate delivery.

Blood Supply

The vulva has a plentiful blood supply from branches of the internal pudendal artery, which supplies nutrients and oxygen to the tissues.

• Structure: The internal pudendal artery divides into the perineal artery and other smaller arteries that supply the various structures of the vulva.
• Function: Adequate blood flow is required to maintain tissue health and support physiological changes that occur during sexual arousal.

Nerve Supply

The vulva is highly innervated, which increases its sensitivity and responsiveness to touch.

• Structure: The pudendal nerve is the primary nerve that supplies the vulva, with additional input from the ilioinguinal and genitofemoral nerves.
• Function: Nerve supply is essential for sexual sensation, arousal, and proper vulval function.

Lymph Drainage

The lymphatic system contributes to fluid balance and immune function in the vulvar region.

• Structure: Lymph from the vulva drains to the inguinal lymph nodes.
• Function: Proper lymphatic drainage prevents infections and boosts immune responses in the genital area.

Clinical relevance

Understanding the intricate anatomy of the vulva is critical for diagnosing and treating a variety of conditions, including infections, dermatological disorders, and cancer. It also has a significant impact on sexual health and function.

Vulva: Physiology and Functions

The vulva has several important functions, including protection, sensation, sexual activity, and overall reproductive health. The following are the primary physiological roles and functions of the vulva:

Protective and Barrier Function

1. Physical Barrier: The vulva forms a physical barrier that protects the internal genitalia from mechanical trauma and infections. The labia majora and minora protect the vaginal and urethral openings from external contaminants, lowering the risk of bacterial and viral infection.
2. Lubrication: The labia majora contains sebaceous and sweat glands, as well as Bartholin’s and Skene’s glands, which secrete fluids that keep the vulvar area moist. This lubricant reduces friction and protects tissue from irritation during sexual activity and other movements.

Sensation & Sexual Function

1. Sensory Nerves: The vulva is densely innervated with sensory nerves, particularly the clitoris, which contains a large number of nerve endings. This extensive innervation makes the vulva extremely sensitive to touch, pressure, and temperature, which contributes to sexual arousal and pleasure.
2. Arousal and Erectile Tissue: During sexual arousal, the erectile tissue in the clitoris and surrounding areas swells with blood, increasing sensitivity and pleasure. The increased blood flow improves lubrication and prepares the body for sexual intercourse.
3. Orgasm: Stimulation of the vulva, particularly the clitoris, can cause orgasm, which is defined by rhythmic contractions of the pelvic muscles and an increased sense of pleasure. Orgasm influences overall sexual satisfaction and reproductive health.

Reproductive Function

1. Facilitating Intercourse: The vulva facilitates sexual intercourse by serving as an entry point into the vagina. The labia minora and vestibule guide the penis into the vaginal opening, while lubricating secretions reduce friction and make intercourse more comfortable.
2. Childbirth: The vulva stretches significantly to allow the baby to pass through. The perineum, in particular, is essential for supporting the pelvic floor during labor and delivery. Following childbirth, the vulva slowly returns to its pre-pregnancy state.

Urination

1. Urethral Protection: The labia minora direct the flow of urine from the urethral opening, lowering the risk of urinary tract infections by limiting the urethra’s exposure to external contaminants.
2. Support for Bladder Function: The vulva’s surrounding structures support the bladder and urethra, allowing the urinary system to function normally.

Vulva: Common Conditions

A variety of conditions and disorders can affect the vulva, as well as other parts of the body, causing discomfort, pain, and other health issues. Understanding these conditions is critical to accurate diagnosis and treatment. The following are some of the most common disorders and conditions affecting the vulva.

Vulvitis

Vulvitis is an infection, irritant, allergy, or other underlying condition that causes vulva inflammation.

Causes:

• Infections: Vulvitis can be caused by bacterial, fungal, or viral infections (such as yeast infections or the herpes simplex virus).
• Irritants: Chemicals found in soaps, lotions, laundry detergents, and feminine hygiene products may irritate the vulvar skin.
• Allergic Reactions: Allergies to specific fabrics, latex, or spermicides can cause inflammation.
• Hormonal Changes: During menopause, decreased estrogen levels can lead to vulvitis.

