Wrinkled Appearance of Vaginal Walls During Pelvic Examination
The wrinkled appearance of vaginal walls that don't resemble normal rugae is most likely vulvovaginal atrophy (VVA), a common condition associated with decreased estrogenization of vaginal tissue that affects approximately 50% of postmenopausal women. 1, 2
Clinical Features of Vulvovaginal Atrophy
- VVA causes characteristic changes to vaginal appearance including loss of normal rugae, pale and dry mucosa, and a wrinkled appearance that differs from healthy vaginal rugae 1
- The condition is associated with thinning of vaginal rugae (92.1% of cases), pallor of the mucosa (90.7%), mucosal fragility (71.9%), and petechiae (46.7%) 2
- Vaginal pH is typically elevated (>4.5) in patients with VVA, which can be measured by dipping pH paper in vaginal secretions 3
- The prevalence of VVA increases with age, ranging from 19.2% in women 40-45 years old to 53.8% in women 52-55 years old 4
Associated Symptoms
- Common symptoms include vaginal dryness (100%), dyspareunia (77.6%), burning (56.9%), itching (56.6%), and dysuria (36.1%) 2
- Despite high prevalence and substantial effect on quality of life, VVA often remains underreported and undertreated 5
- Even while taking systemic estrogen, 10-20% of women may still have residual VVA symptoms 1
Diagnostic Approach
- Diagnosis is based on a combination of patient symptoms (vaginal dryness), objective signs (loss of rugae, pallor, thinning), and vaginal pH >5 2, 4
- During speculum examination, the vaginal walls should be carefully inspected for discharge and lesions 6
- The normal vaginal pH should be <4.5; pH is elevated in VVA as well as in bacterial vaginosis and trichomoniasis 6, 3
Differential Diagnosis
- Other conditions that may cause changes in vaginal appearance include:
- Bacterial vaginosis - characterized by thin, homogeneous discharge with fishy odor and clue cells on microscopy 6, 3
- Trichomoniasis - may present with strawberry cervix (red punctate lesions) 6
- Pelvic organ prolapse - may involve protrusion of vaginal walls but typically presents with bulging rather than wrinkled appearance 6
Management Considerations
- Local estrogen therapy is the mainstay of treatment for VVA 1, 5
- Sedentary women are at higher risk of VVA (OR 1.8), suggesting that physical activity may be protective 2
- Women with VVA are more likely to experience recent vaginal infections (OR 2.48) 2
Clinical Pitfalls
- VVA is frequently underdiagnosed - studies show only 30% of women with the condition had received a previous diagnosis 2
- Nuclear enlargement in squamous cells is an expected normal reactive change in postmenopausal cervical vaginal smears that can be mistaken for cellular atypia 7
- When performing speculum examination, lubricating with warm water (not gel) and inserting completely before opening the blades minimizes discomfort 6, 3
The wrinkled appearance you're observing likely represents the loss of normal vaginal rugae due to decreased estrogenization of the vaginal tissue, which is the hallmark of vulvovaginal atrophy.