Vulvovaginitis

Essentials

• In normal conditions there is always some discharge (leucorrhoea, fluor) in the vagina. It consists of cervical mucus, lactobacillus mass and regenerating epithelial cells. The amount of discharge varies depending on the phase of the menstrual cycle.
• The purpose of leucorrhoea is to keep the vagina clean. The acidity of the discharge and its flow out of the vagina are useful in this process.
• The most common aetiology of increased leucorrhoea is cytolysis (breakdown of cells), which is a normal phenomenon.
• Symptomatic leucorrhoea (itching, burning sensation, altered odour or colour) may be a sign of vulvovaginitis
• Treatment should be directed at the likely (according to assessment) or confirmed cause of the infection.
• It is usually possible to obtain a diagnosis of sufficient accuracy by gynaecological examination and basic laboratory tests.
• In vulvovaginitis, vaginitis is usually the dominant component and vagina is the site of the primary infection, but symptoms in the vulva/external genitalia are often also present.
• Itching and burning symptoms can also be caused by the dryness of skin and mucosae without infection.

Symptoms

• Increased vaginal discharge without pelvic pain or systemic symptoms
• Itching and/or a burning sensation, usually in the external genital organs
• Altered odour, e.g. ”fishy” smell
• Altered colour of the discharge, e.g. greenish, yellowish
• Erythema and ulceration in the external genitalia
• Dyspareunia (pain during sexual intercourse)
• Dysuria; experienced at the urethral orifice
• Change in pH value

Aetiology

• Cytolysis
• Candida species (Candida albicans, C. glabrata)
• Anaerobic bacteria (Gardnerella vaginalis, Bacteroides species etc.)
• Trichomonas vaginalis
• Aerobic bacteria (for example, group G beta-haemolytic streptococcus, E.coli)
• Actinomyces (ALO, actinomyces-like organisms) are sometimes isolated from patients with an intra-uterine device (IUD, worn > 3 years).
• Chlamydia Chlamydial Urethritis and Cervicitis
• Gonococcus Gonorrhoea
• Mycoplasma genitalium Mycoplasma Genitalium Infection

Diagnostics

Strategies for investigation

• The differential diagnostics of vulvovaginitis may require thorough investigations (table T1). It is particularly essential to exclude the possibility of cytolysis if fungal infection is suspected. Only one fourth of women with itching symptoms have a fungal infection. Particularly the use of native vaginal smear, i.e. bedside microscopy of leucorrhoea, and colposcope are helpful.
• Symptoms and clinical picture are usually sufficient to diagnose vaginal mycosis.
• If the clinical picture does not match mycosis, a potassium hydroxide test may be performed: a couple of drops of potassium hydroxide are placed onto the used speculum; a strong odour of fish indicates bacterial vaginosis.
• The pH of the vaginal discharge can be measured with a usual pH paper strip.
• A candidal culture, a Trichomonas nucleic acid sample or, depending on the laboratory policy, a plain specimen for the detection of yeast, clue cells and Trichomonas may be collected.
• If a microscope is available, put one drop of discharge on a glass slide, add one drop of saline and examine with 100- and 400-fold magnification.
• In typical bacterial vaginosis there are clue cells, but only a few leucocytes. If a large number of leucocytes are seen together with clue cells, suspect concurrent cervicitis (remember chlamydia!).
• Very large amounts of leucocytes are visible in anaerobic vaginitis. Additionally, mixed flora is seen and there may also be lactobacilli. If there are also parabasal cells of squamous epithelium, the diagnosis is DIV.
• Fungi can be identified as threads, spores (budding, small, clear and homogeneous cells) or both. There may be a large number of polymorphonuclear leucocytes.
• If vulvovaginitis recurs often despite treatment, colposcopy is warranted in order to exclude other causes.