Vulvovaginitis
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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

PresentationExaminationTreatment
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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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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