section name header

Information

Editors

PekkaNieminen

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

Clinical examination

  • The cause of mild symptoms of itching/burning is very often cytolysis (breakdown of cells) which is a normal phenomenon. However, a large amount of lactobacilli further lowers the pH of the vagina and the acidic discharge causes the symptoms in the external genitalia.
    • Cytolysis typically occurs in the beginning and end of the menstrual cycle, if no hormonal contraception is used. The elevated oestrogen level during ovulation matures the vaginal cells , and hence the lactobacilli are not able to break down the cells to obtain glycogen. Consequently, cytolysis and symptoms are reduced.
  • Intense itching and sometimes a burning sensation in the external genitalia usually indicate vaginal mycosis (candidiasis). The discharge is lumpy, whitish and sticks to the vaginal wall. There may be small ulcers and reddening in the mucous membranes of the external genitalia.
  • A malodorous, homogenous, greyish discharge sticking to the vaginal wall is typical of bacterial vaginosis. Symptoms often also include mild burning and slight itching. The pH of the vaginal discharge is increased from normal 3.8-4.0 to over 4.5.
  • A copious, odourless, often yellowish or greenish discharge, dyspareunia and an ailment non-responsive to antimicrobials targeted at anaerobic bacteria, are often suggestive of aerobic vaginitis (AV) or its most difficult form desquamative inflammatory vaginitis (DIV).
  • A frothy, greenish discharge indicates trichomoniasis. Burning sensation is also common, the vaginal mucous membranes may be reddened and the pH is increased. Trichomoniasis is quite rare nowadays.
  • The mucous membranes of the vagina, external genitalia and urethra become thinner in postmenopausal women, and they bleed and become irritated easily due to the lack of oestrogen (atrophic vaginitis). Remember that slightly brownish discharge can be the first symptom of uterine cancer (take an endometrial biopsy).
  • The uterus and adnexa are not tender in vulvovaginitis. Purulent discharge from the cervix should be examined for gonococci and chlamydia (see pelvic inflammatory disease Pelvic Inflammatory Disease (PID)).

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.

Diagnosis of vulvovaginitis

NormalCytolysisYeast fungusBVTrichomonasAtrophic vaginitisDIV (aerobic vaginitis)
Aetiology-Abundant growth of LactobacilliCandida albicans, C. tropicalis or C. glabrataAnaerobic bacteriaT. vaginalisOestrogen deficiencyAerobic bacteria (GBS, E. coli)
Native vaginal smearLactobacilli dominateHigh number of lactobacilli, loose nuclei and broken down squamous cellsFungal hyphae, fungal cells, varying amount of leucocytesClue cellsMoving trichomonas, leucocytes ++Parabasal cells, varying amount of leucocytesParabasal cells, leucocytes +++, ample bacterial flora, no clue cells
LeucorrhoeaLight, inhomogeneousSubstantial, greyish, sometimes lumpyLumpy or wateryGrey, milkyYellowish, bubbly, substantialMeagre, bloodyPurulent, yellowish, substantial, not always
Symptoms-Mild itching and burningItching, burning, stinging, external dysuriaSmell, itching, mild burningItching, burning, external dysuriaDry mucosa, ”inflammation”Substantial leucorrhoea, no smell, tenderness
KOH test(-)(-)(-)(+)(+/-)(+/-)(-)
pH<4.7<4.7<4.7≥4.7≥4.7≥4.7Varies
  • BV= bacterial vaginosis
  • DIV= desquamative inflammatory vaginitis
  • GBS= group B streptrococcus
Treatment

Cytolysis

  • Cytolysis is not an infection and does not in itself require treatment. Informing the patient is usually sufficient. The purpose of cytolysis is to keep the vagina clean. If the system bothers the patient, application of local oestrogen a few times during the cycle helps to keep the symptoms away by enabling maturation of squamous cells, whereby lactobacilli are no longer able to break them down.

Vaginal mycosis Treatment for Recurrent Vulvovaginal Candidiasis, Probiotics for Vulvovaginal Candidiasis in Non-Pregnant Women

  • Treated according to clinical manifestation. Recurrent symptoms of vaginal mycosis should be confirmed with further examinations.
  • Possible balanitis of the partner must also be treated (e.g. with an antifungal cream).
  • Treated with vaginal suppositories for 1-3 days (clotrimazole, miconazole, tioconazole) or with an oral antimycotic as a single dose Treatments for Vulvovaginal Candidiosis. Vaginal mycosis during pregnancy is treated topically Topical Treatment for Vaginal Candidiasis in Pregnancy.
  • If the patient has a history of vaginal mycosis and typical symptoms recur, for example during antimicrobial treatment, a prescription can at discretion be given for ”a reserve” or over the telephone to the pharmacy.
  • Recurrent mycosis can result from antibiotics, the contraceptive pill or increased blood glucose.
  • Recurrent mycosis may require prophylactic treatment (a single dose of an antimycotic once a week), for example for 2-3 months.

Bacterial vaginosis Antibiotics for Treating Bacterial Vaginosis in Pregnancy, Probiotics for the Treatment of Bacterial Vaginosis, Antibiotic Treatment for the Sexual Partners of Women with Bacterial Vaginosis, Treatments for Vulvovaginal Candidiosis

Trichomoniasis

Aerobic vaginitis

  • Treated with clindamycin (2%): one applicator dose once daily for 7 days. In recurrent DIV prophylactic treatment is an applicator dose once a week for 7-14 weeks. Also dequalinium chloride vaginal suppository on 6 evenings may be useful.

Atrophic vaginitis

Vulvar care

  • Prolonged itching and burning symptoms of the vulva are common and by no means always caused by vulvovaginitis. The most common cause is the dryness and thinning of skin and mucosae, also in young women. The cause of this might be excessive washing of the vulva and/or the use of cleansers. Both cause thinning of the epithelial protective layer.
  • General instructions for vulvar care
    • Washing with water at most twice a day without soap or other cleansers.
    • Drying by patting with towel, after that emollient cream both on skin and mucosal area, but not in the vagina.
    • Air baths, i.e. breathable fabric in clothing and sleeping without trousers, are often helpful.
    • In addition, skin oil may be used a couple of times a day.
    • If the mucosa is still thin and irritated, local oestrogen cream on the vulva a couple of times a week is often helpful.