Symptoms:

• Redness, swelling, and itching in the vulva.
• Pain or burning sensations, particularly during urination or sexual intercourse.
• Discharge or lesions on the vulval skin.

Treatment:

• Identifying and avoiding irritants and allergens.
• To reduce inflammation and treat infections, apply topical corticosteroids or antifungal cream.
• Hormone replacement therapy for postmenopausal women who are estrogen deficient.

Vulvodynia

Vulvodynia is a chronic pain condition of the vulva that has no known cause. It has a significant impact on a woman’s quality of life.

Causes: The exact cause is unknown, but potential causes include nerve injury or irritation, hormonal changes, muscle spasms, and a genetic predisposition.

Symptoms:

• Persistent, unexplained pain in the vulva lasting three months or longer.
• Burning, stinging, or throbbing pain that can be continuous or intermittent.
• Pain during intercourse (dyspareunia), sitting, or while wearing tight clothing.

Treatment:

• Medications include topical anesthetics, anticonvulsants, and antidepressants.
• Physical therapy: Pelvic floor therapy can help relieve muscle tension.
• Nerve blocks or injections: To relieve pain.
• Cognitive-behavioral therapy (CBT) and support groups to address emotional and psychological concerns.

Lichen Sclerosus

Lichen sclerosus is a chronic skin condition affecting the vulva, resulting in thinning, white patches, and scarring.

Causes: Although the exact cause is unknown, it is thought to involve an autoimmune response, genetic factors, and hormonal influences.

Symptoms:

• White, glossy patches of skin on the vulva.
• Itching, pain, and discomfort.
• Skin that tears and bruises easily, resulting in bleeding or ulceration.
• In severe cases, the labia fuse together.

Treatment:

• High-potency topical corticosteroids to reduce inflammation and scarring.
• Regular check-ins with a healthcare provider to monitor the condition.
• In severe cases, surgery may be required to separate fused labia or remove scar tissue.

Bartholin’s cyst and abscess

Bartholin’s cyst develops when the duct of a Bartholin’s gland becomes clogged, resulting in fluid accumulation. If infected, it can cause an abscess.

Causes:

• Infection, injury, or inflammation cause a blockage in the Bartholin’s gland duct.
  Bacterial infections, including sexually transmitted infections (STIs) such as gonorrhea and chlamydia.

Symptoms:

• A painless lump or swelling on one side of the vulva (called a cyst).
• Serious pain and swelling if the cyst becomes infected (abscess).
• Difficulty walking, sitting, or engaging in intercourse.

Treatment:

• Use warm sitz baths to encourage cyst drainage.
• Antibiotics if the cyst becomes infected.
• Incision and drainage of abscesses.
• In recurring cases, marsupialization or surgical removal may be required.

Vulvar Cancer

Vulvar cancer is a rare malignancy that can develop on the vulva and manifests as a lump, ulcer, or persistent irritation.

Causes:

• HPV infection.
• Chronic skin conditions, such as lichen sclerosis.
• Age and smoking are additional risk factors.

Symptoms:

• A bump or growth on the vulva.
• Persistent itch or pain.
• Changes in skin colour or texture.
• Abnormal bleeding or discharge.

Treatment:

• Surgery to remove cancerous tissue.
  Depending on the stage and spread of the cancer, treatment may include radiation therapy or chemotherapy.
• Regular follow-up and monitoring for recurrences.

Genital Herpes

Genital herpes is a sexually transmitted infection caused by the herpes simplex virus (HSV), which causes painful sores and blisters on the vulva.

Causes: Sexually transmitted HSV-1 or HSV-2 infection.

Symptoms:

• Painful vulval blisters or ulcers.
• An itching or burning sensation.
• Flu-like symptoms appeared during the initial outbreak.

Treatment:
Antiviral medications can help to reduce the severity and frequency of outbreaks.

