CHAPTER 64 Vulvar Sores
‘Vulvar Sores’, called Yin Chuang (
) in Chinese medicine, may manifest with vulvar swelling, pain, itching, erosion, lumps, discharge of pus and excessive vaginal discharge. These local manifestations may be accompanied by systemic symptoms and signs such as shivers, fever, lassitude, abdominal distension, dark urine, thirst, constipation, a Slippery or Wiry and Rapid pulse and a Red tongue with a thick, sticky yellow coating.
This Chinese disease category may correspond to various diseases of the genitalia such as vulvitis, vaginitis, boils or ulcers of the external genitalia, inflammation of the Bartholin’s glands, cancer of the external genitalia or genital herpes.
Aetiology
Invasion of external Dampness
External Dampness easily invades the leg channels to settle in the genital system: this is more common in women and it is more likely to happen when women are exposed to Dampness during or immediately after the period. Dampness often mixes with Heat and gives rise to Damp-Heat.
Irregular diet
Excessive consumption of hot, spicy and greasy foods leads to the formation of internal Damp-Heat: this often infuses downwards and settles in the genital system in women.
Emotional strain
Emotional problems such as anger, repressed anger, resentment and frustration often lead to stagnation of Liver-Qi; after some time, stagnant Qi may turn into Fire and give rise to Liver-Fire. Liver-Fire may affect the genitals especially when it is combined with Damp-Heat.
Excessive use of Yang tonics
In the old times, the excessive or improper use of Yang tonics to stimulate libido was a possible cause of disease in the Chinese medicine category of Vulvar Sores. This is not a common cause of disease nowadays, especially in women. However, it may occur, when people self-prescribe Red Ginseng which is hot in energy.
Pathology
The Chinese pathology of Vulvar Sores includes Fire, Damp-Heat and Cold: the first two are by far the most common pathological conditions found in this disease. In addition, the pathology is characterized often by invasion of ‘parasites’. As discussed in Chapter 61 on excessive vaginal discharge, Toxic-Heat or Damp-Heat are often accompanied by infestation of what the ancient Chinese called ‘parasites’ (chong 
); certain types of vaginal discharges and vulvar sores are caused by ‘parasites’. The ancient Chinese doctors were very perceptive because we know from modern medicine that fungal or bacterial infections, spread through sexual contact, may cause vaginal discharges or vulvar sores. In such cases, the treatment principle is to ‘kill parasites’ (sha chong 
), i.e. eliminate bacteria or fungi with herbs that have an anti-bacterial or anti-fungal effect and the majority of which also kill parasites.
Identification of patterns and treatment
When treating vulvar sores, one must differentiate clearly deficiency from excess. Excess conditions include Damp-Heat, Toxic-Heat, Fire and parasites; thus, common treatment principles adopted are to resolve Dampness, clear Heat, resolve Toxic-Heat, drain Fire and kill parasites. The relationship between the external genitalia and internal organs and channels should be studied and the main channels involved are the Directing Vessel and the Liver channel. As for deficiency, the main organs involved are Liver and Kidneys; normally, Damp-Heat and Toxic-Heat occur against a background of Yin deficiency, but they may also occur against one of Yang deficiency.
In the acute phase, one needs to treat the Manifestation by expelling pathogenic factors; in the chronic phase (in between attacks) one needs to treat the Root by tonifying the Liver and Kidneys.
Toxic-Heat with Liver-Fire and Damp-Heat
Clinical manifestations
Sores of external genitalia, redness, swelling, heat and pain of the external genitalia, oozing of yellow fluid or pus. Tongue: Red, redder sides, thick, sticky, dry, yellow coating with Red spots on the root. Pulse: Slippery, Wiry, Rapid.
Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-3 Zhongji, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-1 Huiyin, BL-34 Xialiao, BL-22 Sanjiaoshu. All with reducing or even method.
