Manifestations of Epstein-Barr virus in the genitourinary tract of women are rare, and vary. There isn’t a great deal known about these vulvar ulcers, and some facts are in contention by medical professionals and researchers. It can manifest in the cervix, uterus, fallopian tubes, ovaries, urethra, and anus, though this is not well understood. We know that EBV is present in the genitourinary tracts of both males and females during acute and latent infection. We don’t know if it sexually transmitted, but it may well be. This doesn’t mean this is the only way to spread EBV, nor that people with EBV, including children, have been sexually active, since this is not true.
It is likely that the virus itself does not cause the vulvar ulcers, but in fact it is the person’s own cells that are responding by destroying the infected cell. This results in degradation of the skin in the ulcerated area, with the possibility that female sex hormones aggravate the condition.
What is Epstein-Barr virus (EBV)?
EBV is a virus that is best known to cause infectious mononucleosis (‘mono’). The virus is global, with infection not necessarily causing any symptoms.
Symptoms of EBV
- Triad of fever, sore throat, enlarged lymph nodes
- Vaginal discharge
- Problems urinating
- Pain or burning upon urination
- Vulvar pain and itching
- Vulvar lesions in some women and girls
- Symptoms may recur later in life
Vulvar ulcers and urinary pain or burning
The main symptoms are thought to be rapidly-developing vulvar ulcers, which are typically under recognised. These ulcers may appear over several days, probably on the labia minora (inner labia), but can appear on any part of the genitalia including the perineum and anus. It may start off with burning and a blood-blister. Pus may be present from the ulcer. These ulcers may take several weeks to heal, as the virus is eradicated from the body.
Symptoms do not respond to typical treatments and may worsen, and take time to develop. Mouth ulcers may also appear.
What the ulcers look like
There is often one large lesion that is ‘punched out’. Smaller ulcers may join the larger ulcer, called ‘satellite’ ulcers. They can range from 1-4mm, and be purplish with irregular borders, often with a central point. Reddish or reddish-brown ulcers, raised, clearly defined. Ulcers are likely to be painless, but could be tender.
Diagnosis of EBV with vulvovaginal symptoms
Diagnosis is by blood tests for antibodies, and observation, however with vulvar ulcers, a herpes simplex (genital herpes) diagnosis is likely to be initially sought and treated.
Treatment for EBV with vulvovaginal symptoms
Corticosteroids and pain management are the most common treatments for the symptoms. A moisturising barrier like zinc oxide cream may help soothe the skin for relief of the vulva. Women with urinary pain or burning may benefit from urinating in a stream of water (like in the shower or bath, or using a cup to pour water over the vulva while urinating). Various creams may be used, including low-dose topical steroids, oestrogen cream, topical anaesthetic, and/or antibiotics.
If the ulcers become infected, antibiotics are likely to be used.
What else could it be?
Halvorsen JA, Brevig T, Aas T, Skar AG, Slevolden EM, Moi H. Genital ulcers as initial manifestation of Epstein-Barr virus infection: two new cases and a review of the literature. Acta Derm Venereol. 2006;86(5):439-42. Erratum in: Acta Derm Venereol. 2006;86(6):482. PubMed PMID: 16955191.