Vulvovaginitis

Vulvovaginitis refers to a large variety of conditions that result in inflammation of the vulva and vagina. The causes may be infectious (e.g., bacterial vaginosis in most cases) or noninfectious. Physiologically, the normal vaginal flora (mainly lactobacilli) keeps the pH levels of the vaginal fluids low, thus preventing the overgrowth of pathogenic and opportunistic organisms. Disruption of that flora (e.g., due to sexual intercourse) predisposes to infection and inflammation. Diagnosis of infectious vulvovaginitis is based on histology examination of vaginal discharge. Treatment consists of administration of antibiotics or antifungals (depending on the pathogen).

For information on vulvovaginal atrophy caused by declining estrogen levels, see “Menopause.”

Etiology ^[1]

• Common causes of infectious vulvovaginitis
  • Bacterial vaginosis
  • Vaginal yeast infection
  • Trichomoniasis
  • Aerobic vaginitis
• Other causes of infectious vulvovaginitis (see respective articles for more information)
  • Enterobius vermicularis (especially in prepubescent individuals)
  • Scabies (seven-year itch)
  • Pediculosis pubis (crabs, pubic lice)

Differential diagnoses of infectious causes of vaginal discharge ^[1]

Partner therapy is recommended in most cases of STIs, particularly chlamydia, trichomoniasis, and gonorrhea. Bacterial vaginosis and vaginal yeast infection do not require treatment of the partner(s).

• Epidemiology: most common vaginal infection (22–50% of all cases) ^[2][3]
• Pathogen: Gardnerella vaginalis (a pleomorphic, gram-variable rod)
• Pathophysiology: lower concentrations of Lactobacillus acidophilus lead to overgrowth of Gardnerella vaginalis and other anaerobes, without vaginal epithelial inflammation due to absent immune response
• Risk factors
  • Sexual intercourse (primary risk factor, but it is not considered an STI)
  • Intrauterine devices
  • Vaginal douching
  • Pregnancy
• Clinical features
  • Commonly asymptomatic
  • Increased vaginal discharge, usually gray or milky with fishy odor
  • Pruritus and pain are uncommon.
• Diagnosis: Diagnosis is confirmed if three of the following Amsel criteria are met. ^[4]
  • Clue cells
    • Vaginal epithelial cells with a stippled appearance and fuzzy borders due to bacteria adhering to the cell surface
    • Identified on a vaginal wet mount preparation
  • Vaginal pH > 4.5
  • Positive amine test (sometimes referred to as the “whiff test”): The addition of 1–2 drops of 10% potassium hydroxide to a sample of infected vaginal discharge emits a characteristic amine odor. ^[5][6]
  • Thin, homogeneous gray-white or yellow discharge that adheres to the vaginal walls
• Treatment ^[1]
  • Asymptomatic: reassurance; often resolves without treatment
  • Symptomatic
    • First-line in nonpregnant and pregnant patients: ; ^[1]
      • Oral metronidazole
      • OR intravaginal metronidazole
      • OR intravaginal clindamycin
    • Alternative in nonpregnant and pregnant patients: oral clindamycin ^[1]
    • Alternative in nonpregnant patients: oral tinidazole OR oral secnidazole ^[1]
  • Treatment of sexual partner(s) is not recommended.
• Complications
  • Adverse pregnancy outcomes: preterm delivery, spontaneous abortion, postpartum endometritis
  • Reinfection: Consider retesting after 3 months.

ABCDEFG: Amsel criteria, Bacterial vaginosis, Clue cells, Discharge (gray or milky), Electrons (pH of vaginal secretions is alkaline), Fishy odor of discharge, and Gestation (increased risk for miscarriage) are the most important features of bacterial vaginosis.

