Vulvovaginitis

The term vulvovaginitis is used to describe an acute inflammation of the vulva and vagina. Vulvovaginitis can be caused by several infectious and non-infectious etiologies, and results from disruption of the normal vaginal environment. Common signs and symptoms include pain, pruritis, erythema, and edema of the affected region, as well as vaginal discharge and dyspareunia. The diagnosis is based on the clinical presentation, physical examination findings, and inspection of vaginal secretions. Management depends on the etiology, including antimicrobials for infectious causes.

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Overview

Epidemiology

  • Approximately 75% of women will have at least 1 episode of vulvovaginitis in their lifetime.
  • 55%‒83% will consult a healthcare professional.
  • Common in college-aged women

Etiology

  • Infectious:
    • Bacterial vaginosis (BV)
    • Candida albicans (C. albicans)
    • Trichomonas vaginalis (T. vaginalis)
  • Non-infectious:
    • Atrophic vaginitis
    • Contact dermatitis

Pathophysiology

  • Stratified squamous epithelium of the vagina is rich in glycogen (epithelium is maintained by estrogen).
  • Glycogen is converted to lactic and acetic acid by Lactobacillus and Corynebacterium:
    • Creates an acidic environment (pH 4–4.5)
    • Maintains the normal vaginal flora
    • Inhibits growth of pathogens
  • Vulvovaginitis results from a disruption of this environment:
    • ↓ or ↑ estrogen
    • Alkalinization of the vaginal pH:
      • Menstrual blood
      • Semen
      • Hygienic products
  • Lactobacillus and Corynebacterium colonization (e.g., antibiotics)

Bacterial Vaginosis

Bacterial vaginosis (BV, may also be referred to as Gardnerella vaginalis) is one of the most common causes of vulvovaginitis.

Etiology and pathophysiology

  • Lactobacillus → ↑ pH overgrowth of anaerobic bacteria:
    • Gardnerella vaginalis:
      • Small, pleomorphic, gram-variable bacilli
      • Non-spore forming
      • Non-motile
    • Mycoplasma hominis
    • Peptostreptococcus
    • Prevotella
    • Ureaplasma urealyticum
    • Mobiluncus
  • Anaerobic bacteria produce enzymes break down vaginal peptides into amines, leading to:
    • Vaginal transudation
    • Squamous epithelial cell exfoliation
    • Odor
  • Risk factors:
    • Unprotected sex
    • ↑ Number of sexual partners
    • Other sexually transmitted infections (STIs)
    • Douching
    • Bathing in a bathtub (particularly bubble baths)

Clinical presentation

  • 50%–75% of patients are asymptomatic.
  • Vaginal discharge:
    • Malodorous (fishy)
    • Gray
    • Thin

Diagnosis

  • Microscopic examination (saline wet mount): clue cells (bacteria adhering to epithelial cells)
  • Whiff-amine test: presence of a fishy odor when 10% potassium hydroxide (KOH) is added to a sample of vaginal discharge
  • Cytology:
    • May be detected during a Papanicolaou (Pap) smear
    • Not reliable
  • Amsel criteria (3 of 4 must be present):
    • Gray discharge
    • Vaginal secretion pH > 4.5
    • Fishy odor on whiff test
    • Clue cells

Management

  • Treatment is generally recommended for symptomatic patients only:
    • Exception: Asymptomatic pregnant patients should also be treated.
  • 1st line: metronidazole or tinidazole
  • Alternative: clindamycin

Complications

Bacterial vaginosis is associated with an increased risk of:

  • Other STIs and pelvic inflammatory disease (PID)
  • Postpartum endometritis
  • Chorioamnionitis
  • Preterm labor and birth

Candidal Vaginitis

Etiology

Candidal vaginitis is a fungal vaginitis caused by:

  • C. albicans (80%–92%)
  • C. glabrata

Pathophysiology

  • Not necessarily associated with ↓ Lactobacillus
  • ↑ Estrogen environment → ↑ vaginal glycogen → favorable environment for Candida growth and adherence
  • Risk factors:
    • Pregnancy
    • Contraception
    • Hormone replacement therapy
    • Immunosuppression
    • Diabetes
    • Antibiotics

Clinical presentation

  • Vulvar pruritis, burning, and irritation
  • Erythema and edema
  • Vaginal discharge:
    • Thick
    • White
    • Cottage cheese–like
    • Minimal or no odor
  • Dyspareunia

Diagnosis

  • Vaginal pH is normal.
  • Wet mount with 10% KOH:
    • Budding yeast
    • Pseudohyphae
  • Culture is reserved for:
    • When microscopy is unrevealing 
    • Continued symptoms despite treatment

Management

Treatment options include oral or topical antifungals.

