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Vulvovaginitis

Last updated: December 21, 2020

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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.

Differential diagnoses of infectious vulvovaginitis
Features Bacterial vaginosis Trichomoniasis Vaginal yeast infection Gonorrhea Chlamydia infections
Pathogen
Discharge
  • Gray/milky
  • Fishy odor
  • Frothy, yellow-green
  • Foul-smelling
  • White, crumbly, and thick (cottage cheese-like)
  • Odorless
Treatment
Special features

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).

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.

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

Atrophic vaginitis [8]

  • 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 [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

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

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
  • Diagnostics
  • Treatment
  1. Gandhi J, Chen A, Dagur G, et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Am J Obstet Gynecol. 2016; 215 (6): p.704-711. doi: 10.1016/j.ajog.2016.07.045 . | Open in Read by QxMD
  2. North American Menopause Society. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society.. Menopause. 2013; 20 (9): p.888-902; quiz 903-4. doi: 10.1097/GME.0b013e3182a122c2 . | Open in Read by QxMD
  3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 141: management of menopausal symptoms.. Obstet Gynecol. 2014; 123 (1): p.202-16. doi: 10.1097/01.AOG.0000441353.20693.78 . | Open in Read by QxMD
  4. Nyirjesy P, Peyton C, Weitz MV, Mathew L, Culhane JF. Causes of chronic vaginitis: analysis of a prospective database of affected women.. Obstet Gynecol. 2006; 108 (5): p.1185-91. doi: 10.1097/01.AOG.0000239103.67452.1a . | Open in Read by QxMD
  5. Donders GG, Vereecken A, Bosmans E, Dekeersmaecker A, Salembier G, Spitz B. Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis.. BJOG. 2002; 109 (1): p.34-43. doi: 10.1111/j.1471-0528.2002.00432.x . | Open in Read by QxMD
  6. Donders G, Bellen G, Rezeberga D. Aerobic vaginitis in pregnancy. BJOG. 2011; 118 (10): p.1163-1170. doi: 10.1111/j.1471-0528.2011.03020.x . | Open in Read by QxMD
  7. Donders GG, Ruban K, Bellen G. Selecting anti-microbial treatment of aerobic vaginitis. Curr Infect Dis Rep. 2015; 17 (5): p.477. doi: 10.1007/s11908-015-0477-6 . | Open in Read by QxMD
  8. Heczko PB, Tomusiak A, Adamski P, et al. Supplementation of standard antibiotic therapy with oral probiotics for bacterial vaginosis and aerobic vaginitis: a randomised, double-blind, placebo-controlled trial. BMC Womens Health ;15:115.. 2015; 15 : p.115. doi: 10.1186/s12905-015-0246-6 . | Open in Read by QxMD
  9. American College of Obstetricians and Gynecologists. Vaginitis in Nonpregnant Patients. Obstetrics & Gynecology. 2020; 135 (1): p.e1-e17. doi: 10.1097/aog.0000000000003604 . | Open in Read by QxMD
  10. Koumans EH, Sternberg M, Bruce C, et al. The Prevalence of Bacterial Vaginosis in the United States, 2001???2004; Associations With Symptoms, Sexual Behaviors, and Reproductive Health. Sex Transm Dis. 2007; 34 (11): p.864-869. doi: 10.1097/olq.0b013e318074e565 . | Open in Read by QxMD
  11. Amsel R, Totten PA, Spiegel CA, Chen KCS, Eschenbach D, Holmes KK. Nonspecific vaginitis. Am J Med. 1983; 74 (1): p.14-22. doi: 10.1016/0002-9343(83)91112-9 . | Open in Read by QxMD
  12. Krieger H, Kimmig P. [Survival ability of Trichomonas vaginalis in mineral baths].. Gesundheitswesen. 1995; 57 (12): p.812-9.
  13. Kissinger P, Muzny CA, Mena LA, et al. Single-dose versus 7-day-dose metronidazole for the treatment of trichomoniasis in women: an open-label, randomised controlled trial. Lancet Infect Dis. 2018; 18 (11): p.1251-1259. doi: 10.1016/s1473-3099(18)30423-7 . | Open in Read by QxMD
  14. Vulvovaginal Candidiasis. https://www.cdc.gov/std/tg2015/candidiasis.htm. Updated: June 4, 2015. Accessed: April 9, 2017.
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