• Epidemiology: second most common cause of vulvovaginitis (17–39% of all cases) ^[2]
• Pathogen: primarily Candida albicans (in immunosuppressed patients also Candida glabrata)
• Pathophysiology: overgrowth of C. albicans
  • Can be precipitated by the following risk factors:
    • Pregnancy
    • Immune deficiency: both systemic (e.g., poorly controlled diabetes mellitus, HIV, immunosuppression) and local (e.g., topical corticosteroids)
    • Antimicrobial treatment (e.g., after systemic antibiotic treatment)
• Clinical features
  • White, crumbly, and sticky vaginal discharge that may appear like cottage cheese and is typically odorless
  • Erythematous vulva and vagina
  • Vaginal burning sensation, severe pruritus, dysuria, dyspareunia
• Diagnosis ^[1][2]
  • Diagnosis is confirmed by the presence of symptoms and either of the following:
    • Budding yeast, hyphae, and/or pseudohyphae on a vaginal wet mount with potassium hydroxide (KOH) or saline
    • Fungus on vaginal culture
  • Additional findings: vaginal pH within normal range (i.e., 4–4.5)
• Classification ^[1]
  • Complicated vulvovaginal candidiasis is characterized by presence of ≥ 1 of the following:
    • Recurrent infection (i.e., ≥ 3 episodes of vulvovaginal candidiasis within 1 year)
    • Severe symptoms
    • Causative organism other than C. albicans
    • Diabetes mellitus or immune deficiency
  • Uncomplicated vulvovaginal candidiasis is an infection with no features of complicated vulvovaginal candidiasis.
• Treatment: only indicated in symptomatic patients ^[1]
  • Uncomplicated vulvovaginal candidiasis
    • Nonpregnant individuals: topical azole (e.g., miconazole ;, clotrimazole ) OR single-dose oral fluconazole (adults only) ^[1][2]
    • Pregnant individuals: 7-day course of a topical azole (e.g., miconazole , clotrimazole )
  • Complicated vulvovaginal candidiasis
    • Adults: See “Treatment of complicated vulvovaginal candidiasis”
    • Children: Consult a specialist.

Obtain a vaginal culture in all patients with complicated vulvovaginal candidiasis. ^[1]

Oral fluconazole is not recommended for use in pregnant patients because of a possible association with spontaneous abortions and fetal malformations. ^[1]

• Epidemiology: 4–35% of all cases ^[2]
• Pathogen: Trichomonas vaginalis
  • Anaerobic, motile protozoan with flagella
  • Does not encyst and, therefore, does not survive well outside the human body ^[7]
• Transmission: : sexual
• Clinical features
  • Foul-smelling, frothy, yellow-green, purulent discharge
  • Vulvovaginal pruritus, burning sensation, dyspareunia, dysuria, strawberry cervix (erythematous mucosa with petechiae)
• Diagnosis ^[1][8]
  • Saline vaginal wet mount (initial test): motile trophozoites with multiple flagella
    • If the wet mount is inconclusive, perform a culture or nucleic acid amplification testing (NAAT)
  • pH of vaginal discharge > 4.5
  • Routine screening in asymptomatic (nonpregnant and pregnant) patients is not recommended
• Treatment ^[1]
  • First-line in nonpregnant and pregnant patients: oral metronidazole
  • Alternative in HIV-negative nonpregnant patients: oral tinidazole
  • Concurrent treatment of sexual partners:
    • Female sexual partners: same as treatment for the primary patient
    • Male sexual partners: single-dose oral metronidazole ; alternative: single-dose oral tinidazole
  • Check for other sexually transmitted infections.
  • Screen patients for repeat infection after 3 months of treatment.
• Complications: adverse pregnancy outcomes, e.g., preterm delivery, intrauterine growth restriction

“After sex, Burn the Foul, Green Tree:” burning sensation and foul-smelling, yellow-green discharge are the features of trichomoniasis.

• Definition: an inflammatory vaginitis of noninfectious origin with microbiome disturbance and secondary bacterial infection
• Epidemiology
  • Approx. 8% of all cases of chronic vaginitis ^[9]
  • More common in perimenopausal or postmenopausal individuals
• Pathogen ^[10]
  • Gram-negative: Escherichia coli is the most common
  • Gram-positive: Streptococcus agalactiae, Staphylococcus aureus, and Enterococcus faecalis
• Pathophysiology: lower concentrations of Lactobacillus species in the vaginal flora → increase in vaginal pH → overgrowth of aerobic pathogens may trigger vaginal immune reaction ^[11]
• Clinical features
  • Copious, yellow (purulent), odorless vaginal discharge
  • Vaginal inflammation, redness, and swelling
  • Dyspareunia, burning sensation, itching
• Diagnosis
  • Negative amine test
  • Vaginal pH > 4.5
  • Leukocytes on microscopy
  • Increased parabasal cells
  • Culture
• Treatment: Adapt treatment according to the severity of each of the three disease components (infection, atrophy, and inflammation).
  • Antibiotics
    • Kanamycin OR quinolones (e.g., moxifloxacin) ^[12]
    • Ampicillin for GBS or Enterococcus faecalis infection
  • Local steroids
  • Local estrogens ^[12]
  • Oral probiotics reduce the risk of remission and relapse. ^[13]
• Complications: Aerobic vaginitis is related to an increased risk of preterm delivery and to other severe pregnancy-related complications (e.g., ascending chorioamnionitis, PROM, miscarriage). ^[11]

