Vaginitis may be due to pathogens or to indigenous flora after a change in milieu of the vagina. Candidal vulvovaginitis and bacterial vaginosis (formerly called Gardnerella, Haemophilus, or nonspecific vaginitis) may occur in patients who are not sexually active. These are examples of indigenous flora that may cause symptoms. Bacterial vaginosis, however, is more prevalent in those who are sexually active. In sexually active patients, Trichomonas infection or cervicitis due to sexually transmitted pathogens must be considered. For this reason, appropriate specimens should be taken from sexually active patients or suspected victims of sexual abuse in order to detect STIs, even if yeast forms are present or bacterial vaginosis is identified.
1. Physiologic Leukorrhea
Leukorrhea is the normal vaginal discharge that begins around the time of menarche. The discharge is typically clear or whitish, and its consistency may vary according to cyclic hormonal influences. There should be no odor. Girls in early adolescence may have concerns about such a discharge and need reassurance that it is normal. This may be a good time to tell girls that there is no need for douching. If a vaginal wet preparation is examined, a few squamous epithelial cells may be revealed, but there should be fewer than five polymorphonuclear cells per high-power field.
2. Candidal Vulvovaginitis
Candidal vulvovaginitis is caused by yeast (Candida albicans). It typically occurs after a course of antibiotics, after which the normal perineal flora are altered and yeast is allowed to proliferate. Diabetic patients, those with compromised immune systems, and those who are pregnant or receiving OCPs are more prone to develop candidal infections.
The patient usually complains of vulvar pruritus or dyspareunia and a thick vaginal discharge, frequently beginning the week before menses. Examination of the vulva reveals erythematous mucosa, sometimes with excoriation, and a thick, white, cheesy discharge. The discharge may be adherent to the walls of the vagina. Leukocytes may be seen on a wet preparation, and a KOH preparation may reveal budding yeast or mycelia. The vaginal preparations are often not helpful, and the patient should be treated on the basis of the clinical examination. Vaginal culture for yeast is usually unnecessary.
Butoconazole, clotrimazole, miconazole, terconazole, or tioconazole vaginal creams or suppositories designed for seven nightly doses are effective in most patients. Fluconazole (150 mg once orally) is also effective and may be beneficial on a monthly prophylactic basis for women with recurring infections. Patients with recurrent episodes should be given prophylactic treatment whenever they take antibiotics. It may be helpful to simultaneously treat the partners of sexually active patients with recurrent candidal infections.
3. Bacterial Vaginosis
Bacterial vaginosis may be caused by any of the indigenous vaginal flora, such as Gardnerella, Bacteroides, Peptococcus, Mycoplasma hominis, lactobacilli, or other anaerobes.
The patient generally complains of a malodorous discharge. On examination, a thin, homogeneous, grayish white discharge is found adhering to the vaginal wall. A whiff test, in which a drop of KOH is added to a smear of the discharge on a slide, results in the release of amines, causing a fishy odor. Wet preparation reveals an abundance of clue cells and small pleomorphic rods.
Treatment for bacterial vaginosis is with metronidazole (500 mg orally bid for 7 days) or clindamycin (300 mg orally bid for 7 days). Topical metronidazole or clindamycin may also be effective. Ampicillin (500 mg orally four times a day for 7 days) is the alternative for pregnant patients.
4. Other Causes Of Vulvovaginitis
Sexually Transmitted Infections
STIs are a common cause of vaginal discharge in adolescents. Chlamydia and gonorrhea testing should be done whenever a sexually active adolescent complains of vaginal discharge even when the cervix appears normal.
Foreign Body Vaginitis
Foreign bodies (most commonly retained tampons or condoms) cause extremely malodorous vaginal discharges. Treatment consists of removal, for which ring forceps may be useful. Further treatment is generally not necessary.
Allergic or Contact Vaginitis
Bubble baths, feminine hygiene sprays, or vaginal contraceptive foams or suppositories may cause chemical irritation of the vaginal mucosa. Discontinuing use of the offending agent is indicated.
Brook I: Microbiology and management of polymicrobial female genital tract infections in adolescents. J Pediatr Adolesc Gynecol 2002;15(4):217 [PMID: 12459228].
Vulvovaginitis (also Vulvitis) 616.10
Vulvovaginitis, amebic 006.8
Vulvovaginitis, chlamydial 099.53
Vulvovaginitis, gonococcal (acute) 098.0
Vulvovaginitis, gonococcal, chronic or duration of 2 months or over 098.2
Vulvovaginitis, herpetic 054.11
Vulvovaginitis, monilial 112.1
Vulvovaginitis, trichomonal (Trichomonas vaginalis) 131.01
Revision date: July 9, 2011
Last revised: by Andrew G. Epstein, M.D.