What is the cause of vaginal irritation for 3 weeks in a 52-year-old postmenopausal woman with a possible vaginal wall fissure, no discharge, and no bleeding, with a history of mild bleeding last year that had a negative workup, and last menstrual period (LMP) 8 years ago?

Differential Diagnosis for Vaginal Irritation

Single most likely diagnosis

• Vaginal fissure or laceration: The presence of a possible fissure on the right lateral vaginal wall during the speculum exam, combined with the patient's symptoms of vaginal irritation without discharge or bleeding, makes this a highly plausible diagnosis. The patient's postmenopausal status may contribute to vaginal dryness and increased susceptibility to fissures.

Other Likely diagnoses

• Atrophic vaginitis: Given the patient's postmenopausal status (LMP 8+ years ago), atrophic vaginitis is a common condition that could cause vaginal irritation due to the thinning and drying of the vaginal walls.
• Vulvar dermatitis: This condition could cause irritation and might be related to various factors including allergic reactions, irritants, or infections, although the absence of discharge makes an infectious cause less likely.
• Vaginal dryness: This is a common issue in postmenopausal women and can cause irritation, especially if not adequately addressed with lubricants during sexual activity.

Do Not Miss (ddxs that may not be likely, but would be deadly if missed)

• Vaginal cancer: Although rare, any abnormal vaginal bleeding or lesions, especially in postmenopausal women, warrant a thorough investigation to rule out malignancy. The patient's history of mild bleeding last year with a negative workup still necessitates vigilance.
• Invasive infections: Though less likely given the absence of discharge, certain infections (e.g., necrotizing fasciitis) can present with minimal initial symptoms and progress rapidly. Early recognition is crucial for effective treatment.

Rare diagnoses

• Lichen sclerosis or lichen planus: These are chronic inflammatory skin conditions that can affect the vulva and vagina, leading to irritation and potential scarring. They are less common but should be considered in the differential diagnosis, especially if other causes are ruled out.
• Vaginal foreign body: Although more common in younger populations, a retained foreign body could cause irritation and should be considered, especially if the patient's history suggests the possibility.