• Epidemiology: may affect all age groups, but are especially common in prepubescent girls
• Etiology: allergies (e.g., to laundry or cleaning detergents, textile fibers, sanitary napkins)
• Clinical features: pruritus, redness, swelling, burning sensation
• Diagnosis: Special allergy diagnostics (e.g., prick/puncture, intradermal test) may be indicated if symptoms persist despite treatment.
• Treatment
  • Avoid irritants
  • Soothing lotions, ice packs, and sitz baths (e.g., containing chamomile)
  • Cortisone creams if needed

• Etiology
  • Pruritus (e.g., due to atopic dermatitis, psoriasis, psychosomatic conditions)
  • Friction of tight clothes, obesity
  • Individuals suffering from postmenopausal estrogen deficiency or lichen sclerosis are especially at high risk.
• Clinical features: pruritus, redness, swelling, sometimes dysuria, and/or dyspareunia
• Diagnosis: special dermatological or rheumatological tests to find the cause of pruritus
• Treatment
  • Depends on the cause
  • Soothing lotions/creams, ice packs, and sitz baths (e.g., containing chamomile)

Vulvovaginitis in children

• Epidemiology: most common gynecological disorder in prepubertal children
• Etiology
  • Poor hygiene (most common cause)
  • Foreign body in the genitourinary tract ^[14]
  • Use of perfumed soaps and bubble baths
  • Localized skin disorders
  • In some cases, sexual abuse
• Pathophysiology: Estrogen levels are lower in prepubescent individuals, making the vulvar skin and vaginal mucosa very thin. This makes them more susceptible to vulvovaginitis of any cause.
• Clinical features
  • Vaginal discharge: often bloody, purulent, or foul-smelling
  • Pain in the lower abdomen and suprapubic region
  • Increased urinary frequency, burning during urination, and dysuria
  • In some cases, visible segment of a foreign body at the genital opening
• Diagnosis
  • If an infectious etiology is suspected, then appropriate testing (e.g., Gram stain, culture, prep, DNA PCR) should be conducted.
  • Direct visualization of the foreign body, either on physical examination or by means of pelvic ultrasonography, plain pelvic radiography, vaginography, or MRI
• Treatment
  • In the case of foreign body: removal of foreign body
    • First line of treatment: warm saline irrigation of the vagina in an outpatient setting
    • If irrigation fails, removal under general anesthesia
    • Antibiotics/antifungals are usually not needed if successful removal is achieved, as the vulvovaginitis would then spontaneously resolve.
  • Topical or oral antibiotics/antifungals
  • Conservative measures: improving hygiene, avoiding tight clothing

Infectious vulvovaginitis in pregnancy

• Etiology: infections with the same pathogens of STIs as nonpregnant patients
• Clinical features
  • Depending on the pathogen (e.g., itching, vaginal discharge)
  • Increased risk of adverse pregnancy outcomes: spontaneous abortion, premature rupture of membranes, chorioamnionitis, neonatal infection, postpartum endometritis
• Diagnosis
  • Asymptomatic, pregnant patients
    • No recommendation for screening for bacterial vaginosis, trichomoniasis, and genital herpes virus infection
    • Recommended screening for other STIs (e.g., HIV, syphilis, hepatitis B, hepatitis C, chlamydia)
  • Symptomatic, pregnant patients: same diagnostic studies as for nonpregnant patients (see “Infectious vulvovaginitis” above and “Management of sexually transmitted infections” in “Sexually transmitted infections” article)
• Treatment
  • Targeted treatment according to the pathogen
  • Careful evaluation of whether a drug is safe to use during pregnancy