Perineum Hygiene for Vulvovaginal Health

Women practice to use multiple varieties of intimate hygiene items in their daily life as cleansing agents. Multifactorial reasons impacted including cultural norms, religious thoughts, personal choice , over the counter preference and health care advice. There is proven literature on vaginal health, about the vulva region and on how personal perineum hygiene can affect the biological and physiological stability.

VulvaVagina
Tissue structuralMons pubis,labia,clitoris and perineum (keratinized)
Vulvar vestibule mucosa (non-keratinized)
Fibromuscular canal composed mainly of smooth muscle
pH3.5-4.7Pre-menarche:7.0
Reproductive age:3.8-4.4
Menopause:6.5-7.0 (without hormone therapy), 4.5-5.0 (with hormone therapy)
MicrofloraLipophilic and non-lipophilic diphtheroids; coagulase-negative staphylococci, micrococci, and lactobacilli; streptococci; Gram-negative rods; Gram-negative bacilli; Neisseria; Gardnerella vaginalis; and/or yeastsLactobacillus spp., Atopobium vaginae, Megasphaera spp., Leptotrichia spp., Gardnerella vaginalis, Staphylococcus aureus, and/or Candida albicans
Physiological characteristics of vulva and vaginal area (table 1)

Vulvovaginal area

Vulva is a first line defense to protect from getting an infection into the reproductive organ. Contamination occurs at vulva folds during menses, sweating, increased moisture or hormonal imbalance influence the microbial growth and species balance which results in vulvovaginal infections. The vulva skin is more sensitive and differs from other skin in view of hydration, permeability and visually discernible irritation. Usually the non-keratinized vulvar vestibule is more permeable than keratinized skin. The characteristic and possible microbial infection has been mentioned in table 1.

Microflora

Studies show that there is varying microbiota in vulva, no single species of microorganism is common to all women. The microorganism includes staphylococcus, lactobacili, streptococcus, yeasts, gram negative rods and other species from the fecal route. Normal flora or vulva flora may also affect the imbalance pH level and multiplication of exogenous pathogens causing vagino-urinary infections. Previously thought that Lactobacillus is keeping a healthy vagina. Lactobacillus sp is a non-sporing gram positive bacilli that produces lactic acid which will produce an acidic environment in vagina. pH level varies in different hormonal status of a woman. Basically, Lactobacillus will protect against by preventing the entry of other bacteria in the vagina. A healthy vaginal ecosystem is well maintained by inhibition of bacterial growth by generation of microbiota with innate host defense. Some women will have absent Lactobacilli and replaced by other lactic acid producing bacteria such as Atopobium vaginae, Megasphaera sp or Leptotrichia sp. The concept of healthy versus unhealthy vaginal microbiome is complicated. However, some asymptomatic patients in reproductive age will have colonization of pathogenic species such as Gadnerella vaginalis, Staphylococcus or Candida albicans.

pH

Vulva pH is estimated at 4.7 and the vagina at 3.5 with evidence of studies, the report ranging pH 3.8 to 4.2 during menses. Multifactorial causes can occur which may affect the vulva pH including endogenous and exogenous factors. The endogenous, which are humidity,per vaginal discharge, menstruation, sweat, waste contamination(urine and fecal), genetics, age and/or anatomical influence). The exogenous factors, which are soap, detergent, intimate feminine wash/douche, lubricants, cosmetic products, shaving/waxing, perfumed sanitary pads and/or chemical depilatory product(hair removal). Vulva dryness shown to significantly reduce the pH level. Hormonal influence on the health of vulva and vagina plays an important role. Low estrogen level may be factorial for vulva dryness. Vaginal mucosa is rich in lactic acid therefore it correlates with vagina pH by producing estrogen regulated anaerobic glucose metabolism. The vaginal pH varies from different ethnicities.

Vaginal discharge

It is normal for a healthy woman to produce vaginal discharge. The discharge consists of bacteria and desquamated epithelial cells with mucus and plasma fluid which are produced by the cervix and vaginal. This discharge’s texture and quantity varies during menstrual cycle which is thicker, sticky when the estrogen level is low and the discharge gets clearer and watery even stretchy as estrogen level goes up before ovulation.

Protection from infections

The vaginal discharge, acidic vaginal pH and normal flora are the innate defense mechanism to be a barrier protection from getting vulvovaginal infections. The study shows vaginal fluids collection commonly showed Escherichia coli and Streptococcus group B. Streptococcus groupB is one of the common bacteria which colonize in our body and usually cause no harm. Important for pregnant women as it can colonize the vagina through the colorectal and increase risk for the fetus or infant which can lead to severe neonatal jaundice, neonatal meningitis and also death. It also causes urinary tract infections, bacteriuria, upper genital tract infections and endometritis. Increases in vaginal pH level also increase the risk of HPV and low grade squamous intraepithelial lesions.

Common Vulvovaginal infections

  • Vaginal candidiasis, it is a most common presentation with white, curdy, odourless discharge with or without irritation or itchiness.
  • Bacterial vaginosis is a most frequent cause of vaginal discharge with the presentation of fishy smell discharge. Often are Gardanella vaginalis and Mycoplasma hominis.
  • HPV,HSV type 2, Trichomonas vaginalis and HIV has increased risk of dysbiosis.

Intimate feminine hygiene

Vaginal douching has been common for many women which have no known health benefits and may be predisposing to infections. It is also associated with increased risk of sexually transmitted infection, pelvic inflammatory disease and endometriosis. On the other hand, cleaning/washing the vulva can prevent the contamination by urine/fecal, vaginal discharge and sweat, this method can prevent infections and foul smelling. However, it is not designed to treat infections.

Vulva skin care:

  • Avoid bar soap, harsh detergent, bubble bath which have alkaline pH and abrasive
  • Vaginal douching is not recommended
  • Avoid fabric softener/conditioner, antiseptic detergent and biological washing powder. Preferable to wash panties separately with mild and non biological detergents and rinse properly.
  • Change tampon and sanitary pads frequently. Avoid perfumed sanitary pads.
  • Wear loose fitting clothing or cotton panties. Avoid close fitting clothes.
  • Clean the vulva from front to back before and after intercourse and also after each toilet visit.
  • Do not use talcum powder
  • Choose a safe method to remove pubic hair, either laser or shaving (change blade frequently)
  • Avoid using over the counter cream include nappy cream,
  • Postpartum care should be maintained by cleaning and drying the perineum frequently and wearing suitable underwear with sanitary pads if necessary.
  • Use separate towels to wipe vulva and body
  • Sleep without underwear
  • Avoid using sponge or flannels. Try to use a cleaned hand to wash and gently pat dry with a soft towel.
  • Avoid wearing nail varnish on fingernails if tends to scratch your skin.

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