Vulvovaginitis

almostadoctor app banner for android and iOS

Contents

Introduction
History
Examination
Differentials
Investigations
Management
References
Related Articles

Introduction

Vulvovaginitis is a clinical presentation which can have many causes. It typically presents with one or more of the following; vaginal itch, discharge, dyspareunia, burning, dysuria and swelling.

It is most commonly caused by vaginal thrush, but there are a wide range of other causes, including other infections (e.g. trichomonas, herpes simplex, other STIs), dermatological causes – e.g. psoriasis or eczema, and neurological causes.

Mixed pathology is very common – particularly the combination of vulval dermatitis and thrush.

The treatment typically involves a combination of avoiding irritant causes to the vulvovaginal area, and treating the underlying disorder.

History

Discharge
- Onset
- Colour
- Frequency
- Consistency
- Smell
- Duration
Itch
- External
- Internal
- Associated sensations – burning, sharp pain
Provoking factors
- Always present at rest
- Symptoms provoked by tampons, clothes, exercise
Menstrual history
- Are symptoms cyclical?
Sexual history
- New sexual partners
- Assess STI risk
Pregnancy
- VERY importante because some of the treatments are contra-indicated in pregnancy
Skin conditions
- Any history of psoriasis or dermatitis?
Medications
- Recent antibiotics – predispose to thrush
- Might have trialled over-the-counter treatments for thrush

Examination

Examine external genitalia
- Any skin lesions – e.g. herpes simplex, warts or molluscum contagiosum
- Any signs of dermatitis
- Any visible discharge
- Any lichenifiaction?
  - This refieres to thickening of the skin
Speculum examination
- Examine cervix
- Note the qualities of any discharge
Bimanual examination
- Note pain and tenderness

Differentials

	Presentation	Examination	Treatment
Candidiasis	Thick white discharge Usually NOT foul smelling Itchy, burning Dyspareunia	Erythema of vulva and vagina Swollen labia Normal pH Spores may be seen Positive fungal culture	Antifungals – topical or oral Clotrimazole 1% cream topically for 6 nights, or 2% for 3 nights Oral fluconazole – 150mg single dose. Note – strongly contra-indicated in pregnancy
Bacterial Vaginosis	Often chronic Grey discharge Foul smelling Minimal itch or irritation	Grey discharge pH >4.5 Microscopy – epithelial cells with clue cells	Metronidazole 400mg OD for 7/7, OR Metronidazole 2g stat dose, OR Clindamycin 2% cream applied topically for 7 nights
Herpes Simplex	Vulval itch and irritation Painful vulvar ulcers Blood stained or clear vaginal discharge	Vulva ulcers Vaginal ulcers Cervical ulcers Occasionally purulent discharge	Valciclovir 500mg TDS for 7 days Consider suppressive therapy in recurrent cases – valaciclovir 500mg PO OD Other antivirals are probably equally efficacious
Dermatitis (contact)	Itching, burning, irritation No or minimal discharge	Erythema of vulva Normal pH Negative MC+S	Hygiene advice Avoid used of soaps, douches Loose fitting cotton underwear
Retained foreign body	Usually a tampon Offensive discharge Pelvic pain	Offensive discharge Normal vulva Objects likely to be discovered on speculum examination	Removal of offending object Antibiotics may be indicated
Lichen sclerosus	Severe itch Often asymptomatic	Vaginal pallor Lichenification Atrophiy	Topical steroids Topical oestrogen Retinoids Methorexate or ciclosporin in resistant cases
Lichen planus	Pain Dyspareunia Itch Rarely – a white yellow or grey discharge	Vaginal erosions / ulcers Often also oral mucosal involvement May be skin manifestations	Topical steroids Many cases resolve within 1-2 years, although mucosal involvement is a poor prognostic indicator
Psoriasis	Redness Itchy vulva Vagina is unaffected No discharge	Plaque-like lesions with clearly defined border Often NOT scaly (unlike other psoriatic lesions) due to moist environment Normal speculum examination	As per standard psoriasis treatment; topical steroids (usually + vit D), emollients Specialist referral if this is ineffective – UV therapies, retinoids and methotrexate / cyclosporine may be considered
Tirchomonas	Green / yellow “frothy” discharge Dyspareunia Dysuria Itch is unusual	Vaginitis pH >4.5	Metronidazole
Other STI	Discharge Post-coital bleeding Often asymptomatic	Cervicitis +/- cervical discharge Pelvic tenderness if PID	Likely causes include chlamydia or gonorrhoea. Treat as per underlying cause
Vulval vestibulitis	A syndrome of unexplained vulval pain Dyspareunia Pain on contact with foreign objects – e.g. tampons	Focal erythemaous patches Normal pH Normal MC+S	Some respond to topical oestrogen Some respond to TCAs
Atrophic vaginitis	Chronic Vaginal dryness Post-menopausal Rarely itchy Rarely a colourless discharge	Vaginal wall bleeding Vaginal pallor Patchy erythema	Topical oestrogen

Modified from a table in RACGP Check – Women’s Health – Unit 530 – August 2016

Investigations

Swab for MC+S
Test for chlamydia and gonorrhoea – usually PCR from an appropriate swab. Urine PCR can also be performed but is less accurate
Consider bedside pH testing of any discharge

Management

The management of vulvovaginitis will typically involve with below general measures, in addition to specific treatment for the underlying disorder.

Supportive measures:

Loose fitting cotton clothing
Clean the area once or twice daily without soap (wither water only, or emollient)
Avoid cycling or horse riding until symptoms settle
Avoid irritants
- Soap
- Hygiene wipes
- Fragrances
- Douche
- Lubricant
- Condoms
- Sanitary pads or panty liners
- Tight clothes
- Swimming, saunas, spas

References

Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy