Recurrent fissuring of posterior fourchette

The posterior fourchette is a fork-shaped fold of skin at the bottom of the entrance to the vagina. Vulvar pain may be due to recurrent fissuring or splitting of the posterior fourchette. Pain from fissuring is often described as being 'like a paper-cut' or 'knife-like'.

Recurrent fissuring has been previously called vulval or vulvar granuloma fissuratum.

What symptoms arise from posterior fourchette fissures?

Most women that present with posterior fourchette fissures are sexually active and symptoms follow intercourse. Symptoms may be mild, moderate or severe in intensity, and usually resolve within a few days.

• Pain on vaginal penetration during intercourse (dyspareunia)
• Pain on insertion of a vaginal tampon
• Pain during vaginal examination
• Tearing sensation
• Bleeding or spotting
• Itching
• Burning
• Stinging on contact with semen, water or urine

Affected women may be premenopausal or postmenopausal. Fissuring can occur at the first attempt at sexual intercourse or many years later, in women who have had children or who have never had children. They may also have other symptoms, including fissures in the skin folds elsewhere in the vulva.

What is seen on examination?

On careful clinical examination, there is usually a tiny split or linear erosion at the midline of the base of the vagina on the perineal skin. Colposcopy (magnification with a bright light) may be necessary to see the fissure. The posterior fourchette may form a tight band or tent (membranous hypertrophy). In some cases, signs may be more impressive and include:

• marked tenderness
• deep, wide ulceration
• redness of surrounding tissue
• swelling or lumps
• scarring.

The vulva may appear entirely normal if the examination takes place after the fissure has healed. But often, a new fissure can be observed to appear while gently stretching the vulva.

What causes fissuring of the posterior fourchette?

The splitting occurs when the vulva stretches, particularly during sexual intercourse. This may be because the skin is stiff, inflamed, fragile, or for unknown reasons.

Posterior fourchette fissuring may be primary, i.e., no underlying skin disease is diagnosed, or secondary to an infection or inflammatory skin disease. Common causes include:

• vulvovaginitis due to Candida albicans (thrush)
• herpes simplex infection (genital herpes)
• atrophic vulvovaginitis
• contact dermatitis due to irritants or less often, allergy
• seborrhoeic dermatitis
• atopic dermatitis
• lichen simplex
• aphthous ulceration
• lichen sclerosus
• delayed healing of tear or episiotomy wound following childbirth
• pelvic floor muscle tension leading to vaginismus

Laceration of the posterior fourchette may also be due to straddle injury, violence or rape but in these situations bruising and other injuries are likely to be present.

Similar symptoms experienced in the absence of fissuring or other visible signs may be described as vulvodynia or vestibulodynia.

Investigations

Specific tests are often unnecessary if the history and appearance are typical.

Swabs may be taken to look for vaginal infections such as bacterial vaginosis and Candida albicans, for sexually transmitted infections or herpes virus.

Biopsy may show typical features of the underlying skin disorder. The histopathology of primary fissuring usually reveals nonspecific submucosal chronic inflammation; the clinician may consider the report nondiagnostic. Granuloma formation is rare. Scar tissue may be present.

Treatment

If an underlying infection or skin condition is diagnosed, specific treatment is usually very helpful. Examples include:

• antifungal creams or antifungal tablets for thrush
• Antivirals such as aciclovir, famciclovir or valaciclovir for genital herpes
• intravaginal oestrogen cream for hormone deficiency states during menopause or lactation
• topical steroids for dermatitis or lichenoid disorders.

Women with mild symptoms due to primary fissuring of the posterior fourchette may benefit from:

• explanation
• avoidance of irritants such as soap, spermicide cream, irritating lubricants or rough panty liners
• application of vaginal moisturisers and bland emollients such as petroleum jelly
• warm Sitz baths with bath oil
• non-soap cleansers
• liberal lubrication with oil during sexual activity (water-based lubricant should be used with condoms as oils may cause these to disintegrate)
• topical anaesthetic application (lignocaine jelly or ointment)
• woman-on-top or man-behind positioning
• vaginal dilators
• pelvic floor relaxation exercises.

Perineoplasty

Women with severe symptoms from primary fissuring of the posterior fourchette may consider vulval surgery. Perineoplasty is a surgical procedure that is usually undertaken under general anaesthesia. The fissured skin is completely cut out and replaced by vaginal epithelium that has been undermined then advanced to cover the defect without tension. It is stitched up from front to back. Perineoplasty may allow women with posterior fourchette fissuring to resume normal and painless sexual activity but is not always successful.