Herbal treatment
a. Prescription
Three Treasures remedy
This remedy is a variation of the formula Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction and it drains Liver-Fire and Heart-Fire. It is therefore especially suitable when there is also Heart-Fire deriving from emotional problems. The tongue presentation appropriate to this remedy is a Red body with redder sides and tip and with a dry, yellow coating; it may also have a Heart crack.
Toxic Heat with Liver-Fire and Damp-Heat
Clinical manifestations
Sores of the external genitalia, redness, swelling, heat and pain of the external genitalia, oozing of yellow fluid or pus. Tongue: Red, redder sides, thick, sticky, dry, yellow coating with Red spots on the root. Pulse: Slippery, Wiry, Rapid.
Acupuncture
LU-7 Lieque on the right and KI-6 Zhaohai on the left, Ren-3 Zhongji, SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-1 Huiyin, BL-34 Xialiao, BL-22 Sanjiaoshu. All with reducing or even method.
A 48-year-old woman had been suffering from genital herpes for 10 years. She had attacks every 3 weeks which were characterized by painful vesicles, with the pain extending to the thighs. In addition to this, she also suffered from recurrent bladder infections characterized by burning on urination, a dark urine and hypogastric pain: this problem dated back nearly 30 years and she had received many courses of antibiotics over that time. On interrogation, it transpired that she also suffered with tiredness, dizziness, loose stools, frequent, pale urination, chilliness, night sweating, backache and nocturia. Her tongue was Red, partially peeled and with a Heart crack; in places where there was a coating, it was yellow (Plate 13). Her pulse was Weak in general but especially on the right Front position and slightly Floating-Empty on the left.
Diagnosis
This was a complicated and contradictory case. As far as the herpes was concerned, this was due to Damp-Heat in the genital system, which also caused the recurrent urinary infections. This Damp-Heat occurred against a background of Kidney-Yin deficiency as evidenced by the Red and partially peeled tongue and the night sweating. However, there was a glaring contradiction in that she had many symptoms of Spleen- and Kidney-Yang deficiency: tiredness, dizziness, loose stools, frequent, pale urination (except when she had an infection), chilliness, backache and nocturia. I concluded that this contradiction could only be explained as a transformation of Kidney-Yang into Kidney-Yin deficiency: although the Kidney-Yin deficiency manifested on the tongue, there was still enough Kidney-Yang deficiency to cause the above symptoms.
Treatment principle
The above contradiction made the treatment particularly difficult: if I tonified Kidney-Yang, it would make the Damp-Heat worse; if I used bitter and cold herbs to resolve Damp-Heat, it would injure Spleen- and Kidney-Yang. I decided to rely most of all on acupuncture as this treatment modality does not present the problems encountered with herbal medicine: with acupuncture, one can tonify Kidney-Yin or Kidney-Yang without injuring the other. I did use herbal medicine but only with very simple decoctions which deviated from the ones listed above under the pattern of Toxic-Heat with Damp-Heat.
The treatment principle adopted was to tonify the Kidneys (both Yin and Yang), strengthen the Spleen and resolve Damp-Heat.
Acupuncture
Herbal treatment
I initially used a modification of the formula Zhi Zi Chi Tang Gardenia-Soya Decoction: the original formula, composed of only Shan Zhi Zi Fructus Gardeniae and Dan Dou Chi Semen Sojae preparatum, clears residual Heat. I considered her longstanding condition of Damp-Heat to be a form of residual Heat. The modification used was as follows:
Explanation
I used variations of this formula for several months with additions such as Huang Bo Cortex Phellodendri to resolve Damp-Heat and Huang Qi Radix Astragali to tonify Qi and strengthen the immune resistance. After 9 months of treatment, the herpes attacks became much less frequent and less intense and I was able to change to a Kidney-tonic formula such as Zhi Bo Di Huang Wan Anemarrhena-Phellodendron-Rehmannia Pill (variation):
Rou Gui was added for the reasons explained above. After this formula had been taken for a further 6 months, her herpes attacks did not return.
Retention of Cold
Clinical manifestations
Erosion and pain of the vulva, pale lesions in the genital area, chronic condition with repeated attacks, lassitude. Tongue: Pale. Pulse: Weak.