• Pain relief using over-the-counter pain relievers and topical anesthetics.
• Avoiding sexual contact during outbreaks to reduce the risk of transmission.

Contact Dermatitis

Contact dermatitis is a skin inflammation caused by being in direct contact with an irritant or allergen.

Causes: Contact with soaps, detergents, perfumes, latex, or other chemicals that irritate the vulvar skin.

Symptoms:
Symptoms include redness, swelling, and itching.

• In severe cases, there may be rash or blisters.
• Pain or discomfort, particularly when touching the skin.

Treatment:

• Identifying and avoiding an irritant or allergen.
• Topical corticosteroids to reduce inflammation.
• Skin-soothing and protective moisturizers.

Yeast Infections

Yeast infections (candidiasis) are common fungal infections that can occur in the vulva and vagina.

Causes: Overgrowth of Candida, a fungus that is normally present in small amounts in the vagina.

Symptoms:

• Severe itchiness and irritation.
• Vulval redness and swelling.
• A thick, white, cottage cheese-like discharge.
• Pain while having intercourse or urinating.

Treatment:

• Over-the-counter antifungal creams or suppositories.
• Antifungal medications prescribed for severe or recurring infections.
• Probiotics to support a healthy vaginal flora.

Diagnostic methods

Accurate diagnosis of vulvar conditions is critical for successful treatment and management. Several diagnostic methods are used to identify and evaluate disorders affecting the vulva:

Clinical Examination

A thorough clinical examination is the first step in determining vulvar conditions. This includes gathering a detailed patient history and conducting a physical examination.

1. Patient History: Collecting data on symptoms, duration, frequency, and any potential triggers or contributing factors such as hygiene practices, sexual activity, and personal care product use.
2. Physical Exam: Checking the vulva for signs of infection, inflammation, lesions, or other abnormalities. Palpation can be used to check for lumps, cysts, or tenderness.

Colposcopy

Colposcopy is a diagnostic procedure that uses a magnified image of the vulva, vagina, and cervix to detect abnormalities.

1. Procedure: Examine the vulva and surrounding areas with a colposcope (a special microscope). To highlight abnormal cells, apply an acetic acid or iodine solution.
2. Applications: Used to assess lesions, persistent ulcers, or suspicious areas that could be cancerous or precancerous changes.

Biopsy

Biopsy entails removing a small amount of tissue from the vulva for microscopic examination.

1. Procedure: Local anesthesia is administered, and a small piece of tissue is removed with a scalpel, punch, or other instrument.
2. Applications: Used to diagnose vulvar cancer, lichen sclerosis, and other chronic skin conditions. A biopsy can detect the presence of cancer, inflammation, or infection.

Cultures and Swabs

Cultures and swabs are used to diagnose infections caused by bacteria, fungi, and viruses.

1. Procedure: Using a sterile swab, a sample is collected from the vulvar area and sent to a laboratory for analysis.
2. Applications: Helps diagnose yeast infections, bacterial vaginosis, sexually transmitted infections (STIs) such as herpes simplex virus, and other infectious agents.

Vulvoscopy

Vulvoscopy is a specialized examination of the vulva that employs a colposcope or magnifying glass to detect abnormalities.

1. Procedure: Like colposcopy, vulvoscopy entails a thorough visual examination of the vulva. It may include the use of acetic acid or iodine to improve visibility of abnormal tissues.
2. Applications: Aids in the diagnosis of lichen sclerosus, lichen planus, and other chronic dermatological conditions of the vulva.

Imaging Studies

Ultrasound, MRI, and CT scans can produce detailed images of the vulvar structures and surrounding areas.

1. Ultrasound: Uses sound waves to generate images of internal structures. It can help detect cysts, abscesses, and tumors.
2. MRI and CT Scans: Provide detailed cross-sectional images, which are useful for determining the extent of vulvar cancer and detecting metastases.

Treatments for Vulva Conditions

Treating vulvar conditions necessitates a multifaceted approach that addresses the underlying cause, relieves symptoms, and prevents recurrence. The following are detailed treatment options for common vulvar disorders.