  • Fluconazole oral:
    • Single dose
    • Most convenient
  • Clotrimazole cream or vaginal suppository
  • Miconazole vaginal suppository

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Trichomoniasis

Trichomoniasis is the most common non-viral STI.

Etiology

  • T. vaginalis:
    • Flagellated protozoan:
      • Ovoid shaped
      • 5 flagella
      • Undulating membrane
      • Facultative anaerobe
    • Forms:
      • Trophozoite
      • No cyst form
    • Humans are the only host.
    • Transmission is through sexual contact.
  • Frequently coexists with BV
  • Risk factors:
    • Unprotected sex
    • Multiple sex partners

Microscopic images of Trichomonas vaginalis trophozoites

Image: “Trichomonas protozoa” by isis325. License: CC BY 2.0

Pathophysiology

  • Virulence factors:
    • Bacterial adhesins → adherence to vaginal epithelial cells
    • Cysteine proteinases → break down extracellular matrix proteins
  • Infection is associated with ↓ Lactobacillus and ↑ vaginal pH.
  • T. vaginalis adheres to vaginal epithelial cells:
    • Releases cytotoxic substances → destroys epithelial cells
    • Binds host plasma proteins → evades the host immune system
    • Releases chemotactic substances → attract polymorphonuclear leukocytes (PMNs)
    • May also disrupt the vaginal flora

Clinical presentation

  • May be asymptomatic (usually in men)
  • Vaginal discharge:
    • Yellow-green
    • Scant to copious
    • Frothy and purulent
    • Malodorous (fishy)
  • Vulvar and perineal soreness
  • Dysuria
  • Dyspareunia
  • Red “strawberry” spots on the vaginal walls 
  • “Strawberry” red cervix

Diagnosis

  • Wet mount of vaginal secretions:
    • Motile, flagellated, ovoid protozoans
    • Presence of PMNs
    • pH > 4.5
  • Nucleic acid amplification test (NAAT):
    • Very sensitive and specific
    • Detects and amplifies RNA from T. vaginalis
  • Culture:
    • Uses Diamond’s medium (enriched, liquid medium)
    • Takes 7 days to obtain a result
  • Concurrent infections should be ruled out (e.g., BV).

Wet mount image of vaginal secretions demonstrating several T. vaginalis protozoa (contrast-enhanced image)

Image: “Trichomonas vaginalis” by CDC. License: Public Domain

Management

  • Metronidazole
  • Tinidazole

Non-infectious Vulvovaginitis

Atrophic vaginitis

  • Etiology and pathophysiology:
    • ↓ Estrogen levels → atrophy of vulval and vaginal epithelium: 
      • Menopause
      • Postpartum
      • Bilateral oophorectomy
      • Radiotherapy and/or chemotherapy
      • Immunologic disorders
      • Medications (e.g., tamoxifen, danazol, medroxyprogesterone)
  • Clinical presentation:
    • Most are asymptomatic.
    • Vaginal soreness and dryness
    • Dyspareunia and postcoital burning
    • Occasional spotting 
    • Serosanguinous vaginal discharge
    • Pale, smooth, shiny epithelium that is easily friable
    • Loss of labial and vulvar fullness
    • Sparse pubic hair
  • Diagnosis:
    • Usually based on the history and physical exam
    • Wet mount:
      • pH 5‒7
      • White blood cells
      • Other potential infectious causes should be ruled out.
  • Management: topical estrogen (e.g., cream, vaginal tablet, ring)

Contact dermatitis

  • Etiology:
    • Caused by a substance that irritates the skin or triggers an allergic reaction
    • Common irritants and allergens:
      • Urine
      • Topical medications
      • Latex
      • Spermicidal agents
      • Cosmetics
      • Douching
      • Cleansing products
      • Underwear
  • Clinical presentation:
    • Red, edematous skin:
      • May be followed by exudation and weeping
      • Potent irritants can cause erosion and ulceration.
    • Pruritis and burning
    • Tenderness
  • Diagnosis:
    • Usually based on the history and physical exam
    • Wet mount:
      • pH is normal.
      • Other potential infectious causes should be ruled out.
  • Management:
    • Identification and avoidance of the inciting agent
    • Gentle cleansing of the area (but avoid excessive washing)
    • Topical steroids:
      • Triamcinolone
      • Hydrocortisone
    • Antihistamines:
      • Hydroxyzine
      • Diphenhydramine