Acupuncture
Ren-12 Zhongwan, ST-36 Zusanli, SP-6 Sanyinjiao, BL-20 Pishu, BL-13 Feishu, Ren-6 Qihai, SP-9 Yinlingquan, Ren-1 Huiyin, Ren-3 Zhongji. All with reinforcing method except for the last three which should be needled with even method.
Herbal treatment
Prescription
Explanation
Retention of Cold
Erosion and pain of the vulva, pale lesions in the genital area, chronic condition with repeated attacks, lassitude. Tongue: Pale. Pulse: Weak.
A 41-year-old woman had been suffering from recurrent genital herpes for 6 years: the attacks usually came either before or after the period and were characterized by vesicular lesions which then erupted to form ulcers. The lesions were pale and not very painful. Her tongue was Bluish-Purple with large blue areas on the sides (Plate 14); her pulse was extremely Weak and Deep on the right side and Slippery on the left.
Diagnosis
This is an example of vulvar sores occurring against a background of Cold and Yang deficiency. Her pulse showed a severe Kidney-Yang deficiency, while her tongue showed Cold and stasis of Blood.
Treatment principle
I treated her with both acupuncture and herbs. The treatment principle adopted was to tonify Kidney-Yang and invigorate Blood.
Prognosis and prevention
The prognosis in the treatment of vulvar sores depends, to a certain extent, on the Western diagnosis (see below). The most difficult condition to treat is that of genital herpes. This will necessarily take many months if not years and requires patience on the part of the practitioner and the patient. The treatment should alternate between treating the Manifestation during an attack and the Root (i.e. tonify the body’s Qi) in between attacks. Although herbal medicine is generally better than acupuncture at treating Toxic-Heat or Damp-Heat, the power of acupuncture in the treatment of genital herpes should not be underestimated. I often find that an acupuncture treatment in the acute stage gives almost immediate relief and, in some cases, it may even stop the attack in its tracks.
Western view
Vulvar and peri-vulvar lesions are often associated with pruritus. Vulvar lesions are often classified into red, white, dark and ulcerative. The main types are as follows:
Red lesions
Red lesions can be inflammatory or neoplastic.
Inflammatory
Infections
The most common infections causing vulvitis are those from Candida albicans: this has been discussed in Chapters 61 and 62 on excessive vaginal discharge and vaginal itching respectively.
Vulvitis
Vulvitis is an inflammatory condition caused by irritants such as detergent, dyes, perfume, spermicide creams, lubricants, saliva or semen. It is characterized by erythema, swelling and pruritus.
Vestibular adenitis
The vestibular glands are located between the hymen and the labia minora: when they become inflamed they cause vulvar pain, erythema and pruritus.
Neoplastic
The vulva is the fourth commonest site of gynecological neoplasia. Its peak incidence is in the 60s and 70s although 15% of all vulvar neoplasms occur in women under 40. Vulvar neoplasia has been associated aetiologically with the human papilloma virus. The clinical manifestations of vulvar neoplasm include pruritus, erythema and swelling. The lesions may be grey, white, red or dark.
White lesions
Vulvar neoplasia
Vulvar neoplasm of the white variety is difficult to distinguish from vulvar dystrophy. It is characterized by erythema, swelling and pruritus.
Dark lesions
Ulcerative lesions
Inflammatory: infectious
Viral
Herpes simplex is by far the most common viral infection of the vulva. The infection is acquired through sexual contact. The lesion are vesicular, red, raised, painful and itchy. After some time, the vesicles or papules rupture and often coalesce forming painful ulcers. The lesions usually last 10–14 days, form a crust and then disappear. Common sites of infection are the cervix, vulva, vagina, perineum and urethra.
Bacterial
Bacterial infections of the vulva include infections from Treponema pallidum (of syphilis) or Calymmatobacterium granulomatis. The vulvar lesions of syphilis are papular and soft.
Pyoderma is an opportunistic infection of the vulvar skin deriving from poor hygiene. It manifests with erythema and pruritus.