Vulvovaginitis
Background
- 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
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
- Vulvovaginitis
- 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
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
- Respiratory or enteric flora may be seen in vaginal cultures from pre-puberal females
- Consider O&P
- Pinworms may cause vulvovaginitis in children [2]
Diagnosis
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 [3]
- 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[4]
- 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[5]
- Metronidazole 2g PO x 1 dose is also acceptable[5]
- Multiple studies have not demonstrated teratogenicity from metronidazole use[5]
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)[6]
- 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[7]
[[Trichomonas vaginalis
Non-Pregnant
- Metronidazole 500mg PO BID for 7 days [8]
- 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 [9]
Sexual Partner Treatment
- Female: Same as above
- Male: Metronidazole 2 gm PO x1 [10]
Disposition
- Virtually all patients can be discharges with PCP or Gyn follow up
- Any test sent should be followed for results
See Also
External Links
- ACOG patient information for vaginitis [1]
References
- ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
- ↑ Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:14-27. doi: 10.1016/j.bpobgyn.2017.08.014. Epub 2017 Sep 5. PMID: 28927766.
- ↑ Alvisi S, Gava G, Orsili I, Giacomelli G, Baldassarre M, Seracchioli R, Meriggiola MC. Vaginal Health in Menopausal Women. Medicina (Kaunas). 2019 Sep 20;55(10):615. doi: 10.3390/medicina55100615. PMID: 31547180; PMCID: PMC6843679.
- ↑ Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
- ↑ 5.0 5.1 5.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
- ↑ Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.
- ↑ Molgaard-Nielsen D et al. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67.
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
- ↑ CDC Trichomoniasis 2021. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm
- ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon