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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

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