Vulvovaginitis

Background

Labeled vulva, showing external and internal views.

Pelvic anatomy including organs of the female reproductive system.

• Definition: inflammation of the vulva and vagina
• Candida Vaginitis and Contact Vulvovaginitis may occur in pre-pubertal and non-sexually active people
• Atrophic vaginitis may occur in postmenopausal women

Vulvovaginitis

• Bacterial vaginosis
• Candida vaginitis
• Trichomonas vaginalis
• Contact vulvovaginitis
  • Bubble baths and soaps
  • Deodorants, powders, and douches
  • Clothing
• Atrophic vaginitis due to lack of estrogen (AKA Vulvovaginal atrophy)
• Lichen sclerosus
• Tinea cruris
• Chlamydia/Gonorrhea infection
• Pinworms
• Vaginal foreign body
  • Toilet paper
  • Other
• Genitourinary syndrome of menopause
• Foreign body
• Allergic reaction
• Normal physiologic discharge

Clinical Features

• Nonspecific
  • Discharge
  • Itching
  • Erythema or rash
  • Dysuria
  • Odor
  • Pain with intercourse

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervial Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic Pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

Evaluation

Workup

• Upreg
• Evaluate for infectious causes with cultures, wet mount, and trichomonas NAAT (or molecular vaginitis panel)
  • Respiratory or enteric flora may be seen in vaginal cultures from pre-puberal females
    • Respiratory: Staph, Strep, H influenza, Moraxella, and N meningitidis
    • Enteric: E coli, proteus, klebsiella, shigella etc.
  • STIs are less common
  • Candida and gardnerella may be see on wet mount
• Consider O&P
  • Pinworms may cause vulvovaginitis in children

Management

Empiric Treatment

• Acceptable when clinically suspecting BV, vaginal candidiasis, or a non-infectious etiology
• If signs/symptoms are equivocal for a specific diagnosis or if they suggest possible trichomoniasis, diagnostic testing should first be performed prior to treatment.

Non-Infectious Etiology Treatment

• Hygienic measures for non-specific vulvovaginitis particularly in pre-pubertal females
• OTC Vaginal lubrication products for post-menopausal women with vulvovaginal atrophy symptoms
• Consider hormone replacement therapy in post-menopausal women
  • Best provided by a primary care provider

Treatment for Test-Positive Patients based on Organism and Symptomatology

Positive Organism	Symptomatic	Asymptomatic	Test of cure needed?	Treat sexual partner(s)?
BV	Treat	Do not treat	No, unless persistent symptoms	No
Vaginal candidiasis	Treat	Do not treat	No, unless persistent symptoms	No
Trichomoniasis	Treat	Treat	Yes (in 3 months; use NAAT)	Yes

Bacterial vaginosis

First Line Therapy

• Metronidazole 500 mg PO BID for 7 days OR
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days OR
• Clindamycin cream 2%, one full applicator (5 g) intravaginally qHS for 7 days

Alternative Regimin

• Tinidazole 2 g PO qd for 2 days OR
• Tinidazole 1 g PO qd for 5 days OR
• Clindamycin 300 mg PO BID for 7 days OR
• Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hrs)

Pregnant

• Metronidazole 250mg PO q8h x 7 days
• Metronidazole 2g PO x 1 dose is also acceptable
• Multiple studies have not demonstrated teratogenicity from metronidazole use

Prophylaxis (Sexual Assault)

• Metronidazole 2 g PO x 1 OR
• Tinidazole 2 g PO x 1

Candida vulvovaginitis

Uncomplicated

There is little resistance to azole medications; treatment often dictated by patient preference.

• Fluconazole 150mg PO once (preferred)
  • A second dose at 72hrs may be given if patient is still symptomatic
• Intravaginal therapy
  • Clotrimazole 1 % cream applied vaginally for 7 days OR
  • Clotrimazole 2% applied vaginally for 3 days
  • Miconazole 2% cream applied vaginally for 7 days OR 4% cream x 3 days
  • Butoconazole 2% applied vaginally x 3 days
  • Tioconazole 6.5% applied vaginally x 1

Complicated

Severe or immunosuppressed

• Fluconazole 150mg PO q72h x 3 doses

Non-albicans species

• For example, C. glabrata, C. krusei and other atypical Candida spp.
• Boric acid vaginal suppository intravaginal qday x ≥14 days
  • Can be fatal if taken orally
• If empirically treated and later is found to have non-albicans Candida spp., no change in therapy is needed if patient is improving (otherwise switch to boric acid.

Recurrent (≥ 4 infections in a year)

• Treat as for uncomplicated (see above)
• Once therapy completed, prescribe long-term treatment
  • Fluconazole 150mg PO qweek x 6 months, OR
  • Intravaginal medication, such as clotrimazole 500mg PV qweek or 200mg PV twice a week

Pregnant Patients

• Intravaginal clotrimazole or miconazole are the only recommended treatments
• Duration is 7 days
• PO fluconazole associated with congenital malformations and spontaneous abortions

[[Trichomonas vaginalis

Non-Pregnant

• Metronidazole 500mg PO BID for 7 days
• Tinidazole 2g PO once

Pregnant

Only treat if the patient is symptomatic and avoid breast feeding until 24-hrs after last dose

• Metronidazole 500mg PO BID for 7 days

Sexual Partner Treatment

• Female: Same as above
• Male: Metronidazole 2 gm PO x1

Disposition

• Virtually all patients can be discharges with PCP or Gyn follow up
• Any test sent should be followed for results

See Also

• Pelvic Pain

External Links

• ACOG patient information for vaginitis [1]