• Clinical science

Vulvovaginitis

Abstract

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 topical estrogen creme. Other causes of non-infectious vulvovaginitis include allergic and mechanical.

Infectious vulvovaginitis

Causes

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) according to the CDC!

Differential diagnoses of infectious vulvovaginitis

Infection Bacterial vaginosis Trichomoniasis Vaginal yeast infection Gonorrhea Chlamydia infections
Pathogen
  • Gardnerella vaginalis
Discharge
  • Grey/milky
  • Fishy odor
  • Frothy, yellow-green
  • Foul-smelling
  • White, crumbly
  • Odorless
  • Purulent, creamy
  • Odorless
  • Purulent, bloody
  • Odorless
Treatment
Special features
  • Recent history of antibiotic treatment
  • Pseudohyphae on KOH
  • pH 4-4.5

Bacterial vulvovaginitis

Bacterial vaginosis

  • Epidemiology: most common vaginal infection in women (40–45% of all cases)
  • Pathogen: Gardnerella vaginalis (a gram-variable rod) (Gram-variable)
  • Pathogenesis
    • Lower concentrations of Lactobacillus overgrowth of Gardnerella vaginalis and other anaerobes, without vaginal epithelial inflammation due to absent immune response
    • Sexual intercourse is the primary risk factor, but it is not considered an STD
    • Other risk factors include intrauterine devices (IUDs), douching, and pregnancy
  • Clinical features
    • Commonly asymptomatic
    • Increased vaginal discharge, usually gray or milky with fishy odor (often noticeable after intercourse)
    • Pruritus and pain are uncommon
  • Diagnostics: vaginal discharge sample
    • Amsel's criteria: 3 of 4 must apply to confirm diagnosis
      • Whiff test; (amine test, Hinsberg reaction): add 1–2 drops of 10% KOH to vaginal fluid → intensification of the fishy odor
      • Vaginal pH > 4.5
      • No leukocytes visible on microscopy
      • Clue cells: vaginal epithelial cells covered with bacteria identified on wet mount preparation
  • Treatment
  • Complications: infection of mother results in higher risk of preterm delivery

Bacterial vaginosis - ABCDEFG: Amsel criteria, bacterial vaginosis, clue cells, discharge (gray or milky), electrons (pH of vaginal secretions = alkali), fishy odor of discharge, gestation (increased risk for abortion)

Aerobic vaginitis

  • Epidemiology: approx. 5–10.5% of all cases
  • Pathogen
  • Pathogenesis
    • Lower concentrations of Lactobacillus species in the vaginal flora → increase in vaginal pH → overgrowth of aerobic pathogens may trigger vaginal immune reaction
  • Clinical features
  • Diagnostics
    • Negative Whiff test
    • Vaginal pH > 4.5
    • Leukocytes on microscopy
    • Increased parabasal cells (> 10% in case of severe atrophy)
    • Culture
  • Treatment: adapt treatment according to the severity of each of the three disease components (infection, atrophy, and inflammation)
  • Complications: AV is related to an increased risk of preterm delivery and to other severe pregnancy-related complications (e.g., ascending chorioamnionitis, PROM, and miscarriage)

References:[1][2][3]

Vaginal yeast infection (Vulvovaginal candidiasis)

References:[4][5][6][7][8]

Trichomoniasis

After sex, burn the foul, green tree (trichomonas)!

References:[4][9]

Noninfectious vulvovaginitis

Atrophic vaginitis

  • Etiology
  • 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: estrogen cream (topical) or tablets (systemic)

Estrogen substitution, especially in menopause, increases the risk of endometrial and breast cancer!

Others

May affect all age groups, but especially common in prepubescent girls

  • Chemical irritants (e.g., soaps, shampoos)
  • Allergic (e.g., to detergents; see extra information)
  • Mechanical (e.g., clothing; see extra information)

Allergic

  • 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 or 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

  • Etiology
  • Clinical features: pruritus, redness, swelling, sometimes dysuria, and/or dyspareunia
  • Diagnostics: special dermatological or rheumatological tests to find the cause of pruritis
  • Treatment
    • Depends on the cause
    • Soothing lotions/creams, ice packs, and sitz baths (e.g., containing chamomile)

References:[6]

Special patient groups

Vulvovaginitis in pediatric patients

Vulvovaginitis is the most frequent gynecological disorder encountered in prepubertal children.

  • Etiology:
    • The most common cause is poor hygiene.
    • Use of perfumed soaps and bubble baths
    • Localized skin disorders
    • Foreign body in the genitourinary tract
    • 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
  • Diagnosis:
    • 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 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
last updated 09/07/2018
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