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 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).

Atrophic vaginitis is the most common non-infectious cause of vulvovaginitis and frequently affects elderly women after menopause as a result of decreased estrogen levels. The diagnosis is clinical and treatment includes application of vaginal lubricants and topical estrogen cream. Other causes of noninfectious vulvovaginitis include allergic and mechanical.

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

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

• Epidemiology: most common vaginal infection in women (22–50% of all cases) ^[1][2]
• 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 STD)
  • Intrauterine devices
  • Vaginal douching
  • Pregnancy
• Clinical features
  • Commonly asymptomatic
  • Increased vaginal discharge, usually gray or milky with fishy odor
  • Pruritus and pain are uncommon.
• Diagnostics: diagnosis is confirmed if three of the following Amsel criteria are met ^[3]
  • Clue cells
    • Vaginal epithelial cells with a stippled appearance and fuzzy borders due to bacteria adhering to the cell surface
    • Identified on wet mount preparation: A sample of vaginal fluid/discharge is transferred to a slide and mixed with normal saline. The slide is then examined under a microscope.
  • Vaginal pH > 4.5
  • Positive Whiff test: an intensified fishy odor after adding 1–2 drops of 10% potassium hydroxide to a sample of vaginal fluid
  • Thin, homogeneous gray-white or yellow discharge that adheres to the vaginal walls
• Treatment
  • If asymptomatic: reassurance; often resolves without treatment
  • If symptomatic
    • First-line: oral metronidazole
    • Alternative: topical metronidazole or clindamycin
  • Oral probiotics ^[4]
• Complications
  • Acquisition of STDs (e.g., HSV2, HIV, trichomonas, gonorrhea, and chlamydia infection)
  • Miscarriage and spontaneous abortion
  • Preterm delivery
  • Postpartum endometritis

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) ^[1]
• Pathogen: primarily Candida albicans (in immunosuppressed patients also Candida glabrata)
• Pathophysiology: overgrowth of C. albicans
  • Can be precipitated by the following risk factors:
    • Pregnancy
    • Immunodeficiency, both systemic (e.g., 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, strong pruritus, dysuria, dyspareunia
• Diagnostics ^[5]
  • Pseudohyphae on wet mount with potassium hydroxide (KOH)
  • Vaginal pH within normal range (4–4.5)
• Treatment ^[5]
  • Recommended regimens: topical azole (e.g., miconazole, clotrimazole, butoconazole) OR single-dose oral fluconazole
  • Recommended in pregnant women: topical azole OR nystatin pessary (where available)

• Epidemiology:4–35% of all cases ^[1]
• Pathogen: Trichomonas vaginalis
  • Anaerobic, motile protozoan with flagella
  • Does not encyst and, therefore, does not survive well outside the human body ^[6]
• Transmission: : sexual
• Clinical features
  • Foul-smelling, frothy, yellow-green, purulent discharge
  • Vulvovaginal pruritus, burning sensation, dyspareunia, dysuria, strawberry cervix (erythematous mucosa with petechiae)
• Diagnostics
  • Saline wet mount of vaginal smear: motile trophozoites with multiple flagella
  • If wet mount is inconclusive, perform culture.
  • pH of vaginal discharge > 4.5
• Treatment
  • Oral metronidazole OR tinidazole for the patient and sexual partner(s) ^[7]
  • Check for other sexually transmitted infections

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

Atrophic vaginitis ^[8]

• Etiology
  • Low estrogen levels (e.g., after menopause, bilateral oophorectomy, chemotherapy, immunological disorders, or due to hypothalamic amenorrhea or breastfeeding)
  • Atrophy of epithelium in vagina and vulva
• Clinical features
  • Decreasing labial fat pad
  • Vaginal soreness, dryness
  • Dyspareunia, burning sensation after sex
  • Discharge, occasional spotting
  • Commonly associated with receding pubic hair
• Diagnostics: : primarily a clinical diagnosis, additional tests (e.g., pH test, wet mount) are often nonspecific
• Treatment ^[9][10]
  • Nonhormonal vaginal moisturizers and lubricants if mild symptoms
  • Vaginal estrogen therapy if moderate to severe symptoms
  • Systemic hormone therapy if vasomotor symptoms

Aerobic vaginitis

• Definition: an inflammatory vaginitis of noninfectious origin with microbiome disturbance and secondary bacterial infection
• Epidemiology
  • Approx. 8% of all cases ^[11]
  • More common in perimenopausal or postmenopausal women
• Pathogen ^[12]
  • 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 ^[13]
• Clinical features
  • Copious, yellow (purulent), odorless vaginal discharge
  • Vaginal inflammation, redness and swelling
  • Dyspareunia, burning sensation, itching
• Diagnostics
  • Negative Whiff 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) ^[14]
    • Ampicillin for GBS or Enterococcus faecalis infection
  • Local steroids
  • Local estrogens ^[14]
  • Oral probiotics reduce the risk of remission and relapse. ^[4]
• 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) ^[13]

Allergic vulvovaginitis

• Epidemiology: may affect all age groups, but are especially common in prepubescent girls
• Etiology: allergies to laundry or cleaning detergents, textile fibers, sanitary napkins, etc.
• Clinical features: pruritus, redness, swelling, burning sensation
• Diagnostics: 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

Mechanical vulvovaginitis

• Etiology
  • Pruritus (e.g., due to atopic dermatitis, psoriasis, psychosomatic conditions)
  • Friction of tight clothes, obesity
  • Women suffering from postmenopausal estrogen deficiency or lichen sclerosis are especially at high risk.
• Clinical features: pruritus, redness, swelling, sometimes dysuria, and/or dyspareunia
• Diagnostics: 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 pediatric patients

• Epidemiology: most common gynecological disorder in prepubertal children
• Etiology
  • Poor hygiene (most common cause)
  • Use of perfumed soaps and bubble baths
  • Localized skin disorders
  • Foreign body in the genitourinary tract ^[15]
  • In some cases, sexual abuse
• Pathophysiology: Estrogen levels are lower in prepubescent girls, 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 on urination, and dysuria
  • In some cases, visible segment of a foreign body at the genital opening
• Diagnostics
  • If an infectious etiology is suspected, then appropriate Gram stain, culture, prep, DNA PCR, etc. 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, avoidance of tight clothing