Vulvovaginitis

Introduction

Vulvovaginitis is inflammation of the vulva and vaginal tissues. It is usually characterized by a vaginal discharge and/or vulvar itching and irritation. A vaginal odor may be present. It accounts for 10 million visits to physicians per year in the United States, and is the most common gynecologic complaint in prepubertal girls.

The most common causes of acute vulvovaginitis include:

1. Infections,
2. Irritant or allergic contact,
3. Local response to a vaginal foreign body, and
4. Atrophic vaginitis.

The three most frequent infectious causes are bacterial vaginosis (BV) caused by replacement of normal flora by overgrowth of anaerobes and Gardnerella vaginalis, candidiasis (usually caused by Candida albicans) and, trichomoniasis (caused by Trichomonas vaginalis).2 BV is the most common cause of vaginal discharge or malodor. Polymicrobial infection in women with vaginitis is not uncommon. Vulvovaginal candidiasis, contact vaginitis, and atrophic vaginitis may occur in virgins and after menopause, but other forms of infectious vulvovaginitis are generally found only in sexually active women.

GENERAL APPROACH TO VULVOVAGINITIS

A detailed gynecologic history should be obtained and a pelvic examination performed. Microscopic evaluation of fresh vaginal secretions using both normal saline solution (demonstrating clue cells for BV and motile Trichomonas vaginalis for trichomoniasis) and 10 percent potassium hydroxide (KOH) slide preparation (demonstrating yeast or pseudohyphae for candidiasis) and fishy odor in BV (whiff test) will, in most instances, provide a diagnosis. Checking the pH and microscopic examination of secretions is mandatory because symptoms are nonspecific, signs on physical examination may vary, and patients may have more than one etiology causing vulvovaginitis. Culture for T. vaginalis is more sensitive than microscopic examination but is very infrequently performed. One of the most helpful diagnostic tools is measurement of the pH of the vaginal secretions using Nitrazine paper. A pH greater than 4.5 is typical of BV or trichomoniasis, while a pH below 4.5 represents physiologic discharge or a fungal infection.

Signs of vulval inflammation and minimal discharge in the absence of vaginal pathogens suggest the possibility of mechanical, chemical, allergic, or other noninfectious causes of vulvovaginitis.

All treatment recommendations are taken from the 2002 guidelines for the treatment of sexually transmitted diseases from the Centers for Disease Control and Prevention (CDC).

NORMAL VULVOVAGINAL ENVIRONMENT

In females of childbearing age, estrogen causes the development of a thick vaginal epithelium with a large number of superficial cells serving a protective function and containing large stores of glycogen. Glycogen is used by the normal flora, consisting of lactobacilli and acidogenic corynebacteria, to form lactic and acetic acids. The resulting acidic environment favors the normal flora and discourages the growth of pathogenic bacteria. Lack of estrogen or a dominance of progesterone results in an atrophic condition, with loss of the protective superficial cells and their contained glycogen. This results in loss of the acidic environment. Normal vaginal secretions may vary in consistency from a thin, watery material to one that is thick, white, and opaque. The quantity may also vary from scant to a rather copious amount. This material is odorless and produces no symptoms. The normal vaginal pH varies between 4.0 and 4.5. Alkaline secretions from the cervix before and during menstruation and semen (which is alkaline) reduce acidity, predisposing to infection. Before menarche and after menopause, the vaginal pH varies between 6 and 7. Because of scant nerve endings in the vagina, the patient usually does not have symptoms until both the vagina and vulva are involved in an inflammatory or irritant process.