Differential Diagnosis

  • Chlamydia: an STI due to Chlamydia trachomatis, which can cause cervicitis, urethritis, and PID in women. Signs and symptoms include purulent or mucopurulent (yellow) cervical discharge, cervical erythema, edema, friability, vaginal bleeding, and dyspareunia. Diagnosis is based on clinical findings and NAAT. Management includes azithromycin or doxycycline.
  • Gonorrhea: an STI due to Neisseria gonorrhoeae, which can cause cervicitis, urethritis, PID, and disseminated disease. Signs and symptoms include purulent or mucopurulent (yellow) cervical discharge, cervical os erythema, edema, friability, vaginal bleeding, and dyspareunia. Diagnosis is based on clinical findings and NAAT. Management includes ceftriaxone. Because a concurrent chlamydial infection is common, azithromycin is also given.
  • Scabies: an infestation of the skin by the Sarcoptes scabiei mite that presents with intense pruritus, linear burrows, and erythematous papules. Commonly affected sites include the genitals, interdigital folds, axillary folds, and flexor aspects of the wrists. Scabies is transmitted by direct, human-to-human contact (including sexual contact). Diagnosis is clinical, but can be confirmed by dermatoscopy. Management includes permethrin cream as well as thorough cleaning of bedding and clothing.
  • Herpes: Genital herpes infections are common STIs caused by herpes simplex virus types 1 or 2. Primary infection often presents with prodromal symptoms, followed by clusters of painful, fluid-filled vesicles with an erythematous base, dysuria, and painful lymphadenopathy. Diagnosis is clinical, but confirmatory polymerase chain reaction (PCR) or serologic testing can be done. Management includes acyclovir, valacyclovir, or famcilovir.

References

  1. Sobel, J, & Mitchell, C. (2020). Candida vulvovaginitis: Clinical manifestations and diagnosis. Retrieved January 16, 2021 from https://www.uptodate.com/contents/candida-vulvovaginitis-clinical-manifestations-and-diagnosis
  2. Sobel, J. (2020). Approach to females with symptoms of vaginitis. Retrieved January 16, 2021 from https://www.uptodate.com/contents/approach-to-females-with-symptoms-of-vaginitis
  3. Sobel, J. (2020). Candida vulvovaginitis: Treatment. In Eckler, K. (Ed.), Uptodate. Retrieved January 19, 2021, from https://www.uptodate.com/contents/candida-vulvovaginitis-treatment
  4. Sobel, J.D., & Mitchell, C. (2020). Trichomoniasis. In Eckler, K. (Ed.), Uptodate. Retrieved January 19, 2021, from https://www.uptodate.com/contents/trichomoniasis
  5. Sobel, J., & Mitchell, C. (2020). Bacterial vaginosis: Clinical manifestations and diagnosis. Retrieved January 14, 2021 from https://www.uptodate.com/contents/bacterial-vaginosis-clinical-manifestations-and-diagnosis
  6. Sobel, J. (2020). Bacterial vaginosis: Treatment. In Eckler, K. (Ed.), Uptodate. Retrieved January 19, 2021, from https://www.uptodate.com/contents/bacterial-vaginosis-treatment
  7. Goje, O. (2019). Overview of vaginitis. [online] MSD Manual Professional Version. Retrieved January 19, 2021, from https://www.merckmanuals.com/professional/gynecology-and-obstetrics/vaginitis,-cervicitis,-and-pelvic-inflammatory-disease-pid/overview-of-vaginitis
  8. Goje, O. (2019). Bacterial vaginosis (BV). [online] MSD Manual Professional Version. Retrieved January 22, 2021, from https://www.merckmanuals.com/professional/gynecology-and-obstetrics/vaginitis,-cervicitis,-and-pelvic-inflammatory-disease-pid/bacterial-vaginosis-bv
  9. Morris, S.R. (2020). Trichomoniasis. [online] MSD Manual Professional Version. Retrieved January 22, 2021, from https://www.merckmanuals.com/professional/infectious-diseases/sexually-transmitted-diseases-stds/trichomoniasis
  10. Goje, O. (2019). Candidal vaginitis. [online] MSD Manual Professional Version. Retrieved January 22, 2021, from https://www.merckmanuals.com/professional/gynecology-and-obstetrics/vaginitis,-cervicitis,-and-pelvic-inflammatory-disease-pid/candidal-vaginitis
  11. Krapf, J.M. (2018). Vulvovaginitis. In Isaacs, C. (Ed.), Medscape. Retrieved January 19, 2021, from https://emedicine.medscape.com/article/2188931-overview
  12. Smith, D.S., Holderman, J.C., & Bugayong, K.T. (2020). Trichomoniasis. In Bronze, M.S. (Ed.), Medscape. Retrieved January 24, 2021, from https://emedicine.medscape.com/article/230617-overview

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