Medical Treatments

1. Topical Medication:

• Corticosteroids: Used to relieve inflammation and itching in conditions such as lichen sclerosus and contact dermatitis. High-potency corticosteroids, like clobetasol propionate, are frequently prescribed.
• Antifungal Creams: Helps treat yeast infections (candidiasis). Clotrimazole and miconazole are two commonly used options.
• Antiviral Creams: Antiviral creams like acyclovir can help manage genital herpes outbreaks by reducing their severity and duration.
• Anesthetics: Lidocaine, a topical anesthetic, can provide pain relief for conditions such as vulvodynia.

1. Oral Medication:

• Antifungals: Severe or recurring yeast infections require the use of oral antifungal medications such as fluconazole.
• Antivirals: Oral antivirals, such as valacyclovir or famciclovir, can help manage and suppress genital herpes outbreaks.
• Antibiotics: Used to treat bacterial infections, including those that cause Bartholin’s abscess.
• Pain Management: Chronic pain conditions such as vulvodynia may require the use of tricyclic antidepressants or anticonvulsants such as gabapentin.

1. ** Hormone Replacement Therapy**:

• Estrogen Creams: Topical estrogen creams can help restore moisture and alleviate symptoms in postmenopausal women suffering from vulvitis caused by an estrogen deficiency.

Surgical Treatments

1. Incision & Drainage:

• For Bartholin’s abscesses, a minor surgical procedure to drain the abscess and alleviate pain and swelling.

1. Marsupialization:

• A surgical procedure used to create a permanent opening for recurring Bartholin’s cysts, thereby preventing future blockages.

1. Excision:

• Surgical removal of vulvar lesions, cysts, or cancerous tumors. To ensure complete removal of malignant tissues, a biopsy may be required.

1. Laser therapy:

• Laser treatments can be used to remove abnormal tissues in lichen sclerosus and vulvar intraepithelial neoplasia (VIN).

Physical Therapy

1. Pelvic Flooring Therapy:

• Specialized physical therapy that focuses on strengthening and relaxing the pelvic floor muscles, which can help with vulvodynia and chronic pelvic pain.

1. Biofeedback:

• A technique that uses electronic monitoring to help patients gain awareness and control over pelvic floor muscle function, thereby reducing pain and improving muscle coordination.

Alternative and Complementary Therapies

1. Acupuncture:

• Acupuncture may help reduce inflammation and improve overall well-being, allowing some patients to find relief from vulvar pain and symptoms.

1. Nutrition Therapy:

• Dietary changes and supplements can improve vulvar health and relieve symptoms associated with a variety of conditions.

Innovative Treatments

1. Platelet-Rich Plasma (PRP) Treatment:

• PRP therapy entails injecting a concentrated dose of the patient’s own platelets into the vulvar area to promote healing and alleviate pain, particularly in cases of vulvodynia.

1. Stem Cell Treatment:

• Experimental stem cell treatments to regenerate damaged vulvar tissues and alleviate chronic vulvar symptoms.

Counseling and Support

1. Cognitive Behavior Therapy (CBT):

• Cognitive behavioral therapy (CBT) can help patients manage the psychological impact of chronic vulvar conditions by reducing anxiety and improving coping strategies.

1. Support Groups:

• Joining support groups can provide emotional support as well as practical advice from others who are going through a similar situation.

Proven Supplements for Vulva Health

Supplements can help with vulvar health by providing essential nutrients and improving overall well-being. Here are some proven supplements useful for vulvar health:

1. Probiotics:

• Benefits: Probiotics promote a healthy balance of bacteria in the vagina, lowering the risk of yeast infections and bacterial vaginosis.
• Sources: Yogurt, kefir, and probiotic supplements with Lactobacillus strains.

1. Vitamin E:

• Benefits: Vitamin E contains antioxidants that protect vulvar skin from oxidative stress and promote the healing of damaged tissues.
• Sources include nuts, seeds, vegetable oils, and vitamin E supplements.

1. Omega 3 Fatty Acids:

• Benefits: Omega-3s are anti-inflammatory, which can help to reduce inflammation and pain associated with vulvar conditions.
• Sources: Fatty fish (such as salmon and mackerel), flaxseeds, chia seeds, and fish oil supplements.

1. Vitamin D*:

• Benefits: Vitamin D promotes immune function and has anti-inflammatory properties that can help with vulvar pain and infections.
• Sources include sun exposure, fatty fish, fortified foods, and vitamin D supplements.

1. Zinc:

• Benefits: Zinc improves immune function and skin health by promoting vulvar tissue healing and lowering the risk of infection.
• Sources include meat, shellfish, legumes, seeds, nuts, and zinc supplements.

1. Aloe vera:

• Benefits: Aloe vera has soothing and anti-inflammatory properties that can help relieve irritation and promote healing in the vulvar skin.
• Sources include aloe vera gel, creams, and supplements.

1. Cranberry Extract*:

• Benefits: Cranberry extract prevents urinary tract infections (UTIs), which can harm the vulva and cause discomfort.
• Sources: Cranberry juice; cranberry supplements.

1. Evening Primrose Oil*:

• Benefits: Evening primrose oil contains gamma-linolenic acid (GLA), an anti-inflammatory that can alleviate vulvar pain and irritation.
• Source: Evening primrose oil supplements.

Best Practices for Improving Vulvar Health

1. Maintain Good Hygiene: Clean the vulvar area with mild, unscented soap and water. Avoid douching because it can upset the natural balance of bacteria.
2. Wear Breathable Underwear: Use cotton underwear to promote air circulation and reduce moisture buildup.
3. Avoid Irritants: Avoid scented products, harsh soaps, and tight clothing that can irritate your vulvar skin.
4. Practice Safe Sex: Use condoms to lower your risk of sexually transmitted infections (STIs).
5. Stay Hydrated: Consume plenty of water to keep your body and skin healthy.
6. Eat a Healthy Diet: To support overall health and immune function, consume a well-balanced diet rich in fruits and vegetables, lean proteins, and whole grains.
7. Manage Stress: Try stress-reduction techniques like yoga, meditation, and deep breathing exercises.
8. Regular Check-ups: Schedule regular gynecological exams to monitor vulvar health and identify problems early.
9. Exercise on a Regular Basis: Regular physical activity will improve circulation and overall health.
10. Avoid Smoking and Excessive Alcohol: Smoking and drinking excessively can have a negative impact on skin and immune function.

Trusted Resources

Books

1. “The V Book: A Doctor’s Guide to Complete Vulvovaginal Health” by Elizabeth G. Stewart: This comprehensive guide covers all aspects of vulvovaginal health, including common conditions, treatments, and self-care tips.
2. “Women’s Health: A Guide to Wellness and Self-Care” by Marilyn R. Lamay and Charlotte E. Grayson Mathis: This book provides an overview of women’s health issues, including vulvar health, with practical advice for maintaining wellness.
3. “The Vulva: Anatomy, Physiology, and Pathology” by Miranda A. Farage and Howard I. Maibach: A detailed reference book covering the anatomy, physiology, and common conditions affecting the vulva.

Academic Journals

1. “Journal of Lower Genital Tract Disease”: This journal publishes research on diseases and conditions affecting the lower genital tract, including the vulva. It covers diagnosis, treatment, and prevention strategies.
2. “Obstetrics & Gynecology”: A leading journal in the field of obstetrics and gynecology, it includes research on vulvar conditions, women’s health, and reproductive medicine.

Mobile Apps

1. MyFLO: An app designed to help women track their menstrual cycle and identify patterns related to vulvar health, offering tips for managing symptoms and maintaining overall health.
2. Clue: A period and health tracking app that provides insights into menstrual health, fertility, and vulvar care.
3. Vaginal Health: An app focused on providing information about vulvar and vaginal health, including tips for preventing infections and maintaining hygiene.